*Notes – Bateman and Fonagy

B&F Affect

1-25-07

from below:

Antisocial features increase the patient’s tendency to control and manipulate the other with scant regard for their rights and independence of mind.  The moment the other person shows some independence of mind, radical action has to be taken and violence becomes possible. (Bateman/pbpd/235)”

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“Affects are exaggerated because beliefs are experienced as having comparable force to physical realityThus emotional responses to physical events can be hard to understand without explicating the overwhelming power of the beliefs they give rise to. (Bateman/pbpd/253)”

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IMPORTANT

Unable to experience thinking about himself internally (‘from within’), the borderline patient is forced to understand himself by establishing relationship configurations, as it were from without.  A situation is created in which what is normally an intrapsychic process is established through an interpersonal interaction.  (Bateman/pbpd/254)”

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copied from below, italics, etc. are mine:

“In this way the patient will experience the relationship as a place in which ideas can be played withIn the transitional area thus created, thoughts, feelings, and ideas neither belong internally nor externally and so their power to overwhelm is lost – they are no longer either the therapist’s or the patient’s, but shared.  (Bateman/pbpd/205)”

Where in the world are they, then?  Where is this transitional area?  It’s not REAL but it is real?  This seems an “unsolvable paradox” to me.  If a person has a disorganized insecure attachment, then they cannot “experience the relationship” with anyone, and perhaps not with anything.

Today I believe that humans are not benevolent.  They/we are predators.

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Twilight Zone, here we come!

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Bateman has this in italics:

“There is a gap between the primary affective experience of the borderline patient and its symbolic representation.  This gap has to be bridged in therapy if the reflective process is to develop with a view to strengthening the secondary representational system. (Bateman/pbpd/205)”

TIME

“The core of psychological therapy with individuals with severe personality disorder (PD) is the enhancement of reflective processes.  The therapist must not only help the patient understand and label emotional states but also enable him to place them within a present context with a linking narrative to the recent and remote pastThe gap between inner experience and its representation engenders impulsivity.  The therapist needs to create a therapeutic milieu in which the experiences of the patient can be transformed from confusion to meaning, especially in terms of interpersonal understanding.  This is achieved not only by interpretations of moment-to-moment changes in the patient’s emotional stance but also by focusing the patient’s attention on the therapist’s experience.  This enables an exploration of a mind by a mind within an interpersonal context.  (Bateman/pbpd/205)”

“Interpreting a more complex psychological process, however accurate or inaccurate it may be, is likely to destabilize the patient who will become more and more uncertain and confused about himself as the contradictions and uncertainties are pointed out.  The result will be an attempt by the patient to adhere to a rigid, schematic representation of the relationship between patient and therapist….It is equally important not to focus on a patient’s conflicts and ambivalence (conscious or unconscious).  Change is generated in borderline patients by brief, specific interpretation and clear answers to questions.  (Bateman/pbpd/205)”

“The ever present danger in trying to ‘bridge the gap’ [gap between the primary affective experience of the borderline patient and its symbolic representation] is that when the therapeutic relationship intensifies through confrontation and complex interpretation, this highlights a patient’s difficulties in creating a distance between internal and external reality.  So, the therapist’s task is in some way analogous to that of the parents who first make the situation secure and then create a frame for creative play – except in this case it is thoughts and feelings that need to become accessible through the creation of such a transitional area.  In the move towards mentalization, the therapist must get used to working with its precursors, namely mind states in which internal is identical with external, ideas form no bridge between inner and outer reality, and feelings have no context. The task is the elaboration of teleological models into intentional ones, psychic equivalence into symbolic representation, and linking affects to representationIntegrating the dissociated modes of the patient’s functioning where sometimes nothing feels real (certainly not words or ideas) and at other moments words and ideas carry unbelievable potency and destructiveness can seem an awesome task.  [I don’t think that previous sentence, the end of it anyway, makes sense] Yet progress is only conceivable if the therapist is able to become part of the patient’s pretended world, trying to make it real, while at the same time avoiding entanglement with the equation of thoughts and reality.  (Bateman/pbpd/206)”

ENTANGLEMENT – ENACTMENTS (ENMESHMENT)

Entanglement leads to the activation of the inevitable destructiveness often found in borderline patients in relation to the therapeutic enterprise.  It is rarely adequately dealt with by confrontation or interpretation of aggressive intent.  Rather, comments are more helpfully aimed at the emotional antecedents of enactments – the emotions that cause confusion and disorganization.  The therapist has to remain calm under fire, whilst at the same time being able to demonstrate that words, thoughts, and discussion are eminently more expressive than behaviour.  In order to do this, the therapist may have to show something of himself [sic] at certain moments, for example through humour or irreverence.  (Bateman/pbpd/206)”

“In this way the patient will experience the relationship as a place in which ideas can be played withIn the transitional area thus created, thoughts, feelings, and ideas neither belong internally nor externally and so their power to overwhelm is lost – they are no longer either the therapist’s or the patient’s, but shared.  (Bateman/pbpd/205)”

This is really interesting, but I don’t quite get it yet.  They keep using the word “play.”  It seems that these thoughts, feelings, ideas, intentions, etc. that we have – even from the beginning with our mothers, are not supposed to be SERIOUS!  They are supposed to be PLAYED WITH.  It makes me think of the nervous system development, opiod centerst, and how everything is supposed to be formed for us through some version of excitement, anticipation, joy and enjoyment – an always with healthy feelings of pride and a sense of accomplishment  in ourselves and in our abilities, even from being tiny people – filling those opiod centers of the brain and forming our nervous system so that joy is what excites us, and the rest is calm.

And that ruptures are supposed to be repaired.

Not over excited, but stimulated and challenged when we were infants, and as we continue to develop over the lifespan.  That these things, as per above, do not belong to us!!  I want to understand!

TRANSTIONS – TRANSITIONAL AREA

“Failure in the transitional area in borderline patients receives some support from attachment theory which has stressed the common characteristic, shared by the ambivalently attached/pre-occupied [makes me think of mother keeping her eye on me in the rear view mirror!] and borderline groups, ‘to check for proximity, signalling [sic] to establish contact by pleading or other calls for attention or help, and clinging behaviours’ (Gunderson 1996).  All these phenomena imply a difficulty in maintaining a stable representation of the other and the need to use the therapist as a transitional object, an extension of the patient who lacks separate identity and feelings (Modell 1963).  The importance (Bateman/ pbpd/206) [italics mine] of transitional relatedness in these patients is also demonstrated by striking histories of using transitional objects (Morris et al. 1986) as well as bringing such objects to hospital more frequently than patients with other psychiatric disorders (Cardasis et al. 1997).  Bateman/ pbpd/207)”

transitional relatedness – transitional area or space – transitions between states – transitional object because the “patient” uses these objects or people because as an extension of themselves because they lack “separate identity and feelings.”

