Without getting into revelations about specific patients, I've been making some effort recently to share a little more about how I think about people, letting readers inside my professional mind a bit more. After finishing up a report on Friday, I made a mental note to discuss the experience of evaluating certain kinds of patients. So here you go.
Since I conduct several evaluations a week, I also spend considerable time reviewing test results and my extensive interview notes. With some examinees, a coherent picture emerges easily from the materials and my impressions. With others, not so much.
I've noticed that my mind starts to feel like scrambled eggs in reviewing my notes from interviews with persons whose personality organization is best understood as borderline. In the borderline level of organization, issues related to psychological separation and individuation are most prominent. The notes from interviews of such persons don't have a psychotic flavor; there will definitely be a sense of reality connection conveyed in the notes, but there will also be a sense of chaos there--hence, the scrambled eggs.
There will also be many observations that seem centrally important to understanding the patient. Too many, in fact. Reflecting the pattern of the interview itself, one thing will seem extremely important to understanding the patient, until it is replaced by another thing, then another and another and another.
As in interviewer in this situation, you become quite confused, feeling like you’re missing something that is the key to understanding what's being said. You may wonder if something was said and you didn’t hear it, or perhaps you heard it, but forgot about it. And when you ask another question to get your bearings, things start to feel a little clearer until they don’t feel clearer. You end up feeling like you’re trying to nail Jello to a wall. Or maybe it’s the mental equivalent of trying to herd cats. I have no shortage of metaphors to describe these experiences.
In such an interview, the kinds of stories, revelations and statements that would ordinarily stand out as organizing motifs for character are repeatedly displaced by new themes that sound like they could be core themes, until it becomes impossible to know what to focus on in the content. Adding to the confusion and disorientation, abrupt shifts in attitude and mood can accompany the shifts in content focus. The mood shifts lend an air of creepy emotional inauthenticity to the conversation. What becomes important, then, is that the central motif for character isn't reflected in a central theme or a few interrelated themes. Rather, hints of the core issues are reflected in the instability of themes, the air of emotional inauthenticity and the sense that you can’t quite get on the same emotional wavelength as the patient because there is no steady wavelength.
All of the above are all clues that a borderline personality organization is in play.
For the patient, these erratic shifts are a way to avoid greater distress that would be caused by thinking deeply about very disturbing matters, but the mind-muddling shifts of content and tone serve more than one protective purpose for the patient. Not only does the patient want to avoid the overwhelming distress of dwelling more deeply on a troubling subject, the shifts are also a way to avoid a terrifying sense of merger with the interviewer.
If a deeper, sustained mutual exploration occurs—if patient and interviewer become deeply, mutually attuned—a psychotic-like loss of psychic separateness from the interviewer can occur. By keeping the interviewer confused and misattuned, the patient fends off a frightening sense of psychological merger with the interviewer, thereby maintaining a more clear sense of boundaries* between inside and outside, me and not-me.
This attempted maintenance of psychological boundaries by creating confusion, arises from persistent vulnerabilities in the area of psychological separation and individuation. These patients struggle with falling into terrifying merger states, identity confusion and destructive behavior that can represent an effort to manage unbearable fears associated with merger (loss of self) and separation (abandonment fear). Typically, they either avoid intimate relationships, or they maintain unstable, stormy relationships that vacillate between boundary shifting idealizations and attacks on the intimate partner in attempts to regulate respectively underlying merger terror and separation fear.
If you're a bit confused now, don't worry. It isn't you. This is an exceedingly difficult area of psychology to grasp without considerable theoretical familiarity and clinical experience, or a long-term relationship with someone who struggles with borderline personality organization, or experience as a patient who has struggled with the suffering inherent in this personality organization.
I should hasten to add that casual discussion of these patients often focuses on how hard they can be on clinical staff. But life is even harder on these patients, and the world is not sympathetic because of their often provocative efforts to keep themselves together and functioning. Work with such a patient is also quite hard on the therapist, because you get swept up in the confusion and provocation, and must work hard to stay centered and empathic to the fear and desperation underlying the behavioral and emotional havoc.
There is much more to understanding borderline level personality organization. This is just one way it can be experienced by an interviewer or therapist. There are other intense, difficult feelings that are experienced in ongoing work with such a person, but don't look to the DSM to be informed on the subject. The DSM is what we get from people who think only in terms of diseases, symptoms and pharmacologically responsive states to describe psychological problems.
What's wrong with such an approach? Imagine your car getting stuck on the railroad tracks as a train is bearing down on you. Intense fear and urgency to escape overcomes you. But these feelings aren’t caused by your appraisal of the situation. They are actually caused by an abnormal elevation of your epinephrine levels (the biology). And the subject of interest to your doctor is your increasing trembling and perspiration (the measurable symptoms). If only your epinephrine levels and the excess perspiration could be controlled, you’d be fine.</snark>
*This is the underlying nature of the boundaries problem experienced by patients with a borderline-level personality organization. The boundary problem isn't simply a behavioral deficiency based on a failure to grasp common social rules. While destructive and disruptive social boundary violations can occur, underlying these behavioral problems, there is persistent difficulty with maintaining a sense of separated, individuated self and identity.