7. Abandonment Fears & Attachment - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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Ouch! Where'd that come from?! The Borderline in Couples and Couple Therapy
Chapter 7: ABANDONMENT FEARS AND ATTACHMENT


Individuals with borderline personality disorder make frantic efforts to avoid real or imagined abandonment (Criterion in DSM-IV).  The perception of impending separation or rejection, or the loss of external structure, can lead to profound changes in self-image, affect, cognition, and behavior.  These individuals are very sensitive to environmental circumstances.  They experience intense abandonment fears and inappropriate anger even when faced with a realistic time-limited separation or when there are unavoidable changes in plans (e.g. sudden despair in reaction to a clinician's announcing the end of the hour; panic of fury when someone important to them is just a few minutes late or must cancel an appointment).  They may believe that this "abandonment" implies they are "bad."  These abandonment fears are related to an intolerance of being alone and a need to have other people with them.  Their frantic efforts to avoid abandonment may include impulsive actions such as self-mutilating or suicidal behaviors, which are described separately in Criterion 5 (American Psychiatric Association, 1994).

The infancy and childhood experience of the primary caregivers- the parents being attentive, nurturing, and available facilitate the development of secure attachment.  A sense of positive self-worth and a coherent and consistent sense of self combine with optimistic expectations that significant intimate others will usually be available, accepting, and responsive.  Stable and healthy childhood attachment styles develop that are hypothesized to mature into adult attachment styles.  "This portrait of secure attachment contrasts dramatically with the malevolent or split representations of self and others, as well as with the needy, manipulative, and angry relationships, that characterize persons with BPD" (Agarwal et al., 2003, page 95).  In adulthood, the availability and ready response of the primary intimate figure- the romantic partner or spouse gives the individual a sense of personal safety and security.  When the individual perceives that the intimate partner- the attachment figure is unavailable or non-responsive, then various attachment behaviors get activated to re-establish the attachment bond.  If these behaviors are insufficient to elicit the desired response from the intimate attachment figure, then there follows a pattern of responses, such as "angry protest, clinging, despair, and finally detachment (Bowlby, 1969).  Adult bond disruption is followed by a similar set of predictable responses, namely, protest, despair, and detachment (Sperling & Berman, 1994).  Differences between child–parent attachment bonds and those of adult–adult attachment bonds have been outlined by Weiss (1982), who maintains that adult attachment is between peers whereas child–parent attachment is between caregiver and care–seeker, thus hierarchical in nature.

It should be noted that adult attachment relationships are not as susceptible to being overwhelmed by other behavioral systems, given that adults possess coping mechanisms to deal with stressful situations (Naaman et al., 2005, page 57).  With successful coping mechanisms, trust, safety, and dependency on another individual can be fundamentally fulfilled in a stable intimate partnership.  However, "Distress in a couple occurs when the basic attachment needs for security, protection, and closeness are not met. A real or perceived threat of attachment disruption can lead to anxiety and distress and even suicidal behavior" (Links and Stockwell, 2001, page 495).  If, as, and when a crisis is resolved, the attachment relationship is re-established.  The couple stabilizes.  A couple may be able to do this using its own resources, drawing upon their history of successful resolutions, and creative energy.  With the fragile couple, the therapist helps stabilize attachment crises, which can result in short-term improvement.  In some couples, the experience of stabilizing may be sufficient to give them confidence to fall less often and less intensely into crises.  However, for the very fragile couple with the individual with borderline personality disorder, more extensive and in-depth therapy may be needed to work through attachment difficulties and change the relationship and communication dynamics.  The attachment issues, borderline personality disorder, and resultant couple's complexity alter the definition of the relationship and should alter how the therapist approaches therapy.  Therapy will be more complex and probably, take much more time and effort.  "The longer contract can be useful to create more long-lasting changes. To summarize, using couple therapy may potentiate therapeutic engagement and response in individuals with BPD" (Links and Stockwell, 2001, page 495). The therapist may need to renegotiate the goals and process of therapy from simple problem solving to a much more involved therapeutic process that addresses underlying attachment issues.

Agrawal et al. (2003) identify the attachment styles most characteristic of individuals with borderline personality disorder as unresolved, preoccupied, and fearful.  In each style, individuals show an intense longing for intimacy, while simultaneously fear about dependency and rejection.  The high prevalence and severity of insecure attachments validate the core dynamic of disturbed interpersonal relationships in various theories and descriptions of borderline personality disorder (page 94).  The following shows graphically Bartholomew's two-dimensional model of attachment.  The preoccupied pattern (negative view of self and positive view of others) is characterized by low self-worth, excessive dependency on others' love and approval in close relationships, and an overinvolved, demanding interpersonal style (Henderson et al., 2005, page 221).

