Borderline Traits and Dissociated States in Later Life

Hepple, J., 2001. Borderline Traits and Dissociated States in Later Life. Reformulation, ACAT News Autumn, p.x.

Introduction: CAT has developed a reputation for being an effective and flexible therapy when working with individuals with more disturbed or, as defined in DSM, ‘borderline’ traits. Anthony Ryle (1997) [

Cognitive Analytic Therapy of Borderline Personality Disorder: The Model and the Method

] has applied CAT principles to conceptualise borderline traits as the result of destructive procedures linking dissociated multiple self-states, with abusive, idealising and cut-off reciprocal roles as the core object relations. The model provides a communicable and containing framework both for individual work and to help care givers understand the basis of the powerful transference and counter-transference dynamics they encounter when working with individuals with borderline traits.

Borderline traits and age: There has long been an assumption that borderline traits are most commonly encountered in younger adults and that the worst of the storm has blown over by mid-life, or that the person has died as a result of suicide or indirectly as a result of self-damaging or reckless behaviour, before reaching later life. The existence of these damaging traits has thus been largely ignored in older people, and much borderline psychopathology has been lumped in with the ubiquitous diagnosis of ‘confusion’ or ignored altogether (Kroessler 1990). The reasons for this are likely to be linked with ageist preconceptions in psychiatry and psychotherapy and the unacceptability of disturbed behaviour in older people. All this is to the detriment of both those trapped in the re-enactment of their traumatic and abusive experiences and those trying to help them. Many who have worked with older people will recall cases where early life trauma is vivid and terrible many decades after the event.

The unmasking theory: The concept of personality disorder has been avoided in this paper as being unsuitable to describe accurately the presence of borderline traits in later life. While undoubtedly some individuals do maintain the same borderline traits consistently throughout life and into older age, many appear to go through a quiet period in the middle years where, perhaps contained by an intimate relationship or the diversion of family responsibilities, they appear to have resolved some of the core pain. Faced with often cumulative losses in later life, however, the damaging traits can re-emerge, often with a different range of symptoms and behaviours (Reich et al 1987, Rosowsky and Gurian 1991 & 1992).

The nature of borderline traits in older people: While the more affect based features of the DSM IV list of borderline traits remain consistent features in later life (‘affective instability, chronic feelings of emptiness, inappropriate intense anger and transient stress related paranoid ideas’), other traits manifest in different ways. ‘Frantic attempts to avoid real or imagined abandonment’ are likely to increase due to increased dependency, resulting in prominent sick role behaviour, somatisation and passive dependent behaviour. Unstable, intense interpersonal relationships’ are a marked feature with attempts at idealisation and devaluation of care givers and the development of powerful ‘splits’ in the care system.

‘Identity disturbance’ manifests as an inability to engage in age-appropriate psychological work with a denial of the future and the development of persistent cut off states, notably the syndromes of self –neglect (sometimes called Diogenes syndrome), and hysterical pseudo-dementia. Impulsivity’ may be less immediate and obvious in older people but ‘self-damaging and self-mutilating behaviours’ are still common and can emerge through abuse of prescribed medications, hypochondriasis and factitious illness.

Practical application of CAT in working with borderline traits in later life:

1) Individual CAT: CAT offers an excellent frame-work for working with borderline traits in older people. As a model for individual therapy it has been applied by several practitioners in the UK with notable success. Early abusive experience is found to be vivid and painful eighty years or more after the actual trauma, with the added grief accumulated by a lifetime of repetition-compulsion of the same self-defeating procedures. Older age can offer perspective, wisdom and a desire to finally understand the causes of persistent distress, resulting in excellent engagement in the CAT therapy, as well as providing energy and commitment to the therapeutic work. Older individuals will often see the CAT therapy as a ‘final chance’ to resolve core pain and find the energy needed to carry out the therapeutic work.

