We tend to hold people accountable for their behavior when they have not aroused our sympathy, and we tend to excuse unwanted behavior when they have. We excuse behavior by seeing it as a function of the immediate situation, the person’s learning history, the person’s culture, and, especially lately, the biology of the brain.
It’s hard to find a place from which to discuss a contentious topic like borderline personality disorder without running afoul of this human tendency. If you suggest there is something the person can do about their behavior, you seem to be suggesting that the behavior is morally blameworthy and that the person does not deserve our sympathy.
If you feel sympathetic to the person, you seem to be suggesting that there is nothing they can do about their behavior. Not having a way to talk about this dilemma recapitulates it, since it leads to people either accepting borderline behavior whole hog or avoiding people with borderline features. These reactions strengthen the individual’s sense that others will either totally accept them or abandon them.
Every parent understands this dilemma. Parents generally know the difference between crying to get one’s way and crying from distress, between exploring the shelves of a store out of orneriness and doing so out of curiosity. Parents are good at this because they are generally sympathetic to their children but also to themselves and to store-owners, and because they have a great deal of knowledge about the child. Parents who are too sympathetic to their children tend not to guide them; parents who are too sympathetic to themselves or the store-owners tend not to empathize with their children.
If we knew as much about people with borderline personality disorder as parents know about their own children, we would undoubtedly be better at distinguishing when to sympathize with them and when to sympathize with the people they annoy, including ourselves. (Yes, they annoy others; that is the essence of what brings people with psychological problems to clinical attention—that, or not getting as much out of life as it has to offer.)
The fundamental attribution error describes a tendency to attribute one’s own behavior to situations and the behavior of others to character. The guy who cuts you off in traffic is a narcissist, but if you cut someone off, it’s because you really need to get into the other lane because of a complex array of responsibilities and obligations. Nowadays, the error is more noticeable between character and biology. I misbehave because of serotonin and dopamine; other people misbehave because they’re jerks. We excuse behavior by citing the brain, and we tend to do so when the individual invites our sympathy.
People with borderline personality disorder are too angry to knit together a cohesive narrative of the self. It would be like trying to have a civilized and considerate dinner conversation when one of the guests is hopping mad. Often, what made the person so angry was abuse or neglect early in life. Often, what made the person so angry was a biological disposition toward strong emotions. Very often, what made the person so angry was feeling abandoned, either left to cope with abuse or neglect or strong emotions or left under other circumstances.
Lacking a coherent sense of self—one whose narrative is not derailed by predictable emotions or actual history, as in a person who is convinced he is kind but keeps exploding at people—makes it hard for the person to make plans and follow through on them. The easily disrupted self-narrative makes people with borderline personality disorder overly defined by things that happened in the last few minutes and overly interested in accomplishing things in the next few hours.
The term borderline—on the border of psychosis—came from the observation that these people are rarely psychotic (grossly out of touch with reality) in their daily lives but often lose track of reality in therapy. They don’t just fantasize that the therapist is in love with them or hates them; they really believe it. Presumably, the personal closeness of therapy is hard for them to process when it is combined with the built-in limits of the relationship. There’s pretty good evidence that relational psychotherapy can help patients with borderline personality disorder, if only they stick with it.
Unfortunately, the same fragile self and emotional lability that gives rise to the diagnosis also disrupts the therapy: demanding hugs, hounding the therapist for self-disclosure, insisting that the therapist break rules, and so on. To help with this, Marsha Linehan invented a training program for would-be therapy patients called Dialectical Behavior Therapy.
One way to think about therapy is that it replicates some of the aspects of parenting. I’m not blaming parents by saying this. When a therapist works with an adult, the adult-self of the patient can ally with the therapist to improve the caregiving provided to the child-self of the patient. The parent has to choose between making the child feel abandoned or indulging the child’s fears; the therapist and patient can create a reflective space in which neither occurs.
A way to think about psychotherapy is that it provides exposure to intimacy and exposure to the self. If something bad happened to you in an elevator, you’d be afraid of elevators (and you’d behave annoyingly in them). The only cure is to slowly get used to elevators. Much pain experienced by people, including those diagnosed with borderline personality disorder, occurs in the context of personally close relationships. This can make people skittish, fearful, or even panicked when confronted with emotional closeness. Relational psychotherapy provides intimacy exposure, a chance to get used to being close to someone who doesn’t abuse or neglect the patient.
Similarly, if everything bad that ever happened to you happened while you were wearing a particular sweater, you would be anxious or panicked when wearing that sweater, and if that sweater was necessary to wear for some reason, you would need exposure therapy to get used to it. Well, everything bad that ever happened to everyone happened while they were wearing their bodies while being themselves.
If the bad things sufficiently outweigh the good things, people will panic when they find themselves in their bodies or being themselves. Relational therapy provides a place for patients to get used to being themselves again without anything terrible happening.
Because they sense deeply that others are getting fed up with their anger and unpredictability, people with borderline personality disorder constantly insist on proof that those around them do not find them aversive, that others accept them unconditionally, that others will never abandon them.
But nothing anyone does can be enough, because all efforts to reassure them, though gratifying in the moment, are interpreted as precursors to abandonment. You can prove you will love them tomorrow only by increasing your baseline of tolerance, affection, and deference. Indeed, the more we generally have to yield and cater to some people to maintain peace, and the more we relate to them, afraid of their exploding rather than happy to see them, then the more we fantasize about escaping them: so there is always a grain of truth in their suspicions about us.
They compulsively test the durability of relationships, but the test is never passed, only passed for now. Therapists can help with this pattern only by establishing an ongoing conversation about the pressure to prove they care; if therapists indulge this pressure, real therapy aimed at personality change will thereafter seem like a withholding, an abandonment; if therapists resist the pressure to prove they care, the therapy will come to feel like a rejection. Therapists must neither feed nor starve the abandonment fears; they must engage the patient in walking a different path.
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