Insecure attachment models predict problematic if not disastrous couple's relationships.  Avoiding intimacy, the characteristic that dismissing and fearful attachment styles share is counter-indicated in an intimacy-based relationship.  If the individual seeks out a partnered relationship for other reasons, his or her partner must therefore be willing to accept an intimacy-limited or intimacy-devoid relationship.  The partner may feel betrayed having expected greater intimacy than the intimacy-avoidant individual offers.  Preoccupied attachment offers tremendous intimacy to the partner but demands mutual over-investment to the point of boundary violations and merging of selves.  This can smother the partner.  His or her subsequent efforts to gain some psychic space trigger fears of rejection and abandonment in the individual.  This can set off classic dysfunctional borderline behaviors.  The preoccupied individual feels a great need for love and support while anticipating that disappointment.  He or she gets more and more demanding and possibly aggressive with failure to satisfy attachment desires.  "…individuals whose attachment needs have been frustrated throughout their relationship history and who feel particularly vulnerable to the potential loss of an attachment figure may strike out violently in order to regain proximity to an intimate partner (Bartholomew et al., 2001). (Henderson et al., 2005, page 219).  On the other hand, since he or she is desperate for attention, the individual is often more tolerant of continued abusive behavior from partners.  "…preoccupied individuals appear to gain psychological benefit from interactions that most people would find unpleasant. Even when a partner's response is negative, preoccupied individuals may perceive this as evidence that their partner is engaged and, in a perverse sense, more intimately involved. Thus, preoccupied individuals could be at increased risk for tolerating, and (at an unconscious level) even soliciting, abuse from a partner. Preoccupied individuals also may be vulnerable to staying in abusive relationships because of their tendency to excuse their partner's abuse… tendency to idealize partners may lead preoccupied individuals to create unrealistic expectations of their partner's ability to change" (Henderson et al., 2005, page 226-27).

The strength of the attachment bond does not constitute a simple relationship to the quality of the attachment relationship.  This is demonstrated in looking at situations where the threatened individual- the child seeks attachment to the threatening individual- the parent.  Since the punitive attachment figure normally sets up "the circumstances for the attachment system to be activated, the attachment bond will not only persist but may even be actively enhanced (Bowlby, 1982).  For instance, a parent's rejection of a child's efforts to be close often evokes precisely the opposite effect to what was intended.  Fearful that proximity to the parent is being jeopardized, a child may become even more clingy in an effort to maintain proximity (see Crittenden, 1988, 1992).  Although Bowlby's theory may be applicable to any victimized individual, this concept has been most extensively applied to battered women.  Dutton and Painter (1981) proposed a theory of traumatic bonding, which suggests that the power imbalance and intermittency of abuse typical of abusive relationships enhances the strength of emotional bonds to abusive partners.  This theory was validated in a study by Dutton and Painter (1993), which showed that women were more strongly attached to their assaultive partners when there was more abuse and the abuse was inconsistent" (Henderson et al., 2005, page 221).  Fearfulness and preoccupation were positively correlated with the perpetration of psychological abuse and a various dysfunctional personality traits: anger, jealousy, borderline personality organization, and trauma.  "Dutton and colleagues explain these findings in terms of 'intimacy anger,' suggesting that a violent man's assaultive episodes represent an adult parallel to the angry protest behavior exhibited by an infant when separated from an attachment figure.  They suggest that a man's violence is often precipitated by the perceived loss of an attachment partner and demonstrates an active effort to bring the attachment figure back.  Thus, both fearful and preoccupied individuals, characterized by attachment anxiety, are at risk for high levels of intimacy-anger" (page 221).

The therapist should be wary of the individual who presents domestic violence experiences or a narcissistic partner who emotionally annihilates him or her periodically.  Such experiences draw the clinical attention of the therapist for treatment and intervention.  They may also be indicative of other issues that require therapeutic energy. One or a few experiences of emotional or physical aggression or violence should be sufficient for the individual to terminate a relationship.  Staying in such a relationship to endure repeated fundamental boundary violations does not make sense without some compelling issues.  The individual's tolerance of aggression or violence should be examined as consequential of a borderline personality disorder.  Affairs, sexual addictions, alcohol and substance abuse and other addictions of the partner may also be variations of passive aggressive to more overt aggression that had been acceptable to an attachment wounded individual with borderline personality disorder.  The apparent tolerance, acceptance, and even solicitation of abuse are often off putting to relatives, close friends, and the therapist.  Despite being cared for and otherwise liked, such an individual often lose the respect of previously caring people.  Complaining about mistreatment, disrespect, and indignities may initially elicit sympathy or empathy.  However, continued entry and re-entry into an abusive relationship domain instead of withdrawal frustrates caring family and friends… and the therapist.  Eventually, people do not want to hear about the abusive behavior, blame the individual, and avoid interacting with and caring about him or her.  The therapist needs to be aware of his or her counter-transference around a complaining perpetual victim in order to recognize potential attachment insecurity and/or borderline or other personality disorders.  The therapist

Should assess the attachment experience, possible injuries, and style of the individual;

Address the individual's attachment wounds and injuries from childhood experiences;

Adjust therapy and interventions for the relationship relative to different insecure attachment styles;

Assess and intervene against the individual's aggressive (including passive-aggressive) and violent behaviors towards the partner;

Assess and intervene against tolerance of partner aggression against the individual, including domestic violence, affairs, addictions, and passive-aggressive behavior;

Address and heal the individual's abandonment fears;

Teach appropriate behaviors to deal with abandonment fears and improve intimacy and attachment security;

PATTERNS OF UNSTABLE AND INTENSE RELATIONSHIPS
Individuals with borderline personality disorder have a pattern of unstable and intense relationships (Criterion 2).  They may idealize potential caregivers or lovers... or therapists at the first or second meeting, demand to spend a lot of time together, and share the most intimate details early in a relationship.  However, they may switch quickly from idealizing other people to devaluing them, feeling that the other person does not care enough, does not give enough, is not "there" enough. These individuals can empathize with and nurture other people, but only with the expectation that the other person will "be there" in return to meet their own needs on demand. These individuals are prone to sudden and dramatic shifts in their view of others, who may alternately be seen as beneficent supports or as cruelly punitive. Such shifts often reflect disillusionment with a caregiver who nurturing qualities had been idealized or whose rejection or abandonment is expected. (American Psychiatric Association, 1994).  The individual with borderline personality disorder in the affective cluster demonstrates intense, inappropriate anger, instability of affect that result in dramatic, stormy, and subsequently unstable relationships.

