Questions and Answers

Dear Readers, questions were edited as I exchanged information with Marcus West. Therefore, some parts of the answers may be repeated. Since all answers complement each other and deepen understanding, all questions and answers are preserved in their original form. With regards, Anna Chuykova, medical psychologist.

Questions and Answers

1. The book says that the borderline personality organization is used in a narrow sense, similar to the understanding of A. Stern, and the formation of such a personality organization is considered by you (in contrast to A. Stern) as a direct consequence of the use of a primitive defense reaction “freeze! "; also, the borderline organization of the personality is considered in a broader sense - as a state of consciousness caused by the individual's internal conflict and dysfunction of the ego (further development of this thought goes on in chapters 2, 5, 6, 8).

Could you once again say how you understand the differences between the concepts (terms) " borderline personality organization" and " borderline states of mind" (this can be especially important for those who are not yet familiar with your work).

Marcus West:

Thank you for your questions and for giving me the opportunity to respond further.

I was re-reading Stern’s original paper recently and I noticed, to my great surprise, that he did, in fact, mention the freeze responsealthough only in passing. I have for a long time been exploring how our psyches protect themselves from unbearable (traumatic) experience through various different, necessary ‘narcissistic defences’; I was therefore very excited to discover that these defences correspond very closely to the primitive mammalian responses to threat, which are hard-wired into our autonomic nervous system (as described so well by Stephen Porges).

We all have thesedifferent responses to threat – fight, flight, freeze and collapse – and move between them as the situation demands. However, as Christopher Bollas says, when one of these states becomes our dominant way of responding (which will be due to the particular nature of our early experiences), it becomes our dominant ‘personality organisation’ (Bollas calls them personality disorders), even though we can move into other responses at times. So a borderline personality organisation is an embodiment and development of a freeze response, where the person feels powerless, fundamentally negative, hopeless and despairing; although they may also, at times, have angry outbursts (fight), avoid conflict (flight) or be unable to take action (collapse).

In contrast, someone for whom a fight response predominates corresponds with a narcissistic personality organisation, where the person wants to dominate and blame the other; a flight response with a schizoid personality organisation, where the person withdraws, avoids conflict and can be compliant; and a collapse response with a hysterical personality organisation, where the person suspends their natural way of being and fits in totally with the other, on the surface at least. This is to define the personality organisations in a narrow sense, and the borderline personality organisation very much coincides with the features that Stern described in his original 1938 paper.

What I mean by a ‘borderline state of mind’, can happen to anyone when a traumatic ‘complex’ is triggered. A complex is formed when we experience something our psyche cannot bear at that moment, so there is a highly charged affect (feeling) that is not contained or integrated. When something similar happens to trigger this in the present, for example, someone shouting at us (when that was traumatic in the past) we have peculiar, powerful reactions – we may fight, flee, freeze or collapse – that make us behave in ways that are not very adult or well-adjusted, and we are taken over by these feelings to a greater or lesser extent. At that moment we are in a primitive, ‘borderline’ state of mind.

The term ‘borderline’ has been used differently over the years however, and people like Peter Fonagy now describe it in a broader sense, where the individual’s everyday functioning and relating is compromised due, for example, to the difficulty (threat) of thinking about what is in the other person’s mind (it affect their ability to ‘mentalise’) – perhaps seeing that your parent hates you, cannot bear your needs or distress, or wishes you were dead.

2. In many works of psychoanalysts it is said that " early trauma is the basis of the described disorder (whatever disorder we are talking about)" (quote from the book).

Would it be true to say that early relational trauma underlies the borderline personality organization, understood broadly as a continuum between neurotic and psychotic personality organizations?

Marcus West:

There is a growing consensus and agreement that adult psychopathology can be traced directly back to traumatic early relational experience. A paper by Herman, Perry and van der Kolk (1989), which made an extensive study of people with borderline personality disorder (which I call ‘organisation’, partly in order to avoid bad associations with the term ‘disorder’), first made this link with early trauma explicit.

Psychoanalysis has, from the very beginning, argued about how much adult psychopathology follows from real world trauma and how much from internal conflict and the drives, with Freud at first thinking that ‘hysteria’ was due to sexual abuse (his ‘seduction theory’), although he soon changed his mind and thought it was due to internal conflicts about sexuality; this became the dominant understanding in some schools of psychoanalysis for many years. Of course, there are many types of trauma other than sexual trauma, and we are, for example, more recently recognising the massive, traumatic effects of neglect.

