Roxanne looks at Jason and narrows her eyes. “You let me down again. You don’t care about me, about us!” Jason looks at me hopelessly. He knows Roxanne will probably direct this frenzied rage at him for days. Roxanne has borderline personality disorder (BPD), and periodically is driven to keep hurting Jason for fleeting relief from her own emotional pain. Occasionally thinking Jason is wonderful, the best man ever, and then suddenly knowing he’s evil and feeling driven to attack him consumes much of her life. Is Roxanne “sick?” Twentieth century psychotherapy organized around psychological “sickness,” which everybody agreed to call “psychopathology.” Every psychology department, psychiatric residency program, and graduate school required (and still requires) classes in “Psychopathology,” which fundamentally understands distressed people as sick and needing to be treated. This reflects the traditional Western Medical Model which rests on the idea that people get sick and need to be cured by doctors and other licensed practitioners. In the health care system that emerged with industrialization and medical research, insurance companies, if properly convinced someone was ill, authorized payments for agreed upon treatments. This “distressed-people-are-sick” bias in psychology (sometimes called “the disease model”) largely originated with Freud, who categorized the bulk of “mental illnesses” as neuroses and psychoses. It really hit the mainstream in 1952 with the advent of the DSM (Diagnostic and Statistical Manual), where the American Psychiatric Association climbed aboard the medical model gravy train and officially embraced the disease model for emotional, relational, developmental, and behavioral problems. With the advent of the DSM, psychologists and psychiatrists were eventually required by licensure boards and their professional associations to diagnose patients—at least partially—as being sick with disorders such as depression, anxiety, addiction, or panic (and also being gay back in those days). With official “diagnoses” they could now coordinate with insurance companies to provide drugs and psychotherapy to treat and cure, just like the medical doctors. Developmental arrest. I personally think psychological problems are more issues of developmental arrest. We are biologically and socially driven to grow and become healthier and happier, but bad habits of thought, behavior, and relationship interfere. Psychotherapy is more about restoring and supporting development than treating illness. From this perspective, most “mental illnesses” take on new meanings as characteristic forms of obstructions to personal evolution. In the above example, Roxanne never developed the abilities to soothe her rage and examine violent beliefs and impulses. My job is to help people successfully accomplish such milestones to help establish appropriate skills and neural circuits—thus liberating them to love and grow. In defense of the DSM and the disease model, metabolic imbalances drive lots of syndromes like bipolar disorder, schizophrenia, autism, and so many forms anxiety and depression. In these cases, like with many physical illnesses, medication can help people benefit from the social support they need to heal, grow, thrive, and contribute. Even more, lots of emotional and relational problems are like addiction, which is accurately described as “disease” by everybody in the recovery community, because they have predictable patterns of distress and specific interventions that provide relief. Still, mostly, in all forms of treatment for mental illness, progress is measured by personal and social development. Borderline Personality Disorder and projective identification. No psychological disorder has been more thoroughly anchored in “distressed-people-are-sick” than Borderline Personality Disorder (see Blog #12), where emotionally sensitive people like Roxanne exposed to early abuse or neglect grow into adults who compulsively and repetitively attack people they love the best. This happens through a mechanism called “projective identification” where a person suffering from BPD, unable to face their own violent sadistic side, projects it onto another, and regularly feels compelled to relentlessly attack, with no apparent concern for how horrible this is for everyone. Werewolf sidebar: I’ve always believed the original Werewolf of London fairy tale, where a cursed man becomes a wolf under the full moon and stalks and kills his most beloved, was a mythic reflection of BPD. Projective identification is one of the nastiest defense mechanisms and causes billions of dollars of problems every year (even hundreds of billions if you include political parties and countries engaging in cultural projective identification). On the other hand, projective identification has another, more luminous side. Borderlines also project pure, angelic, idealized images onto other people and then worship and adore them until some real or imagined flaw cues the switch to hatred and attack. One of the eeriest things about therapy with borderlines is watching them make these swooping shifts from idealization to hatred with little or no self-awareness of how they just, all on their own, completely changed their own and their partner’s universe. Psychotherapy sidebar: A main distinction between borderline traits (most of us have some capacity to project and attack) and full-on BPD is that when you confront a borderline too much with their deluded thinking and over-the-top rage they go crazy (“You’re wrong! How dare you suggest I like to hurt people! You’re abusing me!”). The rest of us respond to confrontations like, “Keith, you’re being mean!” with some version of an embarrassed, “I’m sorry. I’ll lighten up.” In other words, most of us get saner when a caring person reflects our destructive thoughts and feelings. Powerful instinctual forces are at work here. Nervous systems can compulsively relate internally and interpersonally in weirdly connected and complementary ways, creating compelling, driving narratives of explosive emotional charge that radically affect us and the people around us. Can we learn to use these forces to love better? Projective identification transformed into sacred tantric practice: Projective identification involves someone being unable to truly face and accept violent, ugly aspects of themselves. These dark inner “selves” feel so horrific that they can’t be acknowledged. Instead, borderlines create yucky beliefs about other people to justify attacks, all the time vulnerable to self-loathing depression. Depressed borderlines often enthusiastically injure themselves, up to and including self-mutilation and suicide attempts (Transactional Analysis—originated by Eric Berne, author of Games People Play—calls relational patterns that attack bodies, “tissue games”). When borderlines enter therapy and actually acknowledge sadistic impulses and destructive behaviors (a necessary and courageous first step towards growth), the self-image that tends to emerge is “Horrible and nasty is who I really am.” “I am a worthless, despicable person, and deserve suffering and death,” statements are staples of sessions. Effective psychotherapy focuses on awareness of such crazy states while supporting self-regulation and non-violence, worthy but limited goals.
- “Worthy,” because self-awareness and self-direction are the paths to clarity and kindness from nightmare stories and yucky impulses.
- “Limited,” because the primary focus is simply on reducing negative thoughts, feelings and behaviors.
- Once we grow past icky self-judgments and creepy violent impulses of projective identification, we can use our capacities for intense relatedness to refine and develop powerful, beautiful interconnectedness.
- Now, instead of identifying with my ugliest side, I accept—but never surrender to—my lapses into anger and attack, and identify “me” as my most beautiful, wise, powerful self.
- Instead of identifying you as abusive or bad as I hurt you, I know you as your most beautiful, wise and powerful self and do my best to love you as you most yearn to be loved.