THE ROLE OF CONTAINMENT IN PSYCHOTHERAPY

WITH THE BORDERLINE PATIENT

by Martha Stark, MD / Faculty, Harvard Medical School

 

34th Annual Scientific Day ~ Sheppard Pratt Health System

Saturday, March 21, 1998

 

 

Over the course of the next 50 minutes, I will be speaking to the issue of how the therapist positions herself in her work with borderline patients who, lacking object constancy (also known as evocative memory capacity), cannot tolerate the experience of being disappointed – which, as we will see, has profound clinical implications. 

 

In my talk this afternoon, I will hope to demonstrate how the therapist can use her self to facilitate development of the patient's capacity to tolerate the experience of being disappointed – capacity that will enable the patient, over time, to internalize aspects of the once-good-even-though-now-bad object and, as a result of such internalizations, to lay down healthy psychic structure (to which self psychology refers as optimal disillusionment and transmuting internalization).

 

I would like to begin my discussion with a definition.  I consider the borderline patient to be someone who can tolerate neither internal conflict (ambivalence) nor intense affect – particularly angry disappointment.  Unable to sit with internal conflict, she externalizes it and then wages her battles with the outside world.  Unable to sit with intense affect, she acts out her anger and her disappointment in rageful, impulsive, destructive ways. 

 

How does someone come to be a borderline?  In the literature, reference is often made to the borderline's difficulty negotiating the separation-individuation process (more specifically, the rapprochement subphase of the separation-individuation process).  It is thought that the mother, often a borderline herself, cannot tolerate her child's movement out of symbiotic merger with her, which she experiences as an abandonment.  As her child is separating/individuating, mother is alternately there and not there, alternately smotheringly present and withholdingly absent – in any event, inconsistent in terms of her emotional availability. 

 

The separation-individuation process, then, is usually seen as the culprit.  But, to be more accurate, I believe that we should implicate not only the separation-individuation process but also the symbiotic phase that precedes it – a phase that (for the future borderline) may be characterized by an unusually enmeshed relationship with a mother who is extraordinarily responsive to her infant's every need, a situation of heavenly bliss that sets the stage for the difficulties the child later encounters as she age appropriately attempts to move away from a mother who does not want to let her go. 

 

The borderline, then, often had an early-on experience of paradise (during the symbiotic phase).  But it is a paradise that is lost (as the child separates and individuates); it is a paradise that is lost and never quite recovered.  As a result, the borderline spends the rest of her life in search of the mother she once had and then lost – unable to hold in her mind's eye the image of a consistently present, positively cathected maternal object upon which she can draw (internally) for sustenance and support.  In other words, she lacks a securely established libidinal object constancy.

 

What exactly does it mean when we say that someone has libidinal object constancy? I conceive of it as an internal structure that develops as a result of having the experience of a "good" (libidinally cathected) mother who was more or less constant in terms of her availability to her child.  When someone has achieved libidinal object constancy, she can maintain good feelings about her objects even in the face of disappointment. 

 

The borderline, whose mother was inconsistent (alternately present then absent) as her child was moving away from her, does not have the opportunity to develop object constancy and, as we will see, cannot therefore tolerate the experience of being disappointed. 

 

Before I discuss further the implications for treatment of a patient who cannot tolerate (and ultimately master) the experience of disappointment, I would like to speak briefly – by way of comparison – to what characterizes narcissistic psychopathology.  As we will see, narcissists have capacity (the capacity to tolerate disappointment) that borderlines lack.

 

I believe that the future narcissist is someone whose mother was unable to be empathically responsive to the needs of her infant – although at least the mother was more or less consistent in terms of her inaccessibility.  I believe that the mother's inability to be empathically attuned to her child is there from the get-go – and very damaging to her young child (at least with respect to the child's development of good feelings about herself).  

 

On some level, the mother (of the future narcissist) breaks her child's heart over and over again, in little ways.  Her failures of her child are not dramatic; but the child feels such failures deeply and, heartbroken, retreats into a defensive but adaptive "splendid isolation" – acutely aware of the fact that her mother is not going to be someone on whom she can count. 

