You are here: Home > Reformulation > Summer 2003 [Issue 19] > Two different presentations with Borderline Personality Disorder

Two different presentations with Borderline Personality Disorder

Fawkes, L. and Fretten, V., 2003. Two different presentations with Borderline Personality Disorder. Reformulation, Summer, pp.32-39.

---

We came across a number of people who, whilst meeting all the criteria for B.P.D., seemed to present in a fairly consistently defended way. Whilst state shifting occurred, there seemed none the less to be some unifying factor in the personality and we wondered what it was.

Presenting Problems

These patients come into therapy struggling with symptoms of early abuse such as flashbacks, nightmares and pervasive fear. They report difficulties in their relationships, often centring around a sense of not connecting with others in a empathic and warm way. They describe feeling isolated, as if they are on the outside looking in and they feel disconnected from others, as if the patient cannot be reached. At the same time they seem to experience others as attacking or demanding. There is either no evidence of care in their world at all, or the world is experienced as threatening. Nothing or attack. The patient is left alone with their terror and feels totally helpless to change their world, as any movement will be met with terrifying attack (either real or imagined). Change is viewed as impossible, because it feels too dangerous to move into unknown territory and there is at least a sense of familiarity and therefore predictability in their current position.

Early Experiences – The Interpersonal World

The earliest experiences for these patients were abusive. The child was born and was abused, usually sexually, and usually from an early age. The person who was supposed to offer safety and nourishment was either actively sexually abusing the child or was seemingly actively complicit in it. For the infant therefore there was no safety, there was no other offering a haven from the pain of being abused. As a child all others were damaging. There were no good objects. Others either abused, tormented and persecuted them or ignored, hated and derided them. The child was helpless to have any effect on such a world; nothing they could do enlisted anyone to meet their needs for safety, security and containment. From the viewpoint of the child, it was as if they truly must have been so bad that others, who should have cared for them, apparently had to punish them.

Implications of the Interpersonal World

From this kind of interpersonal world the child had to struggle for survival, as all humans do. Starting from this place the child faced particular difficulties. It may be that these patients were literally crushed during the abuse, but whether that was the case or not, the weight of the oppression they experienced psychically led, metaphorically at least, to a fight for breath. It may be that this predicates the onset of the panic attacks and hyperventilation that are so common in these patients in later life. The weight of oppression and this battle for breath meant that one of the few routes to survival was to ensure that others were kept away from the psyche. Others had to be repelled, had to be shut out in some way in order to protect the self. From early experiences the child was familiar with others repelling them and, as we understand in CAT terms, the interpersonal world both causes the need for the defence and supplies the means of defence at the same time. Our dear old friends Reciprocal Roles (RRs).

Intrapersonal Implications

It is as if the knowledge that all objects are bad becomes the unifying factor in the personality that we are trying to find, because it seems that everything is constellated around that knowledge. It may be that the nature of the abuse is also significant here. In our experience of this presentation the abuse was uniformly persecutory, punitive and sadistic without any enticement to participate. It is as if the abuser is a ‘whole object’ – all threatening, attacking and bad. There are no split off aspects in the abuser – no ‘good daddy, bad daddy’ split. This means that for the child, there is no hope that if they do what the abuser wants, they will reach a place of no pain, or escape or approval. The only possibility of psychic survival is to be alone, cutting off or repelling the other and dealing with all the after effects of the trauma within the mind and body, i.e. intrapersonally rather than interpersonally. Hence these patients tend to have been very withdrawn in early life, and later suffer from panic attacks, flashbacks and nightmares, often accompanied by severe dissociation.

Interpersonal Implications

We understand in CAT that people’s sense of self originates from the internalization of the child’s primary relationships. The child internalizes both their own role and the role of the other. For these patients, though, this is slightly complicated. The child was treated solely as an object and their emotional needs and their feelings were totally disregarded. They were denied the opportunity to internalise any good objects and therefore experience themselves and their needs as acceptable. Because of this it is as if they were denied even the compensation of seeing themselves as a victim of others’ badness. It is as if there is no Innocent, as if there is nobody whose needs and feelings are disregarded. It is as if the child, as a child, as an individual, does not exist; it is as if the Parent and the Child are merged into one, and that one is the parent. The parent is bad, therefore the merged child is bad. We cannot talk about Other to Self when there is no Self involved. In reciprocal role terms we cannot reformulate this as the traditional Abusing to Abused Victim RR because that means nothing to these patients. For them the experience is more accurately described as something along the lines of Abusing to Bad/Guilty/Culpable.

