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Introduction
From its inception psychoanalysis has been a ‘talking cure’. Analyst and analysand use the spoken word to express and communicate thoughts and feelings. However, it would be inadequate to describe psychoanalytical work as mere conversation. The order of the spoken word is quite unequal to capturing the process by which two people attempt to understand something of an entirely different order or ‘disorder’. There is a paradox inherent in the fact that we use the logic of language to attempt to capture something that follows a different, non-linguistic logic. It might also be said that during analysis one is ‘hearing with one’s primary ear, speaking with secondary language’ (Green 1997b: p. 263).
Poetic language or imagery is far better suited to expressing what happens in this particular form of conversation. D. W. Winnicott is one analyst who was capable of capturing and communicating the essence of psychoanalysis, largely because he chose a style of writing more closely resembling poetry than prose.
Sigmund Freud often used chess as a metaphor for the psychoanalytic process. I myself have compared psychoanalytic work to dance: two people attune their movements, following a rhythm reflecting the erotic games of the body in its choreography.
There are rules, both in chess and in dance. But ideally these should merely be a prerequisite for the free, uninhibited expression of the game, albeit a prerequisite with which the analysand must necessarily come to terms. Once this framework has been established the analysand comes in four times a week, lies on the couch and with reasonable ease proceeds to follow the basic rule of analysis: speaking of whatever spontaneously occurs to him, uninhibited by any censorship.
This frame, quite essential to the psychoanalytic process, is forgotten the second the analysand becomes submerged in the themes at hand. The analyst for her part feels secure in this process, presuming herself sufficiently assisted by her knowledge and technique. She listens empathetically, her attention smoothly suffusing the situation; noting any unexpected impulses, pauses or peculiar linguistic turns, watching attentively for any signs of transference while maintaining a running dialogue with her own affective and cognitive processes.
However, it happens – not infrequently – that the situation is quite different. The analyst may at first notice that her confidence in her analytical techniques and attitude fails her. She becomes confused and insecure when what should have been an unnoticeable frame becomes visible simply because it is not working. Her analysand is unable to settle into the frame and persists in breaking out of it – e.g. by failing to show up for appointments; finding it unnatural to relinquish himself to free association; or reacting to what was intended as a helpful intervention with indifference or irritation, as though experiencing rejection.
In these cases the psychoanalytic situation is apparently failing to function as the intended facilitative frame which works so effortlessly with other analysands.
Psychoanalysis has been shaken and challenged in several ways by these so-called difficult analysands – termed borderline.1 Since the middle of the previous century, clinicians both within and beyond the psychoanalytic community have been carrying on a far-reaching discussion concerning the diagnostic positioning of this group of patients, who do not fit into the canonized diagnostic categories of neurosis and psychosis.
Borderline analysands have caused psychoanalysts to consider modifying Freud’s technique for treating neurotic patients, particularly hysterics. Freud based not only his treatment technique, but his entire personality theory on the development of normal and neurotic personalities. Similarly these borderline analysands challenge our psychoanalytical technique, shaking our firmly rooted trust in our methods and our entire professional identity; they also force us to examine Freud’s models of the psyche.
Freud himself did not use the term borderline, and it was not until his late works that he began to reflect on the psychological mechanisms of psychosis.
Today we might question whether Anna O, with her flamboyant, dissociative states of consciousness, deserves the label neurotic, and we would hardly hesitate to diagnose the Wolf Man as borderline. As regards the latter it should be noted that Freud’s sole interest was in his patient’s infantile neurosis; he centred his case study around it, leaving the impression that this patient’s serious adult disorders could be understood solely in light of this childhood neurosis. Later I shall expand on this case study, which may be read as one of the earliest psychoanalytical studies of the borderline phenomenon.
All Freud’s key concepts are based on neurosis: the Oedipus complex; castration anxiety; the idea of the unconscious as a separate system from the conscious; the notion of desire as a driving force that is resistant to censorship and responsible for a number of physical manifestations from hysterical symptoms to parapraxis, dreams and artistic creation. Furthermore Freud perceived so-called narcissistic neuroses (psychoses) as being unsusceptible to psychoanalytic treatment.
The problem was that, at the time, psychological disorders were divided into neuroses and psychoses. Therefore, when the borderline diagnosis first came into use in the late 1930s, there was a tendency to consider the phenomenon and the concept either from a neurotic or a psychotic angle. This is clearly reflected in the language used. Thus we find terms like pseudo-neurotic schizophrenia (Hoch & Polatin 1949), ambulatory schizophrenia (Zillboorg 1957), pseudopsychopathic schizophrenia (Dunaif & Hoch 1955), schizophrenia without psychosis (Beck 1959), latent psychosis (Bychowski 1953) and larval psychosis (Glover 1956).
