The borderline diagnosis and integration of self

THE BORDERLINE DIAGNOSIS AND INTEGRATION OF SELF

Arnold Mitchell

The subject of borderline conditions has been a major focus of psychoanalytic interest for more than 20 years. Despite-or perhaps because o f - all that has been written, it has remained, in many ways, a frustratingly elusive concept. It has been framed in many different ways, including in terms of ego defects, defensive systems, object relations, narcissism, instincts, false self, and identity diffusion (14). It has meant a level of ego organization, a type of personality structuring, a position within a range of psychopathologies, and a rubric for a potpourri of symptoms. If it is defin- able, there has been a reasonable enough accumulation of data to accom- plish the task. If confusion still accompanies attempts to encompass it in a more scientifically agreeable way, then perhaps it is the scope and structuring of the concept that should be examined; this is the subject of the paper.

SOME B A C K G R O U N D

The term borderline was originally chosen to characterize clinical pictures that could not be assigned easily to any established category and that did not lend themselves to clear delineation (18). The picture was of a person who was close to being psychotic without actually having overt or fixed psychotic symptoms, much like that often seen in the early stages of schizophrenic decompensation in which there is a frantic clutching at many methods of keeping one's self intact, except that in the borderline state the syndrome does not progress to a full-blown psychosis (7). The result was a group of symptoms that defied the usual classifications. Borderline was an apt term, for the dictionary meanings fit just the kind of impressions the quasi-psychotic behavioral patterns create:

situated near a border.., situated between two points or states.., inter- mediate.., verging on one or the other place or state without being definitely

Arnold Mitchell, M.D., Faculty, American Institute for Psychoanalysisl Supervisor, Karen Horney Clinic.

The American Journal of Psychoanalysis © 1985 Association for the Advancement of Psychoanalysis

Vol. 45, No, 3, 1985

234

BORDERLINE DIAGNOSIS 235

assignable to either one . . , not clearly fixed or convincing.., manifesting typical but not altogether conclusive characteristics.., apparently existent but lack- ing definitive development. (19)

In this sense borderline refers to that which in its essential nature eludes precise definition and which tends to be comprehended according to that which it is near, either in character or place. The more the borderline group of disorders was studied, the more the manifest picture came to include a multiplicity of symptoms and behavioral configurations that em- braced much of descriptive psychopathology, as well as exhibiting a pro- tean nature and an apparent lack of stability and ego integration. For instance, in the extensive reviews of borderline conditions by Kernberg (10) and Wolberg (21) the lists of elements attributed to them have broad- ened to include virtually every type of symptom and character style. Kern- berg itemized these typical constellations of symptoms: chronic free-floating anxiety; polysymptomatic neurosis including multiple phobias, obsessive compulsive symptoms, conversion symptoms, dissociative states (amnesia, fugues, altered states of consciousness, etc.); hypochondriasis and paranoid trends; polymorphous perverse sexual trends (see also 7); pre- psychotic personality structures (paranoid, schizoid, and hypomanic personalities), impulse neurosis and addictions, including episodes of impulsive behavior, alcoholism, drug addiction, psychogenic obesity, and kleptomania; lower level character disorders (infantile, narcissistic, "as if," and antisocial personalities). Finally, borderline conditions also include psychoticlike pictures such as primary process thinking on projective tests, transference psychoses, and defenses that include psychotic ambivalence, splitting, and externalizations.

It is such a sense of flux and lack of permanence which is found in the DSM III description of borderline personality:

There is instability in a variety of areas, including interpersonal behavior, mood, and self image. No single feature is invariably present. Interpersonal relations are often intense and unstable with marked shifts of attitude over time. Frequently, there is impulsive and unpredictable behavior.., mood is often unstable... intense anger or lack of control of anger.. , a profound identity disturbance may be manifested . . . . (3)

It would not be difficult then to conclude that disorder and instability are at the core of what is meant by a borderline condition and that, consequently, there is no more basic underlying order. Nor would it be strange if the concept cannot be encompassed satisfactorily when the term stands for a spectrum of psychopathology characterized exactly by its inability to submit to an ordering process. However, increased interest in the subject

236 MITCHELL

has been inevitably accompanied by increased structuring and categoriz- ing of the concept, so these last two decades have seen significant shifts in how borderline conditions are understood-shifts toward a sense of greater clarity and delineation. Kernberg has probably done the most to bring together the large body of work and make the case for a reorienta- tion of the concept toward a view that there is an underlying order, that what confusion appears is not the essence of the process, and that it "accu- rately describes those patients who do have a specific, stable [emphasis added], pathological personality organization" (10, p. 3). Before presenting the list of symptoms given above, Kernberg (10) said,

All these descriptive elements are only presumptive diagnostic signs of borderline personality organization. The definitive diagnosis depends on characteristic ego pathology and not on the descriptive symptoms. (p. 9)

The support for this view comes especially from the attention object relations theorists have given to the elaboration of specific etiologic factors, such as insults at particular developmental stages that lead to a borderline adaptation in adult l i fe-e.g., Masterson and Rinsley's (12) belief about the centrality of developmental failures during the rapproachment stage. Also, borderline behavior was increasingly associated with specific defensive operations, most notably, "splitting," the importance of which was pointed out by Kernberg. With such studies, borderline has tended to take on the shape of a quite distinct diagnostic entity.