To answer your question about the continuum – yes, we have all inevitably, to different degrees, experienced some trauma in our lives (defined as something that our ego was unable to bear and integrate at that particular time). When someone is able to ‘get round’ these traumatic ‘complexes’ most of the time, this corresponds with a ‘neurotic’ disorder, that only affects the personality in certain ways when the complex is triggered. However, when someone has had substantial trauma early in life, the person’s ability to relate and function successfully is more severely affected – then we can talk in terms of a borderline personality organisation in the broad sense. This often corresponds with what Judith Herman called complex posttraumatic stress disorder (complex PTSD), in other words, traumas in early relationship that continued for a number of years; Bessel van der Kolk talks in terms of developmental trauma, in other words, the person’s development has been disrupted.

In regard to psychotic states of mind as part of the continuum, I do not discuss this a great deal in the ‘Into the Darkest Places’ book, although I am exploring this more in the current book I am working on, provisionally entitled, ‘Resolving Narcissism’. With borderline states, the individual is at least able to continue functioning adaptively to some degree, whereas I understand psychotic states as occurring when the psyche regresses to the most primitive form of functioning of the ‘core self’, with a failure of adaptive functioning, which calls up omnipotent defences and primitive ways of thinking and responding to extreme threat, such as withdrawing from relationship and closing down completely. One theory discussed by Stephen Porges is that psychosis follows when the individual is not able to ‘downregulate’ their states of threat. So, this is at the extreme end of the continuum.

To repeat though, when our traumatic complexes are triggered, both neurotic and borderline individuals can all fall into ‘borderline states of mind’ at times, becoming overwhelmed by apparently ‘irrational’ feelings and responses and not responding in the most well-adapted ways. At these times we are reacting from our most primitive ‘core self’. Recognising the triggers, the patterns of behaviour and the different ways and levels on which we are affected, and ‘living these through’ in the therapeutic relationship helps to repair the traumatic complex and integrate the previously unbearable experience. This occurs by the therapist being able to accompany the patient as they reconstruct the early trauma in the therapy relationship, make sense of it and work it through.

3. You have clearly explained the terms borderline personality organization (in a narrow and broad sense) and borderline state of mind. Next I want to give an example from the book by Nancy McWilliams «Psychoanalytic diagnosis. Understanding personality structure in the clinical process». From the point of view of Nancy McWilliams, character organization is the level of personality development, the level of individualization of the client (the level of maturity of the organization of the character) or the degree of pathology (psychotic, borderline, neurotic). While a character type is a defensive style within one of three levels. In the understanding of Nancy McWilliams, " borderline" is the organization of the personality; at the same time, she does not distinguish " borderline" as a type of character. Thus, if character organization is the level of personality maturity, and character type is a defensive style, then is it correct to say that you consider in a narrow sense the borderline personality organization (when it is associated with the " freeze" reaction) predominantly as a defensive style (without relationship with maturity level)?

Marcus West:

I have heard of Nancy McWilliams’ work but have not studied it in any great depth. My understanding comes from trying to make sense of the different ways people present themselves in the consulting room and recognising, as I did in my first book (Feeling, Being and the Sense of Self), that the different personality organisations described and studied by psychoanalysis are all forms of defence of the core self - i. e., narcissistic defences.

They would fall on a spectrum, therefore, between psychotic and neurotic, with borderline (in the broad sense) in the middle. The fight and flight (narcissistic and schizoid) responses are more neurotic as the person is more activated and therefore better adapted, whereas the freeze and collapse (borderline and hysteric) are more toward the borderline-psychotic end of the spectrum as person has collapsed/regressed more and is less well-adapted. I don’t say much about psychosis itself in the Into the Darkest Places book.

My clinical ‘discovery’ was that all these personality organisations relate to the autonomic nervous system and threat. So I don’t see maturity as a linear process, but rather that all these are defensive systems (narcissistic defences) that will affect us in different ways. Clearly, more prolonged relational trauma will lead to more profound defences of the freeze/collapse, dissociative type, which will lead to particular kinds of difficulties. To the extent that they affect development (development trauma) and the functioning of the ego, then the person will have less of a sense of agency and will be more stuck in these problematic ways of being.

