Psychopathology II: Borderline States

Fourth Year Adult Psychoanalytic Training (APT)
2021-22, 3rd Trimester — Fridays, 3:30-5:00pm
Michael Pauly, MD
Charlotte Malkmus, MA LMHC


Hello, and welcome to Psychopathology II: Borderline States.

Early analysts emphasized the fixed character structure of such “primitive” patients. It is our opinion that this fixed view is reductionistic and less clinically useful than a more flexible model whereby structures and defenses and emergent clinical phenomena are thought to be greatly influenced by the framing, containing, and holding capacities of the analytic situation and person of the analyst.

We will approach the affect-laden enveloping quality of the work with a focus on the developmental conditions and clinical manifestations of this psychopathology spectrum. This is rich, intricate, challenging, and at times uncomfortable work. Unbearable discomfort can lead to empathic failure and collapses of the space for thought on both sides of the relationship. We will emphasize how the analyst is affected by such patients, the various means by which disturbing experience is transmitted, and how these processes are a ubiquitous, inevitable, and potentially useful/reparative part of the analytic process.

Immersing oneself in the literature relevant to this psychopathology spectrum can lead to similar disorganizing affective states in the reader, accompanied by a reactive wish for a clearer more durable way of conceptualizing and organizing the material; a wish for more clarity where entropic disorganization often reigns. It is our hope that as a group we can cultivate the space to together metabolize the fragments and integrate the experience into a good-enough whole.

As you read through the articles for this class recall from psychopathology I Sugarman’s model for a neurotically organized mind consisting not of particular mental content but rather certain mental capacities (i.e. self-reflective capacity, capacity for affect regulation, capacity for narcissistic regulation, and internal conflict). We will make use of this to understand the struggles that characterize the phenomena that present in borderline states and states of narcissistic fragmentation / breakdown.  

Considerations For Further Reading:

  • Benjamin, J. (2004). “Beyond Doer and Done To”. Psychoanal. Q., 73:5-46
  • Knafo, D. (2015) Guys and Dolls: Relational Life in the Technological Era. Psychoanalytic Dialogues 25:481-502
  • Mancia, M. (2006) “Implicit Memory and Early Unrepressed Unconscious: Their role in the Therapeutic Process (How Neuroscience Can Contribute to Psychoanalysis)” IJP 87: 83-103
  • Anderson, M.K. (1999) “The Pressure Toward Enactment and the Hatred of Reality” J. Amer. Psychoanal. Assn., 47:503-518.
  • Briggs et al (2012) “Suicide and Trauma: A Case Discussion” Psycho. Psychotherapy, 26:13-33
  • Kernberg, O. (2003) “The Management of Affect Storms in the Psychoanalytic Psychotherapy of Borderline Patients” JAPA 51/2: 517-545
  • Frosch, Allan (2012) “Absolute Truth and Unbearable Psychic Pain: Psychoanalytic Perspectives on Concrete Experience” London: Karnac. Introduction. Pages xix – xxiv.
  • Britton R (2004) “Subjectivity, Objectivity, and Triangular Space.” Psychoanalytic Quarterly. 2004 Jan; 73(1): 47-61.
  • Anderson, M. (2012) “Concreteness, reflective thought and the emissary function of the dream.” Absolute Truth and Unbearable Psychic Pain: Psychoanalytic Perspectives on Concrete Experience. A Frosch, ed. London: Karnac. Chapter 1, pp.1-16. (Not on PEP Web. Provided upon request).
  • Coen, S.J. (2005) “How to Play with Patients Who Would Rather Remain Remote” J. Amer. Psychoanal. Assn., 53:811-834.
  • Stein, R (2005) “Why perversion? False love and the perverse pact” Int. J Psa, 775-799.
  • McDougall, J. (1980) “A Child is Being Eaten—I: Psychosomatic States, Anxiety Neurosis and Hysteria—a Theoretical Approach II: The Abysmal Mother and the Cork Child – A Clinical Illustration” Contemporary Psychoanalysis, 16: 417-459.
  • Gabbard, G.O. (1991) “Technical Approaches to Transference Hate in the Analysis of Borderline Patients” IJP., 72:625-636.
  • Eaton, JL (2005) “The Obstructive Object” Psycho. Review, 92(3): 355-372
  • Caligor, E., Diamond, D., Yeomans, F.E. and Kernberg, O.F. (2009). The Interpretive Process in the Psychoanalytic Psychotherapy of Borderline Personality Pathology. J. Amer. Psychoanal. Assn., 57(2):271-301
  • Blechner, MJ (2009) “Erotic and Antierotic Transference” Contemp. Psychoanal. 45(1):82-92
  • Geist, RA (2011) “The Forward Edge, Connectedness, and the Therapeutic Process” IJP. Self Psychol., 6(2):235-251
  • Akhtar S (1996) “Someday...” and “If Only...” Fantasies: Pathological Optimism and Inordinate Nostalgia as Related Forms of Idealization” JAPA., 44: 723-753
  • Davies, J.M. and Frawley, M.G. (1992). Dissociative Processes and Transference- Countertransference Paradigms in the Psychoanalytically Oriented Treatment of Adult Survivors of Childhood Sexual Abuse. Psychoanal. Dial., 2(1):5-36
  • Socarides, DD. Stolorow, R.D. (1984) “Affects and Selfobjects” Ann. Psychoanal., 12:105-119
  • Tuch, R.H. (2007) “Thinking with, and About, Patients too Scared to Think” IJP., 88:91-111.
  • Fonagy, P and Target, M. (1995) “Understanding the Violent Patient: The Use of The Body and The Role of The Father” IJP. 76:487-501.
  • Steiner, J. (1994) “Patient-Centered and Analyst-Centered Interpretations: Some Implications of Containment and Countertransference” Psychoanal. Inq., 14:406-422.
  • Kohutis EA (2010) “Concreteness, Metaphor, and Psychosomatic Disorders: Bridging the Gap” Psychoanalytic Inquiry, 30(5)416-429
  • Nos, J.P. (2014) “Collusive Induction in Perverse Relating: Perverse Enactments and Bastions as a Camouflage for Death Anxiety” Int. J. Psycho-Anal., 95:291-311.