The only other possible ‘bottom role’ available is that of invisibility or non existence as a person and this has real implications for adult life as well. As a child they learned that their physical survival depended on being as the other demanded. They learnt to be compliant in order literally to stay alive. Their emotional needs were forcibly sacrificed for survival. This continues on into adulthood where they learn to construct a false coping self. They may become the good teacher, the earth mother or the caretaker, anything where their role is to give perfect care to others. It is based on the belief that they have no needs themselves and that they should have no needs themselves. This is partly because they have internalised the early disregard for their needs from their early relationships. However it is also because they have learnt the hard way that they can only experience any kind of safety when they are isolated away from others. Needing anyone would imperil this isolation and therefore their safety. The false coping self or perfect carer also holds some compensation as, for the first time, they can experience themselves as ‘good’, but it is based on a false premise of course, because it is at the cost of their own emotional needs.

Emotionality and Core Pain

In an abusive and persecutory world any emotional expression and spontaneity would have been too dangerous to contemplate. As if to remind themselves never to make themselves visible to others and never to need anything from anyone the child and the adult remain in the primary and only position where they can remain safe. We have come to call this the ‘I am bad’ position. The ‘I am bad’ place becomes more than a belief about themselves. It acts as an absolute truth, an intractable truth. Emotions, other than shame and fear, become extremely dangerous. These patients will often deny any experience of anger and can feel no grief or sadness for the child they were. For these patients to feel rage would be to shift away from the ‘I am bad’ place into a belief that ‘this should not have happened to me because I did not deserve it and because perhaps there are different ways that others can behave’. To feel grief would be to shift into an awareness of one’s needs that have not been met from a world that can meet others’ needs. For these people rage and grief are dangerous precisely because they would entail a shift away from the belief that the world is bad and therefore I am bad, when the holding of that knowledge has been the source of their physical survival.

Implications for Therapy

Recreation of the Interpersonal World

The patient brings with her into therapy the fight for survival. This means that she will repel any attempts on behalf of the therapist to connect with her, remaining invisible through complete compliance and/or by remaining firmly entrenched in the ‘I am bad’ place. It is important to understand that the patient cannot see the therapist as separate or as benign – as a therapist you are an Other to them and Others in their world are always bad.

Likely Enactments in Therapy

The intractability of their belief that they are bad and that they can never move from this position can evoke dislike or frustration in others and that can lead to abusive or rejecting responses. It can be tempting to try and push things on, or to try to contradict the ‘I am bad place’, or even to discharge the patient, but this would merely confirm what the patient knows as familiar. This is one side of a dilemma, the other side of which occurs if the therapist attempts to show any care or concern for the patient. This can be experienced as evidence that the patient has contaminated the therapist and that they should not say anything else that might elicit any more concern. We tentatively believe that this is a result of consistently experiencing the other, and everything they offer, as bad for them. What they have learned is that anything and everything that comes in from the world is poisonous. This then has to include care and concern. They dare not accept it, as if they would be drinking their own death if they did so. They have had to adopt the place that absolutely everything that it is possible to introject is a threat and everything that it is possible to project is equally threatening. They have to keep everything that is inside in, and they have to keep everything that is outside out. Reciprocation, communication is a real and imminent threat to that status quo. The fear is that if they let go of this they will disintegrate.

What we have outlined here is the double bind that the patient lives with and that the therapist will experience and work with during the therapy. As we have seen, one way out of this intolerable dilemma for the patient is to construct a false coping self. In this state the patient presents without any apparent needs or difficulties. In therapy this can lead the therapist to believe that all is alright in the patient’s world and that the therapist has successfully dealt with the issues that brought the patient into therapy. To collude with this state is exceptionally tempting because of the hopelessness engendered in the ‘I am bad’ state, and because therapy seems so impossible in the states where the patient repels the therapist and will not allow any sense of connection. In the false coping self it is easy to feel that there is a strong working alliance and that therapy will be productive. However this is based on the patient’s ability to be as the other wishes, and they are usually very good at that. It is often the only state in which the patient feels acceptable to others and perhaps from this perspective it is a compensatory state – for patient and therapist alike!