But, again, we all have these different responses to threat - fight, flight, freeze, collapse, as well as vigilance and the attempt to control (which I see as affecting the obsessional organisation) so we can all move between these states.

So, in answer to your question - I would see these as all defences which do not necessarily predict maturity although, as I have stated, there will be an overlap. My interest has always been in trying to understand the particular experience of the patient and what they are struggling with - when I give a lecture I always apologise for giving ‘classifications’ or labels, and say I am only interested in understanding the patient and helping them understand themselves.

I want to get away from the notion of ’serious pathology’ and ‘less serious pathology’ as that gives these labels ‘a bad name’ - who would want to be labelled ‘borderline’ if that means ’not mature’? But if you can see that you are stuck in a freeze position due to prolonged threat, that this makes you feel bad about yourself, fearful of others and that your sense of agency has been impaired (through no fault of your own) this is more helpful for people.

I do spend a significant amount of time doing ‘psychoeducation’ which helps people see that they are not ‘bad’, stupid, lazy or wrong.

I hope that helps clarify my position a bit, I know of others who use McWilliams’ classification - each practitioner will use what makes sense to them I think...

4. How do you think specialists from other psychotherapeutic areas (for example, cognitive-behavioural therapy, gestalt therapy, existential therapy) can determine (diagnose) in the early stages of work that this client has an early relational trauma (and, accordingly, it is possible to redirect this client to another specialist)? In other words, are there, in your opinion, any specific signs, symptoms (excluding symptoms directly related to the borderline personality organization or borderline personality disorder), on which a specialist from a non-psychoanalytic approach could rely in his work for a more accurate diagnosis (diagnosis early relational trauma)?

Marcus West:

This is an interesting question. One characteristic of early relational trauma is that, because it happened in an early, formative stage in life, it has become embedded in the personality so that it is ‘who we are’ – even if we can’t bear to be ‘who we are’ – and not liking ourselves and low self-esteem (often to the extent of wanting not to exist i. e. to kill yourself) is an important sign of early trauma; powerlessness, self-hatred and despair are characteristic here as the person feels unable to change.

Another characteristic is the powerful emotional charge, which is triggered by particular experiences e. g. being ignored, being frustrated, being criticised or rejected, with the person reacting in impulsive ways (or having to expend a lot of energy repressing such reactions).

A third characteristic is regression, and where, instead of getting better after some progress has been made the person gets worse (Freud called this the negative therapeutic reaction). I understand this as the person trying to get their deepest traumas fully recognised, acknowledged and repaired, they are not simply ‘being difficult’. It would be like expecting someone to just ‘get over’ the death of a child and ‘get on with’ ordinary life – and in a significant way the person’s inner child has been killed off in some way. This regression may also be in the service of receiving help with the regulation of their emotions that they did not get in childhood.

All of the above characteristics will affect the therapist, who will likely begin to feel useless, hopeless, out of their depth and unable to make any difference to their patient. These feelings are typical and can be worked through with the right support and supervision – they indicate that the patient has managed to successfully communicate their inner state to the therapist (psychoanalysis calls this process projective identification).

In short, I believe we are always working with early traumatic experience. A person may need referring on to a specialist either when other forms of therapy are insufficient to contain or address the difficulties, or when a clinician senses the extent and intensity of the person’s distress and the extent of the disruption of their ego-functioning.

5. The book says that " the influence of the traumatic complex on the personality of an individual can be reduced only after he realizes and works out all the manifestations of traumatic internal working models in direct and reverse forms at each of the four levels" (objective, subjective, level of transference and archetypal levels). Such a deep and multidimensional approach is only possible in psychoanalytic psychotherapy. At the same time, many people (clients), potentially having early relational trauma, turn to short-term forms of psychotherapy, such as hypnotherapy, Hellinger constellations and so on.

What do you think about the possibilities and limitations of short-term psychotherapy methods for treating early relational trauma? Is there potential of short-term methods for clients with early relational trauma?

Marcus West:

Yes, I do think short term therapies can be very helpful, as I will describe, however I think if you are hoping for substantial change in the personality at a deep level, then long-term psychoanalytic psychotherapy will be most suited – particularly one that works from a trauma perspective. This is not always possible, practical or affordable however.