DIFFICULTIES DEFINING "BORDERLINE"

However, when this picture is juxtaposed against the manifestly dis- ordered array of symptoms with its resulting sense of chaos and lack of structure, we are provided with an apparent contradiction that is not read- ily resolved and a most obvious reason for the confusion in conceptualiz- ing what is meant by borderline. For instance, with such a plethora of symptoms to sort out, and such a range of psychopathology over which they are found, it becomes difficult to establish clear criteria for diagnosis or boundaries for what is included within the diagnosis. Meissner, in an article on differentiating borderline syndromes from the psychoses (15), demonstrated just this kind of struggle. First, he wrote the following:

Among the indices used to discriminate between the psychoses and the borderline syndromes, perhaps the most important is reality testing. It is generally felt that the borderline syndromes are able to preserve reality testing, while a loss of this capacity is a specific characteristic of the psychoses.


Meissner then almost immediately seemed to undermine this fundamental premise by writing the following:

An exception must be noted to this general rule in that reality testing may be impaired in varying degrees within the borderline spectrum; there also may be a significant impairment in the capacity to reality test during transient regressive borderline states . . . . Even the loss of the relation to reality to the point of psychotic productions such as hallucinations or delusions may not necessarily be pathognomonic of a psychosis.

Add to this confusion the picture of many people, indisputably diagnosed as schizophrenic, who can function on a compensated or residual level with intact reality testing as long as they constrict the intensity of their encounters with the world, and whose regressions under stress may also be of a temporary nature. The result is that even when employing such a supposedly basic diagnostic criterion, establishing the boundary between borderline and other pathology (psychosis) is a most difficult task.

As a result of this sort of perplexity, there has started to be some backing off from any sureness, even by some from within the tradition that has been the source of most of the significant contributions to the concepts of borderline conditions. The Kris Study Group of the American Psycho- analytic Association (1), in what might be called an agonizing reappraisal, has recently voiced doubts about attributing such a degree of exactitude to the understanding of the dynamics underlying borderline behavior:

In our group there were. . , some analysts who . . . held a certain amount of doubt about the accuracy and utility of the theoretical formulations which ascribe to psychosis, neurosis, and perhaps borderlines as well, unique meta- psychological underpinnings (p. 24) . . . . lit] is important to mention Bak's warn- ing that we cannot equate or establish an identity between various states of regression and a corresponding time period in childhood to which these regressive states refer (p. 106) . . . . The borderline groups of patients represented such a heterogeneous category that to point to a specific fixation point in all these types of cases would not be possible (p. 107) . . . . On the whole, we have been led to adopt a far more skeptical attitude toward the validity of constructs based largely upon theories of early psychic development than have many other analysts. We believe that much of what they propose is based on a speculative inter- pretation of necessarily sketchy data. However plausible such constructions may be, they are difficult if not impossible to substantiate with analytic data gathered from clinical work with adults (p. 222) . . . . The borderline diagnosis is no more than a broad loose category of character pathology, and not a clear diagnostic entity with specific conflicts, defenses, and developmental problems. (p. 237)

A similar position can be taken when looking at splitting as a defense, which Kernberg holds to be a fundamental attribute of borderline dynamics.

238 MITCHELL

Even though it is prominent, it is not exclusive to this type of pathology and it is not enough by which to define it. Splitting is part of a general attempt to maintain a sense of unity of self, and it is operative in all character neu roses.

All this strongly suggests that borderline does not satisfactorily reduce to conceptual organization to the degree that it has been attempted. The problem then would be not with our inability to decode a hidden order, but with the need to find order in all situations. If this is the case, borderline must remain a confused concept as long as an inherent lack of certainty and precision is unacceptable.

This raises another sort of problem when there is a search for order in the area of human behavior, especially as it pertains to the subject of borderline conditions. Most work on this has been within the general province of classic psychoanalytic thought with its tradition of clear-cut stages of development, ego structuring, and defense mechanisms. The result has been, therefore, that there is often an aura of sureness and mechanics to such analytic writing that implicitly suggests both that human nature submits to rather exact delineation and that our understanding of it has reached the degree of scientific precision that allows definitive categorizations.

