got int. J. Poycho-Anal, 73:739-755 Adolescence and Borderline Pathology: Characteristics of the Relevant Psychoanalytic Process Carlos Alberto Paz and Teresa Olmos De Paz SUMMARY This paper results from a research project on the specific characteristics of borderline adolescemts and their analysability. An in-depth understanding of the adolescent process is considered essential because it is superimposed on the specific pathology of the borderline subject. Our cases agree in almost all respects with symptomatologies described in the international literature. although pronounced differences emerge in regard to serious acting out and behavioural disturbances. Separation processes, particularly from the mother, are very important in both cases presented. In the authors’ view, this research shows that borderline adolescents constitute a definite clinical reality: and that strict psychoanalytic technique can be used successfully with them. INTRODUCTION We have long been concerned with the study and definition of borderline pathology. As a result of our many years of experience in different situations in this field, we realized that a characterization of its specific features in childhood, adolescence and adulthood was necessary.our inne aro borderline adolescents led us to conclude that it was essential to acquire an in-depth knowledge of the adolescent process, whereby we would then be able to characterize a pathology in which ve different levels of development and functioning are superimposed - " A critical review of the principal contributions on this subject confirmed the validity of our approach. Our experience is illustrated by the cases of two borderline adolescents, which also enable us to discuss some controversial points such as analysability and the development accruing from the psychoanalytic technique. CHARACTERISTICS OF THE BORDERLINE PATIENT ‘We enquired in 1980 whether there was an internationally accepted definition of the borderline patient, with similar case histories, shared theories and a basic consensus as to the genesis of the condition and its therapeutic accessibility We said at the time, and itis still true, that this level of agreement has not been attained, although there is an impressive abundance of specific research projects and publications; the clinical characterizations concerned are very serious and are accompanied by a variety of opinions and experiences in the matter of the therapeutic possibilities. If we grant that pathological organizations of this type exist, present-day approaches to them are found to fall into two groups. The first accepts different theoretical orientations as correct and seeks constantly to multiply and extend the constructions and hypotheses applicable to these cases; this would seem to suggest that the vast majority of patients who come to psychoanalysts today are in fact borderline cases The other approach prefers to define as exactly as possible the points of agreement and disa between the different descriptions of and theories on borderline subjects. using for instance detailed comparative Studies of possible borderline patients based on questionnaires or specific diagnostic interviews. accompanied by a long-term follow-up of their therapeutic development. These problems are discussed clearly and rigorously in contributions such as those of Michael Stone (1987) and Brenas & Ladame (1985). Stone in particular, working at the University of Connecticut, uses Gunderson's, diagnostic interview for borderline patients and Orto Kernberg's structural interview, as well as “This paper was awarded the 1990 prize of the Libro Anal de Psicoanalisis (MS. received January 1992) Copyright © Instnute of Psycho-Analysis, London. 1992 the various diagnostic headings of DSM-III; a method due to Spitzer, Ednicott & Gibbon for the diagnosis of these organizations is also used. Stone tells us that the use of these multiple approaches has revealed areas of agreement and also of disasreement between the most popular systems of identifying these cases. He emphasizes that it is not possible at present 10 choose rhe correct system for diagnosing the borderline patent (p. 31). Instead, he believes that statis requted are comparative studies based on te use of different diagnostic methods, and he also considers it essential to study borderline children and adolescents. He regards follow-up studies as indispensable for ascertaining which of these patients will become borderline adults 10 or 15 years later, and he emphasizes the need for long-term studies of some of the variables specific to these cases fhe second of the two approaches. and have therefore preferred to characterize by one of us for the study and follow-up of adult borderline main findings of other authors in the definition of these We ourselves here embrace t our borderline adolescents by the system developed Patients, while at the same time taking account of th DED Aechive CD and is copyright 10 heorganizations. The basic features are as follows: 1, Disturbances in the sense of reality, ‘while the judgement of reality is paradoxically preserved, alth is more the result of an adaptive e ton a eens sihough is fort than of genuine discrimination. 