Tasks of Therapy

Initially we believe that the therapist’s task is to hear how bad the patient believes themselves to be and to understand how it is to be in the world when your whole sense is that you are bad. The therapist has to hold the hopelessness that it can ever be any different and resist any natural impulses to offer compensatory reassurance or to move into the active phase of therapy before the patient believes that you know how bad and hopeless their world is. Only in this way can the patient risk trusting the therapist enough to contemplate any movement at all.
Alongside this, our experience is that we became aware of feeling admiration for these patients’ courage in surviving at all. In normal development one of the primary narcissistic needs that has to be met is for the infant to be ‘the gleam in the mother’s eye’ and to experience the good mother’s gaze. For these patients this need has not been met and remains split off, along with all the ‘good’ bits of themselves and others. It is this good part that they need the therapist to hold for them because it provides the seeds of a healthier sense of self. This task cannot happen until the therapist has understood the ‘I am bad’ place, but equally it is only when they can begin to experience the existence of the good that they can begin to explore the possibility of integration – the possibility that there is good and bad in themselves and in the world around them.

Lucy

Presenting and Target Problems

Lucy presented as an anxious woman in her 50s, eager to please and apologetic for everything about herself. She was suffering from chronic anxiety and panic attacks, always feeling unsafe, as well as experiencing dissociative episodes, which she described as blanking out or switching off. She felt inferior to everybody else in the world, and constantly felt exposed and wanted to hide away. She always had to be frantically busy looking after other people in order to distract herself, and constantly became absorbed into other people, minimising anything to do with herself. Finally she reported a sense of severe frustration and impatience with herself and things around her, a feeling she could never express overtly, though she would find herself scratching herself until her skin broke.

Early History – Interpersonal World

Lucy was born a tiny premature baby, the youngest of three girls. She was apparently supposed to have been a boy and was certainly not a welcome addition to the family. Her parents’ relationship was very bad, as was their relationship with the three girls. Her father appears to have systematically sexually abused all the girls, and her mother seemed contemptuous of him on the one hand and terrified of him on the other. Too early in her life Lucy was recruited as a confidante to her mother, who seems either to have been depressed and timid, or abusive and dismissive and very hard on Lucy. Her earliest memories are all of neglect and abuse, sitting as a tiny child in a high chair, wet, cold, ill and terrified. It was only later, and only once, that Lucy could disclose that her mother too had sexually abused her. However it was as if her mother’s feelings and needs had to be the primary focus at the expense of Lucy’s and she had to learn to shut off her own feelings and to listen and be there for her mother. She has since been told that she never ever cried even as an infant.

Alongside this Lucy was experiencing terrifying hatred and abuse from her father. Periodically she had terrible flashbacks and nightmares about this abuse. She was also bullied by her sisters who were both quite a bit older than she was, and at school she was also bullied and ill treated.

Implications of the Interpersonal World

Clearly she could not tell her mother what was happening and she found herself dissociating or ‘going elsewhere’ as she described it. Only later during the follow up phase of therapy could Lucy see that she learnt to survive by shutting herself in a kind of box, never communicating with anybody. She would hide everywhere and anywhere as a child; in the coats at school, in the laundry basket; in short she learnt to become as invisible as possible as any visibility was certain to mean more abuse. However even her withdrawal elicited more attack, as the school became convinced there was something wrong with her, that there was something wilful about her inability to communicate. When they reported it to her mother she confirmed that indeed it must be something within Lucy that was bad.

Intrapersonal Implications

Lucy came to believe this as a truth about herself – that she must have done something to deserve such appalling treatment from the whole world. She saw herself, and felt herself to be; ‘Abused, Bad, Evil, Guilty, Disgusting, degraded and guilty’. There was no sense at all that she could see herself as an innocent victim of others’ abuse. She felt totally culpable. As an adult Lucy struggled with terrible flashbacks, nightmares and panic attacks. Whenever these occurred she simply wished she was dead. Later she understood this was how she had always felt; dying was the only way of stopping the terrible life she was living. There was no other way. She learnt to survive by dissociating or by making herself invisible, and consequently Lucy had no sense of connection with the child that she was. It was as if she was somebody else, and there was no empathy at all for what she had been through and survived. She showed me a picture of herself as a child, but she could barely bear to glance at it.

Interpersonal Implications

This knowledge of herself as evil drove all of Lucy’s way of life, or rather way of survival. She held herself responsible for everybody and everything in her life and could allow no expression of her own needs for anything. She kept herself frantically busy – ‘too busy to think or feel’ – and spent her life apologising for her existence. She learnt to ‘caretake’ others. She was the one who organised her father’s funeral as her sisters were too distraught, even though they treated her as if she did not exist; she was the one who kept her husband alive when he was suicidal even though he would not tolerate any distress from her; she was the one who listened to her first husband’s distress at his 2nd divorce, despite the terrible way she had been treated in their marriage. The compensation for this caretaker – or Perfect Carer self state – was that she could view herself as ‘good’ in some way. The costs were of course immense.