 

But though the mother of the future narcissist is a little bit "off" from the word go, she is at least consistently "off."  As a result, the future narcissist is able to experience her as constant and, in time, is able to develop object constancy.

 

How does it serve a person to have object constancy?  Here I would like to draw upon self psychology and how it conceptualizes the process of adding new good (as opposed to changing old bad) within the therapy relationship. 

 

Absence of good – add new good – self psychology

Presence of bad – change it – object relations theory

 

Some self psychologists believe it is the experience of gratification itself that is compensatory and ultimately healing.  But most believe it is the experience of working through frustration against a backdrop of gratification that promotes structural growth.  In other words, most believe that if there is no frustration of need, no thwarting of desire, then there is nothing that needs to be mastered and therefore no impetus for internalization and the laying down of psychic structure.  Self psychology contends that growing up (the task of the child) and getting better (the task of the patient) have to do with learning to master the disenchantment that comes with the recognition of just how imperfect (yet "good enough") one's objects really are – optimal disillusionment. 

           

According to self psychology, when the selfobject therapist has been experienced as gratifying (or "good") and is then experienced as frustrating (or "bad"), the patient deals with her disappointment by taking in the good that had been there prior to the introduction of the bad – which enables her to preserve internally a piece of the original experience of external goodness.  These "transmuting internalizations" are part of the grieving process and are the way the patient masters her disappointment.  Working through the therapist's empathic failures results, therefore, in the accretion of internal structure and the filling in of structural deficit.

 

Self psychology is ultimately a theory about grieving, grieving the loss of illusions, illusions about the perfection (or the perfectibility) of the object.  It's about having illusions, losing them, and then recovering from their loss. 

 

Because the narcissist has achieved the capacity for object constancy (that is, because she has evocative memory capacity), she is able to tolerate disappointment.  The narcissist has the capacity to grieve because, in the moment of the disappointment, she is able to remember the good that had been there prior to the introduction of the bad.  She then internalizes the good that had been and, as a result, builds up internal structure (or capacity to be internally self-regulating – no longer relying upon the object for external regulation).  Optimal (or nontraumatic) disillusionment, transmuting internalization, and accretion of structure. 

 

The borderline, however, has not yet achieved the capacity to experience optimal disillusionment.  For her, every disappointment is a traumatic one because, in the moment of the disappointment, there is no memory of the good that had been and, therefore, no internalization of good.  

 

We say of the borderline that, because she lacks object constancy, she is unable to contain and to master disappointment (that is, unable to grieve) and therefore unable to build up healthy internal structure.

           

I would like, now, to explore the ways in which we, as therapists, can facilitate the process by which the borderline will be able, gradually and over time, to acquire the capacity for object constancy. 

 

In most instances, the acquisition of capacity (or structure) is the result of some need optimally frustrated (against a backdrop of gratification).  This afternoon, I will be suggesting that it is not so much a matter of need optimally frustrated but rather ... something else.

 

Here goes.  Both borderlines and narcissists have problems with the regulation of their self‑esteem and therefore look to the outside for the provision of this regulation.  The deficit from which both suffer prompts them to look to the therapist to perform as an empathic selfobject.

 

When a selfobject (or narcissistic) transference is in place and the patient is being narcissistically gratified, there is sometimes little to distinguish a borderline from a narcissist.  The difference between the two, however, becomes evident in the aftermath of an empathic failure.

 

As we know, the narcissist reacts even to minor disappointment with rage, despair, and withdrawal – a regressive retreat into splendid isolation.

 

But ultimately the narcissist is able to summon up memories of the therapist as someone who, although frustrating in the present, was gratifying in the past.  The narcissist is able to recover good feelings about the disappointing object because she has, inside her, something that gives her faith – that the relationship will survive, the storm will be weathered, and the disappointment will be mastered.

 

In other words, the disillusionment can be contained and mastered within the relationship because the narcissist has object constancy and therefore the capacity to experience optimal disillusionment; she has the capacity to call upon memories of the once gratifying therapist to sustain her through the crisis.  The relationship, therefore, remains intact.