There is a strong pull to see psychopathology and its causes (as well as most other aspects of reality) as coming in discrete packets. This is part of a natural tendency to master the world by dividing it into cognitively separate and comprehensible units. When viewed this way, the concept of borderline is subject to the same psychic compartmentalization that characterizes instinct, structural, and topographical models of the mind. However, delv- ing into the mind in such an objectifying fashion is somewhat like entering the world of quantum reality. The more one approaches the heart of things, the more the concreteness of reality dissolves into probabilities, possibilities, and intertwinings without definite form (16). Much of reality works only as a complex whole that cannot functionally reduce itself to the kinds of isolated and tested variables encountered in experimentation. Human behavior is far too complex to submit to such scientific reduction- ism. To reduce its infinity of interrelationships to categories raises the spec- ter of losing what one wishes to grasp. This is especially true when we try to grasp the workings of the psyche whose ultimate reality is subjective in nature. We cannot know the whole by knowing the parts.

SELF, "BORDERLINE," AND HORNEYAN THEORY

By whatever analytic theory one can divide up the complexity of being human, such models are doubly removed from psychological reality. Not only does a human mind not function as a collection of parts, but a person


does not ordinarily experience himself as being composed of parts. To do so would mean to be depersonalized. Rather, what an individual knows is a "self," which in this essay refers to a subjectively experienced sense of wholeness more than to its underlying structures. It is what Guntrip called "an inner core of the sense of a separate individuality, of me-hess" (6, p. 268). It is this way of describing the self that will serve as a theme for what will fol low about borderline conditions. What is presented contains no new data, but a different perspective and emphasis of the detailed observations and analyses already extensively recorded. First, rather than consider it in terms of a circumscribable diagnostic entity, it is presented in a more global way as a direction in which one moves away from health. Also, it will be discussed from the viewpoint of the self. Though this has been done before, it is perhaps the least utilized perspective for trying to understand borderline behavior. Much of what follows will be within the framework of Karen Horney's theories about neurosis (8).

Horney's shift away from Freudian formulations in the 1930s led her into a holistic philosophy and psychology of the self. Her ideas contained less of measurables and mechanics, picturing psychodynamics more as transient forms surfacing out of a complex flux that was not ultimately reduc- ible into components. Several themes inherent in her thinking will shape this perspective of borderline conditions. Included are the following themes:

.

2. 3.

4.

.

The mind organizes itself around the subjective experiencing of self. It is necessary that the self be experienced as a cohesive whole. Character structure is the framework for this integrating process. Neurosis may be defined as maladaptive attempts at attaining psychic unity. Symptoms of neurosis (especially character neurosis) not only derive from a past that lives unaltered in the present, but also are very much the product of the ongoing creative acts of the self. Neurosis is not a series of separate pathological states, but a con- t inuum of these maladaptive attempts at psychic unity. Any psychiatric syndrome, including borderline conditions, represents a seg- ment along that continuum, the boundaries of which are arbitrary. A name given to a syndrome does not represent a discrete piece of psychic reality, but a conceptual reification. Virtually any analytic diagnosis is represented by a spectrum of characteristics, always subject to flux in both degree and kind along the continuum so that a person is a shifting gestalt who is better understood in terms of rela- tive rather than absolute qualities.

240 MITCHELL

ON INTEGRATION

Each life form requires an active harmony between its various components for it to survive. There must be a constant dynamic interplay at all levels of organic integration: molecular, cellular, organismic, and societal. For most of life, heredity and instinct provide an automatic closed system of interaction which preordains that each organism is, from the beginning, the totality of what it can be. For human beings, while this pattern fits most levels of functioning virtually up to the cortical layers, the reality of being human requires another, higher level of harmony. The psychological com- plexities that manifest as mind add a qualitatively new dimension to the wholeness of being. A person must be psychically integrated. What we call self is the unified psychic being, just as the organism is the unified biologic being. Self is not simply a collection of psychic functions; more important, it is an awareness, a consciousness of its own oneness. Its subjective essence is what Erikson (4) called identity, a feeling of knowing who we are and being in harmony with that recognition. Kernberg (10) stated:

Clinically, an integrated self is characterized by a continuity of the self experience both historically (or throughout time) and cross-sectionally (or throughout simultaneously existing areas of functioning in different psychosocial interactions). (p. 316)

And Homey (8) emphasized the overriding importance of the self's essential quality:

The search for unity is one of the strongest motivating forces in human beings and is even more important to the neurotic, with his inner division. (p. 240)

While nothing is more intangible and unprovable than the self, at the same time, nothing is so immediately real and compelling. It shapes and moves each individual and is part of any sense of meaningfulness in life. Horney's holism not only is about the objective irreducibility of the psyche into parts but also emphasizes the importance of this subjective experiencing of a sense of wholeness. The failure to attain this is a measure of psychopathology. In analytic work we are ultimately interested in what moves a person in a meaningful way. That depends on what is most immediately real to the person, and much of that involves the experiencing of self in encounter with the world and with one's inner realities.

