December 1997

The following is a modified version of a presentation that I made at a Treatment Center for Borderline Personality Disorders in Trollagen, Sweden.

Psychotherapy, with these conditions, in my estimation is a state of war, at least in the beginning of treatment, because these conditions come to represent more than an illness with symptoms and characteristics. Psychotherapists find it difficult to deal with and understand these problems because therapists have focused on some of the wrong issues. By that I mean, we have been so caught up with dynamics and theories that we do not understand well enough what the intent of the patient is, in reference to guarding his/her condition, which has, in fact become a way of life. Regarding counter-transference issues. Sandor Ferenczi and Otto Rank talked in terms of theory counter-transference which they believed exerted a negative in treatment. I agree and regard it as a interrupting influence on psychotherapy, which also restricts the growth and creativity of the psychotherapist in arriving at therapeutic conclusions that are not dictated by their theoretical formulations. It is critical that we understand the tactics and strategies that these patients use, which are intended to maneuver us out of the picture. We need to deal with these patients in a way which helps them form a therapeutic alliance with us, otherwise there isn’t any treatment. What I look for, in the initial phase of treatment, at least, are what methods are used by the patient to perpetuate his/her condition. I am not so much interested in the characteristics and the symptoms, which I consider to be active defenses, with long term patients but rather, in the deliberate and conscious efforts of the patient and his/her methods in resisting treatment and change. In the psychotherapy of these conditions, insight is hardly enough in my estimation. All the insight in the world doesn’t necessarily lead to corrective behavioral changes. What good is psychotherapy, if it does not lead to corrective behavioral changes? One of the problems that the therapist who is active in the treatment of schizophrenics and borderline personality disorder faces, is the apathy in the field and the indifference that surrounds him/her, which constitutes a major defense for the patient. I think it is essential that when we look at the treatment process, we do not overlook any of the treatment personnel who are an essential part of the treatment package. That includes the primary psychotherapist and the support system. The support system is critical to any successful outcome. If for some reason they are not included, or they do not properly involve themselves, the treatment will not succeed. The importance of the milieu therapists in treatment cannot be overstated. The failure of the milieu therapeutic staff to act in collaboration with the psychotherapist can be a nightmare. Another important consideration is the frustration on the part of the psychotherapist in reference to reaching the schizophrenic and the borderline disorder. The frustration that grows as a function of the patients conscious resistance to change and the anger in the therapist that is a result of the frustration that he/she feels. Anger is not necessarily countertransference. Anger can be a natural reaction to people who are trying to thwart your best efforts. On the other hand when you begin to effect changes in the patient or threaten their homeostasis, they feel anger with you. Anger that is not harnessed and channeled, is destructive. Anger can be a great creative factor in the treatment process providing it is dealt with and channeled productively.

Let me tell you what therapists do and what they say they do. An excellent case in point is a brief description of a case that was treated by Dr. John N. Rosen, with whom I took my initial training. Martin Grotjahan, a very gifted psychoanalyst, a prolific writer interested in many facets of treatment, described Rosen’s working with an adolescent schizophrenic female in his farm house in Bucks County Pennsylvania; this young girl, had a delusional system wherein she thought there were communists on the second floor. Rosen attempted some reality testing, according to Grotjahan and this failed. Rosen then said, "there aren’t any communists on the second floor," she said "there are," Rosen said, "there are not," she again said, "there are," Rosen said, "I’ll take you upstairs and if there aren’t any communists on the second floor, I’ll throw you down the stairs" and she said "there aren’t". Rosen made an effort to describe his techniques of treatment and his theories as an extension of the Freudian method. What he did with this girl, was to shock her into some contact with reality and I believe that this was an effective treatment strategy, however, in no way does what Rosen did, represent an extension of the Freudian method.

Another defense mechanism on the part of the therapist is I believe, the dogma surrounding a particular set of theories and techniques. The doubting of a patient can be a defense mechanism, i.e., the denial on the part of the therapist that the patient has any hope for some in depth change or recovery. The attitude we see in the professional world that is so common is the attitude that is stimulated by the biological theorists and others who do not hold out any hope. These people influence the professional world to the extent that their hopeless and negative feelings become a self fulfilling prophecy. As I said previously, to better understand the schizophrenic syndrome and the borderline disorder, we need to understand something beyond the overt symptoms. We need to have some conception of the logic that develops as a function of the terror that these individuals feel. Perhaps as I discuss the problems related to these conditions, there might be some way of understanding that the greatest defense that these people have are the resistances of the professional world in reference to treating them.

