3. THE BORDERLINE PATIENT Am J Psychiatry 135:1!, November 1978
1306
most discriminating data in their descriptive studies to
be in the observation of the difficulties borderline pa-
tients have in interpersonal relationships, particularly
in terms of their pervasive sense of aloneness and their
tendency to see difficulties as emanating from outside
themselves. Gunderso& suggested from his data that
these attributes, as well as an inability to acknowledge
wants and to discriminate them from needs, are ‘ ‘core
conflicts” in borderline patients.
On unstructured projective tests that provide the op-
portunity for regressive responses, borderline patients
reveal evidence of primary process thinking (7), a
strong tendency to add too much and too specific af-
fect to simple perceptions, and a propensity to pro-
duce these peculiar responses without concern or em-
barrassment. Margaret Singer’s review ofseries of test
reports (8) revealed that these responses do not occur
on more structured tests, suggesting that these pa-
tients can utilize an external organizing structure to
support their thinking. This finding has been corrobo-
rated by repeated clinical observations (2, 9-1 1). Mel-
yin Singer (12) suggested the presence of a cognitive
disturbance in which these patients fail to structure,
delay, detour, and check their impulses and affects
through “cognitive binding” (i.e., through con-
templation, fantasy, reflection, and symbol forma-
tion).
These findings suggest that borderline pathology is
related to difficulties in the management of impulse
and affect, which is perceived most characteristically
in interpersonal relationships and emerges most clear-
ly in relatively unstructured settings. The intensive,
relatively unstructured therapeutic relationship, then,
is an ideal setting in which to study in detail the ele-
ments of the disorder.
TRANSFERENCE DEVELOPMENT AND PROBLEMS
The response of borderline patients in intensive
therapy is characteristically marked by gross fluctua-
tions in perception, thinking, and feeling about them-
selves and the therapist, without awareness of the con-
tradictions (13, 14). Margaret Singer (8) found this tol-
erance and bland acceptance of contradictory thoughts
a unique attribute of these patients.
Kernberg (7) described the borderline patient as
having little capacity for realistic appraisal of others
and, in the absence of a relationship, as experiencing
others as distant objects to whom he can compliantly
adapt. In therapy borderline patients present narrow,
rigid, unmodulated affects (15) and show little ability
to tolerate guilt, concern, or internalized depressive
affect (16, 17). They have difficulty in discriminating
and reporting body sensations and emotions (13) and
manifest little capacity for anxiety or frustration toler-
ance, delay, or impulse control (7). Their unpleasant
‘Gunderson JG: Discriminating characteristics of borderlines and
their families (unpublished paper, 1977).
affects readily escalate to panic without triggering re-
liable defensive operations (18), and they manifest a
profound sense ofidentity diffusion, with little sense of
inner continuity from past to present to future (15).
Unlike the majority of psychotic patients, they are ca-
pable of higher level defenses and good reality testing
in many situations, but they are likely to regress to
transient psychotic states under stress or within the
transference relationship, readily developing fantasies
of extreme neediness, destruction, and abandonment
(7, 19).
The transference of the borderline patient has been
described as immediate, intense, and chaotic, only
gradually developing over time into discernible pat-
terns (7, 15). Modell (20-22) described the patient’s di-
agnostic transference response to the therapist as simi-
lar to the infant’s response to the ‘ ‘transitional object”
(e.g., blanket or teddy bear). He suggested that al-
though the patient recognized the therapist as existing
outside the patient (as is not the case in the transfer-
ence of many psychotic patients), the quality of this
perceived existence is determined by processes arising
within the patient. Although neurotic patients also at-
tribute certain qualities of their own to a therapist,
they seem to have the capacity to recognize the origins
of these perceptions within themselves, while border-
line patients do not (5).
The transference response described by Modell is
seen most clearly in the borderline patient’s difficulty
in asking the therapist for help in a way that would
imply an acknowledgment that the therapist as a sepa-
rate person might reasonably refuse or be unable to
respond to the request. For the borderline patient, to
consider the possibility of the therapist’s refusal is to
become aware of anxious, rage-filled fantasies of aban-
donment that are perceived as potentially arising from
the therapist. To avoid these fantasies, the patient
does not ask directly for help. Instead, he either an-
grily demands a response or overtly ignores the thera-
pist in the session while maintaining an illusion of com-
fort from the therapist’s presence. This response is
seen as similar to the child’s response to his blanket.
Winnicott (23) described the child’s blanket as
something that possesses attributes of its own
(warmth, texture, something “not me”) yet is not al-
lowed to change unless changed by the child. It is
“used” by the child-both loved and mutilated-and
must survive both (24). As in the therapeutic relation-
ship described by Modell, the blanket is not “asked”
for help. It is, instead, symbolically placed as a pro-
tective shield between the child and the dangers of the
outside world; the child is comforted by it. Several au-
thors (23, 25-27) have described the relationship with
the transitional object as representing a phase in the
child’s gradual separation from his mother, a gradual
disengagement in which the blanket partly represents
his mother (and the child) and partly represents the
outside world. Abelin (28) described the father as oc-
cupying this position during the child’s separation-in-
dividuation period.
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In the early stages of therapy, some borderline pa-
tients use inanimate objects, animals, or certain fan-
tasies as transitional ways of relating to the therapist,
metaphorically putting these objects between them
and the therapist both to protect them from a dan-
gerous intimacy and simultaneously to allow a rela-
tionship to exist (25, 26).