Is it also like Ernie’s huge house, as an extension of himself as powerful and WORTHY, and his women as extension of his virility?  We are extensions of his “self” –

I still need to look at that brain research on how the brain processes information on people vs. objects!

That we have not “identified and felt” ALL of our self!

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transference – he italicizes this:

“With borderline patients, transference is not used in the clinical situation as a simple repetition of the past or as a displacement and should not be interpreted in this way.  Transference is experienced as real, accurate, and current by the borderline patient and needs to be accepted by the treatment team in that way.  (Bateman/ pbpd/207)”

“Interpretation in a direct manner simply makes the borderline patient feel that whatever is happening in therapy is unreal.  This leads to a dissociative experience and a sense that their own experience is invalid.  If such transference interpretations are made, the patient is immediately thrown into a pretend mode and gradually patient and therapist may elaborate a world, which however detailed and complex, has little experiential contact with reality.  Alternatively, the patient either angrily and contemptuously drops our of therapy feeling that their problems have not been understood, or mentally withdraws from treatment, or establishes a false treatment which looks like therapy but is in fact two individuals talking to themselves.  (Bateman/ pbpd/208)”

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two individuals talking to themselves:  this is not mentalizing!  I feel this way all of the time!

Maybe it’s like two cars being able to park in the same parking spot!!  It must be able to happen because mentalizing is not “real” and it is evidently not “pretend,” either.  It has something to do with that “feeling felt.”  It is some kind of resonance that is NOT merging – but has to happen in infancy and childhood when the caregivers are REAL PEOPLE and the children are, too.  Otherwise, no-body is talking to no-body!

two individuals talking to themselves — false treatment:  That IS a lonely feeling – and I know it.

Is that why Ernie and I can talk with one another – not to one another as both of us probably do the rest of the time – because we both suffer from the same disability!!  We both talk to ourselves – we both are extensions of the other – our centers are in each other through extension!  We are each only able to see our self reflected in the other – as transitional objects?!?!  This is all getting very strange!

So what if we cannot love ourselves because we were so hated and maltreated, traumatized and abused that we cannot find our goodness?  Then we must use projective identification and externalize this part of our self, also?  Do we find our transitional objects to carry and represent that part of us?  That person would REPRESENT us!  Be our representative at some “congress of nations.”  “I will love in you what I cannot love inside myself – or about myself.”  I actually put the LOVE I have out there.

But on some level, does everyone do this?  I guess not the securely attached.  They can actually love someone separate from them with love that is centered within themselves.  Like “talking to themselves” it can change into “loving to themselves.”  Two people with the same disability, doing this dance with each other – like Ernie and I!!  No wonder we feel so “connected.”  (Well, speaking for myself, but the connection is there.)  He loves himself in me and I love myself in him!  Only he has to do it in multiples!

How strange.  How sad!

Twilight Zone, here we come!

So it IS true that we can do this with other than only the hated parts of ourselves!!  We can put the goodness out there, too!!  OUR goodness, not just our badness!  Do these experts talk about this???

No wonder we don’t want to let go of these “dysfunctional” relationships.  We would lose sight of all that is good and loved and lovable in ourselves!

And it’s not about “boundaries” in any of the way I’ve seen the concept applied.  It is not about a boundary issue or violation between Ernie and me.  Neither of us has an intact, whole self because we were too damaged and to hurt to get one in the first place.  We lack “separate identity and feelings.” This is NOT something we have a choice about, nor is it something that has been made clear to any of us.  We have inadequate boundaries BECAUSE we DO NOT HAVE THEM nor have we EVER had them.  For me, it has been this way from the moment I was born.  I remained UNFORMED and truly unborn and uniformed of this fact! For some, those others with less severe forms of insecure attachment, they were partially formed.  They are like the man was in the fairy tale movie, The Princess Bride, “mostly dead.”  Or varying degrees of the same….

And it isn’t that I have to in any way take away the love I have placed in Ernie.  I just have to “bridge the gap” somehow so that I can stand in that circle of light and love with him, and feel all that within MY SELF!  But HOW?

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When I read that an expert says something that I resonate with, even something simple like “talking to themselves,” I feel felt.  I know that I know what he is saying, and I know he knows that I know what he is saying.  He just doesn’t know the second part:  I know that I know.  I THINK that part of it is within me only.

I can even feel the feeling of what it is like to feel felt.  And like the other day with Ernie when he was leaving the hospital, and I said, “I imagine you are crabby and restless as hell,” and he responded, “God!  Yes!”  And I knew for that split second what “feeling felt” and giving that “feeling felt” feeling to someone else meant and felt like.

And to think that people with secure attachment histories can do that all the time, and never even notice.  What a glorious gift they have to cherish and value!  They have the human birth right, and the rest of us don’t.

I know that you know that I know that you know…

Mirrors reflecting mirrors – the Mobius strip – the infinity sign.

And I suspect that what blocks this, on some deep and fundamental brain and nervous system level, is threat, not safe:  terror and/or despair.

“…reference to different perspectives and internal influences that may be driving them should be simple and to the point.  There is no place for complex statements implying a veridical [truthful, voracious; genuine – word related in roots to diction] truth as seen by the therapist.  Both patient and therapist have to start from a position of ‘not knowing’ but trying to understand. [How nicely put!!)   (Bateman/pbpd/208)”

“The therapist has not focused on the destructive component in relation to the therapeutic enterprise by confrontation or interpretation of aggressive intent.  The patient’s actions and dismissal are best understood as self-protective and interpretation is aimed at the emotional antecedents of the enactment and the emotions that cause confusion and disorganization.  (Bateman/pbpd/209)”

++  they are looking for themes and patterns from the past that will, I would say always, reappear in the present/future

++  need for stable internal representations to be established  [Are these representations, then, like the building blocks of thoughts?  Like they call it in computer software terms, “packets” of information that we can move around and drop into place in different ways within ourselves to build our beliefs, intentions, desires, hopes, etc?  Kind of like the ‘old fashioned’ stereo systems where you had to buy the separate components.]