What is schizophrenia? In my opinion, schizophrenia in the beginning phase is a defense against terror. It begins with an enormous amount of anxiety which creates an identity crisis and the terror syndrome effects a sense of disintegration. People cannot survive without an identity and then as the schizophrenic reaction proceeds, it gradually replaces that lost identity and the reaction becomes to a greater or lesser extent a solution to the terror syndrome. The symptoms and characteristics of that condition develop as the enormous fear is processed and then that condition becomes a survival mechanism, a life style and an adaptive process in the so called "chronic" state. The logic of schizophrenia is a primitive logic. It serves to help these individuals understand what they have to face in life and how to deal with some of the forces they feel threaten their existence.

Historically, the term or phrase borderline has been invoked when clinicians noted that a previously neat two category universe, neurosis and psychosis contained some "messy" cases that were not precisely one thing or precisely the other. The term borderline, therefore, is used to bridge a non-contiguous area of meaning into a continuum. So actually category is converted into dimension. Often the borderline condition is perceived as a vast wasteland between the neurotic and the psychotic. This vast wasteland which lies between the neurotic and the psychotic is a condition that is neither schizophrenic nor neurotic. A condition that is neither schizophrenic or manic may be seen as borderline and that level that is not in keeping with the functioning neurotic nor with the incapacitates of a psychotic can be considered borderline.

The psychoanalysts began to see the borderline as one who did not fit the criteria for analysis and/or was not reachable by analytic techniques. However, the contemporary usage rises from the psychoanalytic papers of the 1930’s. Wilhelm Reich’s Character Analysis, gives a broader dimension, to the understanding of the psychosis and the neurosis and how the character structure assists these individuals in holding onto these maladaptive conditions. Before the term borderline became widely used, one could see the germ of such a notion in Eugene Bleuler’s correction of Kraeplin’s pessimism about dementia praecox and Freud’s de-emphasis of an organic etiology for which he preferred to call the narcissistic neurosis. Eugene Bleuler made it clear that not all cases labeled dementia praecox deteriorated as Kraeplin initially believed, and thus he introduced more optimism. Unfortunately today, in reference to schizophrenia, there is much more influence in the DSM codes by Kraeplin, Schneider and Langfeldt than with Bleuler and it is my understanding that schizophrenia retains a Kraeplin notion of the deteriorating disease entity. In my opinion, schizophrenics regress when in that state of terror to the point and only to that point where the patient feels the safest and then begins to organize around that area of safety a system of defenses to keep him or her safe from intrusions that they perceive as a threat to their lives.

One of the early contributors in this country was a very optimistic man. His name was Adolph Meyers and the optimism of Adolph Meyers and others, primarily Harry Stack Sullivan, in 1922 effected the traditional gloom in the field and more vigorous efforts, therapeutic efforts, were expressed by a growing number of psychotherapists with patients who showed more severe psychopathology. These men, both Sullivan and Meyers were the first men, or the first therapists in this country who introduced psychotherapy with schizophrenia as a treatment of choice rather than relying primarily on the physical methods of treatment. Just to briefly run down what the physical methods of treatment were in the 1930’s: the use of metrazol, wet packs and insulin coma therapy were used almost universally with the schizophrenic. In 1936, a Portuguese Psychiatrist by the name of Monis invented the prefrontal lobotomy and in the l930’s until the 1950’s some 50,000 Americans diagnosed as being schizophrenic received the prefrontal lobotomy and he received a Nobel Prize. In 1938 electro shock therapy was introduced and was used extensively with the psychotic patient population. To continue with the description of the physical methods of treatment in the 1950’s the neuroleptic drugs were introduced and they were heralded as miracle cures. It was said at that time, that the mental hospitals would be cleared of schizophrenics by the 1970’s. But we know that has not happened and we understand that even though it does offer some help to these very very sick people, that this is not a panacea. It is important to evaluate to what extent the medications acts as a therapeutic agent. It is common knowledge that medication has been used exclusive of other treatment modalities and has been not only over utilized but has been prescribed in a reckless and dangerous manner and has handicapped the growth of other treatment efforts especially psychotherapy. I mentioned the importance of the milieu therapeutic staff in the overall treatment of these patients. Psychotherapy has been studied by such distinguished professionals as Thomas McGlashan and John Gunderson who concluded that individual psychotherapy especially psychodynamic treatment has been unsuccessful with this population. I do not believe that their studies consider the importance and the effect of the milieu therapy staff in the psychotherapy with these conditions. I believe that psychotherapy in the hands of those professionals who know how to use it, is a premier treatment tool combined with the other modalities and it gives patients the best opportunity for recovery. But more about this later on.