Emotionality and Core Pain

This caretaker state allowed no expression of either Lucy’s needs or her feelings. In this way it allowed her some sense of safety and control. Feeling her feelings would have felt too dangerous for her early on in life, though it became evident through the therapy that they were there and just had to be protected by layers and layers of procedures to keep herself and others away from them. She feared that if she did feel anything she would disintegrate completely. Of the five basic emotions she had never known happiness, she could own to feeling fear, and shame was familiar to her. She denied ever having felt angry in her life, and she showed/felt no sadness for herself as a child. In the therapy the overwhelming feeling was just anxiety, which served really to remind Lucy to keep away from me, and to remind me to go very gently.

Therapy

Recreation of the interpersonal world

When Lucy first came into therapy her anxiety was overwhelming. She would stop breathing and have to ask permission to have a drink. I felt an incredible urge to protect her, but more than that I felt that I had huge hobnailed boots on and that as delicately as I might try I could not help but trample on her if I moved at all. For Lucy just being in therapy was excruciating – she was not supposed to draw attention to
herself let alone make any demands on another person. Therapy broke all the rules of her family culture. All of them, and that was really really scary. As we began to talk a little about the abuse she let me see how she had lived believing that she was the cause of the all the bad in her world. She kept asking ‘what have I done wrong?’ and she answered the question herself: ‘everything. I was born. That is where my guilt started’.

And her guilt kept her stuck too. Totally stuck. Her version of the map showed ever-decreasing circles of blood, and change felt out of the question. She felt trapped in her unconscious mind by her recurring nightmares, in her body by her physical pain, in her conscious mind by her compliance and ‘caretaking’ and in her external world by her father (who was dying), by her sisters and her fear of their disapproval, and by her husband whom she greatly feared.

We stayed in the stuck place for a long time, and looking back it is as if my task was to understand not only the strength of Lucy’s sense that she was the bad one but also just how much I was also the bad one, the feared Other in her life. Any and every attempt I made to try and move or challenge her basic premise was firmly rejected. I had to stop reassuring, or trying to see things from a different perspective. I had to see how she lived and why she lived that way, and that meant seeing myself from her perspective. I was not a benign presence; put simply she was scared of me. Equally, though, if I was moved by her story she feared that she had overburdened me, that she was contaminating me. I could not move any more than she could, and I had to understand that.

She knew how to comply though. She did any homework task I set her, and she redrew her map beautifully. It was really tempting to believe that she was moving, that she was understanding what I was offering. She could ‘caretake’ me as effectively as she could caretake others. Courageously though and tentatively she let me understand that this was a false position. It was still MY map, not hers, and not ours either. She did not understand what it meant. She could not relate it to her real lived life.

Borderline Patients with Psychotic Features

Presenting Problems

In this second “grouping”, we found patients presented with symptoms of fragmentation [state shifts] depression and despair. They experience periods of psychosis, which they may or may not find disturbing. They live chaotic lives experiencing impulse control difficulties, misusing alcohol and/or drugs. They seem to behave recklessly with a conscious disregard for personal safety. This often started in early childhood. Relationships are difficult, with few people in their world, and they often present with little mental health support. These patients present in an engaging way, minimising their symptoms and distress. If this is accepted at face value they will disengage immediately, so they often present having seen professionals on only one occasion and will rarely have had psychotherapy. If the therapist is able to hear the underlying desperation and pain they may engage in the therapeutic endeavour. In these early encounters the therapist will have to expose her capacity to be the good object, allowing the small hope in the patient that there is a possibility for them to be loveable.

Early Experiences - The Interpersonal World

From the earliest times in the child’s life there have been repeated abandonments where he has literally been left by his mother. Over and over again the child experienced the terror of losing the person he needed most in order to survive. In order to try and keep her he attempts to behave as he thinks she wants, he learned not to express his rage or terror for fear of driving her away. He learned to cut off all his needs, to make no demands, to say nothing, to make no protest. It becomes as if only she exists. The cost of this for the child is that he cannot develop any autonomy. He is frozen at this earliest stage of development.

The basic fear from these early experiences is that the child must be bad in order to be unable to keep the mother. This fear has to be split off. Feeling the fear would mean being in touch with the part of themselves that has needs and feelings and therefore she would be the person who does not provide these needs – the bad abandoning mother. This is intolerable. So the child keeps her good and his self without needs. When the mother is around (either literally or in fantasy) she is the good object. When she is gone she is the bad object. These two experiences are in direct conflict with each other and cannot co-exist. When the mother is around but is behaving as if she is the rejecting mother it raises intolerable feelings within the child. The only way to deal with the other displaying aspects of both the good and the bad is to split them apart again, usually through psychotic experiences of Good and Evil, God and the Devil.