++  need later, through an “incremental” process that “moves from distance to near depending on the patient’s level of anxiety”, to “explore different perspectives” later in the treatment once the relationship between patient and therapist has been established (Bateman/pbpd/210) – [the relationship, then, being where the “transitional area” is that makes this safe to do?]

RETAINING MENTAL CLOSENESS

His italics:

“Retaining mental closeness is akin to the process by which the caregiver’s empathic response provides the infant with feedback on his or her emotional state to enable developmental progress.  The task of the therapist is to represent accurately the feeling state of the patient and its accompanying internal representations.  (Bateman/pbpd/210)”

“…concept of ‘mirroring’…[is] a crucial interpersonal interchange within an attachment context.  It is through this process that the child acquires a sensitivity to self-states [this is down the road from where and when it first begins!] and eventually the states of others.  This sensitivity is an essential element in the development of the representational system and is dependent on the internalization of the caregiver’s mirroring response to the infant’s distress [as well as upon the response to all the other feeling states the infant has, as well!] – the caregiver’s empathic response provides the infant with feedback on his or her emotional state, and as long as it is marked as representing the child’s mental state and is reasonably accurate, it leads to [neurobiological brain and nervous system] developmental progress.  Retaining mental closeness is akin to this process and the task of the therapist is to represent accurately the feeling state of the patient and its accompanying internal representations.  [Because I am so craving this necessary “first step” I cannot tolerate people in my life feeding me back THEIR opinions and perceptions of what THEY think of how I live or how I feel if they don’t first take the time to let me know they understand how I feel – which I don’t think they do.]  In addition, the therapist must be able to distinguish between his own experiences and those of the patient and be able to demonstrate this distinction to the patient – marking (see p. 66).  Fortunately for the therapist, the accuracy of the identification of the patient’s feeling state need only be ‘good enough’.  A slight mismatch or discrepancy between the representation of the patient’s state by the therapist and actual state of the patient may be a main driver of psychological development. A mismatch completes patients and therapists to examine their own internal states further and to find different ways of expressing them if communication is to continue.   In addition, the therapist has to be able to examine his own internal states and be able to show that they can change according to further understanding of the patient’s state.  In this respect countertransference is crucial.  (Bateman/pbpd/210)”

[STATES seems to be a word all these writers use in common – yet I’m not sure anyone defines it – perhaps Siegel does.]

“Countertransferences are generally considered as emotions that arise within the therapist as a result of the patient’s treatment of him as an object of one of the patient’s earlier relationships.  However, other countertransferences are different and akin to empathic responses, based on the analyst’s resonances with his patient rather than resulting from an evocation of earlier object relationships.  These ‘concordant’ countertransferences (Racker 1968) are extremely common in treatment of patients with PD and link with affective attunement (Stern 1985), empathy, mirroring, and a perspective that aspects of all relationships are based on emotional identifications between individuals.  The therapist ‘reads’ the patient’s behaviour and responds in a complementary manner, which is in turn ‘read’ by the patient.  One feeling state has been knowable to another and both sense that the transaction has taken place without the use of language.  In our terms this is ‘implicit’ mentalizing [unconscious or preconscious] with clear marking of the experience by the therapist, which will be met by an equally ‘implicit’ response on the part of the patient.  (Bateman/pbpd/211)”

“In order to retain a mental closeness, the therapist has to maintain a benign split within himself to allow a constant interplay between thinking and feeling,  [left and right brain] between himself and the patient, between his experience and the events the patient is talking about.  Sandler (193) used the term ‘primary identification’ for an equivalent process and regards it as similar to automatic mirroring.  Thus, if the therapist has a direct emotional reaction to a patient’s actions or behaviour, and this reaction is not one that he is being unconsciously pushed into, then this should be seen as primary identification.  If such identifications stimulate unresolved unconscious wishes within the therapist, conflict arises, which results in the mobilization of defences [sic], the formation of blind-spots within therapy, and a distancing of the therapeutic relationship.  (Bateman/pbpd/211)”

“…retaining mental closeness has its dangers and yet is necessary if therapy is to be effective.  (Bateman/pbpd/211)”

++  therapists need supervision so that they “do not become ‘entangled…..there is no doubt that borderline patients may suddenly evoke strong feelings which, if unprocessed, can lead to a mental collapse in the therapist.  (Bateman/pbpd/212)”

WORKING WITH CURRENT MENTAL STATES

Italics are authors’

“There can be little therapeutic gain from continually focusing in the past.  The focus needs to be on the present state and how it remains influenced by events of the past rather than on the past itself.  If the patient persistently returns to the past, the therapist needs to link back to the present, move therapy into the ‘here and now’, and consider the present experience.  (Bateman/pbpd/212)”

“Anger and other strong emotions about the past have to be re-oriented towards the present.  Most people bring anger and other feelings about earlier situations into their present life and in therapy it is necessary to look for the target of the feeling in the present rather than leave it hanging in the past.  (Bateman/pbpd/213)”

“In order to work closely with the current mental state it is always necessary to consider which elements of the patient are projected, which are not, and whether, at any particular time, the therapist is maintaining a mentalizing stance and able to consider their own mental state as well as that of the patients.  [sic]  (Bateman/pbpd/213)”

“…the exploration of the patient’s perspective and its discrepancy with that of others needs to be repeatedly reconsidered within many other current contexts before both patient and therapist can be confident about show feeling is whose.  Only when this aspect is clear can the therapist begin to address the dispositional aspects of the psychological process.  (Bateman/pbpd/213)”

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METAPHOR

“In working with current mental states it is essential to avoid using metaphor as the primary discourse with a patient.  Borderline patients have a poorly-developed ability to use secondary representation and limited symbolic binding of internally-experienced affects so the use of metaphor is relatively meaningless to the patient.  Rather than heightening the underlying meaning of the discourse, use of metaphor is likely to induce bewilderment and incomprehension.  (Bateman/pbpd/213)”

“Borderline patients cannot easily hold more than one idea, desire, or wish in mind at a time and have little access to alternative states.  So, conflict interpretation is likely to be meaningless and confusing.  Some practitioners interpret unconscious phantasy [sic] and conflict directly to borderline patients using part-object body language.  The lack of secondary representation in the mind of the borderline patient, however, leads patients to react to terms such as breast and penis not as metaphors but as the objects themselves.  One patient became terrified in a group when another patient stated that she had had chicken beasts for supper the previous evening.  The patient left the group rapidly saying that no one should eat breasts.  (Bateman/pbpd/214)”

This made me think of my memory of the teacher reading the class a story when I was in the first grade that made reference in it to a goat with a bell around its neck that made a tinkle tinkle sound as the goat ran.  I felt incredibly embarrassed and shocked that the teacher would say such a word in that context.  That was the word my mother used for urination.  I did not understand that a word could have multiple meanings, nor could I adapt to this context shift for that word.