PSYCHOLOGICAL HEALTH

In the healthy person, a sense of basic security allows one to tolerate


and accept the paradox, incompleteness, and uncertainty of life. Inner differences do not result in neurotic conflicts. Diverse ego elements are integrated into a character structure and serve as an enrichment of the wholeness of self rather than create incompatible experiences of self because there has been no significantly deleterious formation of artificial, absolute concepts of self which would drive the person into untenable contradictions. What is not ego-syntonic does not threaten the basic integrity of self and can be either accepted as part of who one is or worked through. In a parallel way, the world is not dichotomized in order to give it artificial and absolute shapes, and so, unreal conflicts between self and world do not arise. The basic security of the healthy person allows for a sense of adven- ture, curiosity, and awe. The incomprehensibility of life creates, in the healthy person, a sense of wonder, pleasure, and grat i tude-not terror. One's limitedness is accepted as part of the experience of being encompassed by the greatness of reality. In religious terms, it is the human being both fearing and loving God. Meaningfulness is then inherent in our will- ingness to encounter and be encompassed by life. The healthy character structure provides a foundation on which to build something new, a springboard for moving on. Erikson made this clear in his formulation of growth as a process by which adequate integration of one level of psychosocial development provides the basis for being able to break out of old patterns and embark on the next level of tasks. Horney's premises about being human fall in with this philosophy that the psyche, if allowed to develop freely as do the organic aspects of life, would move naturally in this direction, toward a holistic sense of self (8):

[I]nherent in man are evolutionary constructive forces, which urge him to realize his given potentialities . . . . [M]an, by his very nature and of his own accord, strives toward self-realization. (p. 15)

THE NEUROTIC CHARACTER STRUCTURE

Too many influences act upon a person to ever permit unobstructed realization of such a goal. In the real world, psychic health (and neurosis) is a concept, a direction in which one moves. Health can be said to prevail as one moves toward the pole of an integration of self. Illness or neurosis is both the degree to which this is compromised as well as the process by which this comes about. There is always a mixture of neurotic and healthy ways of living. In the neurotic character, a subjective sense of unity is also attained, but the result is qualitatively different from that seen in healthy functioning.

Wholeness of being has two component qualities. One is that there is

242 MITCHELL

unity of self; the other that there is richness of self. Together they produce a truly integrated self. The neurotic, however, attempts to find security by narrowing encounter rather than broadening the foundation of self. (This will be addressed again in discussing schizoid behavior.) It is by the elimi- nation or repression of elements of self which are experienced as ego- dystonic and conflictual that the neurotic attempts to attain a sense of unity. Integration, however, is compromised by this. Furthermore, another general attribute of neurosis is that, by its very nature, it creates conditions whereby aspects of self must be experienced as ego-dystonic and neurotic conflict must arise from this. It is the elaboration of this process which forms the substance of Horney's theory of neurosis.

There is an inherent capacity for psychic wholeness in a child. However, to the degree he or she is subject to the traumas of skewed early development, the child will be driven to seek dysfunctional ways to attain a sense of securi ty-ways which in both their nature and purposes are not in harmony with the reality of our humanity. Such attempts inevitably generate inner conflict and alienation from self, both of which are destructive and set up a progressive compromise in the capacity to realize a healthy integration of self. This process can be described in several interlocking ways.

While the feeling life underlays the development of neurosis, its architecture owes much to cognitive processes. The neurotic depends on the creation of a substitute self on which to hang a sense of identity. This self is usu- ally idealized and experienced as special, being both different from and superior to ordinary humanity, thereby conferring status and validity to the self (or so the neurotic believes). In this sense, pathological narcissism is necessarily a basic element in all character neurosis and not just in those deemed narcissistic character disorders.

The basic flaw in such a solution is that the imagination can construct a world that has no relation to reality and, therefore, can never be made real. Inherent in this system is the seeking of absolutes, certainty, and a dependence on comparisons with others rather than the immediacy of self- experiencing in order to gain a sense of self.