Frieda and Cliff had been dating for just a couple of weeks when the drama started.  There continued to be significant drama between them over the years.  Cliff described Frieda getting enraged over simple misunderstandings and miscommunications.  When things were going well, Cliff said it was wonderful.  They had fun, could talk for hours, enjoyed the theater together, went on long walks, and were very sexually compatible.  But Cliff said he didn't know which Frieda would show up: the wonderful loving Frieda or the demon child from the depths of hell!  Frieda described Cliff as being the best boyfriend she had ever had, but he was unreliable from the beginning and into their marriage.  She went on with a story of how he had been late for a date during the first few months together.  He hadn't answered his celphone.  And when he showed up, Cliff hadn't offered any believable excuses.  Cliff explained that his celphone battery had died.  His roommate's mother had an emergency, and Cliff had driven his roommate over to her house before coming over.  Cliff said when he arrived at Frieda apartment, he thought that she was out because she made him wait five minutes before she answered the door.  Then, when the door opened, "The gates of hell opened and she spewed out fire and brimstone!  It took me ten minutes to get out that there had been an emergency with my roomie's mom."  Frieda eventually was very apologetic.  She had sworn not to do it again.  Cliff said, "She has promised not to do it again over and over.  And, then… bam!"  Other times, Frieda accused Cliff of deceiving her into thinking that he could be the one, of ignoring her feelings, and of pushing her away at times.

In a moment of self-pity, Frieda blurted out, "Why they always hurt me?"  The therapist picked up on the word "they" and asked who "they" were.  What did she mean by "always?"  Frieda's parents had divorced when she was four years old.  She went from one parent to another throughout her childhood.  There were stepmothers and stepfathers, "aunties" and "uncles," and periods of time living with one set of grandparents or the other.  She had lived with a friend's family for a while in high school as well.  An "uncle" and the older brother of her friend had molested her.  She had been married twice.  They were abusive relationships.  She had also had three or four tumultuous long-term relationships with alcoholic or drug abusing men.  "They" were the intimate others in her life.  "They" had "always" failed her, disappointed her, abandoned her, and dismissed her.  When the therapist asked if she had tried to work through these losses and traumas, she said that she had been in therapy on and off since she was a teenager.  Initially made to go to therapy, eventually as an adult, Frieda had tried therapy several times from several months to a couple of years.  As the therapist asked about her experiences with therapy, Frieda told the therapist, "You're the best therapist I've ever had."  When the therapist pressed about what happened with therapy and the therapists, Frieda murmured that "Oh, it didn't work out too well."  Frieda had unstable and intense relationships with therapists as well.  Frieda had unstable and intense relationships with every close intimate person.  Cliff was the latest unstable and intense relationship.  Selena as the next and newest therapist would be next on her list.

Despite the intensity of the borderline energy, a healthy invested person may be able to receive and withstand the emotional volatility.  The person would need to be able to tolerate the inevitable turmoil, confusion, and anger.  The person would need to resist being triggered, overwhelmed, and retaliating when the borderline acts out.  That was Cliff's challenge.  Within this dynamic for the intimate couple's relationship to work, the individual with borderline personality disorder must still somehow meet some of the partner's needs.  Despite everything, Cliff got a lot from the relationship with Frieda.  "Couples in which one spouse has BPD and the other demonstrates relative psychological health require another specific couple intervention.  In our experience, a psychoeducational model for the healthier spouse can stabilize and maintain the relationship" (Links and Stockwell, 2001. page 503).  The therapist would build upon how the partner is getting some needs met and how it is still "worth it."  The individual with borderline personality disorder would then be prompted, guided, and required to further meet needs in gradually more functional ways.

The pattern of intense and unstable relationships often occurs with the therapist as well.  The therapist who works through forming an intimate relationship between self and client- for example, a humanistic orientation find him or herself on unstable and erratically eruptive grounds.  Instability can express in shifts from idealization to angry accusations of betrayal.  When the individual with borderline personality disorder feels uncomfortable and helpless, he or she often looks at the omnipotent other with envy.  Cliff as a relatively healthy partner or Selena as the caring knowledgeable therapist became that other at times.  The other person is controlling, strong, and full of life and energy as opposed to the individual who is out of control, weak, and empty (McGlashan, 1983, page 52).  In childhood, the other person may have been an omnipotent parent, while in adulthood it is the intimate partner.  In therapy, it can be the therapist.  The envy motivates the individual to seek relationship for "help, sustenance, or succor.  If too intense and mixed with high titers of resentment, however, such envy can have a markedly destructive effect upon the relationship and upon the core sense of self that becomes the nucleus of the personality" (McGlashan, 1983, page 53).  While the individual with borderline personality disorder experiences him or herself as helpless, the dyad of the couple is omnipotent.