 

By way of contrast, the borderline is unable to tolerate disappointment of any kind because (as we noted earlier) she cannot evoke memories of the good in the face of the current bad and, unable to sit with her rageful disappointment, is inclined, instead, to react impulsively, to "act out."

 

Remember our definition of the borderline as someone who lacks the capacity to "sit with" intense affect (particularly rageful disappointment), tending instead to "act it out" in rageful, impulsive, destructive ways.

 

The borderline is unable to tolerate frustration of any kind because she does not have object constancy, does not have faith in the consistency and the reliability of others, does not trust the durability of relationships, and does not believe in her own ability to survive disappointment and heartache.

 

In the aftermath of the therapist's disappointment of the borderline, the once all‑good object becomes perceived by the patient as an all‑bad, intolerably frustrating object.

 

As a result, the borderline now experiences the selfobject as having been lost to her, both externally and internally; and she reacts with rage, with panic, and with a sense of terrifying aloneness.

 

Whereas the primary vulnerability for the narcissist is the precariousness of the self‑esteem, the primary vulnerability for the borderline is the precariousness of the self.  And the anxiety that the borderline experiences is annihilation anxiety, often of panic proportions.

 

The borderline, therefore, must rely upon a selfobject not only for regulation of the self‑esteem but also for maintenance of the very integrity of the self.  The issue is one of self‑preservation – the survival of the self is at stake.

 

When the therapist frustrates, disappoints, or fails the patient in some way, no matter how minor, the borderline tends to act out her rageful disappointment and her panic in the form of impulsive and destructive behaviors, either to the self (the ultimate being suicide itself) or to the therapy relationship (perhaps in the form of "breaking the rules" or even premature termination).

 

If the relationship is to survive, the therapist, through both verbal and nonverbal means, must be able to contain the borderline's tendency to act out.  The therapist must provide such containment because the patient lacks the internal resources that would enable her to provide such containment on her own. 

 

The borderline has a structural deficit – namely, an impaired capacity for self‑containment.  In fact, such a deficit is the hallmark of the borderline.

 

As we noted earlier, deficit creates need – the need, in this instance, is for the therapist to perform as a containing selfobject, providing containment of the patient's tendency to act out.

 

In her capacity as a containing selfobject, the therapist serves as a deterrent.  She functions as a lid for the patient's id.  She must neither withdraw nor retaliate, much as she might be tempted to do so.  Instead, she must demonstrate that she is indestructible and that she will fight to preserve the relationship.

 

Please note that it is not about insight.

 

The therapist has what the borderline lacks; she has faith in the durability and the resilience of relationships – because she has libidinal object constancy.

 

The heart of treatment for the borderline, then, lies in the therapist's preservation of the relationship in the face of the borderline's tendency to act out in rageful, impulsive, destructive ways.  The therapist's provision of external containment enables the relationship to continue, despite the frequent storms and crises.

 

I am suggesting, therefore, that what the borderline most needs, at least initially, is external "containment," because she cannot provide such containment internally.

 

I choose the word containment in order to emphasize the importance of "containing" the patient's tendency to "act out" because of her inability to "sit with" disappointment.

 

In the aftermath of a disappointment, the borderline is tempted to sever her tie to the disappointing object.  Both her inability to tolerate her disappointment and her sense of outrage and frustrated entitlement at having been failed by her object fuel her impulse to act out and to take flight from what has become an intolerably painful situation.

 

The therapist must do everything she can in order to keep the patient alive and in treatment.

 

I would like to propose that the therapist can use containing statements to limit the borderline's tendency to act out.

 

Let me clarify what I mean.  The containing statement is a particular psychotherapeutic intervention that works well with borderlines.

 

An example:  the end of the hour has come and the borderline remains seated.  How to get her out of the office?

 

Let us imagine that we have been reading our Kohut and decide to try being empathic.

 

And so we say:  “You would wish that you could stay.”

            certainly a nice thing to say

            the borderline feels understood (legitimized), nods agreement, and remains seated

 

So we remember that thing about setting firm limits with the borderline – that is, providing external structure to compensate for her lack of internal structure.