The reason that they cannot integrate the mother as whole i.e. the good and the bad mother is because of their fragile sense of self – it is too embryonic. The sense of self is mainly defined by how they experience the other. This fragility of the boundary between the self and the other gives rise to the paranoid fear that others will perceive them to be bad. The terror of being with others leads to isolation and avoidance of others.

Because these patients are often without others in their world they live a lot of their life in their own heads and their infantile phantasies then have no other to challenge this belief system, no capacity to mature or to fade into natural repression. Their psychotic states seem to be just an extension of this. The real world becomes too dangerous and depression beckons. One solution is to become psychotic and therefore either give themselves over to others to care for or to stay alone locked away from the world where others are the dangerous ones and therefore must be avoided at all cost.

Symptomatic defences against these fears are commonly crushing depression (often where activity is minimal) and social phobia.

Interpersonal Implications

When they have to engage in the world their survival is dependent on the establishment of other states from which to function and interact.
States:

1. Compliant/placatory: The good girl or good boy, who becomes as the object demands.
2. The conscious adoption of the bad place; e.g. prostitution, for which a rationale can be provided (becoming as the object defined).
3. Manic. This is a defence against the crushing depression. The places where the demands and definitions of the other are thrown off. There can be the belief that others like them in this state. This state offers a sense of relief, which is mistaken for a positive feeling / sense of self where they feel enjoyed by other people and themselves. These patients have not separated from their basic objects; they are still merged with them.
4. Perfect carer/perfectly cared for. This is where they seek to do everything for others or have others do everything for them. This is also about merging. They are both the subject and object. Often these patients still have collusive relationships with the abusive/abandoning/enticing primary object (s).

Emotionality

For these patients there is virtually no display of emotion at all. What is visible is terrible anxiety, but emotion appears to be shared only through projective identification, as any display of emotionality would cause intense shame and anyway their experience tells them that it does not elicit anything from the Other.

Implications for Therapy

Recreation of the Interpersonal World

These patients often elicit a very warm caring response. However the sense of connection feels very fragile, because their core feeling is that they cannot affect the world around them and therefore that they do not exist to others. Their existence is invested in the other, but the Other is not a real object for them, merely a repository for their projections. Their experience has been that they will be rejected and abandoned, they cannot invest any hope that anyone is going to be any different. There is always the sense that, whilst they elicit a sense of care, you as a therapist mean nothing to them at all. In effect they both entice and reject.

Likely Enactments in Therapy

If the therapist is a woman then all the complications of the multiplicity of transference come into play. There is a powerful inducement to act into the rejecting, enticing, and abusive maternal roles. This is made more difficult because the patient will identify with these roles, and see themselves as rejecting, or abusive, or enticing.

Core Pain

The primary feeling is terror. The core belief seems to be about not existing, as the self has never been allowed to develop a separate life. It is ever dependent on the enticing, rejecting, abusive mother. For the infant protest was futile. They had no power. It was always invested in the mother and all they could do was to wait for her return. The state of utter terror is unsustainable for protracted periods, so the infant learned to cut off. Having cut off and buried their vulnerability it is kept at bay by chemical means or by the development of a false coping self.

Task of therapy (and snag)

The initial task is to engage these patients in therapy. Unless the therapist can be sensitive to the hopelessness that these patients experience, that others in their world will ever be any different, then they will abandon therapy, thereby depriving themselves. However, whilst the therapist is idealised, the patient cannot share the bad things they see of themselves. (‘If you are good, I am good’). Only if the patient allows himself to introject some of the hope from the therapist that he will not be rejected or abandoned can the real task of therapy begin. This is to help them separate from the primary caretaker, and to help them integrate their various self-states.

Craig

Presenting and Target Problems

Craig presented as an attractive man in his early thirties. He immediately shook my hand and with a smile, good eye contact, and very pleasantly, explained the reasons for his referral to our clinic. He belonged to a fundamentalist church and their very strict injunctions about sexuality had been impossible for him to live up to. He had attempted to find absolution through various other churches, but at this point had been unable to get it, and is left feeling intensely guilty about his sexual feelings. The other issue he flagged up was his social isolation. He wants relationships but his intense fears of others and himself and his ways of managing these fears have thus far prevented any real meaningful connection – and this has been the case for as long as he can remember.