I think CBT can be particularly helpful in trying to support and repair damage to adaptive ego-functioning, which may manifest as acute anxiety, obsessional thoughts or symptoms, low self-esteem etc. by challenging the person’s thinking and offering them strategies to function better once again. If this is successful, that is great. In every case there will be some underlying set of traumatic experiences, but if this can be repaired through the methods of CBT is may not be necessary to work through the traumatic experiences in the context of a psychoanalytic / psychotherapeutic relationship. However, if the traumas are widespread and of a borderline nature it is very likely that CBT will be insufficient to work things through fully at the deepest level.

An important part of working through the traumas will probably require an understanding of the effects of the traumas on the psyche, in other words, some ‘psychoeducation’ concerning the fight, flight, freeze and collapse responses and how best to address and manage those. Increasingly the importance of yoga, meditation and other forms of body therapies has been recognised and shown to be helpful in down-regulating the somatic distress related to early trauma. The STEPPS programme (Systems Training for Emotional Predictability and Problem Solving) has been developed to help the person understand their emotional reactions and to think how best to respond when their complexes have been triggered.

Gestalt therapy is almost always addressing relational trauma (I would suggest that almost all trauma is relational trauma to a significant extent), in helping the person face and engage with the traumatising other. Existential therapy is particularly good at focusing on traumatic issues related to our fundamental existence – meaning, worth, purpose – which will inevitably be emphasised by traumatic early experience.

Kernberg and colleagues have developed a method which focuses precisely on the direct and reverse forms on the dynamics I describe in the transference – called Transference Focused Therapy – where they address the way the analyst is seen, for example, at one moment as the persecutor, and where, at another moment, the patient is punishing the analyst. They particularly focus on these positive and negative relational dyads as they manifest themselves in the therapy relationship. Kernberg says, ‘borderline personality disorderis a chronic but treatable disorder’ (2008, p. 611).

The short-term (or relatively short-term) therapy that I think is most effective in addressing trauma, including early relational trauma and complex PTSD, is EMDR (Eye movement desensitization and reprocessing). I have done a training in EMDR myself and I have found it works very well alongside psychoanalytic psychotherapy (I don’t know how widespread EMDR is in Russia? ). It works similarly to the way that Rapid Eye Movement works in dreaming, which helps work through difficult experience; that is, by focusing on the traumatic experience and then stimulating both sides of the brain through eye movement, auditory or other regular stimulation (such as hand-held buzzers). This decreases the level of distress associated with the experience, thus making it more bearable and able to be talked about and integrated.

This list of treatment modalities is not exhaustive, as there are also therapies such as Dialectical Behaviour Therapy, supportive psychotherapy, Arts therapies, Mentalisation Based Therapy, and Schema Focused Therapy and no doubt others.

6. What is the most promising and interesting for you now in the study of the relationship between early relational trauma and borderline states of mind?

Marcus West:

I have become particularly interested in the way that those part of ourselves that were not accepted and able to be expressed in childhood remain in a primitive, dissociated state and press to be made manifest (Thomas Ogden calls them our ‘unlived lives’). I understand this as the essence of what Jung talked about in terms of the pressure towards wholeness. I believe that it requires a relationship with another person, such as a therapist, to understand, appreciate and accept those parts of the self (including the apparently aggressive, destructive, ‘shadow’ parts), and that this process underlies all therapies and is in the service of repairing these ‘primary narcissistic wounds’. This presents significant challenges to the therapeutic relationship, as these parts remain in primitive, extremely powerful, ‘archetypal’ form, are hypersensitive and can seem (and sometimes be) psychotic in nature.

In researching this process I have been studying the neuroscience of the core self, which tells us a lot about the development of the personality and the struggles and difficulties we have in doing this. I think those people with a borderline personality organisation have been profoundly frustrated in expressing themselves and having themselves accepted, and have been particularly taken up with hatred and destructiveness in response to the destruction they experience to their early developing selves. They have therefore turned against relationship, seeing it as a threat rather than a potential help. If one can understand why this is, and particularly why relationship is so important for someone in coming into being, one can be much more effective in assisting people in leading the fulfilling lives that they never believed were possible.

I hope you might find these comments helpful. I think all treatment modalities are working on these issues from their specific perspective – we are therefore all engaged in a joint venture to help those whose early lives were particularly difficult and traumatic.

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