 

And so we say:  “I'm sorry but our time is up, and we do have to stop.”

            said with a certain kind of no‑nonsense affect

            the borderline, now enraged, just sits, rooted to the spot

 

My proposal:  a containing statement – in which we do both – we both resonate with the affect and remind the patient of a reality

 

And so we say:  “Perhaps you would wish that you could stay; but, as you know, our time is up and we do have to stop.”

 

We first resonate with what the patient is experiencing in the moment (namely, a desire to stay) and then we remind the patient of the reality of the situation (namely, that her time is up).

 

We first gratify by empathizing, and then we frustrate by reminding the patient of reality.

 

Actually, in suggesting that resonating with the patient's affect is being "empathic," I am really misusing the word, because the truly empathic therapist will recognize that what the borderline most needs is not just empathic recognition but also actual containment.  The truly empathic therapist will recognize that what the borderline most needs is both understanding and restraint.

 

By resonating with the affect that the borderline is experiencing in the moment, we are of course appealing to her experiencing ego.  And by reminding her of the reality of the situation, we are attempting to engage her observing ego.

 

And so we say:  “Perhaps you would wish that you could stay; but, as you know, our time is up and we do have to stop.”

 

Notice that I insert the phrase "as you know" (sometimes, "as you and I both know") when I say "...as you know, our time is up and we do have to stop."

 

I am clearly addressing her observing ego.  I want to empower her and am encouraging her to take some responsibility for her actions, to recognize that the locus of control is an internal one.  I am emphasizing the element of "choice" for her and, in so doing, am trying to help her preserve her dignity.

 

Other examples of containing statements:

 

“You just can't get rid of this conviction that if you feel hurt by me, then you get to do anything you want, including breaking the rules, which you and I both know we need to have in order for our relationship to continue.”

 

“You just can't get rid of this idea that when you feel hurt by me, you are allowed to retaliate – even though you know that such behaviors are destructive to our relationship and to the bond that we have worked so hard to develop.”

 

“When you get angry like this, you think about taking flight; but we both know that someday you're going to have to stop running.”

 

“You're hating me right now and thinking about killing yourself or breaking off treatment; but you and I both know that if you are ever going to understand why you have such trouble getting close to people, then someday you're going to have to slow down and give yourself a chance to figure out what keeps going wrong for you in relationships.”

 

“I know that you're in deep, deep pain right now and wishing you were dead; but you and I both know that, if you killed yourself, then your kids (whom you love deeply and would never want to hurt), your kids would never get over it.”

 

or   “You think all the time about killing yourself to ease the pain, but you know that if you did it your kids would never get over it and would never forgive you.”

 

Let us think, for a moment, about the patient who is ever busy threatening suicide even as she is insisting that she will never go willingly to a hospital.  Does that put you in a bind?  No, it doesn't.

 

The bind is not yours; the bind, or, more accurately, the "choice" is the patient's.

 

You let the patient know that she can talk of her despair, her hopelessness, her rageful disappointment, her outrage at you for not understanding, for not appreciating just how much she is suffering, and so on and so forth, but for her to know that, from here on out, if she ever says anything at all that sounds to you as if she is saying that she may actually kill herself, then you will see that as her way of letting you know that she needs some kind of containment.

 

If she tells you that she is suicidal, then for her to know that you will take that as your cue to take action, which you will do in the form of insisting that, before she can come back to you, she must present herself to a psychiatric emergency room in order to be evaluated for her suicidality.

 

Your very clear message:  If you talk suicide, I will assume that you are needing me to do something to stop you (that you are needing to provide some form of containment).

 

You are teaching the patient cause and effect, teaching her to take responsibility for her actions, that if she does something, then something else will result.

 

You are helping the patient recognize the impact her behavior has on others.  And so you say to the patient:

 

“Although you might wish that you could talk of suicide and your wish to kill yourself, the reality is that if you talk suicide in here, I will take you seriously and will take action to stop you.”