2. Unequal development of ego defences, without a fully fledged mechanism of repression; primitive mechanisms persist and predominate ne *—€.8, projective identification, splitting, idealization, constant disavowal and negation. Obsessional mechanisms are essential ftom infancy: omnipotent control and also undoing and isolation, These mechanisms contribute to these subjects’ high-level intellectual attainments considering their pathology, their achievements are often surprising. Presence of confusional anxieties and severe states of confusion, especially under stress. 4. Disturbances in the regulation of aggression, characterized by ‘narcissistic rage’, although in our experience this may be lacking, concealed behind extreme submission or paranoid defences, 5. Disturbances of affectivity, with the characteristic feeling of loneliness and serious problems in the expression and fine distinction of emotions and feelings. 6. Disturbances of sexuality, with bizarre sado-masochistic fantasies, sometimes serious enough to impede adult sexual life. 7. Typical bodily expressions and movements, which, surprisit clearly observed by the use of the couch y, are ego-syntonic, These can only be 8. A primary, or delusional, transference, alternating with phases of neurotic-level infantile transference. Serious disturbances of symbolization processes are evident during primary transference phases. 9. A ‘demanding’, overwhelming or possessive countertransference of uncommon intensity, bordering on the unbearable. Adolescent cases feature in addition symptoms such as suicide attempts, anorexia-bulimia, drug addiction, obsessional rituals or conversions, and intense claustroagoraphobias. CRITICAL REVIEW OF RESEARCH AND THEORIES ON THE BORDERLINE ADOLESCENT Elizabeth Geelerd was the first to discuss and characterize this problem complex in adolescence (1958). In this contribution she presents two of the most exciting and concise case histories of this pathology. She characterizes the clinical pictures concerned as displaying an intolerance of frustration, emotional immaturit incomplete development, uncontrollable id impulses, and lack of social adaptation, Various neurotic symptoms make these subjects difficult to diagnoses: they’are not in contact with reality and, although they: do not have delusions, they feel frustrated when alone and withdraw into a fantasy life or have outbursts of bad temper. At these times they lose contact with reality and act, defending themselves from an attack. They have not achieved object constancy, and expectations of ratification have not developed normally. Geelerd considers that these subjects do not have ‘the measure of reality’; the observer notices es pad of increasingly terrifying fantasies, with different contents and on different levels. They are incapable sie anxiety, but develop only ‘basic anxiety’ which paralyses them: representations of self and of t oe tend to fuse together inside them, so that the loss of the mother signifies danger of annihilation yright to the WARNINIc! Thie rave ie neinted for the personal use of the owner of the PEP Archive CD and is copyright (0!patient. She sees this pathology as a continuous thread running through the subject's life, disturbance may vary from age to age accordi ey eae ese a ing to developmental and environmental factors. The basic Mary Singer's ‘Fantasies of a borderline pat i Patient’ (1960) is the only contribut it to show the development ofa typical borderline child through rine andaicksece nee wt This eae Study of the child's fantasies within a psychoanalytic process is admirable and affords indisputable evidence of the Passage from borderline childhood to borderline adolescence. Oto Kemberg, the central figure in the study ofthis pathology, defined the essential criteria for diagnosis of the borderline adolescent in 1976 (1976-78). He emphasized the severity of neurotic symptoms, rapid swings in identifications suggestive of poor ego integration, and grave object-relations pathology, often underestimated because compatible with the apparent neurotic superstructure, He also considered narcissistic reactions and the ‘ypical emergence of perverse sexuality, as a result of which homosexual experiences must be distinguished from ‘rue homosexual features Kemberg considered a multidimensional approach to be essential for differentiation of the above pathology from a schizophrenic process of insidious development. Kemnberg returned to the subject of differential diagnosis in 1984, discussing other clinical pictures liable to confuse us: he presented three presumed cases of ‘borderline organizations’ which turned out not to be such, a case of schizophrenia originally confused with a borderline organization, and the case of a genuine borderline adolescent. Note that Kernberg considers fully developed reality testing to be an essential criterion of the borderline adolescent. Paulina Kernberg (1979), (1982) shares Otto Kernberg's views and maintains that the borderline adolescent is incapable of integrating experiences owing to the intensity of splitting and associated defences. The instability of his superego deprives him of valid guides for the evaluation of his own self and others, and as a result his identity is unstable and precarious These subjects are unaffected by the positive experiences in their lives and are unable to learn from experience: time appears to stand still in them, She describes their uncontrolled affective reactions. essentially intense anger, lack of social tact and failures of normal repression, Their masturbation fantasies combine oedipal and aggressive contents and may be accompanied by perverse