Learning Objectives

The clinical associate will:

  1. as a result of gaining greater knowledge of the hypothesized etiologies of borderline-level character disorder, have a greater capacity to understand, empathize, and connect interpersonally with this clinical population, and thereby improve the odds of the treatment retention necessary for a positive clinical outcome
  2. as a result of gaining a greater understanding of and capacity to work with the intense transference-countertransference phenomena that develop when working with this population, have an increased ability to assist their patient in reflecting on these phenomena, and thereby improve the odds of a positive clinical outcome
  3. as a result of gaining a greater capacity to work with collapses in reflective functioning under the weight of unbearable affect, become more capable of assisting this population in such a way that they are better able to tolerate, regulate, and reflect on their affect states and associated triggers, thereby improving their defensive structures, self-understanding, interpersonal relationships, and overall life functioning

March 25, 2022 — Etiology/Conceptualization

[48 pages]

We will begin with Fonagy, Robbins, and Winnicott to highlight the relational – etiological factors contributing to the emergence of these character / self-disorders.

In Attachment and Borderline Personality, Peter Fonagy outlines how the caregivers’ reflective capacity impacts their child’s capacity for mentalization and the development of a secure attachment. He links these concepts with the idea that early trauma may result in a child’s inhibition of mentalization in an effort to avoid the pain of reflecting on their lived experience, thereby resulting in impaired reflective abilities and an impaired sense of self. Per Fonagy, these impairments may explain the link between childhood maltreatment and character pathology.

In The Mental Organization of Primitive Personalities and its Treatment Implications, Michael Robbins encourages us to think of more primitive personalities as differing in qualitative rather than quantitative ways and that assumptive errors along these lines lead to technical approaches that may be regressive or promote what Winnicott described as an analysis with the false self.

Fonagy, P. (2000) Attachment and Borderline Personality Disorder, Journal of the American Psychoanalytic Association. 48:1129-1146.

Robbins, M. (1996) “The Mental Organization of Primitive Personalities and its Treatment Implications”, JAPA, 44(3):755-784

April 1, 2022 — Etiology

[24 pages]

Fear of Breakdown is a classic. In it, Winnicott tells us that there is a storing in the implicit memory systems an awareness of lived events of past emotional overwhelm (primitive agonies) that have not been fully psychologically experienced and hence have not been thought about and hence haunt the person and at times present in treatment as a fear of breakdown. This paper and its concepts offer a foundational link to many papers that follow in this course. Thomas Ogden walks us through Winnicott’s paper and Claire Winnicott offers an (optional) illustrative case. Please bring in clinical material of your own.