The individual denies that everyone experiences helplessness.  He or she asserts or believes the other person holds omnipotence and can give or take power and control from him or her.  Frieda asserts that Cliff is just fine and/or that Selena as the therapist is in full control.  The individual with borderline personality disorder tries to merge with the other person- not unlike an undifferentiated baby with his or her mother to re-create the secure dyad.  The individual tries to manipulate the environment to keep the fantasy of omnipotence and "the feeling of being able to control the loved object.  This control is executed through various primitive strategies and manipulations, both autoplastic and alloplastic.  Autoplastic control restores the dyad primarily through fantasy, whereas alloplastic control achieves the same result through manipulation of actual external objects" (McGlashan, 1983, page 53).  The therapist thus has two streams of information for assessing the individual and in at least three areas.  The three assessment areas are current and previous intimate relationships and the therapeutic relationship.  The two streams of information are when the individual lashes out, shuts down, isolates, condemns, and other classic borderline behaviors (alloplastic); and the individual's fantasizing and idealizing relationships, current and prior partners, and the therapist (autoplastic).  Early in therapy, the therapist should reality check idealization and fantasy preoccupation.  Frieda telling Selena that she's the best therapist that Frieda has ever had is an early indication of the idealization.  Idealization and fantasy are more likely to occur between the individual with borderline personality disorder and the therapist in the initial stages of therapy, and should be taken as forewarning later angry punishing behavior.  If the therapist recognizes seductive idealization as borderline precursors, he or she can attempt therapeutic interventions to forestall, prevent, or minimize later borderline behaviors; and to create therapeutic opportunities out of the behavior.

In the extreme, the projective process of the individual with borderline personality disorder may not only be uncomfortable, but also threatening and dangerous. The individual can intensify to an extent of rage and vengeance towards the therapist as he or she has done to other intimate figures.  "Meloy (1989) proposed that a form of pure erotomania could be identified which he referred to as borderline erotomania. An object relations framework was used to formulate this condition as 'an extreme disorder of attachment . . . apparent in the pursuit of, and the potential for violence toward, the unrequited love object' (p. 477). The attachment or emotional bonding is grossly disturbed (tumultuous, intense and discrepant to the reciprocal attachment of the loved object) and non-delusional in form, with no loss of reality testing and occurs in the context of borderline and narcissistic personality pathology" (Pollock, 2001, page 217).  Preoccupied or insecure attachment patterns may be the cause of the personality pathology of erotomanic patients with common personality disorders. Borderline personality and preoccupied adult attachment patterns seem to predict a greater potential for violence and for obsessive harassment.  Someone with borderline erotomania reacts to perceived rejection or frustration bonding with a desire to hurt the person who up until then was loved and chased.  In the extreme, this can include homicidal desires.  The urge to destroy the now hated object of affection is a way to claim ownership of the other person. The individual becomes obsessed and anxiously preoccupied to possess the love-hate object.  "Ideas expressed by borderline erotomanic patients include a sense of entitlement to own the pursued object ('if I can't have you, no-one will'), a romantic image of fusion through death (a macabre variation of 'till death do us join') and a 'felt quality of perfection' (Rothstein, 1984; p. 17) exhibited in masochistic subjugation and pride in persistence despite repetitive rebuff. In a similar vein, Zona et al. (1993) proposed that erotomania can be categorized as pure erotomania, love obsessional (no prior contact between the sufferer and sought object) and simple obsessional in which a prior relationship has 'gone sour'" (Pollock, 2001, page 217).

The drama of intimacy cannot help but be intensified when one member projects such inordinately intense energy into the relationship.  Stability may be achieved, but difficult to maintain if it is fantastically intricate and/or requires extraordinary effort that is intrinsically non-sustainable.  The therapist should elicit the "story" of intimacy from each partner to see if it is realistic to pragmatic, romantic to fantastic, and passionate to delusional.  Words to be alert to include: "always," "never," "all the time," "perfect" along with highly romantic phrases.  When Frieda saw Cliff and their relationship positively, she waxed poetic about how wonderful they were together.  The affect or emotional arousal in glorifying someone or the relationship in the story may be indicative of a disassociative emotional or cognitive perspective.  There may also be a developmental incongruity.  For example, an adult with life experiences- that is, with reality should have evolved from his or her pre-teen infatuation with media romances.  The therapist should note if the "story" is sad, tragic… with a happily-ever-after ending and redemption or vengeance and justifiable destruction!  The subjective quality of the tale should give cues to the individual's relatively functional to borderline to even erotomanic borderline emotional perspectives and views.  The therapeutic goal for developing non-borderline romantic expectations would be important… and very challenging.  The therapist should

Identify the individual's relationship pattern;

Identify the stability and intensity of relationship patterns;

Promote stable relationship behavior;

Caution the individual against over-idealization;

Restrain the individual from over-investment in the relationship;

Uncover the romantic relationship story;

Assess the individual for developmentally appropriate intimacy beliefs;

Anticipate both positive and negative over-reaction by the individual from idealization;

Maintain stable therapeutic presence and role;

Help the partner anticipate over-idealization, over-reaction, and erratic behavior;

Help the partner maintain stable presence and role.