activities. These patients may suffer short-term psychotic episodes associated with stress. They display paranoid symptoms, depersonalization and derealization, and may attempt suicide, Their fear of annihilation due to abandonment by the mother exacerbates the adolescent's normal difficulties in separating and cathecting different objects. The author who has concerned himself most with this subject, and has also presented the largest number of case histories, is James Masterson (1972), (1974). He considers the essential factors to be ‘oral narcissistic fixation’ and ‘abandonment depression’; these have prevented the borderline subject from growing towards autonomy and left him fixated in Mahler's separation-individuation phase. Masterson & Rinsley (1975) state that the main cause of the borderline patient's fixation is withdrawal of the mother's libidinal availability during the child's rapprochement subphase of separation-individuation; this occurs when the child's individuation constitutes the worst threat to her defensive need to cling to her infant, asa result of which she withdraws her libidinal availability from him (p. 163). These authors consider that the intense oral aggression of borderline subjects is caused by this maternal withdrawal, in which every effort by the child towards individuation provokes further withdrawals Of libido. The mother, who also suffers from this syndrome, is available only if the child clings to her and acts regressively. Masterson (1976) later extended his ideas to the various phases of human development, ai g circumstances, xiving rise to maintaining that latent abandonment depression may become manifest in different Pees en different clinical syndromes. He thus distinguishes between ‘borderline states—subjects wih CANOE depression and ego fixation, but adapted and without clinical symptoms—and the ‘borderline ¢ = 07 and is copyright to theHi gainst abandonme i eee in concentration, antisocial behaviour, drug addiction Raise ee NEL pace eee ae Paper referred to earlier (1985), are among the authors who have most '¢ appropriate and necessary method of treatment for th discuss five cases, three of which they treated i riods They consider piel” . Psychoanalytically for long periods. They consider typical symptoms to the suicide attempts, anorexia or bulimia, massive claustro-agoraphobias, obsessive alr conversions, drug dependency and compulsive delinquency or fugues. For these authors, the adolescent process, which ought to lead from spitting to integration, has failed in borderline subjects, with splits of all kinds being strengthened instead of weakened, so that introjective mechanisms are blocked and the restructuring proper to this phase of development does not take place. Brenas & Ladame maintain that realty testing, which other authors consider to be satisfactory, is merely the result of a capacity to use mechanisms of identificatory projection and an as-if adaptation, which is completely superficial and applicable to external reality situations. Instead they stress separation anxiety, which they consider to be clinically present and which they exemy in their clinical material. They assign to separation anxiety, with its correlate, fusion anxiety. an essential place in the genesis of this pathology, and they hold that ‘annihilation anxieties’ underlie the other anxieties, These authors mention long-term psychoanalyses and a strict setting, and present three cases: Paul and Michéle, each aged 19, and Christian, aged 13%. They describe and exemplify stages in these three analyses. although they do not specify the duration of these processes or the results obtained. The absence in these patients of certain features which we regard as characteristic is noteworthy—for instance, sado-masochis sexual fantasies, bodily movements, and levels and intensity of confusional anxiety; these differences may perhaps be attributable to the face-to-face technique apparently used by the authors to cope with the regression which may occur on the couch at later stages of adolescent psychoanalyses, thereby achieving a better split between the symbol and what is symbolized (a process also observed in our adolescent cases, as we shall show below). These authors also emphasize the importance of separations, ‘which may be experienced as extremely difficult and almost catastrophic’ (p. 503). Two other French authors, Marcelli & Braconnier (1983), hold that ‘only a psychoanalytic approach can furnish the key to an understanding of this conflictual organization’ (p. 269). Like many of the authors considered here. in regard to both symptomatology and genesis, they emphasize certain symptoms which we too have alway’ considered important, such as outbursts of violent feelings: anger, rage, impotence or distrust. They also state that reality testing is reserved only for the external and superficial, whereas the qualitative aspect of reality is altered by projective identification They emphasize the diagnostic importance of boredom, lack of interest, emptiness and feelings of uselessness. These subjects have a floating idgntty and a narcissistic fragility and are extremely sensitive to losses. The prevailing type of object relation leads them to form superficial relationships, which may end suddenly, This reinforces the pathological aspects of their mental organization and comes to predominate in the ul ey recommend an analytically inspired face-to-face