Borderline patients demonstrate their characteristic
unmodified, polarized responses in the therapeutic
relationship (15, 22). They have magical expectations
from therapy, often anticipating improvement without
their own active participation. They may experience
the therapist as benevolent but demonstrate the con-
stant fear that he or she will be transformed into the
opposite. Under stress, they may experience the ther-
apist as attacking and may fear that they will be domi-
nated, controlled, or abandoned by him (19, 29). In the
latter experiences they feel alone, helpless, and needy
and appear unable to maintain a reliable sense that the
therapist remains with them in a caring way (19). Be-
cause ofthese tensions, they present the manifest con-
flict of extreme dependence and intense fear of close-
ness, the solution to which appears to be a constant
preoccupation with maintaining the ‘ ‘ proper’ ‘ distance
from the therapist in order to regulate their anxiety
about both distance and closeness.
EGO DEFENSES
The use of specific primitive ego defenses has been
described as characteristic of the borderline patient in
intimate relationships. Kernberg (7, 30), in describing
the borderline patient’s disjointed, contrasting behav-
iors and fantasies in intensive therapy, suggested that
there is an underlying pattern of sharply polarized fan-
tasied relationships that is “activated” in the transfer-
ence. The polarization of these fantasies is determined
by the defensive maneuver labeled “splitting.” Kern-
berg suggested that borderline patients’ core difficulty
lies in their inability to bring together and integrate
loving and hating aspects of both their self-image and
their image of another person. Kernberg’s observation
was that these patients cannot sustain a sense that
they care for the person who frustrates them. Kern-
berg saw this characteristic failure in the achieve-
ment and tolerance of ambivalence and in the modifi-
cation of affects as diagnostic. He suggested that lov-
ing fantasied relationships and hating ones are
internally ‘splif’ for the borderline patient to prevent
the anxiety that would result if they were experienced
simultaneously. These positive or negative stereo-
typed fantasies are activated in a relationship depend-
ing on the degree of gratification or frustration per-
ceived by the patient. In a gratifying relationship, the
patient develops positive fantasies, with the negative
ones dissociated or “split off” and therefore unavail-
able. When frustrated, the patient elaborates negative
fantasies and loses all memory of the positive relation-
ship.
Other authors (1, 4, 13, 31, 32) have been less
comfortable with the idea of splitting as a primary
mechanism for borderline patients. Most, however,
acknowledge the patient’s failure to integrate and
modify impulses and affects as an important character-
istic.
Splitting as a defense is to be distinguished from de-
nial, which is the disavowal of whole percepts and the
substitution of a wish-fulfilling fantasy, and repres-
sion, which is the repulsion of mental content from
consciousness due to a linkage of that content with a
conflicted memory (33). In splitting, the positive and
negative fantasied relationships remain alternatively in
consciousness with the complementary side dissoci-
ated.
Defensive splitting also contributes to the patient’s
alternating view of the therapist as omnipotent and de-
valued. In these responses to the therapist, the patient
experiences no real dependency on him in the sense of
love or concern. Instead, the patient experiences a
sudden shift from total need to total devaluation (7).
A second major defense ofborderline patients, often
associated with both splitting and transitional related-
ness, is that ofprojective identification (7, 34-38). This
defense involves the dissociation of uncomfortable as-
pects of the personality (elements of impulse, self-im-
age, or superego) and the projection of them onto an-
other person, resulting in an identification with the
other person because of having attributed qualities of
the selfto him. Included in this intrapsychic and inter-
personal mechanism, particularly for borderline pa-
tients, is the unconscious attempt to evoke feelings or
behavior in the other that conform with the projection
and the willingness (conscious or not) of the recipient
of these projections to accept these attributes as part
of himself (32).
The person using this defense is selectively in-
attentive to the real aspects of the other that may con-
tradict or invalidate the projection (39). In addition,
the other (now seen as possessing the disavowed char-
acteristics) is consciously identified as unlike the self
(36), while an unconscious relationship is sustained in
which the projected attribute can be vicariously expe-
rienced.
This defense differs from projection in that the indi-
vidual maintains some contact with that which is pro-
jected. The projections are not simply placed onto an-
other; an unconscious attempt is made to develop a
relationship with the other and to involve him as a col-
lusive partner in conforming to the way in which he is
perceived (37, 40).
Projective identification is a defense used along a
spectrum of psychopathology from normal to psychot-
ic. The severity of the pathology is determined by the
content of the projection, the capacity of the subject to
test reality and to differentiate himself from another
person, and the intensity of the subject’s defensive
need to avoid conflict by disavowing a dystonic aspect
of himself. Depending on the interaction of these fac-
tors, projective identification can endow a relation-
5. THE BORDERLINE PATIENT Am J Psychiatry /35:1/, November 1978
1308
ship with emphatic qualities or create a delusional
distortion and give a binding quality to the interac-
tion (38).
Ofcentral importance in the borderline patient’s use
of this defense are its consequences in terms of a
weakening of his or her ego functioning. Klein (34)
noted that projection of aggressive aspects of the self
may result in a loss of attributes important for the de-
velopment of power, potency, strength, and knowl-
edge. Kernberg (30) suggested that the resultant failure
of integration leads to incomplete development of in-
ternalized standards (e.g., guilt and internal delay of
impulses) and other internal “structures” (18).
