Borderline Personality Disorder A Critique

We now examine Borderline Personality Disorder as an example of a personality disorder diagnosis that, it could be argued, fails in the intended goals of any diagnosis to clarify etiology, indicate treatment interventions, and determine prognosis. This diagnosis in particular may also have iatrogenic effects on many patients. For instance, one patient commented that other treaters had called her "a borderline," and she added that she knew that wasn't "good." In fact, she felt they were maligning her and taking an adversarial position with her of distance and guard-edness; she felt that under such conditions, she actually was triggered more easily into traumatic disconnections and "acting crazy." In short, she felt unsafe. Applying a pathology-based label such as borderline does not contribute to the creation of a healing connection in therapy with people who have been severely harmed in violating interpersonal relationships. The emphasis conveyed by this label on the disturbance, as located in the personality of the patient, avoids a confrontation with the larger societal factors that make physical and sexual abuse of children almost normative. Some have noted that as many as 25% of all females suffer some form of sexual abuse before they reach the age of 18 (Russell, 1986). Locating the problem within the individual or even within the pathology of the nuclear family often leaves the larger societal conditions that directly produce the problems unexamined and untouched (Root, 1992).

A diagnosis is meant to be a descriptive device to capture symptom clusters, to provide a core understanding of etiology, and to suggest some useful prescriptions for treatment as well as offer some prognostic guidelines. Serious questions can be raised about how well personality disorders meet these criteria. But with personality diagnoses, the diagnosis also often sets a tone for treatment. For instance, when meeting with a patient with the borderline diagnosis, therapists often assume a distanced, judging, and adversarial stance. Their empathic attitude may actually decrease. Clinicians treating "borderline" patients tend to take a "doctor knows best" stance, expecting the client to be manipulative, angry, and characterized by rapid mood shifts and unstable interpersonal relationships. Most therapists also expect this will be a "challenging" treatment with someone who will "take up a lot of space and energy." An attitude of respect, curiosity, and working toward connection is easily lost with such a set of expectations on the part of the therapist. The frustration and anger of the therapist is most evident in case descriptions of "flaming borderlines" or "black holes." Some have even suggested that the borderline diagnosis is more a statement of the clinician's feelings of anger and frustration toward the patient than of etiology, treatment recommendations, or prognoses. Others have indicated that the borderline diagnosis may be synonymous with "the difficult patient" (Kernberg, Selzer, Koenigsberg, Carr, & Appelbaum, 1989).

Kernberg's (1975) understanding of etiology of the borderline personality disorder described an excess of instinctual aggression or faulty regulation on the part of the mother, particularly maternal failures in the rapprochement stage. There was no acknowledgment of the role of childhood abuse. Kernberg's hypotheses represented the prevailing wisdom about borderline diagnoses until the late 1980s (Kernberg et al., 1989; Stone, 1980). Despite new information, particularly about the role of abuse and relational violation in the lives of those diagnosed with borderline personality, the theory and clinical protocols built on this erroneous understanding of etiology have not been sufficiently altered to reflect this new evidence.

The prevalence of sexual abuse in the etiology of patients diagnosed as borderline has become well established in the past decade (Herman & van der Kolk, 1987). In those diagnosed as borderline, as many as 55% to 80% have been found to have a history of childhood sexual and/or physical abuse. An appreciation of the role of trauma in the development of people diagnosed with borderline personality organization renders a very different picture of their dynamics. Rather than focusing on maladaptive internal traits, resulting from failures of the mother in rapprochement and leading to failed separation and individuation, we begin to appreciate the impact and centrality of relationship and disconnection on the individual's ability to function in many life arenas. Thus, we see that the chronic stress and violation that is created by physical and sexual abuse of a small child leads to the most dramatic and cruel disconnections from others. There is obvious isolation, shame, immobilization, and affective instability (Herman, 1992). Furthermore, we begin to understand that some of these symptoms are normal reactions to an abnormal level of threat; they are physiologically determined, sometimes part of strategic adaptation to aversive conditions that threaten the lives of the victims. These adaptations involve an extreme survival effort (van der Kolk, McFarlane, & Weisaeth, 1996). Many of these strategies of disconnection and responses are etched in the biochemistry of the abuse survivor and lead to symptoms and behaviors that interfere with healing through connection, which survivors so desperately want and need. For instance, these strategies can involve a complete closing down emotionally at the first hint of interpersonal disappointment; the withdrawal can leave the person with an immediate sense of safety, but the larger movement toward the deeper safety of connection is compromised by these strategies. The paradox of longing for authentic, healing connection at the same time that the individual is terrified of the vulnerability necessary to move into real connection is dramatically played out in the lives of trauma survivors. There are traumatic disconnections in therapy and elsewhere, which are sudden, bewildering, and isolating for the PTSD survivor and the therapist. Ironically for the trauma survivor, connection does not equal safety. Each step toward trust and toward relinquishing protective strategies of disconnection reawakens the early fear of being injured and violated. Just as empathic failures stimulate anxiety and abrupt movement out of connection, so does the gradual movement toward more connection stimulate terror and closing down. In working through the patterns of disconnection, both survivor and therapist experience a series of whiplash shifts in direction. Relational stability is lacking. But safety ultimately for these most injured individuals arises in beginning to establish closer, mutual relationships, not in retreating into "power over" relationships, where they either seek protection from a powerful other or exercise some coercive control over the other person. The control battles emanating from either person's efforts to get the upper hand or exercise power do not lead to safety. Being in a relationship with a powerful and needed other usually initially triggers panic for the PTSD survivor. Connection in which the clinician or therapist is responsive, real, engaged, and working toward mutual empathy and respect offers the path out of fear and chronic disconnection. The "cure" arises in relational resilience, reestablishing the capacity for mutuality, finding "empathic possibility" (Jordan, 1989, 1999).

Relational images and expectations guide the movement of relationship for all of us (e.g., "If I am vulnerable, I will be injured or abandoned" versus "If I am vulnerable, I will be welcomed and respected"). These images are not static traits or internal characteristics but are constantly being affected by context and current relationships. We create each other and ourselves in relationship in an ongoing way. Where there have been early, chronic violations of trust and safety, the negative and fear-filled expectations for relationships often become rigid and overgeneralized. Developing some capacity to move back into connection following disconnection and getting clear about which relationships are safe and which are not are central to growth. For the PTSD patient and others violated in early relationships, we must first establish the possibility of empathic responsiveness and safe connection. This involves reworking relational patterns and establishing mutual respect and empathy (Jordan, 2000).

Therapy is about movement toward mutual connection, not about control and power. This is not to deny that, at times of danger, therapists move in to protect and support the healthy functioning of patients. But the larger work of therapy is not directed toward getting someone "under control" or exercising control over others to get them to "shape up" to some ideal we hold, however subtle or blatant that may be. When therapists move into a position of trying to establish control, we often move out of connection and into a place of power over others. Although chronic disconnection is almost always problematic, it creates special problems when working with patients who have PTSD. The language of limit setting and control is often evoked in treating the so-called borderline patient: "They need authority, firmness, to know they cannot run things"; "If you give an inch, they'll take a mile"; "They will always test you, so set limits clearly." What is seen as a control battle, infringing on the therapist's need to be in charge, does often involve a kind of testing, but it might better be described as "trying to find the real person" in the therapist and trying to find out what real responses are evoked in the other person (Jordan, 1995).

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