 

OK.  So my contention, more generally, is that the therapist functions as an external container because the borderline lacks the capacity to provide such containment on her own.  It is the therapist's external provision of containment that enables the relationship to continue.  The therapist fights to preserve the relationship.

 

There are two situations in which it is particularly important that the therapist be able to provide containment:  in situations of potential crisis and in situations of actual crisis.

 

As an example of a potential crisis:  the situation we talked about earlier, in which the end of the session has arrived and it is clear that the patient has no intention of leaving.  The therapist, in her capacity as a containing selfobject, intervenes with a containing statement:  “Perhaps you would want to stay longer; but, as you know, our time is up and we do have to stop.”  The therapist wants to avert a potential crisis.

 

In the event that the patient has already been traumatized by an actual disappointment, then it is important that the therapist be able to contain the patient's rageful disappointment so that the patient will not impulsively act out her rage in destructive ways, either to herself or to the relationship.

 

And so, to deal with an actual crisis, the therapist might say something like:  "I know that at times like this you think about never coming back because it hurts so much to be here; but we both know that, if you are ever going to get better, then someday you are going to have to give somebody a second chance."

 

I would like to examine in greater detail the numbers of containing statement that the therapist can make.  Remember that in the containing statement, you first resonate with the patient's affect and then remind the patient of reality.

 

In order to let the patient know that you do understand, you put the anxiety‑assuaging part first and then intentionally bring the patient up short by reminding her about what she knows are the cold hard facts of the situation.  You first resonate with her affect and then remind her of what she knows to be reality – because we are wanting her to recognize that she has some control over her behavior.

 

Another example:

 

“I know you're hating me right now, I know you can't imagine ever being able to forgive me, and I know you want to walk out this very minute, but you and I both know that someday you're going to have to figure out why it's so much easier for you to get rid of people in your life, even people who have been good to you, than to forgive them.”

 

In the first half of the containing statement, we are resonating with the patient's affect.  We are being "empathic."  Theoretically, then, we can put into this first part of the statement anything that is empathic.

 

“Given that you never really felt supported by your mother, but of course now you desperately want that kind of support from me; I have tried hard to give you that support although there are times when I let you down terribly.  But we both know that if our relationship is to survive, you're going to have to learn to forgive me when I don't always get it just right.”

 

“You had been feeling so good about our work, understood in a way that you had never felt before, and now you are feeling that I don't know you at all and that I don't care; but we both know that if I really didn't care about you, then I wouldn't have bothered to make myself available for this Sunday morning appointment.”

 

“When someone lets you down as I have, your temptation is to flee; though we both know that if you ever want to have a relationship, then someday you're going to have to stop running – so that you can figure out why you are so unforgiving, why you are so relentless, and what happens for you when someone disappoints you.” 

 

“When you're feeling this frustrated and angry, your first impulse is to lash out at the world; but we both know that if you are ever to get better, then someday you will need to learn to put into words how awful you feel instead of acting it out in desperate and in destructive ways.”

 

“Whenever I don't seem to understand or to get it just right, you are furious at me and think about killing yourself in order to show me how enraged you are; but we both know that you will need someday to find another, better way to tell me about how hurt you are.” 

 

Finally, let me tell you about something to which I refer as the integration statement, one of our most important tools in working with a borderline.  The integration statement is used in the aftermath of the therapist's failure of the patient.  It is used when the patient is feeling so devastated that she cannot remember ever having felt good about the therapist.

 

In the integration statement, the therapist enters into the patient's internal experience of devastation and appreciates that the good of the past cannot, for the moment, be remembered in the face of the current bad.  Furthermore, hope for the future cannot be sustained, in the face of the current devastation.

           

The integration statement, then, acknowledges the patient's difficulty holding on to good feelings when she is feeling so bad.  The therapist is wanting to facilitate the development of ambivalence, that is, development of the capacity to hold in mind both good and bad, simultaneously.

 

I'm sure you can appreciate that it is going to be a particularly useful intervention with the borderline, who, lacking libidinal object constancy, cannot revive memories of the good in the face of the current bad. 