BEARING IN MIND THE DEFICITS

“Deficits in the capacity for mentalization can be masked by an apparent intellectual ability that lures therapists into believing that borderline patients understand the complexity of alternative perspectives, accept uncertainty, and can consider differences….Constancy of belief and consistent experience of others elude the borderline patient, resulting in idealization at one moment and denigration the next.  The task of the therapist is to establish continuity between sessions, to link different aspects of a multi-component therapy, to help the patient recognize the discontinuity, and to scaffold the sessions without holding the patient to account for sudden switches in belief, feeling, and desire.  The borderline patient does not lie but is unable to hold in mind different representations and their accompanying affects at any one time. All are equally true, and the therapist must accept the balance between opposing perspectives and work with both even though they appear contradictory.  (Bateman/pbpd/215)”

That gets complicated.  In thinking about mother – is that why she had to split the good and the bad between Cindy and me?  Because she was  “unable to hold in mind different representations and their accompanying affects at any one time?”  (Bateman/pbpd/215)”

Is that why she specifically split the “idealization” and the “denigration” in particular?  Is that what “It’s” mother also did?  This goes way beyond “scapegoating.”  This must be what they are referring to when they say borderlines cannot tolerate ambiguity.  But in looking for the roots of the word ambiguity, I found that it is a scientific word, and does not offer the specific information we need to truly understand this phenomenon.  This information from Bateman is accurate.

They evidently cannot contain and process opposites or paradoxes.  Does it have something to do with attentional deficits?  That they cannot attend to both equally somehow?

Maybe we all do this with projective identification – not holding both our own good and bad together within us so that sometimes we hold the good within ourselves and project out the bad (we can feel self righteous or hurt) because that other person is bad.  Or, we feel that we are bad, unlovable, and worthless when we project the good out onto someone else.

++  “motivation of the other is judged and responded to according to the outcomes.  (Bateman/pbpd/216)”

++  the self structure is often tied to, or connected to, events and objects in the material world

“A primary aim of therapy is to help the patient move from a teleological [phenomena explained by final causes] understanding of motivations….many borderline patients convince therapists to do things on the basis that actions have real meaning…. (Bateman/pbpd/216)”  [as in “I will only believe you if you do this or that…]

REAL RELATIONSHIPS

Italics are authors’

“Borderline patients crave therapeutic relationships that are emotionally charged, supportive, compassionate, accepting, special, and personal.  There is a danger that the therapist may respond to these demands either by withdrawing from the patient or by allowing the difference between the relationship of therapy and intimate relationships outside to disappear.  (Bateman/pbpd/216)”

++  patient afraid that others will “lose” them from their minds which leads to an instability of their self-structure – I know I experience this with Ernie – and relates to my “inability to attach” because I cannot truly hold others “correctly” in my mind, either – not even my children.  It must be similar to how I never saw the abuse incidents coming because I did not link and connect anything, so that each time was a first time.  I cannot link the past MEMORY of being with someone to my present self, or to my future self, and it feels like my OWN past self does not exist, and nor does my OWN future self, and barely a cohesive PRESENT self.  NO LINKS!

WORKING MEMORIES

++  when patient’s retrieve memories – what stance should the therapist take?

“…it must be wrong to collude with the patient’s attempt to use the therapist to reduce the unknowable to a fact….It is far more difficult to empathize with the patient’s not knowing than to reduce uncertainty by pretending to know.  (Bateman/pbpd/218)”

if therapist gives false confirmation on a patient’s suspicions of a memory….

“Through giving reassurance, the analyst not only colludes with one side of a patient’s ongoing conflict, but also communicates an inability to withstand the patient’s demands for false certainty.  In this way, his own incapacity to tolerate uncertainty is communicated.  The patient is then obliged not only to live what may be a false reality, but, perhaps even more damaging, to support what he unconsciously perceives as the therapist’s psychic fragility.  Paradoxically, many therapists intend such interventions to show the patient something quite different – that is, an inner strength in facing up to unbearable images and to think the unthinkable.  (Bateman/pbpd/218)”

HYPERACTIVE MENTALIZATION AND PRETEND MODE

Borderline patients have knowledge but not belief.  Their beliefs are changeable, fragile, fleeting, and contradictory and this is countered by seeking out others who appear to have beliefs and understanding.  (Bateman/pbpd/218)”

I have in as many words, said this to Ernie.  That his boundaries appear strong and clear – truthfully, rigid – but that he does not enmesh or entangle with me.  He does not seem to question his own beliefs – which can be good, or harmful, like with this medical mess he is in.  Ernie will not consider alternatives…]  In doing so they take on others’ beliefs as their own, becoming excited by them, adept at developing them and applying them to themselves. [I wonder if this isn’t connected to my past experience of what I called “giving away my power” in believing the ceremonies, the Baha’i faith, always searching to belong.

Related to a “boundary violation” which is like the computer error message when you try to open a file that is already open – “sharing” violations – if one does not have one’s own beliefs, that is part of not having a self.  I have always thought that at least anger does that – points to one’s values which are violated, and from values to beliefs.

“…pretend mode in which ideas appear to have meaning but in fact have no links to other ideas, no depth, and no personal value.  (Bateman/pbpd/219)”

“in general it is best not to confront the patient with inconsistency, at least initially, since, in pretend mode, they have no access to their previous understanding of others.  (Bateman/pbpd/219)”

That’s an interesting concept – one can pretend anything is anything, whenever, because there is no contingency

Also, when author is talking about this (see next paragraph below) it made me think of mother’s “dream house” – and how literal it must have been for her to tear up that book with the pictures in it.  Also about why she could never pick up a hammer and saw and ACTUALLY do something to change her own physical environment – this must be connected

“…their elaboration is overly rich and frequently assumes complex and improbable unrealistic aspects….when reflectiveness occurs it doesnot [sic] seem to have any ramifications.  (Bateman/pbpd/219)”

“The involvement of the therapist in this process stabilizes the patient who then becomes ‘addicted’ to therapy and can never leave because his identity is part of a complex ‘psychoanalytic identity’ which is two-dimensional rather than developmental.  Experience of mental states has no implications so there can be a hyperactive feeding on itself, a generation of ideas, a complex interweaving of scenarios, a stage play that at the end seems to have gone nowhere.  (Bateman/pbpd/219)”