Similarly, according to Klein (34), the chronic pro-
jection of positive aspects of the self (as seen in primi-
tive idealization) may result in extreme dependency,
loneliness, fear of parting, and fear of the loss of the
capacity to love. Kernberg (7) suggested that the bor-
derline patient’s use of idealization in its primitive
form involves no regard for the real person who is
idealized but represents a use of the other as a
‘ ‘thing’ ‘-an ‘ ‘all positive’ ‘ magical protection in a
dangerous world (3, 7).
The borderline patient has been described as having
a peculiar ‘ ‘empathy’ ‘ for the unconscious impulses of
other people (41 , 42) and as having little or no ability to
recognize the mature defenses, reaction formations, or
other adaptive ego functions manifested by the other
person in his struggle with these impulses (7, 43). This
intuitive sensitivity allows for a powerful coercive use
of projective identification because there is often some
degree of perceptual accuracy in the projection that
touches a conflicted area of the recipient. When frus-
trated and projecting their anger in therapy, for in-
stance, borderline patients may utilize this intuition to
provoke a response in such a way as to justify their
distrust and may then destroy, devalue, or reject all
the therapist has to offer (44).
COUNTERTRANSFERENCE
The use of these primitive defenses contributes to
the transference-countertransference difficulties often
seen in intensive treatment. Many authors have de-
scribed the powerful countertransference responses
evoked by the borderline patient (11, 13, 14, 19, 20, 22,
45). Unlike the more gradually developed, complex,
empathic understanding that characterizes his or her
response to neurotic patients, the therapist’s response
to the borderline patient’s transference appears to be
more rapid, intense, and stereotyped. Different thera-
pists discover similar responses to these patients; the
response seems less related to specific problems of the
therapist’s past and more to the patient’s poorly in-
tegrated impulses (7).
Because of their defensive inability to integrate lov-
ing and angry aspects of the same internal image, bor-
derline patients are inordinately sensitive to minor
frustrations in treatment. In the face of such frustra-
tions, their characteristic response is to withdraw all
affectively positive perceptions of the therapist and
reinvest them elsewhere. At this point, patients
“lose” all memory of positive experiences with the
therapist and feel abandoned. Through the mechanism
of projective identification, they experience the thera-
pist as attacking and rejecting and respond defensively
to control their now projected rage (46). Their defen-
sive response may include rage, devaluation, with-
drawal, or paranoid thinking and an inability to call up
the previously experienced image ofa comforting ther-
apist (19).
If the therapist exposed to these raw affective inter-
changes undergoes an “empathic regression” (7) in an
attempt to keep in touch with the patient, he may be-
come vulnerable to countertransference guilt and anx-
iety. Many therapists who have devoted their lives to
healing are concerned at some level about their capac-
ity to hurt, which borderline patients unconsciously
sense. In his introspective attempt to understand the
patient, the therapist might find a punitive aspect of
himselfat whom the patient might “accurately” be an-
gry. Such a counteridentification might evoke guilt in
the therapist which, when perceived by the patient,
would validate the patient’s projection, making it diffi-
cult for the therapist to work on it collaboratively with
the patient as a projection (46, 47). This blurring of ego
boundaries between patient and therapist might con-
tribute to the familiar regressive transference psycho-
sis in which patients’ reality testing is lost, their un-
modified rage and guilt increase, and they experience
the therapist as a reincarnation of the fantasied early
frustrating parent.
Similarly, the unexpected and uncontrolled intensity
ofthe patient’s rage may make the therapist vulnerable
to his own anxiety, which is potentially disruptive to
the therapeutic work. Such anxiety in the therapist
could be related to the possible loss of the relationship
with the patient (with specific countertransference im-
plications) or the need to manage his own hatred and
need to retaliate (45, 48). In response to these counter-
transference feelings, Kernberg (7) suggested that oth-
erwise sophisticated therapists may at times experi-
ence an almost masochistic submission to the patient’s
aggression, disproportionate doubts in their own ca-
pacity, and exaggerated fears of criticism by third par-
ties.
In their description of the therapeutic task with bor-
derline patients, several authors have discussed the
need for the therapist to withstand these unmodified
affects without withdrawal or retaliation. The thera-
peutic position is characterized as the provision of a
“holding environment” (49), a response that includes
the need 1) to reflect, absorb, transform, and feed back
the patient’s responses (7), 2) to maintain contact, con-
cern, and emotional availability (50), 3) to set limits for
the patient to help him or her manage internal and ex-
ternal stimuli, and 4) to accept the patient’s ambiva-
lence with continuing concern (19). This description of
the therapeutic response in situations in which inter-
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pretation appears to have no effect (51) has its parallels
in the developmental observations described below.
OBJECT RELATIONS THEORY
Much of the data derived from the above observa-
itons has been used by theorists in the development of
object relations theory (7, 21, 33, 52-55). The basic as-
sumption behind this theory is that one can understand
the relationships between people through an examina-
tion ofthe internal images they have ofone another. In
the healthiest people, these images correspond rather
accurately to the reality of the other person and are
continually reshaped and reworked as new informa-
tion is perceived and integrated. In less psychological-
ly healthy people, the images are stereotyped, rigid,
and relatively unchanged by new information. The the-
ory proposes a model for the developmental shaping of
these images as the child begins to separate the image
of himself from that of his mother. Anna Freud (56)
characterized this developmental line as proceeding
from dependency to emotional self-reliance to adult
relationships.