2) Systemic CAT: Many of the older people who might gain benefit from CAT are already beyond the reach of individual therapy due to their retreat into cut off and uncommunicative states such as severe somatisation (only being able to communicate via a physical symptom,), self-neglect or apparent dementia. CAT used in a case conference setting can provide a clear and communicable framework for describing the distress in both the older person themselves and the effect this has on the larger system of care givers. The SDR in particular can be an invaluable tool in this setting and can both describe and contain strong emotional responses as well as acting as the basis for the formulation of ‘system exits’. A template SDR for understanding borderline traits in later life is
given in Fig 2.

Case History: Mrs X is a woman in her mid seventies who has consistently displayed borderline traits and dissociated self-states throughout her life. Due to the intensity of the somatisation of all her distress into a single symptom (‘the pain’) and refusal to consider any psychological model, attempts at individual work have failed and information on Mrs X’s life and childhood is patchy.

What is known is that she is the youngest of six siblings and step-siblings and had polio as a child. Her father died in the first World War and her step father, who was a war casualty and was unable to work in civilian life, described Mrs X as keeping him poor due to her need for repeated hospital treatment in pre-NHS Britain. She married aged twenty years to an older man with chronic respiratory problems and whom she nursed essentially until his death 47 years later. They had two daughters.

Mrs X has a long psychiatric history with diagnoses of anxiety, depression, hypo-chondriacal neurosis and opiate dependency. She has been treated with a wide range of psychotropic agents and ECT to little effect. She has taken several overdoses, most recently in 1998. The most consistent feature of her presentation is chronic and intense abdominal pain which, contrary to many specialist opinions over the years, Mrs X believes to be due to undiagnosed Bechet’s disease (an ulcerative condition affecting the gastrointestinal tract). Mrs X has devoted herself to finding the doctor with the ‘cure’ for her pain and has involved and enormous system of practitioners and providers in both the NHS, private and voluntary sectors. Failure to cure the distress results in the angry rejection of help and the setting out again on a new mission to be understood.

From what has been discovered about Mrs X’s past as well as the present tense experience of care givers and Mrs X’s family to the abusive and idealising dynamics, an understanding of the main procedures has been formulated into a simple SDR. (Fig 3). With the careful maintenance of boundaries and unanimity of purpose, system exits have been formulated over the courser of a series of case conferences. The effect has been a dramatic reduction in feelings of helplessness and anger in the care givers as well as some reduction in Mrs X’s own distress and a limitation of the damage caused by deliberate self-harm and abuse of prescribed medications.

Conclusion: It is clear that CAT has much to offer our understanding of older people exhibiting borderline traits and can facilitate containment and reduction in distress in the both the older individuals and those involved in the wider system around them.

Jason Hepple

Jason Hepple and Laura Sutton have written a new CAT text on working with older people entitled

Cognitive Analytic Therapy and Later Life: A New Perspective on Old Age

you can order your copy from Amazon.co.uk via ACATonline.

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Full Reference

Hepple, J., 2001. Borderline Traits and Dissociated States in Later Life. Reformulation, ACAT News Autumn, p.x.

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Differences Between Borderline and Narcissistic Personality Disorders
Ryle, A., 2002. Differences Between Borderline and Narcissistic Personality Disorders. Reformulation, Autumn, pp.16-17.

Developing a Language for the Psychotherapy of Later Life
Hepple, J., 2003. Developing a Language for the Psychotherapy of Later Life. Reformulation, Autumn, pp.10-12.

Book Review: Cognitive Analytic Therapy and Later Life by Sutton and Hepple
Ardern, M., 2004. Book Review: Cognitive Analytic Therapy and Later Life by Sutton and Hepple. Reformulation, Summer, pp.28-29.

Developing a CAT understanding of Anti-Social Personality Disorder (ASPD)
Kerry Manson, Sunil Lad and Marisol Cavieres, 2017. Developing a CAT understanding of Anti-Social Personality Disorder (ASPD). Reformulation, Summer, pp.42-48.

The CAT Articles Review
Knight, A., 2008. The CAT Articles Review. Reformulation, Winter, p.30.

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