Boy, that reminds me of my life – how events are not connected.  Even going to grad school from “ceremony” – not being connected, everything as a stage play.  2-dimensional – perhaps easier to think about Ernie – 2-D relationships, 2-D mansion – nothing real or of substance or meaning or attachment.  Hollow, empty, disconnected

A continual RE-EN-ACT-MENT – an ENACTMENT of a life – nothing linked or having true meaning

Like leaving “ceremony” for grad school, and just getting lost again.  As Jered used to say when he was little, “Mother, you KNOW we are on the road to nowhere.”  Scary stuff, this is NOT easy to look at, because I have to look within – the reflections in the mirrors that are NOT real– hyperactive or pseudo-mentalization

“For an individual therapist whose aim is to increase mentalization, challenging pretend mode in which mentalization seems well-developed raises the possibility of embarking on a strategy which invalidates the aim of therapy itself.  First the therapist has to avoid encouraging hyperactive or pseudo-mentalization.  To do so some techniques should be avoided.  The therapist should never talk about complex mental states but keep his interventions brief and to the point.  Sessions should be focused rather than discursive and patients not encouraged to elaborate too much and the therapist has to keep in mind the apparent mentalization as a deficit rather than a strength….excessive meaningless mentalization…. (Bateman/pbpd/219)”

CONCLUSION OF CHAPTER

“…a mentalistic, elaborative stance on the part of the therapist … ultimately enables the patient to find himself as he really is, first in the therapist’s mind and later in his own as he integrates this image as a part of his sense of himself.  For the patient, enhancing mentalization, encouraging affect representation and preventing escape into pretend mode gradually transforms a non-reflective mode of experiencing the internal world, which forces the equation of internal and external, to one where the internal world is treated with more circumspection and respect, separate and qualitatively different from physical reality.  The therapist’s respect for minds generates the patient’s respect for self, respect for other and ultimately respect for human narrative.  (Bateman/pbpd/220)”

CHAPTER 8 TECHNIQUES OF TREATMENT

“The initial task is to stabilize emotional expression because without improved control of affect there can be no serious consideration of internal representations.  Even though the converse is true to the extent that without stable internal representations there can be no robust control of affects, [and how is this linked to the damage to the neurochemical switch in the ANS???]  identification and expression of affect is targeted first simply because it represents an immediate threat to continuity of therapy as well as potentially to the patient’s life.  Uncontrolled affect leads to impulsivity and only once this is under control is it possible to focus on internal representations and to strengthen the patient’s sense of self.  (Bateman/pbpd/221)”

Uncontrolled affect, impulsivity, what he said before about connections to attentional deficits, connected to living life as a “stage play” – no stable internal representations…..

Four major psychoanalytic treatment goals:

++ identification and appropriate expression of affect

++ development of stable internal representations

++ formation of a coherent sense of self

++ capacity to form secure relationships

“Borderline patients become overwhelmed by feeling and are unable to differentiate between affective states at time of high general arousal.  [that old ANS switch again]  Their capacity to regulate their manifest emotional states appears impaired.  This has been generally recognized as a core symptom of the disorder.  Within the current programme we conceive of the failure of emotion regulation as a consequence of a general difficulty with understanding the emotions that arise, their conscious and on-conscious determinants, and labeling affect states in appropriate ways.  (Bateman/pbpd/222)”  [enactments often follow]

“General strategic recommendations for identification of affects

+ continually clarify and name feelings;

+ understand the immediate precipitant of emotional states within present circumstances;

+ understand feelings in the context of previous and present relationships;

+ express feelings appropriately, adequately, and constructively within the context of a relationship to the day-hospital team, the individual session, and group therapy

+ understand the likely response of the team member involved in an interaction  (Bateman/pbpd/222)”

“Patient’s have a tendency to overgeneralize their own subjective states to others around them (externalization).  (Bateman/pbpd/223)”

Learning to mentalize:  learning to “feel better,” i.e., gaining information, skills and abilities so that I can do a better job of feeling!

“Impulsive acts commonly take place in the context of high emotional arousal.  We view them, in part, as a result of failed attempts to control emotional states or come to terms with interpersonal interactions.  Many authors have identified this as a secondary effect of inadequate emotional regulation.  Others consider the acts to have meaning, with which we agree.  But we take a view that first it is important to help the patient to understand the precursors that led to their impulsive action….self-harm is consequent on dysregulated arousal from social challenges with the normal range.  (Bateman/pbpd/224) ….it is absolutely essential to make use of episodes to help patients achieve a better understanding of the way in which their inability to understand their own internal states or those of others can provoke them to desperate actions and to use these experiences to deepen their understanding of their states of mind.  (Bateman/pbpd/225)”

same paragraph con’t

“Second the patient needs help to identify the feeling state and place it in an interpersonal context if he is to establish freedom of movement to the extent that he can think about himself and others without recourse to action.  This may be facilitated by getting the distress out of the head [HELLO!  It is very much IN THE BODY as well!] and into the world through drawing, writing, and art which helps the patient move from enfeebled, implicit mentalization to explicit mentalization.  (Bateman/pbpd/225)”

“A common theme linked to suicide attempts and self-harm is fears of abandonment and the therapist should ask specifically about epidosdes in which the patient has either feared or experienced abandonment, starting as early in life as the patient can remember.  Borderline patients’ self-coherence is realized through relationships and dependent on them, Aspects of themselves, specifically the alien self (see p. 89), are externalized and lodged in the other in order to form a bearable, but fragile, self-representation, which is experienced as life-saving by the patient.  Potential abandonment by the other threatens this tenuous stability and suicide and self-harm are seen either as a way out of unbearable collapse of the self-representation or as a last-ditch attempt to re-establish the relationship which supports the alien self.  (Bateman/pbpd/226)”

“It is important to distinguish between suicidal acts and those of self-harm.  Often they are seen as lying along a continuum but in fact they are behaviours that probably represent different psychological states albeit with some aspects in common, have distinct meanings, and require different interventions.  (Bateman/pbpd/227)”