SENSE OF SELF
There may be an identity disturbance characterized by markedly and persistently unstable self-image or sense of self (Criterion 3).  There are sudden and dramatic shifts in self-image, characterized by shifting goals, values, and vocational aspirations.  There may be sudden changes in opinions and plans about career, sexual identity, values, and types of friends.  These individuals may suddenly change from the role of a needy supplicant for help to a righteous avenger of past mistreatment.  Although they usually have a self-image that is based on being bad or evil, individuals with this disorder may at times have feelings that they do not exist at all.  Such experiences usually occur in situations in which the individual feels a lack of meaningful relationship, nurturing and support.  These individuals may show worse performance in unstructured work or school situations (American Psychiatric Association, 1994).

The individual with borderline personality disorder often has difficulty differentiating an "I" as an individual self as subject, object, or agent.  The only identity that can be formed is as part of the fused dyad, as the individual is fixated on oneself as defined through oneness with the other (the parent originally).  The result is two dyads: one being the good dyad where the sense of fullness comes from an omnipotent other and an omnipotent self; the second being the bad dyad with emotional disconnection between self and other.  The bad dyad contains a helpless other and a helpless self.  The two parts becomes the core of each other's sense of self positively or negatively.  The individual with borderline personality tries to and succeed often in actualizing one or both dyads with another person through projective identification.  The individual tries to make the other person think, feel, and act as the "actual primitive symbiotic other.  As Khan described it, borderline patients introduce an 'urgency' towards externalizing and acting out their past experiences and current tensions…" (McGlashan, 1983, page 49-50).  The baby begins to realize that he or she can influence the greater world through his or her crying, for example.  The baby feels distress, cries, and finds that crying brings a caregiver with soothing behaviors: food, warmth, caresses, etc.  The relief feels within his or her control if it comes quickly.

With delays or poor responses from the caregiver, the infant becomes aware that he or she is not omnipotently in control of gaining relief.  He or she realizes relief is under the control of an all-powerful caregiver.  The caregiver as a result becomes idealized.  The infant then feels separate, devalued, dependent, and helpless.  This is hypothesized to be the experience of the adult individual with borderline personality disorder.  The other person- the partner or the therapist is seen as omnipotent and again, the self is seen as helpless and envious.  The individual compulsively tries to re-fuse with the other and re-establish the good dyad.  Feeling helplessly wanting and the other omnipotent, fusion is conceived as controlling and manipulating the other (McGlashan, 1983, page 50).  The therapist should focus the individual on developing a healthy sense of self within and outside of the relationship, couple, or family.  The individual's instinct to subordinate him or herself and to accrue resentment needs to be identified, confronted, and worked on.  Whether the individual idealizes or condemns him or herself or the partner or therapist, the therapist should challenge and prompt for a balanced and nuanced sense of self, of self with another, and of dyads.  The therapist challenges

The individual's helpless by prompting assertive behavior;

The individual's omnipotence by pointing out incapacities;

The individual's fantasies about perfection relationships through reality checking;

The individual's assertion of other (partner or therapist) omnipotence by pointing out other's limitations;

The individual's denigration of other (partner or therapist) amoral intent through reality checking;

The individual merging self with the other (partner or therapist) by revealing autonomous choices;

The individual to find and express a core of self;

The partner resist the individual's loss of self, attempts to merge selves, idealization, and other problematic actions;

The partner to maintain personal autonomy while encouraging and requiring the individual to have personal autonomy as well.

IMPULSIVITY AND SELF-DAMAGING MOOD
Individuals with this disorder display impulsivity in at least two areas that are potentially self-damaging (Criterion 4).  They may gamble, spend money irresponsibly, binge eat, abuse substances, engage in unsafe sex, or drive recklessly.  Individuals with Borderline Personality Disorder display recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior (Criterion 5).  Completed suicide occurs in 8%-10% of such individuals, and self-mutilative acts (e.g., cutting or burning) and suicide threats and attempts are very common.  Recurrent suicidality is often the reason that these individuals present for help.  These self-destructive acts are usually precipitated by threats of separation or rejection or by expectations that they assume increased responsibility.  Self-mutilation may occur during dissociative experiences and often brings relief by reaffirming the ability to feel or by expiating the individual's sense of being evil (American Psychiatric Association, 1994).

Examination of the different explanations and criteria for a diagnosis of borderline personality disorder finds that many overlap and have influence upon each other.  While attachment issues appear to be at the core of abandonment fears, Fossati et al. (2005) proposed that adult attachment patterns did not have direct effects on borderline personality disorder.  Instead, "our best fitting model indicates that individual differences in adult attachment characteristics are related to individual differences in the personality traits of impulsivity and aggressiveness, which in turn predict BPD features… Overall, adult attachment patterns seem to be related more to aggressive personality features than to impulsivity" (page 532).  There is a significant relationship between low attachment security and high aggressiveness, along with a lesser relationship with impulsivity.  Preoccupation with relationships, which is indicative of anxious/ambivalent attachment best predict aggressive personality characteristics.  A combination of "an intense desire to merge with another person and by fears of being rejected by that person (Hazan & Shaver, 1987; Feeney et al., 1994) seems to be moderately predictive of the level of aggressiveness, at least in clinical subjects.  This result parallels findings from nonclinical adult samples, in which relationship anxiety (cf. anxious/ambivalence) has been associated with high levels of conflict, coercion, and domination (e.g., Feeney, 1999).  Moreover, our findings are not only consistent with previous studies linking 'preoccupied' attachment and BPD (Fonagy et al., 1996; Patrick et al., 1994; Sack et al., 1996), but also clarify the nature of this association by suggesting that preoccupation is an indirect risk factor for BPD because of its association with aggressive traits" (page 533).