Winnicott, D.W. (1974) “Fear of Breakdown”, International Review of PSA, 1:103-107

Ogden, T.H. (2014) “Fear of Breakdown and the Unlived Life”, IJP, 95:205-223

April 8, 2022 — Part vs. Whole Object-Relating

[27 pages]

Donald Winnicott’s paper The Use of an Object deserves to be read many times over. In it he introduces his distinction between object relating and object usage. He walks the reader through the transition from object relating to object usage (the capacity of which is determined by an adequate facilitating environment). The transition requires the placing of the object outside of the subject’s omnipotent control. Failure to make this transition can explain many areas of difficulty in this population (separation-individuation, narcissistic rage, capacities to empathize / love, stability of interpersonal relationships, acceptance of external reality).

In Problems of Narcissistic Love, Sheldon Bach provides a vibrant picture of narcissistic character pathology, paying particular attention to disturbances in object-relatedness.

Winnicott, D.W. (1969) The Use of an Object. IJP, 50:711-716.

Bach, S. (1994) Ch2, “Problems of Narcissistic Love” in The Language of Perversion and The Language of Love. London: Aronson, pp29-49.

April 15, 2022 — Trauma

[37 pages]

Joyce McDougall provides us with ample clinical material to show the impact of traumatic experiences that occur in the preverbal period of development and to highlight how these early experiences present via route of the non-verbal expressions affecting that analyst’s countertransference. She calls these primitive communications. Her paper speaks of the analytic process as helping to transform action-communications / action-symptoms into that which can be verbally represented in language, allowing containment of the experience.

McDougall, J. (1978) “Primitive Communication and the Use of Countertransference-Reflections on Early Psychic Trauma and its Transference Effects”, Contemp. Psychoanal., 14:173-209

April 22, 2022 — Trauma

[49 pages]

This week we continue our focus on the deep and lasting impact of trauma.

Davies and Frawley: in this article, update the definition of dissociation in accordance with contemporary research on traumatic states and demonstrate the manifestations and impact of dissociative phenomena in the psychoanalytic treatment of adult survivors of childhood sexual abuse. Please bring any clinical material that the reading of this article brings to mind.

Lawrence Brown: in Julies Museum: The Evolution of Thinking, Dreaming, and Historicization In the Treatment of Traumatized Patients, complements and extends Bromberg’s paper by linking trauma’s destruction of one’s internal thinking-containing capacity with the concretization of thought. His clinical example highlights the importance in these cases of the analyst’s imaginative capacity being crucial for helping their patients begin to think and dream, and to free themselves from the mental captivity of concrete thought. How do you share your imaginative capacity with your patients?

Davies, J.M. Frawley, M.G. (1992). Dissociative Processes and Transference-Countertransference Paradigms in the Psychoanalytically Oriented Treatment of Adult Survivors of Childhood Sexual Abuse. Psychoanal. Dial., 2(1):5-36.

Brown, L. (2006) “Julie’s Museum: The evolution of thinking, dreaming and historicization in the treatment of traumatized patients” IJP, 87:1569-1585

April 29, 2022 — Reflective Collapse, Disintegration, Emptiness and Suicide

[27 pages]

John Maltsberger, in The Decent Into Suicide, discusses the factors leading to suicidal collapse (affective flooding, desperate maneuvers to counter the emerging mental emergency, loss of control as the self begins to disintegrate, and grandiose mental scheming for mental survival) and connects these with the difficulties in the realm of affect regulation, ego helplessness, narcissistic surrender, breakdown of the representational world, and loss of reality testing.

In The Subjective Experience of Emptiness, Otto Kernberg writes about the chronic emptiness analysts often encounter when working with patients suffering from character pathology. He provides readers with important distinctions between depressive, narcissistic, and schizoid emptiness as experienced in the patients’ emotional worlds and in the countertransference.

Maltsberger, J.T. (2004). The descent into suicide. Int. J. Psycho-Anal., 85(3):653-667.

Kernberg, O. (1985) “The Subjective Experience of Emptiness” Borderline Conditions and Pathological Narcissism. Jason Aronson (213-224).

May 6, 2022 — Projection, Splitting and Countertransference Enactment

[35 pages]

Kathleen White in Surviving Hatred and Being Hated: Some Personal Thoughts About Racism from a Psychoanalytic Perspective, brings a discussion of the experience of being the object (as a result of one’s race) of toxic attributions and projections. She highlights the subsequent response(s): the self-hatred stemming from the internalization and identification with such projections; and the emergence of the hatred of the other. She stresses that hatred is learned and that the analytic endeavor must include helping patients recover the learning process in hateful experiences so that unlearning and relearning is possible. Please bring in accounts of any experiences (personal or professional) this paper stimulates in you.