According to the theory, there are at least three ma-
jor developmental tasks in this progression: 1) self-ob-
ject differentiation, 2) the integration ofloving and hat-
ing images and the development of object constancy,
and 3) the further integration ofthese images into flex-
ible psychic structures (for example, superego and ego
ideal).
These ideas are based primarily on clinical observa-
tions of transference relationships with psychotic, bor-
derline, and neurotic patients and are inferentially re-
lated to early child development. Self-object dif-
ferentiation refers to the child’s capacity to separate
intrapsychically the boundaries of his own experience
from his experience of his mother. Failure in this task
is presumably seen in psychotic patients who have dif-
ficulty in recognizing the therapist’s independent exis-
tence. The attainment of object constancy (or the “de-
pressive position”) (16, 34) is a consequence of the
child’s capacity to recognize himself simultaneously as
both loving and hating in response to the image of an-
other who is both gratifying and frustrating. Accom-
plishment of this task presumably allows the child to
tolerate and master separation and loss by being able
to maintain a comforting image of the mother (a “con-
stant object image”) despite her frustrating the child
by her absence (11, 56). Further, the capacity to ac-
knowledge angry feelings toward the image of a loved
person leads to the development of the capacity for
reality testing and the capacity to tolerate guilt, con-
cern, and “internalized depression” (11, 56). “Inter-
nalized depression” in this sense refers to an experi-
ence of mourning and regret over lost “good” internal
images, rather than the more primitive sense of impo-
tent rage and defeat by external forces (7). Failure in
this achievement of object constancy is presumably
characteristic of borderline patients who have mas-
tered self-object differentiation but cannot tolerate
separation or ambivalence without regression.
This object relations view of borderline pathology is
of interest in that it suggests a basis for the failure of
object constancy. Presumably, the child must have a
strong enough image of his positive relationship with
his mother to be able to tolerate the integration of his
images of negative interactions with his mother with-
out being overwhelmed. Kernberg (7, 30) suggested
that this failure of integration and the persistence of
splitting is due to excessive aggression, either consti-
tutional or from excessive or chronic early environ-
mental frustration.
Homer (57) described the person who has mastered
these tasks as ‘ ‘ a separate individual who has a firm
sense of self and other, who is able to relate to others
as whole persons rather than simply need satisfiers,
who can tolerate ambivalence . . . and who has the
ability to sustain his own narcissistic equilibrium from
resources within the self. ‘ ‘ Further integration, modifi-
cation, and ‘ ‘depersonification’ ‘ of these internalized
relationships evolves into such psychic structures as
superego and ego ideal (7, 30).
DEVELOPMENTAL PSYCHOLOGY
Many psychoanalytically oriented researchers who
study preverbal infant development focus their atten-
tion on the intimate mother-child relationship, an area
of particular interest to the student of borderline psy-
chopathology. The literature, however, is filled with
warnings about the dangers of direct extrapolation
from infant observations to adult phenomena (58-61).
Since the infant has a unique cognitive apparatus with
little capacity for conscious memory and verbal sym-
bolization, it has been suggested that the child observ-
er’s inferences are likely to be distorted by “retro-
spective falsifications and adultomorphic errors in em-
pathy” (62). Several observers (63, 64) have suggested
that the closest one can get to preverbal experience in
the adult patient is that which is filtered through the
fantasies of the oedipal period, when the child’s men-
tal and verbal capacities begin to approximate more
closely those of the adult. Theodore Shapiro (64)
warned of the danger of the “great oralizing fallacy,”
which suggests that the first year of life so determines
what follows that its stamp is irreparable. He offered
the alternative hypothesis that each developmental
stage presents a new opportunity for mental reorgani-
zation that allows earlier experiences to become less
toxic.
Others (34, 54, 65) have argued that the very crude-
ness of the infant’s mental apparatus and his crucial,
all-encompassing internal struggle to differentiate him-
self from a symbiotic unity with the mother contain
such a core, global, organizing experience that its
traces must be seen (particularly if unsuccessful) in
subsequent stages. At the very least, the metaphors
derived from this struggle seem to be applicable to re-
7. THE BORDERLINE PATIENT Am J Psychiatry /35:11, November 1978
1310
petitive dynamic issues with which the borderline pa-
tient struggles.
As described above, the clearest, most comprehen-
sive formulation about the relationship between bor-
derline psychopathology and developmental psycholo-
gy is that of Kernberg (30) and the object relations the-
orists (54). Kernberg suggested that borderline
pathology is a consequence of a developmental failure
occurring after self-object differentiation but before
the development of object constancy. He described
this failure as marked by a continuing defensive use of
splitting, with resultant limitations in the capacity to
test reality, to tolerate anxiety and frustration, and to
sustain a stable, integrated relationship with an under-
lying attitude of basic trust (7, 46).