psychotherapeutic therapeutic process. For this reason th approach “That brings us to the end of our critical review of the research and theories applicable to borderline adolescents, ADOLESCENCE FROM THE PSYCHOANALYTIC POINT OF VIEW tage of human development in which ‘normality’ and pathology are very Because adolescence is a unique st _ iy important for our purposes to consider first of all difficult to tell apart, we considered it fundamental ‘Archive CD and is copyright to the i in any form whatsoever. WARNING! This text is printed for the personal use of the owner of the PEPAdolescence, of the ad OF the adolescent process, isa wid metapsychological approach sheen doce 8 wide-ranging, complex and difficult subject. While a !ould be given priority from th epsyeh 1 Psychoanal view, a inrrclaonsnny charm specifi individual questions can efeoure ooh trata sidy } environment are taken into account. Adolescence is an individual Jacl, but i takes place in a specific cultural, social and histor ir which impresses its stamp on the ‘fic cultural, B spe if al, social and historical environment which impres Adolescence literally ly means the condition or process of growth. In th Pa of history of human life, adolescence is isually pone as the link between childhood and adulthood; however, hi (ory is, of course, = ae an a Seauente of scenes, events and characters in which pas, present and future are united bya linear plot an a at the past leaves traces, which the subject-as-historian will interpret, As Freud said, pat, presen trung together on the thread of the wish that runs through them (1908). ‘The interweaving of the threads of fantasy and of thought must also be taken into account in regard to the work of the ego. Adolescence is therefore a time of restructuring and a space full of history and potential. It isa state of attribution of new ‘meaning to the childhood world—a mental state in which fundamental new aspects are added, such as the achievement of erotic life and the procreative capacity. All these aspects will subsequently be reflected in @ sense of identity and a better consciousness of temporality. Time will then come to include not only past and present but also the future—the future that is so much involved in the restructuring of the ego ideals The adolescent crisis begins with puberty and itis a phase of life which entails both danger and opportunity When the child leaves behind the ‘latent’ state and emotional turbulence arises in him as a result of the metamorphosis of puberty, there supervenes a crisis of ‘deidentifications' which calls his being profoundly into question. It is crisis equivalent to the loss of his childhood identity, which was grounded on former identifications, and it may become dangerous if he is unable to find a container for it in his mind. It may also develop in a way that expands psychic reality by producing mental growth; inthis respect it also implies opportunity. The adolescent crisis involves a ‘catastrophic change'—a particular type of configuration inherent in extremely diverse structures of change and transformation, The constant conjunctions of phenomena linked together by Bion (1966) with this term includes the alteration of the system (violence and invariance) within the container-contained relationship, Some elements undergo the adolescent change without modification (invariance), but there is also an alteration of the former system (violence) resulting from a change that disorganizes the latent’ system that has been constituted: this is ‘catastrophic change’, which does not imply an actual catastrophe, although it may in some respects come close to one. Hence the crucial importance of the identificatory ‘route ‘According to Aulagnier (1984) the characteristic feature of ths ‘route’ is that, ‘while an identifier remains alive, it can never be closed off, but must be available as a fixed anchorage to guide the traveller, who can thereby discover the sense of the route—in both meanings of the term—that is, where he has come from, where he has stopped, and where he is going’ (p. 209) The sure anchorage (invariance) is essential if the adolescent ‘traveller is to be able to continue on his, ioumey when confronted by the crisis of deidentticatons, instead of stopping and becoming fixated in a position because he cannot tolerate the suffering caused by his identity crisis, hich may sometimes even cause him to lose his own individuality. For instance, the impact of adolescence on which n ; the precarious structure of Martin, a borderline adolescent whose case will be discussed below, was ‘catastrophic’, as he himself put it to one of us — es his secur The adolescent is particularly vulnerable because he is in a state of transition in which he loses right tothe hive CD and is copyright WARNIN@At Thie rave ie neinted for the personal use of the owner of the PEP Archive © An coveyay | | identity crisis. The dis in. in which the acute loss of family i Rice crats: The disillusionment is accompanied by other fundamental Behan cae rei Pasa an level ofthe cz rane 2b adult characteristics (pubic hai, breast growth, genial developmen ), the adolescent , et.) the adolescent looks in the mirror and asks himself: eee eae ‘Who does this body belong to?" and he isnot at all sure ihe is seing his puberty isthe phase of greatest madness in the development ofthe individual (1980, p. 18). Is easy to imagine }ow this ‘madness of puberty’ can disorganize a borderline adolescent. We shall see how our patient Martin's ‘confusion confronted him with insuperable barriers, which led him to seek analytic help All the authors who have studied adolescence have described the difficulties presented by the adolescent to the analyst. For instance, in 1958 Anna Freud mentioned the peremptoriness of his needs, his intolerance of frustration and his tendency to use any type of relationship as a means of satisfying his wishes rather than as a source of understanding and clarification. These difficulties are intimately bound up with the reactivation of his narcissistic organization, his oedipal conflictuality, the unfolding of his sexuality, the loss of his childhood body and mourning for the parents of infancy. Having regard to all these factors, we believe that, in addition to the concept of identification. mourning is calls for consideration of the narcissistic relation to the object and of oedipal conflictuality It is easy to understand the difficulties presented by borderline organizations to these complex processes. The severe narcissistic disturbances and consequent deficiency in the structure of the ego ideal make it impossible for borderline adolescents to accomplish the work of mourning. ‘If any given universe. writes Bion ‘cannot yield a meaning for the individual, his narcissism demands the existence of a god. or some ultimate object, for which it has a meaning from which meaning he is supposed to benefit’ (1965, p. 73). As we shall see. these words of Bion are illustrated almost literally by our patient Maria, who tumed to God for confirmation of her precarious contact with reality and her own identity To sum up, we believe that adolescence is a time of restructuring and a space full of history and potential. is process of performance ofa set offundamental symbolic operations, one of the most vital of which is the= adolescent's symbolization of himself as ‘other’ on the basis of his bodily otherness and his assignment of new CEE taeaning to himself in regard to such questions as ‘who am 1?"'who are my parents” and ‘what death This, vvinsent of new meaning involves travelling the arduous route from the omnipotent narcissistic ideal ego to, piney -m 10 the working through of the oedipal constellarion—the central, the ego tdegl, from infanule narcissi phenomenon of adolescence, i Maria or the ‘impossibility’ of detachment? It extremely anxious: she was very afraid that she would make a bad Maria, a girl of 14, fe jon her. She was an intelligent adolescent but doubted her ‘AS a result, she had to make an tation, she was in the first year of her they would aband .dy because of the anxiety that invaded her. Jy good marks, At the time of consul impression on people and that capacities, feeling unable to stu enormous effort to achieve consistent lower certificate course. Wal the TI i ive CD and is copyright t0 # f the owner of the PEP Archive C °° VARNING! This txt is printed forthe persons) uss of or ee or eirulate it in any for watsonHer father, a 50-year-old industrial engineer, putit, Asa result, he acted like an absent father. narcissistic personality who felt guilty at because she did not like children’ and th Was an intelligent, sensitive man, ‘cut off from reality’, as she The mother, a 45-year-old doctor of literature, was a “Raving left her daughter in the care of nannies when she was litle jought that this had damaged Maria. eed had been @ precocious child with a difficult childhood. She had had sleep disturbances from 'yhood; she had been a fearful little girl, who had needed to sleep with her mother on many nights from her earliest years. Maria would then calm down and could only fall asleep in this way, sometimes sucking her mother’s nipple; this situation had persisted to the present day , At one of the interviews, Maria told the analyst: 'I have always fed on my mother. so she is worn out and it is my fault. When she got angry, she would say ‘I am going to kill myself, and at the age of 8, when her sleeplessness had become chronic, she had one day begun to scream in terror that she could see spiders and bats: she had scratched her neck so badly that the scars were still visible, She also had fits of temper, and so her parents had consulted a child psychiatrist when Maria was 10. The diagnosis had been infantile psychosis. Ather first interview with the analyst she told her: ‘I feel very bad, I cannot live and I do not want to take pills, they do not cure; I want to be psychoanalysed and see if | can change; if nor, it is better to Kill myself. Life seems to me boring and empty. I am bored for much of the time and I have problems with my thoughts, I want to be a good person .... I need to be somewhere, with people, because then I get in touch with reality and I come out of my fantasies’, she said afterwards. In addition to all this, she remembered how afraid she had been since early childhood of Count Dracula and of bats. She said: ‘I was afraid the bats, or someone else, would come along and kill me’, An example of the split in her, which was much more intense than the characteristic adolescent split, was in her conversations with God. Maria said: ‘It is as if | were two people; | do something and I consult God, and God tells me: do this. God keeps me in reality. Sometimes | say to myself: that wasn't me, it was God. Ot noteworthy points were the failures of the mechanism of repression, and