 

Examples:

 

“When you're feeling this devastated, it's hard to remember that you used to feel good in here with me and looked forward to coming.”

 

“When your heart is breaking as it is now, you can't imagine that you could ever dare to trust me again.”

 

The therapist wants to help the patient hold in mind, simultaneously, both the good (that is, the past experience of having been gratified) and the bad (that is, the present experience of frustration and disappointment).  The integration statement resonates with the patient's current feeling of dissatisfaction and, in highlighting the patient's difficulty remembering the good in the face of the current bad, indirectly reminds the patient of her previous experience of having felt good.

 

“When you feel this despairing, you can't remember ever having had any hope whatsoever.”

 

Now let's put an integration statement into the first half of the containing statement:

 

“When I keep letting you down like this, you wonder if you will ever be able to trust me again, though we both know that unless you're willing to do the work of trying to understand what happens for you when you don't get exactly what you want, then you'll never get any better.”

 

“At times like this you can't remember ever having valued me or the therapy and you think about stopping treatment, but we both know that if you are ever going to get anywhere in your life or be in a position to pursue any of your dreams, then eventually you're going to have to give up your investment in seeing yourself always as the victim.”

 

OK.  So the therapist, in her capacity as a containing selfobject, provides the patient with external containment, because the patient cannot be internally self‑containing.

 

So how is it that the capacity for object constancy develops?  Whereas with the concept of optimal frustration, failures by the selfobject therapist provide the impetus for internalization and the development of internal capacities, I am going to be suggesting something quite different now.

 

My claim is that, with respect to the development of object constancy in the borderline, it is not the therapist's failure but the therapist's success that makes the difference.  It is the therapist's success in containing the patient's tendency to act out that makes the difference.  It is the therapist's repeated success in meeting the patient's need for containment that gives the patient the experiences she must have in order, ultimately, to develop the capacity to be internally self‑containing, that is, in order to develop libidinal object constancy.

 

The therapist, in essence, meets the patient's aggression and survives the patient's repeated attempts to destroy her and their relationship; in surviving the patient's attempts to destroy her, the therapist gives the patient something she has never before experienced, the experience of containment.

 

If the therapist can meet the patient's need to have her impulsive, rageful, destructive behaviors limited, contained, then the patient has the experience of having intense affect (including murderous rage, debilitating anxiety, and suicidal despair), without devastating consequences.

 

The therapist's meeting of the patient's aggression, the therapist's refusal to be daunted by it, and the therapist's containment of the patient's destructive acting out behaviors enable the relationship to survive and to withstand the frequent storms and crises.

 

The therapist refuses to let the patient destroy their relationship.  The therapist also refuses to let the patient abuse her.

 

So, in the moment of disappointment, it is true that the borderline, lacking the internal resources to sustain her, forgets all the good that had been, and, in her rage, is tempted to act out.  But if she is held in the relationship by a therapist who refuses to let her act it out and gives her a place to talk about her anguish, her panic, her desperation, her rage, her wish to take flight, her wish to lash out, her wish to retaliate, her wish to destroy, then the patient may be able, in time, to recover the good feelings she once had.

 

The therapist fights to preserve the relationship.  She makes liberal use of the integration statement and the containing statement.

 

As an example of an integration statement:  “When you're feeling this enraged, you can't imagine being able to give me a second chance.”

 

Or, the therapist may use a containing statement, such as:  “You're feeling terrible right now, cursing the day you ever met me, and thinking that you will never trust me ever again, but we both know that surviving these crises is part of our work.  We've done it before, and we'll do it again.  Nobody said it would be easy.”

 

The therapist does whatever she needs to in order to contain the patient's acting out.  She demonstrates her own reliability and consistency and her faith in the durability of their relationship.

 

In time, the patient recovers her good feelings.  The disappointment is survived.  The relationship endures.

 

The therapist can then use something I call an inverted integration statement.  Such a statement is used, not when the patient is feeling bad, but in those moments when the patient is feeling good.  In the inverted integration statement, the therapist underlines the fact that, when the patient is feeling good, it is hard for her to remember the bad that had come before.