This formulation is apparently applicable to a large
number of borderline patients, but it has been ques-
tioned by some authors, who have found two dis-
cernible groups or at least two different qualities of ex-
perience within the borderline population. These two
qualities are variously described as schizoid versus ag-
gressive (19), constricted versus expansive (12), com-
pliant versus aggressive (13), obsessive (“as-if,”
“false self”) versus hysterical (66), and ‘ ‘those who
have given up” versus ‘ ‘those who are still searching”
(3). Although Kernberg’s formulation appears to apply
to the second group in each of these pairs, it does not
seem adequately to describe members of the first
group, with their distant, ‘ ‘pseudoautonomous’ ‘ func-
tioning and their difficulty in engaging the other in any-
thing but a compliant manner (13). Clearer formula-
tions about both groups emerge from the development-
al data of the symbiotic and separation-individuation
periods (ages 0-3), when the issues of intrapsychic
separation and the development of formed images first
appear.
Symbiotic Period
Mahler (6) described the symbiotic period as ex-
tending from the second month (when the infant begins
tactilely and visually to explore the mother) to the fifth
month (when the infant begins to explore beyond the
mother). She defined this period as characterized by
the infant’s acting as though his internal experience of
himself and his mother were joined by a common
boundary with no recognition of separateness.
During this period the tasks of the mother are to sat-
isfy the infant’s needs, to buffer and modify the stimuli
he receives (both internal and external), and in effect
to act as an auxiliary ego. Preparation for these tasks is
facilitated by a regression in the mother (49, 68) that
increases her empathy, reawakens fantasies of her
own childhood experiences, and helps develop her ca-
pacity to provide a “holding environment” (49) in
which the infant’s “absolute need for empathy” is
met.
Mahler (67) described the “mutual cuing” that must
take place between infant and mother for normal sym-
biosis to take place. The infant’s contribution to this
interaction requires attributes of both perceptual abili-
ty (i.e., the capacity to receive and seek nurturance
and attachment and to link patterns of experience)
and stimulus sensitivity (i.e., sensitivity to touch and
visual responses). The mother’s tasks require her rec-
ognition and acceptance of her own infantile impulses,
with a resultant continuing empathic responsiveness to
similar impulses in her child.
Unacknowledged conflict in the mother in inter-
action over time with specific attributes of the child
may result in an empathic failure that interferes with
this ‘ ‘optimal symbiosis. ‘ ‘ Some authors (39, 42, 57,
69-71) have suggested that in such situations the infant
may prematurely inhibit his dependency on his mother
in order to respond to her defensive needs, a response
that may result in premature ego development. Failure
in the mother-child interaction during this period has
been suggested as the origin of pathology for the first
quality of experience within the borderline spectrum
(i.e., the “pseudoautonomous” complaint, detached
response).
If, for example, because of unconscious conflict
about her own needs, the mother disavows them, sees
them as ‘ ‘ bad,’ ‘ and projects them onto her child, she
may persistently withdraw from or be relatively unre-
sponsive to the child’s actual needs because of the
confusion with hers (projective identification). Several
authors have suggested that such chronic non-
responsiveness is experienced by the child as a mean-
ingless interruption, resulting in his eventual detach-
ment (39, 70, 71) and formation ofa “false self” (51) in
which the child compliantly adapts to his mother’s
needs with relative abandonment of his own, since
they represent a threat to a mother whom the child
absolutely needs and who is relatively immune to his
feedback (70).
This detached self is the consequence of a pre-
mature severing of the symbiotic tie before any inter-
nalization of maternal functions can occur. It leaves
the child with a sense of detachment (72), a profound
emptiness, and an undeveloped potential for the direct
and personal experience of living (70). It is a distancing
maneuver, presumably developed by the child to ward
off the negative experience of the mother’s chronic
empathic failure and misinterpretation. The pseudoself
is that which validates the mother’s projection (70).
According to Friedman (70), Winnicott suggested that
the failure of interpretation in the therapy of patients
with such false self-organization is due to their per-
ception of the interpretation as another “act of attribu-
tion” by a nonempathic parent.
Separation-Indis’iduation
Mahler and associates (27) divided the separation-
individuation period (5 months-3 years) into four sub-
phases: 1) differentiation (5-8 months), 2) “prac-
ticing” (8-16 months), 3) rapprochement (16-25
months), and 4) object constancy (25 months-3 years).
Within this period the child’s task is to emerge gradu-
ally from the symbiotic unit and to develop increasing
autonomy both internally and externally. Successful
8. Am J Psychiatry /35:1/, November /978 EDWARD R. SHAPIRO
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completion of this developmental period results in the
capacity for frustration tolerance, the mastery of sepa-
ration anxiety, and the maintenance of self-esteem.
It is during these subphases of separation-individ-
uation that the issues central to the dynamics of bor-
derline psychopathology first appear. It is here that the
conflict between the push for autonomy and the wish
to unite is for the first time apparent in the behavior of
the child.
During the differentiation subphase (5-8 months),
the child remains anchored to the mother but develops
an increasing alertness, an outer orientation, and final-
ly, a social smile that increasingly focuses on the
mother (59, 73). In her absence the child gets restless
and unhappy, but he smiles on her return. This fact
suggests the initial development of ‘ ‘ recognition mem-
ory’ ‘ : the ability for perception to revive a memory
trace (73, 74).
At 8 months the infant develops ‘ ‘ stranger anxiety.”