Inner conflict is an inevitable consequence of this process (which Homey called the Search for Glory), for it must cause splitting of the experiencing of self into that which is accepted as self (the unrealistic, idealized image) and that which is rejected as part of self, i.e., whatever does not harmonize with and enhance that image. The rejected parts of who one is come to be experienced as a despised, hated self. Very often, however, what is thus rejected may be just those aspects of self that are the healthier parts of the whole, e.g., compassion in one who idealizes power or asser- tiveness in one who clings to the magic of merging love. Here is the essence of neurosis, that one is inexorably torn, in conflict,.divided, and a sense of


wholeness is compromised. It might be noted here that in the practical description of the self as divided, much of what Kernberg, representing the classical approach, and Homey, representing the neo-Freudians, describe is not only quite similar, but often virtually identical. The differences lie not in the observations, but in the metapsychologies and languages used to express them. One way to put it might be that in Horney's view the experienced dichotomies do not reside in the nature of the psyche (e.g., the intrapsychic world being innately divided by aggressive and libidinal drives and their derivatives) but in the mind's ability to create artificial and absolute categories that do not correspond to the nature of things. Dichotomy is a quality of cognition, not of the world or the architecture of the psyche.

Moreover, not only are neurotics removed from the reality that shapes life, but they are also removed from the richness and wholeness of themselves as they could be. For the natural solution to such inner turmoil is to submerge, deny, and lose touch with all the aspects of their humanity that constitute the idealized image. This permeating process in neurosis is what Homey called Alienation from Self.

All this means the neurotic is rigid, brittle, and quite vulnerable, first, because reality increasingly presents threats to what is a basically untenable position, and second, because alienation from self denies the neurotic the resources of the real self with which he or she has lost touch. Homey (8) explained it succinctly:

[A]lienation from self is more basic because it lends to the other impairments their injurious intensity. We can understand this more cleariy if we imagine what would happen if it were possible for the other processes to occur without this alienation from the alive center of oneself. In that case the person would have conflicts, but would not be tossed around by them; his self-confidence (as the very word indicates, it requires a self upon which to place confidence) would be impaired, but not uprooted; and his relations to others would be disturbed without his having become inwardly unrelated to them. (p. 21)

Horneyan theory describes a more mature, cognitive kind of psycho- dynamic process in which one's value and belief systems, one's patterns of thinking and perceiving, are the threads which weave a sense of self upon the loom of character structure. It is less concerned with the developmental roots of failure of an integrated self and focuses on the active, present efforts that produce a continuum of maladaptive attempts at unity. The causes of neurotic living are broader than the legacy of a lack of basic trust (4) or basic anxiety (8) or ego weakness (6) or ego relatedness (20) or a basic fault (2). Whereas this refers to the genesis of it, neurosis is also the deeply rooted self-perpetuating compulsive character systems evolved by the individual which acquire a life of their own. They not only serve to

244 MITCHELL

compensate for and protect one from the emergence of basic anxiety; they also provide the experienced sense of unity and self.

Neurosis then, is a direction one takes in coping with life, one that moves a person away from the nature of being human and into fantasy substitutes for self. At the same time that energies are redirected in this way, the person is striving to maintain a sense of unity of self. Since the system within which he or she is working has inherent conflicts, the neurotic process takes him or her down skewed paths in the search for unity, paths that actually lead away from an integrated sense of self.

There is one further point to be brought up here about the need to expe~ rience self as unified. When Homey and later Kohut (11) spoke of an idealized, grandiose self image about which one can narcissistically organize a consistent sense of self-esteem and patterns of relating to the world, the emphasis is on idealization and superiority as the key to a sense of self. From another perspective, however, the essence of the process may be rather a more basic need to feel unified. For it is not an uncommon experience for an analyst to find a patient organized around and adhering franti- cally to what can only be seen as a self-denigrating, self-abasing self concept. Whoever one experiences himself to be, that self must be consistent and enduring, even if that self is rejected, loathed, isolated, or inferior. Efforts will go into perpetuating that rather than to doing anything which would threaten what structure and unity one has organized around. Pride in self-even a hated self-then may not have a primary goal of raising one's self above others as much as justifying the maintenance of a particular form of skewed self for the sake of a sense of unity.

THE C O N T I N U U M OF MALADAPTIVE DEFENSES

There is a hierarchy of processes which represents varying degrees of ability to organize an integrated sense of self. At the top of the hierarchy is the healthy character structu re that accepts and integrates diverse aspects of self into a flexible and self-fulfilling whole. From this pole there is a continuum along which neurotic traits and defenses accumulate until at some point they form a significant enough constellation of symptoms and compromises of self-realization to warrant a diagnosis of character neurosis. Dissatisfac- tions and impairments in living are still considered within the normal range of behavior. There are no obvious symptoms. It is only the urge toward self- realization on the part of the patient and the deeper understanding of the psychodynamics of self by the therapist that lead to a mutual agreement that there is a state of compromised living and there is work to be done.