Early History – Interpersonal World

Craig is the eldest of four brothers, all born within a four-year period. From his earliest years he was witness to the alcoholic violence his father meted out to his mother. During the first three years of his life he was often hospitalised because of chronic asthma. When he was six, his mother left the family to live with Len. Almost immediately his father put the four boys into care [a convent] with the injunction to Craig that he was now responsible for his brothers. Although Craig describes this as the happiest time of his life little attention was paid to his emotional needs and his desire to die began at nine years old after he got into terrible trouble for looking at a soft porn magazine - which he had found. He recalls no contact with his parents during this time although is fairly sure that his mother probably visited him and his brothers a couple of times during these years. However, when he was 12 years old his mother took the boys away from the convent to live with her and Len – this only lasted six months. During this time Craig was battered by Len, sexually abused by a neighbour and bullied at school. Len asked Craig’s mother to choose between her boys and him and she chose Len. The boys were back in care, this time separated. School continued to be a dreadful ordeal until he left, as he was verbally taunted and physically abused by his peers and regarded with suspicion by most of the staff. He understood that this was happening because he had been sexually abused and because he was in care. Craig experienced various foster homes but they all broke down. His father came into his life for a brief period when he was 14 years old but again this was not sustained and at this point Craig began to cut himself very badly, or to burn his skin. He was still doing this on occasion when he began therapy with me. His memories and stories of his teen years centre around having whatever gave him any pleasure being taken from him. He was extremely good at football and played for a premiership youth team, but he was fostered and this abruptly ended. He was very artistic and describes the art department as his family, but despite interventions by the art teachers he was not allowed to continue with it. All this he bore stoically.

When he left care he spent a number of years living in hostels. His youngest brother lived on the streets selling his body to men, became an alcoholic and H.I.V. positive. He eventually died when Craig was 26 years old. Craig has never come to terms with this and feels intense guilt. Between 26 and 30, Craig had a period of very disorganised behaviour. He slept with men, accepting very little in exchange for his body, feeling both that he needed to understand why his brother had done this and also perhaps as a proof of his wretchedness to his very strict and punishing God. His mother’s relationship with Len ended when Craig was in his mid twenties and he has been living with her since this time.

Implications of the Interpersonal World

The themes in Craig’s life are of abandonment; abuse and the feelings that surround these issues are misery and terror. He describes being frightened every day as a child and teenager. He also discovered very young that protest was pointless, no one was there for him – he learned then to cover up his feelings, hence today the smiling personable presentation and his difficulties telling others how he is feeling. His picture of his mother was of a loving person and he held this in his mind as if in compensation for the misery of his world. His lack of any sustained positive relationships meant that he has an active inner world, creating phantasies of demons and angels to perhaps represent his experience of the world of others. He developed a strong religious belief in God. However the God he believes in is a demanding and exacting one and Craig is never able to feel worthy enough, however hard he strives. In relationships he gives too much either of himself or his possessions and the other ultimately abuses him in some way. He seeks to find rescue from the intolerableness of this but then finds he cannot live up to the perceived demands of the rescuer, usually his God or the Church, and ends up feeling criticised and terrified – alone. He has a need to be loved – as he felt he had been for brief periods by his mother when she was in his life, but the consequence of this in his relationships is that when others are seemingly needy of him for company, money or nurture he is unable to say no – when the other is enticing he cannot resist as if the other when abusive is a different person. He seems unable to hold the memory of the other as bad, when they are enticing. He cannot ask for anything from another – even what they may owe him. His mother borrows money from him which is never returned, he cannot ask, he cannot feel when with her that she should. Receiving gifts from any other also causes intense difficulties and he has to reciprocate doublefold or give these gifts to some other who admires them or seems to need them.

Intrapersonal Implications

Craig’s world from his earliest months has been one of abandonment, abuse and emotional deprivation. This left him feeling that he is nothing, worthless, and nothing in his life has challenged these beliefs. His protests have never been registered by another; whatever has given him any satisfaction has been taken from him. In order to manage this he has attempted to cut off from his needs, emotional and physical. He feels responsible for the sexual abuse he experienced at 12 years old. The aftermath of this and years of taunting and bullying by his peers merely confirmed to him that he is the sexual pervert the nuns at his convent had defined him as. His conscious fears surround his fear that he may be – hence part of the reason for his avoidance of the outside world. Because he has not developed a stable sense of identity what is felt as himself is also the other - what is the other is also felt as himself. Thus the terrifying feeling he has been abused because he is bad, those that abuse can therefore see his badness and will hurt him – hence his paranoid fears, coupled with his fear that he will abuse. He splits this into his fear of men abusing him and his fear that he will sexually abuse women. His head is filled with demons and if only he could purge them and become as defined by his God [man], then he could find only the angels within himself and therefore the other [mother] and live in the blissful merged place he dreams of.