“Self-harm is associated with dissociative experiences and patients report the onset of a bewildering feeling which rapidly escalates out of control, becomes unbearable, and is relieved only when cutting takes place.  (Bateman/pbpd/230)….Some individuals become addicted to self-harm, integrate it into their lifestyle, and gain pleasure in a secret ritual in which they use razor blades or special knives to provide reassurance wherever they go.  We understand this as arising from their recognition of the fragility of their representations which cannot be ‘called forth’ at times of anxiety.  Cutting provides proof of existence and makes their unbearable feelings bearable.  The addictive quality of some self-harm may be related to the release of endogenous opiates which has led some practitioners to use naltrexone, an opiate receptor antagonist, to break the addictive cycle (Roth et al. 1996).  It has met with limited success probably because of the powerful psychological factors dominating self-harm.  (Bateman/pbpd/231)”

++ thinking about leaving our “other” who is the “repository” for our alien self creates instability, and “thinking about leaving” becomes “tantamount to actual leaving” and this is destabilizing  (Bateman/pbpd/231)

  1. (Bateman/pbpd/234)”

“…Aggression is aroused defensively to deal with a perceived threat to the stability of the self, commonly a threatened or actual humiliation, and this occurs because the intention of the other is poorly understood or the person feels threatened by their own state of mind.  For instance, a patient may feel intensely and constantly self-critical and be unable to ward off such self-criticism.  The result is intense anxiety, which results in projection of the criticism onto the other who is then attacked, leading to the overt aggression.  (Bateman/pbpd/234)”

gives example, and then

“In this example the violence arises from the patient’s experience of being dismissed and humiliated by both his former partner and now the patient in the group [and by his father].  His fragile sense of fatherhood and manhood becomes unstable as his self-regard is undermined, his own fears of being unimportant are verbalized by another patient, and the return of an alien self becomes a possibility.  [Was this why mother had to be so persistent in abusing and hating me?  Because she could not take the risk of having to take this alien self back?  Is that why she so disintegrated when left alone, because all the hate came to rest within her – though it was never hers in the first place, only given to her?  Is that part of what threatened me when all my children left home, that I had no one left to put the “lovable” alien part of myself into?  Is that what destabilizes me even today, this Saturday, when I cannot contact Ernie and I so miss him and being with him?  When I have nobody “out there but close to me” to love, am I left only with my unlovable self?]  In this case the alien self is an impotent irrelevant self that he does not recognize as part of him because he experiences it as inaccurate and not his own. [What if it WAS accurate/ This confuses me.  If it was a truth does that mean that it would not be displaced and externalized as an alien self?  Would it mean that he would have an easier time integrating it if it WERE a truth?]  He himself was constantly humiliated by his own father who used to taunt him about the size of his penis and he needs to retain a self-representation of himself as a father and man [which they said above is fragile] to remain stable [he fears being unimportant].  When it is threatened his reaction is viciously to dismiss the group member and the group itself to restablize himself.  (Bateman/pbpd/235)”

“Many borderline patients at the severe end of the spectrum show co-morbidity with narcissistic and antisocial personality disorder (ASPD). Antisocial features increase the patient’s tendency to control and manipulate the other with scant regard for their rights and independence of mind.  The moment the other person shows some independence of mind, radical action has to be taken and violence becomes possible.  Independence of mind not only may be represented by a partner ‘doing his own thing’ but also by a partner wanting a more intimate and closer relationship.  For the borderline patient with antisocial features, both represent danger.  (Bateman/pbpd/235)”

I absolutely do not understand why they do not talk about how these dynamics affect their ability to parent!  In extreme and severe cases such as mine was with her, and so, too, for all my siblings to degrees, we were not allowed to achieve any  independence of mind.  Her control and manipulation of me was nearly perfect and complete.  Her pretend “other” children were allowed to fit a more “good” pretend picture, but it was still pretend!

“This has consequences for therapy since it is inevitable that the therapist will show independent mental existence by attempting to explore more emotional aspects of problems and pointing out different perspectives, all of which may endanger him physically if the patient has developed some dependence on the relationshipInitially the patient may terrorize the therapist to see the fear within him since this will reassure the patient that the externalized alien self remains firmly embedded in the relationship.  (Bateman/pbpd/235)”

+++++++++++++++++++++

Initially the mother may terrorize the child to see the fear within her since this will reassure the mother that the externalized alien self remains firmly embedded in the relationshipMan!  This could exactly describe the mother-child dynamics!  From what Bateman says above, I would have to suspect that as a mother, she had “some dependence on the relationship.”   So great was her need.  For the first time, I am wondering if her psychotic break wasn’t retrospective – that it arrived, even the part about the devil sending me to kill her during our labor – after I was born and after she saw that I was a girl!

++++

Is it also somehow that Ernie’s “independence of mind” both saves me and at the same time tortures me?  That it is essential so that I don’t “enmesh” or “merge” with him, that he doesn’t allow it?  That I am that afraid, with any other man, that defense and protection would not be there, and I would either devour that other “weaker” man and he would vanish – like my father did with my mother?  Or that I would disappear into him and vanish – also like my father did, but also like I did because she did not allow any other option?  When “boundaries” such as this fail, when they were never even erected – when there is no boundary, no border, no line between self and the other, when the self does not have enough solidity to have a line of differentiation or demarcation –

As in the Baha’i marriage prayer:  “He hath let loose the two seas, that they meet each other:  Between them is a barrier which they overpass not.”  I always read this and imagined that if a red sea and a blue sea met one another and mixed themselves together in life, the overall combined sea would appear purple.  Yet each individual drop and particle of the two separate seas would remain intact, and if the two seas could be pulled apart again, they would be restored to their original colors.

These pathologies that result from damage to the developing infant’s brain-mind-self seems to me to have something to do with this.  We do not know, from our very beginnings, where we started and stopped, and where our caregivers started and stopped.  We do not have internal self-integrity.  We do not recognize the borderlines between our selves and other selves.

When do we, according to these experts, stop being objects and become being human beings?

++++++++++++++++

“An increase in risk arises if the patient experiences his alien self being forcibly returned to him.  [A reason why adults pick on kids – they can’t “forcibly” return the alien self to their parents.  Yet the parent also know that nature will take the child away just through growth and development.]  This destabilizes his self-state and  violence becomes a last desperate bid to destroy it and prevent its return.  So, finally, the therapist should retain the ‘alien self’ and not try to return it through forceful interpretation.  Understanding of the violent impulse takes place gradually when a crisis is over and risk reduced.  (Bateman/pbpd/236)”

So they are trying to destroy the alien self they have externalized into the child so that it will not and cannot return to them!?!  That is why this child abuse is so powerful and deadly.