The first to give the term borderline formal status was a psychiatrist by the name of Stern who in 1938 outlined the characteristics of a group of office patients as being to quote him, "too ill for classical analysis". He was another person who could not see the patients as being neurotic and/or psychotic, but had to make a different category because these patients were not candidates for classical analysis. Some of the characteristics he stated were narcissism, hypersensitivity and negative therapeutic reactions, which meant that the patients reacted to interpretations as if they were unloved or not important enough or not worthwhile considering. However, I can see in his findings that the patients viewed the analytic interpretations as a method of prying them, the patient, loose from the therapist and of the secondary gains in this symbiotic attachment with the therapist. There are some who hold there is such a condition as borderline schizophrenia. Seymour Kety and his colleagues referred to this category as those patients who exhibit symptoms and characteristics of lesser intensity. In my opinion, this is another expression of schizophrenia, not anything to do with the borderline condition, because schizophrenia is not only expressed in an obvious state of regression with positive and negative symptoms but there are also many subtle levels of the schizophrenic syndrome.

Borderline cases defy traditional categories. We are often at a loss of how to diagnosis them within the framework of our standard nomenclature. The borderline condition is not the classical neurotic patient described by Freud and his followers, nor does it fit the classification of schizophrenia as described by the DSM codes that are usually used for diagnosis. However, it is very disturbing to me that the DSM codes, have become almost a bible to the mental health professionals in this country and other parts of the world. The DSM codes are especially designed to meet the needs of the third party payers and do not adequately describe any of the mental illnesses.

What Otto Kernberg diagnosis as borderline is considered a character neurosis by Giavonchini. I find something interesting in that: if the character neurosis resembles a character disorder, which I believe that it really does, we may have something that is common in all emotional disorders. I see the character disorder as an acquired defensive system to protect the basic condition which has become a lifestyle or survival system for the schizophrenic and the borderline personality disorder. Masterson places the fixation point for borderline patients at the separation individuation point, which I consider to be of paramount importance. According to Margaret Mahlers ideas about symbiosis in the normal, symbiosis leads to separation and individuation in the early part of the infants life. However, in the borderline condition, the fear of loss or of detachment creates an intolerable anxiety which inhibits or prevents individuation. Compare this to the schizophrenic. They may see attachments as life menacing and they almost all have a fear of annihilation, which increases or decreases with the exacerbating influences. The differences, in my opinion are, the fear, or the anxiety of the loss and/or the detachment in the borderline and the fear of annihilation involved with the schizophrenic, who sees attachment very often as life menacing.

Some of the characteristics of the borderline condition are compared with the schizophrenic reaction. There is an awareness of social convention with the borderline, even if they are in defiance of them. They lead socially active lives outside of their families and feel that they get along, even if they do not get along. They do not work effectively. Schizophrenics are less likely to have an active social life involving groups of people and are more unsuccessful socio-economically than the borderline personality. The borderline personality looks socially more like the neurotic, but they behave vocationally more like the schizophrenic. Borderline patients act out in a variety of ways: self destructive acts, destructive acts towards others, anti-social behavior, such as drug and alcohol abuse. They frequently overdose, threaten suicide, mutilate themselves and make manipulative suicidal attempts. According to the literature, this seems to be more with the borderline personality, than with the schizophrenic or the neurotic population. However, we need to be aware that the rate of suicide with the schizophrenic is greater than the "normal population". Affect in the borderline personality includes depression, anxiety, terror. This is also true of the schizophrenic reaction. These patients report frequently that life is not worth living. Many relate depression to chronic feelings of loneliness or emptiness. Anger, is expressed by irritability or sarcasm or hysterical, delusional like accusations. Benedetti, the Swiss Psychiatrist, whose borderline concept is widely respected lists three main clinical characteristics: hypochondriasis, ideas of reference and depersonalization.