Core Pain and Emotionality

Craig’s primary feeling is of not existing. His sense is that if he could not keep the “good other” this must be because of not having value, his protest was never acknowledged confirming that he did not impact on any other, no one was there. He was powerless and alone. The constant abandonment engendered terror, and today fear is his constant companion. However, all that is visible to others if they look very carefully is his constant anxiety. His choices from this position are to either plunge into utter misery where the only release is suicide, or to hide his vulnerabilities, deny his needs and develop a false smiling personae or escape into alcohol which deadens his fears and anxieties. He denies ever feeling any anger or any vengeful fantasies, always feeling that he is just not good enough and if he strives hard enough to obey the injunctions of powerful others he will be relieved of his fears of his own badness and feel some existence through the power others’ approval and acknowledgement of him will bestow.

Therapy

Recreation of the Interpersonal World

When Craig first came into therapy he was extremely agreeable, polite, smiling and very open about his problems and his history. He spoke in an intelligent way with no trace of any emotionality, neither sadness, anger nor complaint about the overwhelmingly painful events he described. He however named his fear, the fear he lives with each day. He told me about the sense of evil he experienced, and about the frozenness he felt during these hallucinations – but nothing in these early presentations gave me any clue to the psychotic episodes I would later witness, although in the writing of it now I see that they should have. As his story continued he let me see how much he needed a Father, someone to contain him, hold the boundaries – be proud of him. He let me see how he had attempted to respond to the abusive others by being caring. He wanted to be a nurse in these early sessions. He told me how important it was that he get away from his mother and his difficulty with this as she “is so dependent on me”. Throughout a lot of the therapy Craig continued to tell me the stories of his life but my perception was always that we were not talking about him and that when I did try to attend to him he somehow disappeared. How when I attended to the pain he hid - he would move us away. Later he told me how he did this “smiling, Val means you cannot cry”.

My task was to hold him in therapy, and to hold all he could not express, to hear what was beneath the pleasantries, to hold him when he talked of others. I found that I could not feel anything except the goodness of Craig. I could split off and discount all that was “less desirable” in him. He had indeed enticed me into seeing him as all good the ultimate victim of others. He saw me as holding this and identified with it and for a while we danced in the idealised place. However, much as he moved me I knew that for him I did not exist as if he could leave the therapy and me without a backwards glance. If I ever did anything that he considered beyond my remit, help him with forms, write a letter for him, go with him to a C.P.A. meeting he would always give me a present, small enough so that it was not refused but as if I could not offer anything, as if he could not have anything extra, he could not be in my debt, because this made him feel less of a man and filled him with shame. At the same time he assumed that I liked what he did, so he would talk about music as if I shared his tastes, as if I were not seperate from him.

Similarities

Same diagnosis BPD with depression anxiety and social isolation.

Isolation in childhood and adulthood.

Abuse and trauma in early life.

Abandonment and/or failure to care by parents.

Desire for death early in life.

Guilt and shame.

False coping / caring state - disavowal of their own needs in an attempt to be good.

Abusive relationships in adulthood.

Issues with merger with others and no stable identity.

There are a lot of similarities and it is easy to assume therefore that the tasks of therapy will be the same too.

However there are some very significant differences ...

Differences

For Craig there was an actual good mother albeit intermittent.
For Lucy there were no good objects.

For Craig there is a search for bliss [the lost good mother] through alcohol / drugs or mania.
For Lucy there is no point searching. There is no lost good object.

For Craig that leads to splits - Good / Bad.
For Lucy that leads to uniformity - The Bad.

For Craig the inner world is peopled by demons and angels leading to psychosis.
For Lucy the inner world is full of overwhelming pain leading to the need to dissociate.

Craig entices the other to care and projects his needs into them.
Lucy repels all others only allowing others to engage with her false self.

For Craig if you engage with his false self he will abandon therapy.
For Lucy therapy is possible with the false self - meaningless but possible!

For Craig you have to start in the idealised place ...
For Lucy you have to start in the “bad” place ...

Liz Fawkes and Val Fretten

liz@acat.org.uk

Petition to NHS England - The Case for Funding Training in the NHS 2021 Alert!
ACAT's online payment system has been updated - click for more information

Full Reference

Fawkes, L. and Fretten, V., 2003. Two different presentations with Borderline Personality Disorder. Reformulation, Summer, pp.32-39.