Reisch (2008) reported that their controls more than individuals with borderline personality disorder activated joy and interest when not perceiving joy.  This implies that individuals with borderline personality disorder are in addition to being sadder, angrier, and more fearful, but also less often activate positive emotions (page 47).  The glass is half-empty, emptier, and going to be even emptier rather than being hopeful and positive.  The therapist may need to focus the individual on positive emotions and activate positive energy and action as a part of therapy.  Therapy may need to examine why the individual has difficulty being positive and joyful.  It may be a defensive survival mechanism acquired to avoid disappointment.  The individual's difficulty being joyful or being positive translates into negativity and anxiety.  That can create a negative reciprocal effect between them if one member's discomfort or unfamiliarity with emotional intimacy aggravates the other member's anxiety about not gaining or having intimacy.  "This can potentially set the stage for a self-feeding cycle of abuse from the anxious partner who resorts to increasingly aggressive strategies in order to hold on to a distant partner" (Henderson et al., 2005, page 228).  Therapy that works on reducing aggressiveness and impulsivity may help reduce overall borderline behaviors.  Working on attachment anxiety- increasing attachment security and being joyful should coincide with the other strategies.  Experience, including childhood attachment issues, cultural, and ongoing influences and temperament is displayed in many personality characteristics of the individual with borderline personality disorder.

Impulsivity is considered a core characteristic of borderline personality disorder.  There are biochemical explanations for impulsivity.  "Impulsivity is a central characteristic of both borderline and antisocial personality disorders.  It may be related to reduced serotonergic modulation of key cortical inhibitory areas, resulting in a loss of the normal inhibition of aggressive acts (often manifested as deliberate self-harm, suicide, and violence towards others)… borderline (and also in mood-disordered) patients who demonstrated a blunted response to agents that normally enhance serotonin activity.  Structural and functional imaging studies subsequently localized this reduced serotonergic responsiveness to the orbital frontal cortex and related ventral medial and cingulated cortices, which are involved in evaluating incoming affective stimuli" (Smith et al., 2004, page 136).  The therapist should be aware of brain chemistry theories and neurotransmitters among other biological explanations to help understand and help the individual and partner understand the temperamental foundation of the individual.  However, the therapist who conducts psychotherapy works primarily with the emotional, psychological, and other social/cultural environmental influences that interact with biochemical characteristics.  The individual with borderline personality disorder may be biochemically predisposed to impulsivity.  With other environmental influences including gender standards, the individual's impulsivity may manifest in various ways.  The therapist may examine for harmful sexually impulsive behaviors.  "…theoretical and clinical analyses frequently underline how women diagnosed with BPD often adopt problematic sexual behaviors and evidence a pattern of intense and unstable love relationships (Neeleman, 2007) …sexuality is often used to avoid chronic feelings of emptiness or to soothe abandonment anxiety, and disturbances in sexual identity are common.  Thus, sexual symptoms observed in BPD patients are heterogeneous, ranging from persistent promiscuity and perversions to severe inhibitions and ambivalence" (Bouchard et al., 2009, page 106-07).

Dysfunctional attitudes toward sexuality may arise from various sources.  Women with borderline personality disorder have rates of childhood sexual abuse ranging between 60-80%.  Sexual abuse is likely to distort what are healthy perceptions of intimacy and sexual behavior.  In addition, a "significant portion of this population exhibit high impulsivity and temperamental disposition toward sensation-seeking (Cloninger, & Svrakic, 2000) which puts them at high risk of erratic and high-risk sexual practices.  For example, Hull, Clarkin and Yeomans (1993) found that 46% of their sample of women diagnosed with BPD reported that over the past 5 years they had impulsively entered into at least one sexual relationship with partners they did not know well."  In addition, insecure attachment with abandonment fears and trust issues may be closely associated with sexual motives, strategies, and feelings.  The individual with anxious attachment preoccupation with abandonment or rejection may engage in sex to get reassurance that a partner cares about him or her and to captivate his or her attention.  The individual may also be more compliant with partner's sexual demands to avoid his or her displeasure or rejection.  Bouchard et al. report women with borderline personality disorder have more negative attitudes toward sexuality, greater sexual ambivalence, and feeling more pressured to have sex than other women.  "The hypothesis that women suffering from BPD would evidence more ambivalence toward sexuality is supported and is consistent with previous observations in a sample that also examined childhood sexual abuse (Noll et al., 2003)" (page 116).  Anxiety about abandonment anxiety appears to not only affect overall interpersonal functioning, but specifically the individual's subjective sexual experience, which includes romantic relationships.  Sexual relationships in the couple gets mixed up with desperate needs for closeness and fear of rejection.  "One explanation could be that these women may feel they have to engage in sex with their partner (i.e., feeling pressured) because they have the inner need to calm the fear that their partner would reject them or worse if they were to refuse to engage in sex with them (i.e., anxious attachment)" (page 117).  The therapist, as a part of assessment should therefore explore the sexual intimacy dynamics between the partners.