Mahler and associates (27) observed that if there is a
good symbiotic period the infant reacts to strangers
with curiosity and wonderment; if it is less good the
infant demonstrates more anxiety. These observations
are congruent with Kernberg’s formulation (30) that a
greater quantity of frustration during symbiosis would
threaten the infant’s loving experiences, resulting in a
prolonged defensive splitting and projection of fear-
some negative experience onto the “stranger.”
In the ‘ ‘practicing’ ‘ subphase (5-16 months), the in-
fant develops the capacity for locomotion with an exu-
berance and excitement that temporarily enables him
to ignore the presence of his mother. Exhausted by
autonomous movements, the infant periodically re-
turns to the mother for “emotional refueling” (27), a
brief contact that rapidly enables the infant to restore
his or her energy and momentum. During this sub-
phase there is evidence that the child begins to notice
and tolerate his mother’s departure, since he tones
down his activities (“low keyedness”) in her absence
(27).
Kernberg (7, 30) suggested that the child begins to
be able to differentiate between positive images of
himself and his mother during this period; similar self-
object differentiation within images of negative experi-
ences occur somewhat later. He suggested, however,
that this differentiation of images is still tentative at
this point and vulnerable to “regressive refusion” at
times of stress.
The rapprochement subphase (16-25 months) is the
period during which the conflict between autonomy
and reunion is demonstrated most clearly in the child’s
behavior and response. Even the language of the de-
scriptions evokes images familiar to therapists of bor-
derline patients. It is in this phase that the toddler’s
behavior indicates a sense of increased separateness,
loneliness, helplessness, a constant concern with the
mother’s presence, and increased separation and
stranger anxiety. It is during this period, according to
Kernberg (7, 30), that the child develops firm bounda-
ries between the experience of himself and that of his
mother. The infant now responds to more than a re-
fueling place, he responds to her.
Observers of the child in this subphase have de-
scribed the toddler’s active interest in his mother’s
presence and his developing need for her to share ac-
tively in his autonomous achievements. Mahier (58)
noted two normal patterns: shadowing of the mother
and darting away expecting to be swept up in her arms.
Inferred from this behavior is both the wish for reun-
ion and the fear of engulfment.
In children who have difficulties during this sub-
phase, Mahler (58) observed increased aggressive be-
havior manifested by rapidly alternating clinging to
and repudiation of the mother. McDevitt (73) noted
that the less a child can assert himself pleasurably in
independent play, the greater the frequency of aggres-
sive clinging and repudiation. The implication of these
observations is that significant conflict is precipitated
in the mother-child relationship if their interaction
does not support the child’s developmental move to-
ward autonomy.
With the development of the capacity for ‘ ‘represen-
tational thought’ ‘ (75) and symbolization, the toddler
develops the use of transitional objects and begins to
use his relationship with his father more significantly
as a way to mediate the shift from the exclusive tie
with his mother toward autonomy (28).
At about 18 months the infant develops the capacity
both to retain the memory of a concrete object after it
has disappeared (“object permanence”) and to evoke
the image of the mother in her absence (‘ ‘evocative
memory”) (74, 75). Throughout most of rapproche-
ment, although the image of the mother appears to oc-
cur to the child, it does not seem to persist during her
absence, suggesting an incomplete internalization of
the mother’s caring functions and a persisting reliance
on her actual presence. Kernberg (7, 30) suggested
that when the child is frustrated by his mother’s depar-
ture, he is overwhelmed with rage and his comforting
image of the loving relationship with her is threatened.
To preserve this comforting fantasy, the child dis-
sociates it and sees himself as a “bad” child aban-
doned by an angry mother. The child then experiences
profound separation anxiety in the form of hopeless-
ness and a negative sense of self, with complete loss of
the “good” images.
The task of the mother during this subphase is to
tolerate sufficiently her own wishes for dependency
and autonomy so that she can respond in a stable em-
pathic way to corresponding wishes in her child with-
out seeing them as “bad” or dangerous and respond-
ing with retaliation or withdrawal (49, 76). Mahler and
associates (76) described two kinds of empathic fail-
ure. One group of mothers who had difficulties in toler-
ating their own dependency responded with hurt and
anger to their child’s clinging by saying in effect, “A
minute ago you didn’t want me, now I don’t want
you.” Presumably, this response would evoke anxiety
in the child about his wishes for nurturance. A second
group of mothers with conflicts about autonomy re-
9. THE BORDERLINE PATIENT Am J Psychiatry 135:1/. November 1978
1312
sponded to the child’s autonomous moves with, ‘ ‘You
think you can manage on your own, well go ahead.”
This response threatens the child with abandonment
and inhibits his freedom to explore because of the re-
active fantasy: ‘ ‘If 1 grow up, I’ll be all alone.”
The implication drawn from these observations is
that this kind of chronic withdrawal represents the
mother’s defensive inability to distinguish between her
own unresolved needs (for the child’s response to her)
and her recognition of the needs of her child for auton-
omy and support. This defensive response from the
mother is contributed to by her own conflicts and by
the increased aggressiveness of her 2-year-old during
the anal period.
Adler (44) described the ‘ ‘good enough mother’ ‘ (49)
of this subphase as one who is not afraid of her own or
her child’s anger and can be firm when she needs to
frustrate. She has confidence in her basic goodness
and a capacity to care without having to retaliate for
old hurts. The descriptions of Mahler and associates
(27) indicate that there is a broad spectrum of ‘ ‘good
enough’ ‘ mothering responses. Typical failures in the
interaction between mother and child, then, are likely
to represent chronic empathic insensitivity from
mothers at the ends of this spectrum in interaction
with particularly sensitive infants.