 

“When you're feeling this good, it's hard to remember that you ever had doubts about me and our work together.”

 

“When you're feeling hopeful, you want to forget about the times when you were desperate and filled with rage and despair.”

 

In essence, the therapist is suggesting – this too shall pass.

 

The therapist, then, makes liberal use of both the integration statement (in which she recognizes the difficulty the patient has remembering the good of the past in the face of the current bad) and the inverted integration statement (in which she reminds the patient of the bad that had been prior to the current good).

 

Such statements enable the therapist to highlight the continuity of the patient's internal experience.  The alternation of good and bad, gratifying and frustrating, are all part of the patient's experience of the therapist.

 

So the process goes as follows:  The patient experiences disappointment, is unable to tolerate it, and is tempted to act out in destructive ways.  The therapist provides external containment, which serves as a deterrent to the patient's tendency to act out, enables the relationship to continue, the storm to be weathered, and the good feelings to be restored.  This happens over and over again.

 

The patient's internal experience, then, is one of disappointment, bad feelings, containment, good feelings, disappointment, bad feelings, containment, good feelings, and so on.  The cycle of crisis, resolution, crisis, resolution happens repeatedly.  Disappointment, relief, disappointment, relief.  Bad, good, bad, good.

 

In essence, the patient survives disappointment.

 

Eventually, the patient begins to recognize this.

 

My claim is that, over time, the patient's repeated experience of bad, good, bad, good, bad, good in ever more rapid succession will develop in her, eventually, the ability to experience both bad and good at the same time.

 

She will have developed the capacity to believe in the possibility of restoring good feelings and surviving heartache.  She will have come to appreciate that good and bad can apply to the same person.

 

At this point, she will have developed the capacity to relate to others not as all good or all bad part‑objects that either gratify or frustrate but as whole good‑and‑bad objects that both gratify and frustrate.  She will have developed the capacity to tolerate ambivalence.  She will have developed the capacity for evocative memory and libidinal object constancy.

 

She will now be able to tolerate disappointment and frustration without externalizing it; she will have developed the capacity to tolerate internal conflict and intense affect without acting it out in rageful, impulsive, destructive ways.

 

At this point she will no longer be a borderline.  Where once she looked to the outside for the provision of external containment of her aggression and her tendency to act out impulsively, now she has the capacity to be internally self‑containing.  Where once she needed external regulation, now she has the capacity for internal regulation.

 

 

In closing:  I am suggesting, then, that the crucial "deficit" from which the borderline suffers is the lack of capacity for libidinal object constancy.  The therapist, in her capacity as a containing selfobject, provides such containment initially.  In time, the patient takes over such functions and comes to be able to provide them for herself.

 

Please note that, as I mentioned earlier, I am proposing that development of the patient's internal capacity for self‑containment is not the result of a need optimally frustrated but the result of a need (for containment) gratified.  It is not the result of failures survived (grieved) but the result of successful containment.  It is not the result of defensive and adaptive internalization; it is the result of a corrective experience, the experience of surviving over and over again crisis, resolution, devastation, relief, frustration, gratification, bad, good – an experience provided by somebody who believes in the viability of relationships and is willing to fight to preserve the relationship, on behalf of a patient who truly does not know how.

 

As the patient develops internal constraints and resources, as she develops the capacity to summon up the memory of the gratifying object in the face of the current frustration, then her underlying narcissistic and neurotic issues become more prominent and can then be addressed by way of working through both the narcissistic and neurotic transferences that unfold over time.

 

Once a borderline, always a borderline?  No, I don't think so.  Once a borderline has achieved object constancy, she will have acquired the capacity to sit with both internal conflict and intense affect--capacity that will enable her to tolerate disappointment and, therefore, to grieve – all of which are necessary for further therapeutic growth and change.

© 2020  Martha Stark, MD ~ Founder / CEO, SynergyMed for MindBodyHealth ~ 617.244.7188 ~ MarthaStarkMD@HMS.Harvard.edu


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