I would like to point out again that the major differences is the detachment fear of the borderline and its major anxiety the fear of object loss and with the schizophrenic, the fear of attachment and the terror of annihilation.

Reality testing comes and goes with the borderline. There are sharp contradictions in attitude that interfere with everyday life with the borderline personality. What is here this hour, is in conflict with the next. What is committed at this moment, is in contrast with the next moment. It seems confusing, however, it is understandable if you comprehend the logic of the borderline personality in view of the tremendous anxiety, once again, related to individuation, which is perceived by the borderline personality as a loss of object relations. In my estimation, the loss of object relations by the borderline personality is comparable to the identity crisis and the loss of identity suffered by the schizophrenic during the onset of the acute reaction and the terror syndrome. There are other important indicators of the borderline, which is also true in many cases with the schizophrenic. Let me recite some of them. The borderline has low anxiety tolerance and has a higher vulnerability to stress than the neurotic. This is also true of the schizophrenic. The borderline often has a poor record in school and work as does the schizophrenic. Obsessive compulsive symptoms could be true of both conditions. Hypochondriacal behavior can often be confused with schizophrenic delusions. However, when one carefully evaluates what is going on with the borderline, one finds that these hypocondriacal fears are not as persistent with the borderline as it is with the schizophrenic, who has delusions and hallucinations in reference to all kinds of terminal illnesses. Hysteria, in the borderline induces paranoid ideation and creates a language like the schizophrenic, but only temporarily. What I mean by a language like the schizophrenic uses, is that hysteria will bring all kinds of accusations and paranoid like thoughts about people around the person who suffers the condition. Poor impulse control is another feature of the borderline condition and it is also common with the schizophrenic. In therapy, this is expressed by projection which puts the blame on the therapist for all the wrong doings and harmful happenings during the course of the patients life in the past and in the present time. This projection has to do with the basic figures in the life of the patient. This should not be confused with the delusional transference that happens with schizophrenia. This puts the current therapist in the position of responsibility for the feelings of the patient that his/her life is threatened or he/she faces annihilation or that the therapist is responsible for everything that everything that happened during the course of the patients life, which is negative. The delusional transference bears serious consideration because the therapist who does not understand this difference, could end up with a suicidal or homicidal patient.

In treatment with a borderline personality, some therapists express concern that a confrontation approach is a counter productive technique. They say this because they fear that any exacerbating stimuli may break down the defenses of these individuals. There are many possible therapies given the condition of the patient and changes in approaches in therapy as the patient changes. One of the problems with the borderline is that they are often described, or understood, as being more or less alike. Isn’t that also true so very often with the schizophrenic who sadly, like the borderline personality, has in most cases been treated by nothing more than the neuroleptic medications? Borderline conditions are difficult to treat. Some people believe that the borderline is difficult to treat because they are so much like us wherein the psychotic can be seen as decidedly different. With the borderline, we can identify with their healthy parts and when they become irrational, we may fear we may go mad also. Without any doubt this is true with the schizophrenic as well, who has periods of clarity and healthy parts that we may identify with and we may be threatened by their irrationalities and fear that we are going to go mad. I think that this is one of the reasons that they go untreated, or why the treatment is so very poor. Some of the treatment approaches are as follows and we should not forget that successful treatment is very much dependent on the relationship and the therapeutic alliance that is the context where all successful treatment takes place.