Generally one might say that while psychiatry tended towards defining borderline patients as a diagnostic group affiliated with psychosis, out of loyalty to Freudian metapsychology, psychoanalysts were inclined to understand it from a neurotic perspective.
The borderline concept has been used as a term both in relation to hospitalized psychiatric patients and to analysands undergoing analysis on the psychoanalyst’s couch. Thus in more than one respect the concept reflects a border problematic.
The concept exists in the borderland between two scientific discourses. On the one hand we have a psychiatric discourse, based on an empirically positivistic, scientific paradigm and on the other a psychoanalytical paradigm, more closely related to a humanistic, hermeneutic, phenomenological scientific tradition.
Additionally, the borderline concept is characterized as a border problematic within the field of psychoanalysis. Both the phenomenon and the concept itself have rendered it necessary to reassess and rethink basic psychoanalytical concepts. There is no doubt that some of the most original and groundbreaking work in the last 30 years of psychoanalysis derives from attempts to understand these difficult border cases and from communicating experiences from this work in a language that in more than one sense reflects their borderland existence. There are pragmatic justifications underlying the concept of borderline, which additionally reflect a categorial problem: the word itself indicates delineation or a line of demarcation. Are we using this word in reference to a phenomenon in the world? In other words: can one be a borderline or have a borderline?
A border may denote a line or a surface, or it may refer to some form of overlap as happens when two clouds border on each other. The borders of neurosis and psychosis appear to be somewhat indistinct. In other words, we are not dealing with a clear line of demarcation but with an area lacking clearly delimited borders: a no man’s land.
The French psychoanalyst Jean Laplanche (1976: p. 87) spoke of terminological ‘slippage’, indicating that this must be countered by a certain slippage in reality itself if these concepts are to hold any depth and originality. By extension the borderline concept could be said to reflect a phenomenon originating in the concepts of neurosis and psychosis but corresponding to a phenomenon distinctly delineated from both. If, however, this concept is to be more than a pragmatically justified in-between category, one might ask whether it is indicative of the psychological borders of borderline patients. What is a psychological border? Initially we might think of psychological structures or of the contacts or exchanges that take place though bodily delineations – between the somatic on the one hand and reality on the other (Green 1997b).
I suggest that the term borderline reflects a number of problematic borders relating to regulatory mechanisms or demarcation lines of the psyche; necessary partly for communication and making contact and partly for protection against what may be experienced as threatening invasion.
We are confronted with the necessity of delineation – of setting up limits – on a daily basis. This necessity becomes particularly obvious in expanding our perspective from the narrower position of psychopathology and adopting a global and political view (Anzieu 1989). I shall briefly mention a number of phenomena where this border problematic appears to be of some considerable urgency: the limits of economic growth; the increasing gap between rich and poor countries; the rising populations of certain countries, and the insatiable consumption of others; the Icarian flight of science; the invasion of the private sphere by mass communication; and the boundless desire for new world records, leading to doping and rigidly enforced training, as the problematic costs of a sporting world which has become a prestige-ridden, financial necessity rather than a healthy competitive practice. We are reminded of the importance of imposing limits on the violation of earth, air and water. We feel this necessity to establish and regulate borders in the current confrontation between the western world – particularly the U.S. – and the desperately destructive battle of Islamic cultures to create a place for themselves in history, sensing our powerlessness in the face of attempts to stop this process in which we are ourselves agents.
However, the purpose of this work is not to investigate limits and borders at the political level, but rather the border problematic I encounter in my professional practice through people who have difficulty delineating and regulating borders. What these patients who we term borderline have in common is a certain insecurity concerning various borders: between fantasy and reality; between reality ego and ideal ego; between desire and fantasy. They also have difficulties in balancing what appear to be contradictory but equally urgent desires: the desire for intimacy and the fear of invasion; the desire for self-realization and the fear of defeat. The consequences of this lack of ability to achieve equilibrium – and to establish and regulate borders – are evident in a fluctuating sense of self, depressive feelings of emptiness and undefined or diffuse feelings of non-belonging in oneself. These people often feel like observers in their own lives.
This pathological picture is a far cry from the conflictual pattern noted by Freud in his patients a century ago, which led him to the assumption that a cure for these people must consist of a freer realization of libidinous desires in love, work, and other forms of sublimated activity. While Freud observed that the prevailing borders of his time were rather too narrow and prudish, today we see virtually the opposite situation. There are practically no limits on ambitions of individual realization and expansion, but this limitlessness is shrouded in paradox, both psychologically and in light of the development of individual persons. In contemporary families children are exposed to almost traumatic levels of attention within borders that are becoming ever more restrictive and insecure because they are played out within severely delimited familial spaces, where parents must nurse their own ambitions as well as trying to nurture their love life. This combination of concentrated attention and lack of continuity has the potential to create immature and highly fluctuating regulatory mechanisms in children, who must learn to adapt to a society that requires early competency while perhaps limiting the space in which children can play spontaneously. The result may be that in adulthood these children will have difficulty achieving fulfilling relationships. They yearn for intimacy but attack or flee when it is offered because intimacy appears to them to be an invasive and self-effacing bond. This problematic encompasses both ordinary ambivalence and pathological forms that turn every intimate relationship into a potential battlefield. In Chapter 2 I shall discuss the psycho-developmental preconditions for pathological development and show that this trauma is not necessarily characterized by the violent and sexual attacks so frequently described in the currently ongoing professional debate. There is a trauma of the immature ego that consists not of singular events but rather of a certain kind of contradictory and disastrous lack of ordinary care.