As such compromises become more severe and unity of self is bought with increased rigidity, fantasy, and skewing of character, psychopathology


manifests more blatantly until it falls within the realm of the DSM III classifi- cation of personality disorders. Though these are extreme in style, they form major continuing patterns of living and are stable in the sense they remain essentially character solutions; i.e., there is enough of a character structure to form a framework for consistency of behavior and sense of identity. However, such characterological solutions harbor significant pathology. They have created a narrow base on which to build a sense of unity; a limited aspect of one's humanity becomes the entirety of how the world (and one's own self) is encountered and experienced. For instance, the schizoid and dependent personalities are extreme patterns of moving away from and toward others; the schizoid personality cannot permit closeness and requires total distancing, whereas the dependent personality cannot permit distance and requires total closeness. There is extreme externalizing, as in the paranoid personality. There is a reliance on fantasy as in the narcissistic personality. All these dynamisms reinforce alienation from self, and the resources which, in a healthier person, could provide a depth and flexibility of being are no longer available to counter the vicissi- tudes of living. Consequently, such neurotics are rigid, brittle, and suscep- tible to the intrusion of nonintegrating defenses in an attempt to preserve a sense of unity.

As the continuum then extends toward what Kernberg called the lower level character disorders, character structure is no longer clear or evolved enough to provide a firm scaffolding for the creation of a sense of continuity and cohesiveness of self. Noncharacterological defenses start to dominate the picture. Defense mechanisms are used that cannot be integrated into and support character structure and identity. Increasingly ill- suited mechanisms are used in attempts to keep from feeling divided, mechanisms which are ego-dystonic and alienating in their effects. Symp- toms such as anxiety states, phobias, obsessive-compulsive behavior, dissociative states, and hypochondria-or, as is likely, a combination of many of these-undermine ego integrity and promote a fragmented sense of self. In such situations, the conflicting elements are incapable of being faced or integrated and they are experienced as if they belong to separate spheres and not as part of a unified self. Finally, to bypass the self in such disarray and in such intolerable conflict and self-hate, one may resort to such amorphous living as drug and alcohol abuse, impulsivity and acting out, and psychopathic behavior. We have now moved deep into the heart- land of borderline symptomatology.

If we look back to the earlier description of borderline behavior, we see we are now in the realm populated by a daunting proliferation of nonintegrating symptoms and defensive postures. While there are desperate attempts at unity, they are all disrupting and inherently incapable of

246 MITCHELL

accomplishing such a purpose. As the character solutions have become more extreme, lability of personality has increased. A morbid-dependent person may turn homicidally vindictive; the grandiose narcissist becomes suicidally self-abnegating; the schizoid, withdrawn person becomes cling- ing. Often, such contradictions are simultaneously present, evoking reso- nances with what is seen in schizophrenic ambivalence and bipolar illness.

Whatever the style of a particular character structure operating at this level, the underlying inner conflicts acting to split the sense of self are of a more basic nature than what Homey described in higher level character neurosis. Rather than a conflict being primarily between expansive and dependent needs, one sees a more primordial struggle between the deci- sion to stay in the world or withdraw from it. Similarly, the conflict between self-idealizing and self-hate becomes so polarized that the particular character traits from which they arise become of secondary importance. What experience of serf a person holds on to in order to retain a sense of unity may flip suddenly; there is no consistency to one's identity. No one partial "self" that a borderline person utilizes is sufficient to incorporate the dramatic inconsistencies of the rest of him. The more the defenses cannot be integrated into a character structure, the more borderline the person is~

"RAGE AGAINST THE DYING OF THE LIGHT"

In this outline, psychic health is seen as the capacity to bring various aspects of self together in an enriching way. Neurosis then is the degree to which, and methods by which, this is compromised. The more that unrealistic unworkable concepts of self are clung to as the salvation of who one is, then the more do defensive attempts at stabilization of self become active causes of further conflict, the more character structure fails as an integrating device, and the more one moves in the direction of borderline disorganization. In this sense, the borderline condition is at the opposite pole from health. It manifests to the degree one has moved along a path that precludes the capacity to experience one's self as unified, let alone integrated. There is no stable core around which to build a self.

