One of the most striking features of individuals who exhibit borderline personality organization is that the defenses they use are primitive defenses. Because they rely on archaic and pervasive mechanisms such as denial, projective identification, and splitting, it may become difficult to distinguish these individuals from psychotic patients during periods of regression.
In terms of the defenses they use, an important difference between borderline patients and psychotic patients is that when the therapist interprets the operation of primitive defenses that dominate the borderline patient's experience, the borderline patient—at least temporarily—demonstrates some degree of insight. When a therapist offers a similar interpretation to a psychotic patient, however, the patient’s internal distress will only increase. Consider, for example, the primitive defense of devaluation. The interpretation of this kind of defense is as follows: “You seem to want to see me as defective all the time. Perhaps this attitude saves you from having to admit that you may actually need my expertise here.
Perhaps if you did not see me as defective, you might feel ‘one step below’ me, or you would be left alone with feelings of shame, and you too are trying to avoid these feelings.” (If the word “defective” is the one used by the patient, then it should be used in the interpretation.)
The borderline patient may dismiss such an interpretation with contempt, may reluctantly accept it, or may respond silently; however, regardless of the reaction, the patient will show some signs that their anxiety has decreased.
The psychotic patient’s reaction, however, will be an increase in anxiety; for a person living in existential terror, the devaluation of the therapist’s power may be the only psychological means by which they feel protected from total annihilation. If the therapist treats this only means of psychological survival as if it were merely one option among many—which may or may not be used—this would be overwhelmingly frightening for the patient.
Borderline patients resemble psychotic patients in terms of identity integration, yet they also differ from them. Their experience of self is expected to be full of inconsistencies and discontinuities; when asked to describe their personality, they may not know what to say—similar to psychotic individuals. Likewise, when asked to describe important people in their lives, borderline patients often give responses that exclude vivid and three-dimensional descriptions of familiar individuals. A typical response is: “My mother? Just one of those mothers you know.” Or their minimal description may be: “He’s just an alcoholic.” Unlike psychotic patients, however, their speech never becomes excessively concrete or disorganized; yet borderline patients tend to disregard and distance themselves from the therapist’s attempts to explore the complex nature of themselves and others. Borderline patients are also skillful at coping with their identity-integration deficits, but they do so through hostile defenses.
For example, when a borderline patient is given a questionnaire to complete, they may become extremely angry at a question such as “I am a person who…”. They may consider this task and its application utterly absurd.
Although borderline and psychotic patients resemble each other in their lack of identity integration, borderline patients differ from psychotic patients in two ways regarding their relationship to identity:
- The sense of inconsistency and discontinuity that borderline patients suffer from does not include the existential terror experienced by schizophrenic individuals. Borderline patients may suffer from identity confusion, but they know that they exist.
- Individuals with psychotic tendencies are less likely than borderline patients to respond with hostile attitudes when questioned about their own identity or the identity of others. Psychotic individuals experience the fear of losing their sense of existence so intensely that they cannot feel offended by the therapist focusing on this issue; whether or not this sense of existence is coherent becomes relevant only afterward.
The common point between borderline and psychotic patients is that—unlike neurotic patients—both groups make heavy use of primitive defenses and suffer from a fundamental deficit in their sense of self.
The dimension in which the two groups differ entirely is reality testing. No matter how strange or extreme their symptoms appear, borderline individuals—if interviewed in a sufficiently sensitive manner—can fundamentally perceive reality.
Assessing the patient’s degree of “illness insight” is important for distinguishing between psychotic and non-psychotic individuals.
To differentiate between borderline and psychotic levels of personality organization, Kernberg suggests examining how the patient evaluates traditionally agreed-upon reality. Accordingly, the therapist selects an unusual feature in the patient’s self-presentation, comments on it, and asks whether the patient recognizes that others may find this feature strange (for example: “I see that you have a tattoo on your cheek that says ‘death.’ Can you understand how unusual this might appear to me and to others?”). The borderline patient will acknowledge that this feature is not one commonly encountered in everyday reality and that those unfamiliar with it may not grasp its meaning. The psychotic patient, however, is expected to become frightened and confused, because the feeling of being misunderstood is profoundly destabilizing for them.
The borderline patient's ability to observe their own pathology—at least those aspects noticeable to an external observer—is quite limited. Individuals with borderline personality organization typically seek therapy not to change their personality but for specific complaints such as panic attacks, depression, or various stress-related medical issues identified by a physician, or they come due to pressure from a relative or acquaintance. However, during their sessions with a therapist, they do not intend to change their personality, and their motivation for therapy is weak. Their desire for real change usually emerges only when a serious relationship problem arises, when they risk losing a loved one, or when they feel overwhelmed in a relationship. Because all of their experiences of themselves are organized within their existing character structure, they lack an emotional understanding of experiences such as identity integration, use of mature defenses, the capacity to delay gratification, and tolerance for ambivalence or uncertainty. Their expectation from therapy is that their current suffering will be relieved very quickly—or that they will be freed from the person who pressured them to seek therapy.
This is why establishing a therapeutic alliance with borderline patients at the beginning is very difficult. Because their capacity to delay gratification is weak, they initially appear very demanding, insistent, and pressuring. If the therapist lacks knowledge about these patients and their dynamics, they may suddenly find themselves sympathizing excessively, offering advice, suggestions, or reassurance. And soon after, the therapist will encounter a justified devaluation such as, “I already know all that.”
When not in regression, borderline patients are able to reality-test adequately, and they can present themselves in ways that keep the therapist’s empathy within certain limits; thus, they often do not appear “sick” at first glance. Sometimes it is only after therapy has continued for some time that the therapist recognizes the patient’s character as borderline. Usually, the first clues arise when the therapist’s well-intentioned interventions are experienced by the patient as attacks. In other words, the therapist attempts to reach an observing ego; however, because the patient either lacks such an ego or possesses only a small fragment of it, the patient believes that certain aspects of themselves are being criticized. The therapist attempts to create a working alliance similar to what is possible with neurotic-level patients, but each attempt ends in disappointment.
Masterson (1976) observed in his work with borderline patients that when they feel emotionally close to someone, they panic due to fears of being engulfed and completely controlled; on the other hand, when they feel distant in a relationship, they experience the traumatic belief that they are being abandoned. This conflict—central to their emotional life—creates a constant oscillation between approaching and withdrawing in their relationships, including the therapeutic relationship; within this oscillation, neither closeness nor distance provides internal relief (“Can’t live with them, can’t live without them”). Because this fundamental conflict cannot be immediately shown to the patient through therapeutic interpretation, living within such a dynamic is profoundly exhausting for borderline patients themselves, for their friends and family, and for their therapists. These patients are well known in psychiatric emergency services because of their frequent “help-seeking and help-rejecting behavior” and their recurrent suicidal threats.
