Once considered a rare and esoteric personality disorder found in western societies, borderline personalities are now somewhat ubiquitous in any Indian mental health professional’s clinic. A majority of clinical psychologists and psychiatrists when treating such patients feel exasperated as individuals with borderline personality evoke a gamut of strong and conflicting feelings in the therapist. While working with a borderline personality, the therapist simply forgets the basic rules of counseling: neutrality, encouraging independence in the client, viewing the client with empathy and keeping a certain degree of positive regard for the client.
At one extreme, the treating doctor may feel hostile, scared, confused and helpless in front of patient and end up terminating the treatment while on the other end the doctor may feel intense love and nurturance and wish to heal the patient by taking charge of their lives.
The treating doctor cannot see a middle path and both these extreme positions tend to further damage the patient. As a result these patients are often abhorred within the mental health community. One can often hear therapists working with of these patients saying, “if only I could throw away this patient, it is maddening….Oh my God, it is Thursday, that borderline is coming…..I’m tired to the core, cannot take this criticism any more…..If I continue working with this patient I’ll lose my own sanity.” Many clinical psychologists and psychiatrists feel that these patients are untreatable.
Family and friends feel terrorized
Interestingly, outside the clinic the borderline patient evokes similar powerful and incompatible feelings in their close ones. Fathers, mothers, sisters, brothers, spouses and friends all are caught up in the swirl of these powerful emotions. These people often urge “Why doesn’t she die…….I feel scared of him, he will make me crazy……….Though I have strong moral and ethical values, I would not mind killing him.”
Symptoms of borderline personality disorder
Psychological and psychiatric literature finds following symptoms to be characteristic of borderline personality: huge efforts to avoid real or imaginary abandonment, intense and unstable interpersonal relationships, unstable sense of self, impulsive behaviour, suicidal behaviour, and frequent changes in mood, intense anger and feelings of emptiness.
A closer look at a borderline
So, what is it about a borderline personality that makes everyone crazy? Are they mad? Are they simply very bad? The fact is that they are in extreme pain, a subtle and yet vehement pain. They do not have a capacity to handle this pain and therefore pour it in all their relationships in an extremely raw manner. Let us understand the inner world of a borderline personality in an attempt to come closer to their pain:
The struggle between ‘good’ and ‘bad’: Most of us have learnt that the same person can have both good and bad qualities and we love and relate to our close ones keeping this important reality in mind. The borderline personality has not learnt this very basic fact of life that ‘good’ and ‘bad’ can coexist. In their close relationships, the view of the other person shifts from one extreme to another and consequently there are major changes in the way they react to and feel about the same person. For instance, Rahul, a borderline patient felt that his wife Megha was good at a certain time. He found her perfect, totally devoted and available. Consequently he felt happy, the world appeared to be full of trust, warmth and joy and he showered intense love on her making her extremely happy. Just a few hours later, his state of mind changed and he felt that she was bad. In this state he also forgot that just a while ago he had noticed some good qualities in her. He found her to be cold, hostile, unavailable and self-absorbed and felt rejected by her. Rahul felt that the world was black, devoid of love, trust and warmth and harbored intense anger and hatred towards Megha. In this anger he beat her up profoundly. Such behavior is definitely very traumatic for the people close to the patient as was with Megha in this case. Though Megha is not responsible for it in any way but Rahul also goes through intense pain as he feels intensely rejected and unwanted and finds human relationships to be devoid of any goodness.
Dilemma of closeness versus abandonment
When borderline individuals get close to any person they fear being psychologically swallowed up but when they are separate they feel painful abandonment. This conflict results in their going back and forth in relationships as they are uncomfortable with both closeness and distance. A majority of us have an intact sense of self, i.e. we know that we are psychologically separate from others, we have an inner private space where we experience our emotions and thoughts and we decide to what extent we should share these with people close to us. We also understand that other people also have a similar emotional and mental space. This sense of self helps us in deciding how close we wish to be with another person.