So what is the process when the projected, externalized alien self is the good “stuff?”  We would not want to destroy that – but neither do we have any way to “bring it home” to ourselves, either, any more than we can the dark side we have put “out there” into someone else.  But maybe it’s the same thing – we have to keep both out there because we can’t accept either into our self, our belief system.  So we still HAVE to have an “other out there.”

I can’t minimize or ignore or trivialize this process.  I experienced the power it had over my mother.  If this is the same process that is hurting me so much with Ernie – and actually did the whole time I had my children at home and put my “lovable” alien self out there – it is major and its power cannot be underestimated.

That means that on very young and little terms, the process is some sort of “kiss it and make it better” thing, which is a manifestation of pretend thinking and literalizing:  “You take what I cannot bear to hold within myself, good or bad, and I will be better.”  Or, in extremely damaged cases, “You take what I cannot bear to hold within myself so that I will be able to stay alive.”  Period.

We have to realize that we are talking about what Siegel called, THE UNBEARABLE PAIN, the unsolvable paradox.  How can I communicate the full impact of this, the ramifications of this process and this state of being, to anyone?

This experience is profound, and just the act of assigning words to it in some way trivializes and minimizes it, for it is a deeply felt experience that operates on unconscious levels, deep within the psyche, the nervous system, the body, and probably deep within the right brain.  Once words are assigned by the left brain to describe it, and the words are read by another left brain, the translation can be very easily nearly completely lose the impact and the fundamental truth about these realities.  The left brain has no depth, and does not care about anything.  Its job is just to assign a linear and logical order to what it perceives as facts, irregardless of context.

“Crucial to interpersonal dynamics in narcissistic and ASPD is anticipated or actual humiliation, which is the most potent threat to the self.  In the absence of full mentalization, the shaming experiences is felt as actually potentially annihilating (see Gilligan 1997 for a comprehensive psychological model of violence) not an ‘as if’ experience but one where the psychological experience of mortification comes to be equated with the physical experience of destruction, or ‘ego-destructive shame’ (Fonagy and Target 2000).  (Bateman/psbpd/236)”

++++

ENVY

“Envy is a paradoxical emotional reaction which entails an attack on something which is felt by the patient to be helpful or useful.  It is perplexing to an observer because the attack seems to make little intuitive sense.  It seems to be against their own as well as everyone else’s interest…..Good things are seen as being in the other person’s control; they cannot have them just because they wish for them, so it is better not to have them or to want them at all.  It is better for them to be destroyed and therefore not available…..These reactions are not the same as aggressive attacks related to paranoid anxieties but they are more a result of the inability of the patient to maintain envious feelings, as with all other feelings, within reasonable bounds.  (Bateman/psbpd/240)”

“Envious attacks occur in groups but in this situation the therapist needs to distinguish them carefully from jealousy or other types of triangular relationshipsJealousy is a more sophisticated emotion than envy and requires a capacity to recognize complex interpersonal processes.  (Bateman/psbpd/240)”

++++

“Hate and contempt are affects that borderline patients use to protect their self-esteem.  …The effect of the hate and contempt is to distance the patient from others and to protect a fragile self which has been threatened by an experience of need.  The emotions cover a deep mistrust of others and inner fears of becoming dependent on others and having to recognize that others have a separate existence and their own individual motivations.  The identity of the borderline patient is safe in their inner castle, contemptuously obliterating all others as unnecessary or useless to them.  There is an illusory sense of control.  Occasionally a patient may appear better when this state of mind is manifest since it distances them from closer interpersonal interactions and closes (Bateman/psbpd/247) their mind to that of others.  It is when their mind is open and they are able to experience their feelings for and the feelings from others that they become more disturbed.  (Bateman/psbpd/248)”

++++

Love and Attachment

“It is often stated that aggression is a central problem for borderline patients but, in our view, the experience of love and positive attachment causes severe difficulty.  Patients are unable to distinguish between love and other feelings such as dependency, need, and sexual desire and attraction….As the therapist gradually activates feelings of attachment in the patient, disorganization of the attachment system becomes more evident.  For example a patient may start to cling helplessly believing that physical proximity is necessary which in turn can be met with inappropriate attempts by the therapist to avoid the patient who is experienced as devouring and controlling.  Alternatively attachment to the therapist can be manifest paradoxically by intensification of enactments including suicidal gestures and manifest hate of the therapist.  It can be hard to remember that the root cause of increasing difficulty in the therapy is the patient’s increasing awareness that the therapist and treatment matter.  Commonly the patient remains unaware of the strength of their attachment.  (Bateman/psbpd/250)”

“The principle of treatment is to explore the defences [sic] rather than to interpret the underlying loving feelings themselves.  Sometimes the patient seems to need the therapist just to have someone to maltreat [or to love] or to have him in close proximity, for example to hear the therapist’s voice.  This may put increasing pressure on the therapist to be available.  It should not be confused with attachment that evokes internal feelings of security since it is more likely to represent the opposite, namely a profound sense of insecurity.  (Bateman/psbpd/251)”

ESTABLISHMENT OF STABLE REPRESENTATIONAL SYSTEMS

Whenever borderline patients develop a relationship of personal importance, their interpersonal representational system is at risk of becoming unstableThe representation of their own internal states and those of others becomes fluid and so they are unable accurately to recognize what they are feeling and thinking in relation to the other or to know what the other is feeling or thinking in relation to them. As a consequence, they resort to rigid and crude schemas in which relationships lose their subtlety and can become (Bateman/pbpd/252) exaggerated caricatures of normal ways of relating. The therapeutic task is to establish internal experiences as more robust states.  This is more effectively done after affects are more stable and present less of an interference with the patients’ and therapists’ ability to think.  This is the case both in the overall treatment programe [sic] and within the microcosm of the individual session or the group.  It is usually ineffective to attempt to stabilize internal representations when there is too much ‘affect noise’ in the backgroundAffects are exaggerated because beliefs are experienced as having comparable force to physical realityThus emotional responses to physical events can be hard to understand without explicating the overwhelming power of the beliefs they give rise to. (Bateman/pbpd/253)”