Alex Bateman, in Thick-Skinned Organizations and Enactment in Borderline and Narcissistic Disorders, proposes that narcissistic and borderline individuals move between thick and thin- skinned positions, lending an instability to the clinical picture which is both a danger and an opportunity for the treatment. He helpfully uses clinical material to outline his impression of the three countertransference experiences contributing to enactment (complementary, concordant, and defensive) and to highlight three levels of enactment (collusive, defensive, and the un-named role of father, corrective). The last he feels serves as a new helpful developmental experience that moves the treatment forward.

White, K.P. (2002). Surviving hating and being hated: Some personal thoughts about racism from a psychoanalytic perspective.. In Contemporary Psychoanalysis, 38, pp. 401-422

Bateman, A. (1998) Thick-Skinned Organizations and Enactment in Borderline and Narcissistic Disorders. IJP, 79:13-25.

May 13, 2022 — Hysteria / Psychosomatic States

[32 pages]

This course would be incomplete without making connections between early life trauma, deficits in the capacity to mentalize / symbolically represent and reflect on internal psychic experience, and the expression of psychic phenomena through bodily experience and / or illness.

Anita Weinreb in, Healing the Split Between Body and Mind: Structural and Developmental Aspects of Psychosomatic Illness, follows the analytic journey of two women with multiple somatic problems. They discover and examine how their bodies became the vehicle into which unprocessed feelings had been emptied and how with treatment helped them to develop the ability to verbally represent their experience, contain it, and reflect upon it, thereby revealing the underlying conflicts and functions embedded in their previous somatic expression.

Trevor Lubbe’s Diagnosing a Male Hysteric gives readers a detailed clinical account of a patient who uses sex as a defense against fears of separation and exclusion to compensate for early developmental deficits.

Weinreb, A. (2010) Healing the Split Between Body and Mind: Structural and Developmental Aspects of Psychosomatic Illness. Psychoanal. Inquiry. 30(5):430-444

Lubbe, T. (2003). “Diagnosing a Male Hysteric” Int. J. Psychoanal., (84)(4):1043-1059

May 20, 2022 — Sadism and Masochism

[52 pages]

The last two weeks of this course are dedicated to the exploration of perverse mechanisms, within which sadomasochism resides. While somewhat heavy on the reading, given the difficulty engaging, surviving, and proving helpful to this character type, we hope the time spent is worthwhile.

Sheldon Bach’s chapter, Sadomasochistic Object Relations, is invaluable in terms of working with sado-masochistically organized individuals. The chapter draws on many of the themes described in articles earlier in the course (difficulties in the realms of separation- individuation, developmental trauma, role of aggression, inability to mourn, narcissistic omnipotence, failures of seeing the other as separate, concrete mental processes) to explain the developmental line of perverse relating and guide the treatment approach.

Emmanuael Ghent’s Masochism, Submission, Surrender, provides us with a link between Winnicott’s groundbreaking work from the 60’s and 70’s and the relational theory of Jessica Benjamin in the 2000’s. Ghent posits masochism as a distorted attempt at surrender, which he defines as a universal desire to be wholly known by the other.

Bach, S. (1994) Ch1, “Sadomasochistic Object Relations” in The Language of Perversion and The Language of Love. London: Aronson, pp3-25.

Ghent, E. (1990). Masochism, Submission, Surrender—Masochism as a Perversion of Surrender. Contemp. Psychoanal., 26:108-136.

May 27, 2022 — Perverse Relatedness

[42 pages]

Richard Tuch, in Murder on the Mind: Tyrannical Power and other Points Along the Perverse Spectrum, gives comprehensive overview of the history of thinking about perversion and perverse relatedness.

In Perverse Female Relating, Andrea Celenza updates old notions of perversion that were based on male development as normative and gives readers a new self-structure to consider: the Objectified Self. She suggests that in contrast to male perverse relatedness, a hallmark of female perverse relating is self-objectification, the aim of which is to control a dangerous subjectivity within.

Tuch, R. (2010) Murder on the Mind: Tyrannical Power and other Points Along the Perverse Spectrum. Int. J. Psycho-Anal., 91:141-162.

Celenza, A. (2013) “Perverse Female Relating: The Objectified Self.”  Contemporary Psychoanalysis, 49:586-605