Search the Bibliography

Type in your search terms. If you want to search for results that match ALL of your keywords you can list them with commas between them; e.g., "borderline,adolescent", which will bring back results that have BOTH keywords mentioned in the title or author data.

Related Articles

Change your Parenting for the Better - exploring CAT as a parenting intervention
Dr Alison Jenaway, 2013. Change your Parenting for the Better - exploring CAT as a parenting intervention. Reformulation, Winter, p.32,33,34,35,36.

Reformulating Futh, the ‘hero’ of the ‘The lighthouse’ by Alison Moore
Jonathon Strauss, 2013. Reformulating Futh, the ‘hero’ of the ‘The lighthouse’ by Alison Moore. Reformulation, Summer, p.26,27.

Looking at a Therapeutic Relationship In CAT
Raymond, C., 2008. Looking at a Therapeutic Relationship In CAT. Reformulation, Winter, pp.26-27.

A Study of Birth Stories and Their Relevance for CAT
Wilton, A., 1995. A Study of Birth Stories and Their Relevance for CAT. Reformulation, ACAT News Spring, p.x.

The Impact of Different Views of God in Therapy: Healing or Perpetuating the Split in the Split Egg
Melton, J., 1995. The Impact of Different Views of God in Therapy: Healing or Perpetuating the Split in the Split Egg. Reformulation, ACAT News Spring, p.x.

Other Articles in the Same Issue

ACATnews: CPD Update
Buckley, M., 2003. ACATnews: CPD Update. Reformulation, Summer, p.12.

ACATnews: East Anglia and "CAT and Later Life"
Sutton, L., 2003. ACATnews: East Anglia and "CAT and Later Life". Reformulation, Summer, p.11.

ACATnews: Scotland
Gray, M., 2003. ACATnews: Scotland. Reformulation, Summer, p.11.

Book Review: 'Language for those who have nothing. Mikhail Bakhtin and the Landscape of Psychiatry' Peter Good (2001)
Pollard, R., 2003. Book Review: 'Language for those who have nothing. Mikhail Bakhtin and the Landscape of Psychiatry' Peter Good (2001). Reformulation, Summer, pp.40-43.

Editorial
Scott Stewart, M., Nuttall, S.,, 2003. Editorial. Reformulation, Summer, p.3.

Letters to the Editors: Consciousness & The War
Dunn, M., 2003. Letters to the Editors: Consciousness & The War. Reformulation, Summer, pp.4-5.

Letters to the Editors: Mindfulness
Clark, J., 2003. Letters to the Editors: Mindfulness. Reformulation, Summer, pp.8-9.

Letters to the Editors: New, Modern, Dependable?!
Welch, L., 2003. Letters to the Editors: New, Modern, Dependable?!. Reformulation, Summer, pp.9-10.

Letters to the Editors: On the War
Dunn, S., 2003. Letters to the Editors: On the War. Reformulation, Summer, pp.5-6.

Letters to the Editors: Pausing for Breath, Personal Reflections on the War
Wilde McCormick, E., 2003. Letters to the Editors: Pausing for Breath, Personal Reflections on the War. Reformulation, Summer, pp.6-8.

Letters to the Editors: The War in Iraq
Dunn, M., 2003. Letters to the Editors: The War in Iraq. Reformulation, Summer, p.6.

Letters to the Editors: War and CAT
Benninck Bolt, F., 2003. Letters to the Editors: War and CAT. Reformulation, Summer, p.4.

Nacissism - A CAT Perspective
Tanner, C. and Webster, P., 2003. Nacissism - A CAT Perspective. Reformulation, Summer, pp.16-18.

Psychoanalytic Theories of Perversion Reformulated
Wood, H., 2003. Psychoanalytic Theories of Perversion Reformulated. Reformulation, Summer, pp.26-31.

Reciprocal Roles and the 'Unspeakable Known': Exploring CAT within Services for People with Learning Disabilities
Lloyd, J. and Williams, B., 2003. Reciprocal Roles and the 'Unspeakable Known': Exploring CAT within Services for People with Learning Disabilities. Reformulation, Summer, pp.19-25.

Two different presentations with Borderline Personality Disorder
Fawkes, L. and Fretten, V., 2003. Two different presentations with Borderline Personality Disorder. Reformulation, Summer, pp.32-39.

Working With Shame
Gilbert, P., 2003. Working With Shame. Reformulation, Summer, pp.13-15.