Frieda and Cliff thought couple therapy would help for communication problems.  Before attempting communications training with the couple, the therapist explored what they meant by communication problems.  Their sexual intimacy including initiating sex and frequency of intercourse came up as a place where there were communication problems.  When asked how often each of them wanted to have sex and how often they had sex, Cliff said he liked to have sex two or three times a week, but that they had sex about once a week.  Frieda said she had lost a lot of her sexual energy after having kids, so she could take it or leave it.  She disagreed with Cliff and said they had sex a couple of times a week.  When asked who initiated sex and how agreeable the other person was to have intercourse, Cliff said Frieda hardly ever initiated sex.  When he did, she was relatively compliant but seemed resentful about it.  "I know I'm not Don Juan, but a little enthusiasm would be nice.  Sometimes in the middle of making love, I feel like I'm on my own."  Frieda said, "I do my wifely duties, so what are you complaining about?  I see how you look at young women.  How do you think that makes me feel?"  The therapist began asking about her sexual energy and if it were true that she wasn't particularly passionate about making love with Cliff.  It turned out that Frieda was usually sexually compliant even when she wasn't interested or aroused.  Having sex anyway- it hardly felt like making love caused her to become resentful.  And, Cliff's complaints about her not being passionate and passive were essentially true.  She resented that as well.  With more investigation, both members confirmed that their sexual relationships had slowed deteriorated over several years.  Cliff's awareness of Frieda's passivity and resentment had grown slowly, while Frieda's resentment had always been there.  "I didn't even know she was all upset about this," said Cliff.  "I believed her when she said she was just tired.  And I believed her when she said it was ok to make love.  I didn't know she thought I was forcing her to have sex.  Shit… I'm no rapist!"  Frieda had not expressed her changing feelings about sex however and would not have until the therapist confronted them about it.  Dealing with these feelings was going to take much more than merely communications training.

The individual with borderline personality disorder may appear willing and compliant sexually with his or her partner, but may be anxious and feel coerced or forced sexually.  All the while, the individual unbeknownst to his or her partner is accruing a reservoir of resentment.  The partner's assumption of mutual and compatible sexual activity leaves him or her unprepared for an explosive borderline outburst.  The therapist should examine for this history and predict and prepare the couple to avoid or minimize its reoccurrence.  The therapist should prompt the individual with borderline personality disorder to reveal hesitancies, reluctant acceptance, and avoidance choices so that the couple can negotiate choices overtly without hidden resentments accumulating. Such issues are not uncommon in couples and often come up in couple therapy.  The intensity of feelings, the toxicity of behavioral consequences, and underlying causes however will differentiate readily and how well these issues are managed.  These common sexual issues in couples can become very destructive when there are borderline vulnerabilities to amplify them.

Links and Stockwell (2001) feel that highly impulsive individuals are not likely to function well enough to stay married.  On the other hand, the marital relationship may be able to modulate more moderate levels of impulsivity.  The level of impulsivity strongly predicts the course of borderline personality disorder.  Previous impulsivity predicts future impulsivity and levels of affective and psychotic symptoms over time.  As a result, Links and Stockwell recommend individual therapy with the individual has high levels of impulsivity rather than couple therapy.  As stated earlier, the therapist may not have this choice when the couple has presented for therapy.  Links and Stockwell note in their own experience, that the individual with borderline personality in a relationship tends to demonstrate less suicidality.  Since suicide or suicidal gestures can be a dysfunctional attempt at communication, couple therapy can identify and teach more functional alternate communication.  Addressing other impulsive behavior including substance abuse can also be integrated into with couple therapy with the partner as an active participant (page 496).  The partner can be empowered by joint agreement among the members and the therapist to monitor and intervene as the individual with borderline personality disorder becomes impulsive.  On his or her own, the individual's impulsivity may trigger and intensify without any restraint or effective awareness.  Both the partner and the therapist, if empowered by the individual can anticipate triggers and attempt to modulate intensification.  The therapist

Should assess for the individual's history of impulsive behavior, including temperamental characteristics;

Should assess for the individual's aggressive tendencies;

Should teach the individual and the partner how to anticipate the individual's triggers for impulsive and aggressive behavior;

Should teach the individual self-management skills for his or her impulsivity and aggression;

Should evaluate the individual's ability to have joy and work against his or her dysphoria;

Should examine the role of sexual activity, compliance, and impulsivity in the individual's relationship history and present;

Should examine for sexual abuse history in the individual;

Should conduct psychoeducation of the origins and effects of impulsivity for both the individual and the partner;

Should guide the partner in responding appropriately to the individual's impulsivity.

REACTIVITY OF MOOD
Individuals with borderline personality disorder may display affective instability that is due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) (Criterion 6).  The basic dysphoric mood of those with borderline personality disorder is often disrupted by periods of anger, panic, or despair and is rarely relieved by periods of well-being or satisfaction.  These episodes may reflect the individual's extreme reactivity troubled by chronic feelings of emptiness (Criterion 7).  Easily bored, they may constantly seek something to do.  Individuals with borderline personality disorder frequently express inappropriate, intense anger or have difficulty controlling their anger (Criterion 8).  They may display extreme sarcasm, enduring bitterness, or verbal outbursts.  The anger is often elicited when a caregiver or lover is seen as neglectful, withholding, uncaring, or abandoning.  Such expressions of anger are often followed by shame and guilt and contribute to the feeling they have of being evil.  During periods of extreme stress, transient paranoid ideation or dissociative symptoms (e.g., depersonalization) may occur (Criterion 9), but these are generally of insufficient severity or duration to warrant an additional diagnosis.  These episodes occur most frequently in response to a real or imagined abandonment.  Symptoms tend to be transient, lasting minutes or hours.  The real or perceived return of the caregiver's nurturance may result in a remission of symptoms (American Psychiatric Association, 1994).