++++

“Borderline patients hold particular beliefs about themselves and about how the world has treated them in the past and how others will treat them in the future.  These beliefs are held with a tenacity that goes well beyond any present reality and govern all interpersonal interactions, especially when anxiety is aroused…..Common examples include ‘the world is a malevolent place’, ‘anyone whom I like rejects me’, ‘I am the most difficult patient you have ever treated’, ‘people can’t be trusted’.  However, it is important for the therapist to understand that these are more than straightforward beliefs, that could be questioned through, for example, Socratic techniques.  The beliefs form part of the way in which the borderline patient organizes his internal world through harnessing the interpersonal context.  Primary beliefs are but one aspect of a complex representational system that determines how the individual understands and interprets events.  Unable to experience thinking about himself internally (‘from within’), the borderline patient is forced to understand himself by establishing relationship configurations, as it were from without.  A situation is created in which what is normally an intrapsychic process is established through an interpersonal interaction.  (Bateman/pbpd/254)”

For the patient to feel safe, not to feel persecuted [I would add, deprived] from within the therapist must play the assigned role in order for the patient to confirm his expectations about himself and relationships. Yet for the therapist to be effective, he must not fully engage with the patient’s efforts to force him into a specific role-relationship.  The therapist must go alongside the beliefs but not go along with them or argue against them.  If he challenges or opposes them at an early stage the patient is either thrown into confusion and distress or disengages from therapy.  Typically, the therapist feels provoked, forced to oppose an accusation, to deny a complaint, or to defend himself.  If he does so the patient has no choice but to insist further on his representation of events in order to protect his fragile sense of reality and to stabilize his self-representation.  Ideally, the therapist must accept the patient’s need for a ‘flawed’ therapist without actually enacting too many of the limitations the patient imposes.  As soon as rigid beliefs become apparent, the therapist must identify the triggering event, the (Bateman/pbpd/254) overpowering viewpoint it gave rise to, and the affects which naturally accompany the experience.  (Bateman/pbpd/255)”

++++

IDENTIFYING AND UNDERSTANDING SECOND-ORDER BELIEF STATES

“The rudimentary development of mentalization in borderline patients reduces the complexity of their representation of mental states and understanding of the motivation of others; only one version of reality is possible, there can be no false belief.  A remarkable rigidity of beliefs is the consequence.  Mentalization acts as a buffer:  when actions of others are unexpected, this buffer function allows one to create auxiliary hypotheses about beliefs, which forestall automatic conclusions about malicious intentions.  These are second-order belief states.  But for the borderline patient, at times of close engagement with another person, no such process is possible. (Bateman/pbpd/255)”

No wonder I could not fight against my mother:  remarkable rigidity of beliefs

Internal reality becomes identical with physical reality.  Thus imagination of threat is tantamount to the reality of threat.  Some of these reactions can be readily understood.  For example, internal working models constructed on the basis of abuse assume that malevolence is not improbable.  However, being unable to generate auxiliary alternative hypotheses, particularly under stress, makes the experience of danger far more compelling.  Normally, access to the mentalization buffer allows one to play with reality since understanding is known to be fallible.  (Bateman/pbpd/256)”

It wasn’t in my case – it was so perfectly clear there was no question and no alternative way to consider reality – so I suppose this ability to mentalize, to play with reality, was not developed.  There was no possible way mentalization could have provided a buffer.  Only, I suppose, was dissociation an option.  I didn’t have to “assume” anything.  Abuse and malevolence was not only “not improbable,” it was my ONLY reality.  There was no possible NEED for an auxiliary alternative hypotheses – so why would I ever get the skill to create one?

“But the borderline patient cannot play with the ideasNo alternative realities can be envisioned, there is only one way of seeing things.  This state of affairs changes only slowly.  It is, therefore, important during the early part of the treatment not to try to argue patients out of their understanding.  Attempts by a third party, such as a therapist, to persuade the patient that they are wrong may be experienced as an assault and an attempt to drive them crazy.  Only when mentalization has been to some degree re-established [In my case that would be a wrong assumption!  You cannot re-establish what never WAS!] can the therapist begin to challenge the patient’s perspective.  (Bateman/pbpd/256)”

++  “…putative beliefs about the self can be devastating and the individual may take extreme measures to attempt to protect themselves from the overwhelming painful reality associated with these thoughts.  Shame associated with beliefs about critical views that others might hold can be experienced as devastating.  Violence towards the self (or the other) might be the only way o reducing the discomfort.  The problem is exaggerated by the rudimentary nature of the patient’s capacity accurately to identify the belief that the other actually holds about the self.  Similarly, their flawed beliefs about beliefs might lead them to experience their minds as non-opaque to the scrutiny of others.  The patient comes to feel that others can read his mind [OK here, Schore would say that we CAN do this with one another – that it is natural if we have developed correctly.  The problem is that a damaged person’s brain can’t do it back, and doesn’t understand when and how it is operating for others!] and this in turn can lead to unrealistic expectations about the extent to which the other can meet the patient’s need.  Frequently the patient might feel distressed because the other has not acted in was that indicates accommodation to their thoughts and feelings.  This feeling is rooted in the false assumption that the other had access to the internal experience of the patient without it being communicated verbally.   [Well, not mind read to this extent!?  Sounds like the codependency stuff….]  (Bateman/pbpd/256)”

++++

WISHES, HOPES, FEARS AND OTHER MOTIVATIONAL STATES

“The third phase of reflecting on internal states involves exploration of motivations.  This involves first identifying affect states ….When this has been achieved to some degree, the underlying states need exploration within an interpersonal context.  The affects are seen in terms of how they are expressed in the individual’s motivations within (Bateman/pbpd/257) the group, towards the individual therapist or with other people in their life.  (Bateman/pbpd/258)”

“In both goup and individual session it is important:

++ to clarify with the individual their current feeling;

++ to identify the other feeling which the current feeling is a reaction to;

++ to explore the underlying reason for that second feeling;

++ and tentatively to suggest that this was the underlying hope, fear etc. that went unrecognized or was thwarted.  (Bateman/pbpd/258)” [they use a dot at beginning and skip a space]

“In individual therapy the patient has to challenge his own understanding of others which presents considerable difficulty since it confronts his rigid, schematic representations of his own motives as well as those of others along with their teleological beliefs.  (Bateman/pbpd/258)”

Somehow the word ‘rigid’ in the above sentence made me think of being a prisoner – and how this therapy is trying to help them know they are free.  Just the fact that we escape the brutal abusive environments of our childhood in no way guarantees us freedom.  We didn’t have it then and don’t have it now.  These deep pathologies are not automatically corrected, or self-correctable…

“Later in treatment it may be possible to work on the conflicting wishes and desires or beliefs and to explore how the affect the patient’s relationships.  (Bateman/pbpd/260)”

FORMATION OF A COHERENT SENSE OF SELF

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