This is the central fact of the borderline condition: to remain caught in an agonizing limbo of intractable inner conflict between incompatible and absolute self concepts and ways of being. As one lives in a borderline state, he or she is unable either to create a sense of unity within a stable character structure or to find sanctuary from the pain of this inner dividedness. This inner chaos has its interpersonal counterparts. Guntrip's description (6) of the schizoid dilemma is exactly what it is like to live in the world as a borderline person:


The chronic dilemma in which the schizoid individual is placed (is) that he can neither be in a relationship with another person nor out of it, without in various ways risking the loss of both his object and himself . . . . Thus he must always be rushing into a relationship for security and at once breaking out again for freedom and independence: an alternation between regression to the womb and the struggle to be born, between the merging of his ego in and the differentiation of it from, the person he loves . . . . This "in and out" programme, always breaking away from what one is at the same time holding on to, is perhaps the most characteristic behavioural expression of a schizoid conflict. (p. 36)

This schizoid dilemma and conflict is an interpersonal component of the borderline position. Intrapsychic and interpersonal aspects of neurotic conflict are reinforcing. The person moving in and out, toward and away from others will, at the same time, also be in a situation of experiencing himself as absolutely valuing love while he is just as absolutely valuing freedom. He will be just as much a morbidly dependent person as a resigned one. Both are at once, each the totality of who he is, two intractably conflictual selves occupying one psyche.

Now, the corollary to this central fact is that these conflictual states remain so alive and poignant because the borderline individual, though in inappropriate and desperate ways, in the end continues to struggle to be in the world. Sanctuary from conflict through sanctuary from the world and self is not his solution. The borderline individual stays alive by staying in contact. He tries to take from the world, from people, whatever would make him feel together. The borderline individual lives through others in morbid dependency, and when his claims are not met, in virulent hosti l i ty-and often both at the same time since he cannot utilize a consistent self-image to unify his attitudes. In good part, this accounts for the virtually diagnostic immediacy and strength of transference reactions when the patient cuts through all social barriers to establish, from the start, an intense emotional bond, either positive or negative. Unlike the person who has accepted the solution of a schizoid resignation and would "go gentle into that good night," there is a drive within the borderline person that makes him "rage against the dying of the light."

THE SANCTUARY OF RESIGNATION

Comparison of the borderline position with the schizoid one may help give a feeling for the special quality of borderline turmoil. It was said previously that the neurotic attempts to find security by narrowing encounter rather than broadening the foundation of self, and while this may lead to a sense of unity, the cost is the aliveness of self. The schizoid person

248 MITCHELL

represents an extreme in the journey along this path. It is the simplest, and at the same time, most drastic method of avoiding intolerable feelings of being divided. Guntrip (6) gave this description:

The oscillation of "in and out," "rushing to and from," "holding on and breaking away," is naturally profoundly disturbing and disruptive of all continuity in living, and at some point the anxiety aroused becomes so great that it cannot be sustained. It is then that a complete retreat from object relations is embarked on, and the person becomes overtly schizoid, emotionally inaccessible, cut off. (p. 37)

What Guntrip called the schizoid position, Homey had previously described as part of a character neurosis she termed "the resigned solution." She (8) drew a comparison between it and other ways of neurotically dealing with the world:

[T]hink back to the other two major solutions [expansive and self-effacing]. In them we see a more turbulent picture, one of reaching out for something, going after something, becoming passionately engaged in some pursuit-no matter whether this concerns mastery or love. In them we see hope, anger, despair . . . . By contrast the picture of resignation, when maintained consistently, is one of life at a constantly low ebb-of a life without pain or friction but also without zest. (p. 260)

If this move away from others is to succeed in bringing some respite, it must become a consistent position, pattern, and attitude. This requires a move away from self-awareness, from feeling, caring, and wishing; a move away from anything that could reawaken a desire to participate in life. The overall process of intrapsychic withdrawal, including all the methods and reasons for such narrowing of life, Homey called "alienation from self." It is more than simply the consequences of neurosis. It is an active, sustained retreat into deadness, the ultimate defense against intrapsychic conflict. Whereas the person in a borderline position (i.e., a schizoid dilemma) presents with a picture of pain whether in involvement or in isolation because he remains in active conflict, the resigned person (i.e., the schizoid position) does not experience isolation or rejection as so intolerable. Rather, it can harmonize with his need for freedom from involvement and can actually be comforting and strenuously defended. Such a person comes to identify with these qualities of the schizoid life and takes pride in them. It becomes his identity, and therefore, aside from all other functions it serves, it is held onto because it is now ego-syntonic and unifying.

Resigned living takes many forms and is present in varying degrees. It is concealed in the guise of ordinari ly unquestioned normal behavior, in the


conventional ways of living wherein responsibility for one's life is delegated to custom, authority, and duty. This has been recognized as a common dis- ease of modern man and duly recorded by many: Dostoyevsky in his chapter on "The Grand Inquisitor" in The Brothers Karamazov, Eliot's "hol- low men," and Rank (17), Jung (9), Fromm (5), and May (13) in their descriptions of the emptiness and abdication of responsibility for self to be found in patterned living by rote. The alienating process pervades the realm of what we consider normal living. As it increases its deadening influence, it merges into the schizoid personality and, at the psychotic end of the spectrum, into what used to be called simple schizophrenia.