Toward the end ofrapprochement, the child’s cogni-
tive apparatus sufficiently matures so that he can no-
tice that the same mother both gratifies and frustrates.
Winnicott (24) suggested that if the mother can “con-
tam’ ‘ the child’s aggression (by nonanxious, firm limit
setting) while continuing to provide love and under-
standing, she will demonstrate to him that she is not
created or changed by his impulses and that she is sep-
arate from him and not a creation of his projections.
Such a response allows the child to develop a relation-
ship with her as a real and autonomous person and
helps the child to tolerate his anger and put it in per-
spective by allowing him to recognize that it cannot
destroy his loving mother (by turning her into a bad,
angry, or anxious mother). In addition, the mother’s
response will help strengthen the child’s conviction in
the strength of his good self-image and that of his
mother and will decrease the child’s fear of his own
aggressive tendencies (7).
Alternatively, if the mother, because of unacknowl-
edged conflict revived by the interaction, retaliates for
her infant’s aggression or withdraws from his de-
mands, she will confirm his fear of aggressive fan-
tasies, making it difficult for him subsequently to in-
tegrate them. Responding to the withdrawal, the infant
generates increased rage and greater demands (e.g.,
clinging), which contributes to a spiraling crisis in their
interaction and an intensification of the infant’s need
for defensive splitting and projection, the phenomena
characteristic of borderline patients.
With successful negotiation of rapprochement the
child develops the capacity for ambivalence and object
constancy (27, 74). The ambivalently held image of the
mother is more stable in the face of frustration, provid-
ing the infant an inner sense of comfort and contrib-
uting to his or her capacity to experience guilt, con-
cern, depression, and increasing anxiety tolerance.
The infant’s image of himself now begins to develop
increasing complexity, affects are modulated, ego con-
trol of impulses is increased, and there is a clearer
sense of self and others. Observers of the child during
this subphase (59, 73) have noted that with this devel-
opment there is a shift from self-centered, demanding,
clinging behaviors to more mature expressions of af-
fection, trust, confidence, regard for the interests and
feelings of others, cooperation, sharing, making sacri-
fices, and offering gifts.
Latency
The relative absence of clinical descriptions of bor-
derline phenomena in the literature ofthe latency pen-
od (ages 6-10) suggests a relative decrease in sympto-
matic behavior during this period. Chiland and Lebo-
vici (77), however, described the two borderline
qualities of inhibition and excitability as emerging in
some children during latency in response to the dis-
ciplinary and learning requirements of school. These
children were described as rejecting attempts at com-
munication and refusing to carry out tasks. Despite
high learning performance, they were described as ex-
ploding periodically in rage. The authors commented
on the characteristic contrast between good in-
tellectual development and poor relationship modali-
ties in these children that marked their ‘ ‘developmen-
tal disharmony. ‘ ‘ Again, in these descriptions, the two
types of borderline presentation were seen: cold, de-
tached, and removed versus subject to unpredictable
outbursts of rage. The authors also commented on the
probable use of projective identification by these chil-
dren, noting that “the interlocutor himself feels the
whole burden of anxiety.”
Adolescence
Several authors (65, 78, 79) have perceived a reca-
pitulation of the dynamic themes of separation-indi-
viduation during the adolescence of the borderline
child, a period when borderline symptomatology often
becomes apparent. With my colleagues at NIMH (78,
79) I observed a family group regression that occurs
during the adolescence of the borderline patient in
which family members respond with retaliation or
withdrawal to autonomous or dependent behaviors of
the adolescent. The conflict between the striving for
autonomy and the fulfillment of dependency needs re-
vived in adolescence is inadequately resolved in these
families because of a regressive, shared use of projec-
tive identification (38) in which the adolescent be-
comes the bearer of disavowed aspects of the parents.
In some families the child’s dependent wishes are seen
as devouring demands from which the family members
withdraw. This withdrawal often represents parental
anxiety about their own wishes to be given to, which
they cannot acknowledge. In other families, the ado-
lescent’s autonomous strivings are interpreted as a
10. Am J Psychiatry /35:1/, November 1978 EDWARD R. SHAPIRO
1313
hateful abandonment of the family, which the parents
cannot accept. In these families parental strivings for
autonomy are disavowed, seen as bad, and projected
onto the adolescent, resulting in a defensive inability
to respond to the adolescent’s autonomous develop-
ment with the necessary support.
Masterson and Rinsley (65, 80) described the latter
group in terms of the adolescent’s ‘ ‘abandonment de-
pression,’ ‘ which is defended against by splitting, act-
ing out, and other pathological maneuvers. They
viewed as the ‘ ‘basic dynamic theme’ ‘ of the border-
line patient that ‘ ‘the borderline mother withdraws
emotional supplies at her child’s efforts to separate
and individuate. ‘ ‘ This is a characteristic phenomenon
observed by several authors (42, 78). The consequence
of this maternal withdrawal in the face of separation is
that the child is torn between the engulfment of sym-
biosis if he moves toward his mother and the experi-
ence of loss and abandonment if he moves away. Zin-
ncr and my study of the families of these patients in
interaction (78) revealed that this retaliatory with-
drawal of supplies is a shared family dynamic that is
only one element in a family regression involving all
family members.