The individual with borderline personality disorder experiences depression differently from others.  "Depressive experiences in patients with borderline personality disorder can be expected to be associated with anger and anxiety and with primitive forms of object relations" (Leichsenring, 2004, page 11).  Moreover, the individual's emotional mood tends to be unstable.  Reisch et al. (2008) states that the individual with borderline personality disorder has emotional instability as manifested with switches from anxiety to sadness and from sadness to anxiety.  Mood instability can lead to dysfunctional behavior (page 47).  "According to Linehan's biosocial theory, the defining pattern of BPD is emotional vulnerability characterized by heightened sensitivity and reactivity to stressors.  Heightened sensitivity in BPD is manifested by a low threshold for emotional reactions, while heightened reactivity gives rise to immoderate reactions… BPD patients demonstrated lower levels of emotional awareness, an impaired ability to cope with mixed valence feelings, as well as reduced accuracy in recognizing facial expressions of emotions, and more intense responses to negative emotions than non-borderline controls… BPD patients exposed to induced frustration while gambling showed an aggression level three times that of controls.  After assessing mood ratings for a 14-day period, Cowdry et al. found that BPD patients exhibited higher mood variability when compared with other psychiatric groups.  Stein discovered that the diary entries made over 10 days by female BPD patients contained more unpleasant affect and greater short-term fluctuation of emotions than entries made by controls.  Correspondingly, Herpertz et al. found a lowered threshold for affective responses together with rapidly changing affects (affective hyperactivity) for this patient group.  Hochhausen et al. point out that disinhibition of emotions is a potentially important component characterizing BPD.  Such traits fluctuate rapidly in intensity to beyond adaptive to maladaptive expression… Stiglmayr et al. were able to demonstrate that symptoms (dissociation) of BPD patients were strongly related to stress, indicating that it is crucial to focus emotion states beside traits.  In another study, Stiglmayr et al. showed that BPD subjects experience more frequent and prolonged states of aversive tension.  Koenigsberg et al. found that both oscillation between depression and anger, as well as oscillation between anxiety and depression, seem to be key features of BPD"  (Reisch et al, 2008, page 43).

The individual has a variety of negative rapidly fluctuating emotions including aggression that come from either temperamental makeup, environmental influences, or some combination of the two.  "Regardless of origin, high levels of aggression interfere with the normative developmental process of integrating disparate representations, and instead the high levels of aggression result in a division between positive and negative representations" (Levy et al., 2006, page 484).  Emotional instability interferes with developing a stable sense of self and of others.  "Kernberg and colleagues (Clarkin, Yeomans, & Kernberg, 2006) also note that emotional instability in borderline personality disorder can be secondary to a lack of differentiation and integration of internal images of self and others, which leads to instability in one's sense of self and ultimately to affective instability.  Thus, the relationship between lack of integration of representations and affective instability may operate in a vicious circle, as the intensity of early affects results in a split experience of self and others to protect positive representations, which then may lead to further affective instability by failing to provide a foundation from which to understand oneself and others" (page 484-85).

Emotional instability may be related to a deficiency or an inhibition of the ability to mentalize.  Mentalization refers to the individual with borderline personality's ability to recognize his or her and others' mental states.  In addition, mentalization includes the ability to see mental states as separate from behavior. The individual has difficulty thinking about thoughts, emotions, wishes, desires, and needs in him or herself, as well as in others- particularly his or her partner.  The individual does not recognize how internal experiences might affect the actions one or others take, while being separate from those actions.  Improvement in the ability to mentalize therefore becomes a goal of therapy.  This would "increase emotional stability in BPD patients by allowing them to shift their attention when experiencing negative emotional states and to find more contextualized meaning in their own and other people's behavior" (Levy et al., 2006, page 495).  Dialectical behavior therapy utilizes mindfulness meditation, where the individual focuses on breathing and observes emotions come and go without acting on them (Carey, 2011).  When the individual is able to be more mindful of his or her internal emotional and mental process, he or she can make different choices behaviorally.  "Mindfulness involves the ability to observe, reflect, and describe emotional states while developing focused attention, and it is thought to help BPD patients to develop perspective and tolerate and regulate negative affective experiences without being overwhelmed.  According to Linehan, and similarly to Kernberg's conceptualization, the patient begins to understand a separation between the observer and the observed, and thoughts are not taken as literally "true" and to be acted on.  Although there are subtle differences, the concepts of mindfulness, mentalization, and integrated representation share important conceptual overlaps.  Fonagy (Fonagy et al., 1997) notes that RF is intimately related to the representation of the self (Fonagy & Target, 1995, 1996; Target & Fonagy, 1996)" (page 495).  Therapy for the individual with borderline personality disorder and his or her partner can include mindfulness training and concepts from related theories and processes such as emotional intelligence. The therapist

Needs to be knowledgeable and prepared for the reactivity of emotions in the individual;

Needs to train the individual to modulate emotional reactivity;

Should help the individual better mentalized his or her and other people's thoughts, emotions, wishes, desires, and needs;

Teaches the individual how internal experiences affect choices while being separate from them;

Promotes mindfulness and emotional intelligence.

ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
phone: (510) 614-5641
fax: (510) 889-6553
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