A borderline patient does not have this sense. As a result whenever they feel close to any person they fear that their self would be totally controlled or destroyed in the process. Gauri, a 22-year-old borderline patient had a history of short unstable relationships. Then she started coming closer to a new colleague named Ravi at the office. Initially she liked him as a person and felt that he understood her. However, things changed when Ravi also started reciprocating to her feelings. Gauri then felt that her mind was coming under the control of Ravi and that she had lost her freedom and become a prisoner in the relationship. At such moments, borderline individuals feel trapped and therefore they attempt to move away. But when they move away they feel abandoned and lonely. Interestingly, due to their fluid sense of self they do not recognize that in fact they are the ones who are moving back and forth but they see the other person doing it and blame them. They may harm themselves and display suicidal behaviour when they feel abandoned. This leads to chaos in their close relationships; the other person feels mad and at some point terminates the relationship. These patients are extremely desperate for a good and consistent loving relationship but due to their conflicts it never happens and this ends up in a lifetime gloom for them.
Split image of self: Healthy personalities have an integrated view of self, they know that they have some positive attributes and at the same time have some negative attributes and love their self as a whole. Borderline individuals in contrast have two opposite images of their selves that come into play at different times. Sanjay, a 31-year-old man diagnosed with borderline personality disorder at times concluded that all other men in the world were better of than him. He considered himself an underachiever, weak, stupid and ugly man. He felt extremely depressed at this and many a times contemplated suicide. However, on other occasions he felt that he was very brilliant, other men paled in comparison to him and he just needed an opportunity to show everyone down. Sanjay continuously struggled with these polar opposite views of self feeling either extremely majestic about himself or hating his self.
Home is where they start from
An important factor in the development of a future borderline personality is faulty care giving in the childhood. The relationship between the child and their primary caregiver (need not be the biological parent but one who rears up the child in the initial two years of life for most of the time) contributes significantly to the child becoming a borderline personality. When the child is around two years, he/she tries to separate from the primary caregiver psychologically by creating their own independent space. They may want to be alone or with others apart from the primary caregiver for brief periods. This is a healthy step as it makes the child gain independence. Around this time, the primary caregiver should respect this need of the child and allow a separate space and yet be fully available whenever the child comes back. The caregiver who feels insecure or angry at this makes the child confused. Typically, the caregiver loves and rewards the child when they cling to them but withdraw their affection whenever the child attempts to separate. As a result the child’s experience of the caregiver gets split into two- the ‘good’ caregiver and the ‘bad’ caregiver and this colors all their future perceptions, relationships, view of self and the world. They also feel intense rage towards the caregiver which overwhelms them, this rage is never mastered or overcome and it often comes into play in all their relationships. In all the people they meet in their life, borderline patients continue to see the shadow of this caregiver without realizing it.
Living with a borderline individual
Anyone who comes close in contact with a borderline personality whether it is a spouse, parent, sibling, friend, doctor or a therapist therefore must keep this in mind that the patient is not bad or gone mad but they are constantly struggling with this mammoth pain of uncertainty, rejection, self-hatred, engulfment and the dialectic of good and bad. At the same time keep this in mind that abundant and unconditional love WILL NOT CURE a borderline personality. If you are close to a borderline personality then your emotions are bound to run hot and cold and most probably you would feel consumed by the relationship. Dealing with these people is extremely difficult. Rather than aggressively condemning them, one could gently point out the contradictions in their behavior with emotional warmth. An attempt should also be made to keep one’s personal boundary intact as the borderline individual would try to violate it by coming up in a miserable state and asking for special favors prompting one to transgress ethical and moral boundaries. By giving in to their demands one is encouraging their dependency. The borderline individual would always try to put others in a black or white category, rather than acceding to this, one may also gently point out that everyone has both aspects. However, it must be kept in mind that these understandings should be communicated to these patients when they are in a calm state. If they are in an enraged state such communications would further worsen the condition.
Professional help from a mental health professional experienced in working with borderline personalities is certainly required. Various psychological treatments have been found effective in treatment including psychoanalytic therapy, cognitive therapy, cognitive analytic therapy and dialectic behavior therapy. Psychiatric drugs are also useful in controlling the impulsivity and aggression in BPD patients.