The borderline adolescent’ s alienation , aggressive
responses, and inadequately structured self-image (81)
contribute to this family turmoil, but parental contri-
butions are also significant. Our analysis of family in-
teractions (79) revealed that these parents depend
heavily on projective identification for their own de-
fensive organization and that in this process there is
considerable collusion from the child. We also ob-
served a blurring of parental capacity to experience
themselves as separate from the particular child in the
areas of conflict and an idiosyncratic but often over-
lapping content of parental projections involving dis-
avowed wishes for dependency or autonomous striv-
ings (78, 79).
Although Masterson (82) found the parents of the
borderline patient to be borderline themselves, this
finding does not agree with our observations of signifi-
cant variability in parental psychopathology (79) or
with the observations of Margaret Singer (8), who
found that 84% of borderline patients had normal or
neurotic parents according to psychological tests. Al-
though some authors (6, 65)’ have discussed these par-
ents in descriptive terms (i.e., “ineffectual, passive fa-
ther,” “intrusive, dependent mother”), other authors
(78, 79, 83) have described a more dynamic, shifting
tension between parent and child.
The latter observers illustrated how family mem-
bers’ use of primitive defenses may be encapsulated in
response to issues involving certain offspring. In inter-
action with siblings or the outside world, they may use
more advanced ego defenses and greater maturity but
may regress to fixation points relating to deficient reso-
lution of symbiosis and identity formation in relation
to the designated borderline child. Singer and Wynne
(83) commented on the discrepancy between the se-
verity of the disturbance when family members inter-
act compared with the relatively mild disturbance each
family member shows individually. They suggested
that in attempting to understand the family pathology
it is insufficient to look only at the individual parent in
relation to the individual child. Their data and ours
(78, 79, 83) indicate that there are contributions from
the entire family group that affect the nature of the de-
velopmental interference.
DISCUSSION
The continuing study of the psychopathology of the
borderline patient has inevitably led to an increased
interest in and examination of a two-person psycholo-
gy. The remnants of early symbiotic interaction seen
in the interpersonal use of projective identification by
the borderline patient are evident in the patient-thera-
pist interaction, the mother-child response, and the
family life of the borderline adolescent. In contrast to
the complex fantasy life of the neurotic patient, with
his more differentiated and articulated presentation of
intrapsychic conflict (usually involving triadic fan-
tasies), the borderline patient presents more stereo-
typed , primitive difficulties, frequently communicated
nonverbally. Often the key to a comprehension of
these difficulties lies in the affects and reactive fan-
tasies of the caretaker (e.g., therapist or mother).
The growing experience in intensive work with such
patients has led to a closer study of counter-
transference phenomena (7, 30), the setting or “frame-
work” of the therapeutic interaction (21, 84), the na-
ture ofthe “holding environment” (10, 46, 50, 62), the
components and complexities of empathy and its fail-
ures (10, 24, 36-40, 44, 48, 57, 62, 71, 79), and the un-
conscious communicative process involved in family
interaction (78, 79, 83). In addition, the nature of psy-
chological defense has been reevaluated.
Although Klein (34, 35) focused her study of projec-
live identification on the nature of the child’s internal
fantasies, more recent work has focused on the collab-
orative nature of this defense (38, 39, 70, 78, 79, 84,
85). Much of this work supports the idea that there is
an entire range of interpersonal defenses in which the
collaboration of a particular other is required to main-
tain defensive equilibrium.
Certainly, unconscious conflict in the mother, ex-
ternalized in her relationship with the infant, appears
to be related in some way to difficulties in the process
of “adequate symbiosis” as well as in the carefully
choreographed movements required for normal sepa-
ration-individuation. Unconscious fantasy and the de-
fensive collaborative use of particular family members
to represent disavowed aspects of inner conflict in the
family of the borderline adolescent seem to be a signif-
icant impediment to development. It remains to be
seen how these family interactions affect the environ-
mental matrix in which the infant’s earliest sense of
self develops. This question remains a relatively unex-
plored frontier of developmental theory.
11. THE BORDERLINE PATIENT Am J Psychiatry /35:!!, November /978
1314
Although there remains significant controversy
about the applicability of child observation to adult
phenomena as well as serious debate about the possi-
bility of recreating elements of the relationship be-
tween infant and mother in the therapeutic situation
(86), conceptual attempts to make these comparisons
have produced fascinating new insights. The delinea-
tion of the therapist’s “holding” function, of his task
of “containing’ ‘ the patient’s affects and projections,
and of the hazard of his own projections interfering
with the therapeutic process (46, 84, 85) have all
emerged in part from this study of the borderline pa-
tient and his development. All seem in some way to
have relevance to the developing understanding of the
complex preverbal interaction between infantile im-
pulses and human environmental responses from
which personality evolves.
The increasing overlap of the observations, formula-
tions, and inferences derived from the three different
areas of study reviewed above suggests at least an ap-
proximation to reality that future follow-up studies
should address. The data from the current studies have
already made an important contribution to the thera-
pist’s ability to listen better to particular elements of
these patient’s productions, to develop more accurate
empathic responses, and to provide borderline pa-
tients with some coherent organization for their chaot-
ic experience.
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