An additional word should be said on the comparison between the borderline and schizoid directions people may take. These two paths are not truly distinct and separate. While the intention is clearly different, the compromise in wholeness of self is a unitary process. Each of the two directions is only a manifestation of a preponderant tendency toward one or another way of dealing with the dividedness of self. Neurotic consequences in one area arise out of and cause reverberations in all areas.

SUMMARY

To try to encompass what is meant by borderline with parameters that are too delineating can lead to conceptual difficulties and confusion for several reasons: The human psyche is too complex and probably has too much of the quality of a gestalt to be understood adequately by dichoto- mizing thinking; an individual does not experience himself as operating in discrete units, but as a unified whole; and the most characteristic manifest quality of the borderline picture is its tendency toward a chaotic functioning that somehow always spills over any defining boundaries which are set up to attain conceptual containment. If we then accept our limitations on the precision and order with which we can comprehend it, the understanding of borderline might be supplemented by seeing it in terms of the subjective experience of an integrated self. This offers a more holistic approach that tends not to be so subject to objectifying compartmentalization. It is more in tune with the subjective experiencing a person has of that which defines and moves him in the world. And it offers a referent axis along which the distance one has traveled in the borderline direction might be gleaned. Finally, the relationship of the borderline diagnosis to character disorder might be looked this way: The diagnosis does not refer to a particular character disorder or to a group of disorders. It emerges in all character pathology to the degree that the experiencing of an integrated and whole sense of self, which is at the heart of character structure, is diminished.

250 MITCHELL

REFERENCES

1. Abend, S., Porder, M., Willick, M. Borderline Patients: Psychoanalytic Perspec- tives. New York: International Universities Press, 1983.

2. Balint, M. The Basic Fault. London: Tavistock Publications, 1968. 3. Diagnostic and Statistical Manual of Mental Disorders (3rd ed.-DSM-III). Amer-

ican Psychiatric Association, 1980. 4. Erikson, E. Identity, Youth and Crisis. New York: Norton, 1968. 5. Fromm, E. Escape from Freedom. New York: Farrar & Rinehart, 1941. 6. Guntrip, H. Schizoid Phenomena, Object Relations, and the Self. New York:

International Universities Press, 1969. 7. Hoch, P. H., and Pollatin, P. Pseudoneurotic forms of schizophrenia. Psychiat. Q.,

23: 248, 1949. 8. Homey, K. Neurosis and Human Growth. New York: Norton, 1950. 9. jung, C. G. Two Essays on Analytic Psychology. (H. B. and C. F. Baynes, Trans.).

New York: Dodd, Mead, 1928. 10. Kernberg, O. Borderline Conditions and Pathological Narcissism. New York:

Jason Aronson, 1975. 1 I. Kohut, H. Analysis of the Self. New York: International Universities Press, 1971. 12. Mastersan, J. F., and Rinsley, D.B. Borderline syndrome and the role of the

mother in the genesis and psychic structure of the borderline personality. Int. ]. Psychoanal., 56: 163-177,

13. May, R. Man's Search for Himself. New York: Norton, 1953. 14. Meissner, W.W. Theoretical assumptions of concepts of borderline person-

ality. J. Am. Psychoanal. Assoc., 26: 559-598, 1978. 15. Meissner, W.W. Clinical differentiation of borderline syndromes from the

psychoses. Psychoanal. Rev., 71: 185-210, 1984. 16. Pagel, H. R. The Cosmic Code. New York: Simon & Schuster, 1982. 17. Rank, O. Will Therapy and Truth and Reality. (Jessie Taft, Trans.). New York:

Knopf, 1945. 18. Stern, A. Psychoanalytic investigation of and therapy in the borderline group

of neuroses. ]. Am. Psychoanal. Assoc., 467-489, 1938. 19. Webster's Third New International Dictionary. Springfield, Mass.: G.&C. Merriam,

1976. 20. Winnicatt, D. W. The Maturational Processes and the Facilitating Environment.

New York: International Universities Press, 1965. 21. Wolberg, A. R. The Borderline Patient. New York: International Medical Book

Corp., 1973.

Address correspondence to Arnold Mitchell, M.D., 4 East 89th St., New York, NY 10128.

The borderline diagnosis and integration of self

Documents

Transcript of The borderline diagnosis and integration of self