My investigation of borderline phenomena opens with a historical account of the development of the concept from the first steps in the late 1800s to the introduction of an actual borderline diagnosis in the 1930s right through to the manifold and diverse literature of today. This chapter focuses on the border problematic outlined between psychiatry on one side and psychoanalysis on the other. Even within the ranks of psychoanalysis there are indications of the technical difficulties created by Freud’s neurosis-based theory when clinicians and researchers need to explain a psychological problematic beyond neurosis.
Chapters 3 and 4 describe the two currently dominant explanatory models relating to borderline aetiology. All theories have concentrated on the so-called pre-Oedipal phase in a conscious effort to find explanations beyond the presumed Oedipal conflict of neurosis. While some analysts have concentrated on early mother–child interaction, others – particularly in recent decades – have drawn attention to the frequency of sexual and/or violent childhood trauma in borderline patients. I have selected a few representatives of these two explanatory models, discussing their relevance for a psychoanalytical theory concerning both normal and pathological development of what I have termed respectively the mother–child interaction model and the trauma model. In other words, this is a discussion of two explanatory models, both identified – with various degrees of justification – with psychoanalytic theory. The argument goes that psychoanalysis inevitably leads back to childhood and to traumatic experiences that become determinants for our future lives. However, while this is not entirely erroneous, nor is it the whole truth. My work is an attempt at establishing a detailed understanding of the nuances of interplay between past and present and of how development – whether it be normal or pathological – may be understood not as a linear, causally defined sequence but as an ongoing transformational process.
In Chapter 5 I shall introduce the concept of betweenity, which is my contribution to the ongoing discussion of the manner in which borderline patients forge relations. In this chapter I make use of a selection of psychoanalytical theories, seeking inspiration in existentialist continental philosophy to outline some of the key dilemmas that these patients pose to us as therapists. At the same time I attempt to pave the way for a renewed theoretical examination of the psychological regulatory mechanisms that appear to be so fragile in these patients.
In Chapters 6 and 7 I begin by tracing the concepts of classical Freudian theory that may contribute to an understanding of psychopathology beyond repression and the return of the repressed in form of the symptom. I point to concepts such as foreclosure, disavowal and negation, which Freud himself introduced in his few discussions on the relationship between neurosis and psychosis and which have later been developed and systematized not least in French psychoanalysis. Then, in Chapter 7, I attempt to demonstrate the use of these concepts through the study of a specific borderline patient whom I worked with through ten years of psychoanalysis.
My work for this book has partly been inspired by contemporary French analysis and partly – and most significantly – by Winnicott’s work, which gave rise to my fundamental assumption that the problematic relating to these patients appears in betweenity or, to use Winnicott’s term, in the intermediate area. His work provides a vast amount of knowledge about the significance of this space, defined as between outer and inner, between fantasy and reality. With this concept of an intermediate area of experience, Winnicott has contributed to mending the subject–object polarization that has plagued western thinking ever since Descartes. The intermediate area is also where what Winnicott terms the ‘me’ and the ‘not-me’ come into being and it is in this potential space (as Winnicott refers to it) that the creative unfolding of spontaneous activities of the self may take place. Because some of these patients that we term borderline have had difficulties in forming experiences in this area, their selves have corresponding difficulties in finding a place to belong. Frequently the result is a feeling of not being ‘at home’ in oneself, and the patients complain of lacking an anchor, a place in themselves from which thoughts, actions, and ideas may emanate. Winnicott indicated that something has taken place in these patients that has failed to find a psychological location. The result is what Winnicott and others have termed ‘negative experience’.
Chapters 8 and 9 are devoted to discussing this notion of negative experience, which turns out to be an essential form of experience in the psychological lives of borderline patients. While negative experience refers to experiences that have failed to find symbolic representation, play and the transitional area in which it arises indicate a positive experience that assists the child in the early differentiations of me/not-me, as well as facilitating experiences of its own creativity within an illusory space.
I previously referred to chess and dance as metaphors for what takes place in an analytical situation. Winnicott suggests that psychotherapy takes place where the play-areas of patient and therapist overlap. If a patient is unable to play, then the initial action must be one which enables him or her to do ...