One approach to treatment has to do with the interpretation of the hear and now rather than the classical type of interpretation of content analysis. It is very important to understand when we hear content from the patient, whether the content is designed to confuse us rather than to help us understand the underlying factors. It is clear, that because of their fear of change and/or loss that these patients do everything they can to perpetuate their condition. Another treatment approach is an intrusive approach, i.e., putting pressure on the patients inner resources, activating the potential for reality testing which makes the patient more accessible to effective psychotherapy. Certainly the same is true for the schizophrenic syndrome, however, with the schizophrenic, we make efforts to overcome their resistances in order for them to understand that what they see is a reality distortion. Medication in moderation maybe useful, if it is used with psychotherapy. Without psychotherapy it simply does no more than mask or modify symptoms.

I have found that with patients who begin to respond to psychotherapy, that medication becomes more effective. It is said that medication makes the patients more accessible to psychotherapy, but I am inclined to think that effective psychotherapy makes medication more effective. A hospital can be useful, but also very dangerous, if not used for a short period with the borderline because hospitalization becomes an omnipotent shrine or refuge for the patient which permits the patient to wallow in their own symptoms and therefore, hospitals become iatrogenic, in fact, they make the patient worse. It is not the best possible place for treatment, however, in view of what we have, as far as other treatment centers are concerned, there seems to be few alternatives for any patient who is experiencing an acute reaction. Other psychotherapeutic directions: crisis intervention is extremely important and the focus should be on the involvement of the therapist with the patient rather than relying primarily on the physical methods of treatment, such as medication or restraint. I think that we do not understand well enough that changes comes as a function of pain and suffering. Sometimes we make an urgent effort to overcome the pain without involving ourselves as intimately as we should and in that sense, I think that we do not give people a choice and an understanding that they are not alone in the world and rob them of their dignity. There is no medication that can replace the empathy that comes from another human being, nor is there any of the physical methods that will persuade another human being that there is hope for them, that they can be understood and the quality of their lives can be improved. The feeling of victory or achievement for the patient comes as a result of overcoming some of the conflicts that create the pain they experience. Then, they the patients, have chosen the road that they wish to travel and walk down that road with a sense of dignity and self respect. We do that with them because we care.

Other psychotherapeutic ways include supportive therapy, which at times, is a useful technique, however, unfortunately like so many other factors that are considered to be therapeutic, it is over-utilized by therapists because they cannot be consistent in terms of dealing with the patient in an involved manner. Reality therapy is effective at times. Short term problem uncovering therapy is important and also it has its dangers. Uncovering therapy may lead to a loosening of associations and can exacerbate the condition of both the borderline disorder and the schizophrenic. Intensive therapy aimed at character defenses is a very important effort that needs to be made by the therapist in order to overcome the character defenses, if that individual is to individuate and lead an independent adult life. I consider the character disorder to the be the back bone of schizophrenia and certainly perpetuates the condition called borderline disorder.

The needs and the demands of the borderline and the schizophrenic place an enormous burden on the therapist which can give rise to counter-transference reactions that make the therapist act inappropriately and counter productively and destructively. One sees, very often, where the therapist may enter into a therapeutic conspiracy with the person who has these diagnoses in order to avoid the contact that they need to make in order to make corrective behavioral changes. There are many developments that can result as a function of the above. One is the worsening of the patients condition, the perpetuation of the condition of the patient and getting rid of the patient because you cannot stand the pressures that are on you as therapists.

The therapist involvement in the borderline personality and also with the schizophrenic must be very strong and strength is expressed in a number of different ways. The therapist must feel free enough under certain conditions to impose limits and structure. The therapist must have enough strength to control impulses and acting out and when the therapist helps the patient gain controls over his impulses and his acting out behavior, there can be a gradual reduction of the imposed limits. In my opinion, regarding schizophrenia and the borderline condition, there are differences, which should direct the therapist to respond with greater sensitivity. These are very, very sick human beings, who require not only dedicated and involved therapists, but therapists who are spontaneous, intuitive and also not too loose or too careful. Change comes about as a function of the skilled therapist who when the therapeutic alliance is achieved, is willing to exercise tactics needed to overcome the defensive characteristics of the borderline condition and the schizophrenic syndrome and reinforce the healthy areas that all human beings have somewhere in their lives no matter how sick they are.

In the next edition of the Newsletter:

As Clinical Director Emeritus of the Anne Sippi Clinic, I intend to discuss the workings of the Anne Sippi Clinic, an alternative residential treatment program.

Until we meet again.

Jack Rosberg