confusion by projective identification with the figure of the mother, as exemplified by the following: ‘I went to Madrid with my father and he treated me like a grown-up woman. I thought he was attracted by me and I was afraid he might seduce me. I then ra my mother to tell her what was going on and there, as it happens, was my mother’. On another occasion she wished that her mother would die, as she would be more secure with her father and would free herself from. dependence on the mother. It was surprising to see oedipal material emerging so manifestly, as well as the use of this situation as a defence against the link of extreme dependence with the mother; however, this is not unusual in borderline cases, ‘At the same time, Maria proved to be an adolescent of high intellectual calibre and capable of original thought. Sometimes she exhibited serious confusions, for instance between the internal and the external world or between fantasy and reality, with consequent failures in her symbolization processes. The principal srechaniems at work in her were splitting. idealization, omnipotent control. excessive projective identification and intellectualization. She showed a symbiotic link with the mother and low self-regar Maria began‘her analysis at four sessions a week: like many adolescents ofthat age, she did not at first lie dlown on the couch. The predominant themes in the first period were her extreme anxiety, her need to be periéct and her difficulties with her school work due tothe anxiety that invaded her and stopped her from thinking an SMring. She needed to dwell onthe most minute deals, and for his reason she would goon studying unt ate into the night. Other themes in the sessions were her fear of sleeping alone and her dread that her mother her, she would calm down and could fall asleep: sometimes, as already stated she would even suck at her mother’s breast. These fears would trigger fits of panic in her, as on one occasion when a spot on her mother’s face had to be examined. Her father had to bring her tothe session by car because Maria was terrified that she might become paralysed and unable to walk. might die, If she was in bed with 1D and is copyright to the Al This text is printed fe se of the owner of the PEP Archive CD and is copyright RNING! This text is printed for the personal use of " es Journal in which it originally appeared. It is illegal t0 copy. distribute or circul 7In that day's session, she said in a falterin s ig, confused and panic-stricken voice: ‘My mothe cancer; I cannot live, it is better for me to die’, ‘The anal 4 ey c , lyst devoted the entire session to trying to contain her anxiety and help her to differentiate the elements of her confusion, which resulted from her fear that her death wishes towards her mother were being fulfilled and from the consequent guilt feelings. tea Repeated interpretation of these fantasies allowed Maria to overcome her extreme confusion; her mother a in eters these fantasies with comments such as: "The best thing would be for me to die, to give you a break and allow you to be free’. She would also intellectualize and needed to know everything. In the transference, Maria felt understood and helped by the analyst, although at the same time guilty and afraid of draining her’. The analyst in her countertransference really did feel drained, and sometimes almost. exhausted, by the demands of this patient—presumably an expression of part of the negative transference, connected with Dracula and the vampires of her childhood. On the other hand, we believe that this negative transference was also manifested in her constant references to how the analyst approved, disapproved or judged her acts and thoughts Maria dreamed very little, but we feel that the following dream clearly illustrates her psychic structure and the conflictual link with her mother: '/ dreamed that everything was divided into little pieces, and my cousin Diego told me: all this is the proportional share-out’, She described this situation with great anxiety, as being like @ circle occupied by lots of pieces. The dream was interpreted as a reference to her fears about how the parts of herself and of her mother would be shared out if she were to separate from her. The analyst also pointed out that it was a weekend dream brought in the Monday session; in view of the patient's confusion, she preferred for the time being not to say anything about the obvious triangular situation, There was now a gradual development in the patient as she came to feel more contained in the analysis. She began to be able to sleep by herself and to have friends of both sexes with whom she went out at weekends. She could study better and read without getting as anxious as she had before. This was the climate at the time of the session reported below, which is presented because it is considered typical of this patient; it dates from a point two years into the analysis. Maria arrived with her now customary punctuality and lay down on the couch, as she had done on her own initiative since the second year of her analysis. She arranged the cushion and then performed a series of movements to make himself comfortable on the couch, but also, as it appeared, to expel something with her head. ‘These movements have been a constant feature of Maria's analysis, and we believe them to express a form of transformation into hallucinosis (Bion, 1965), with muscular discharge. This phenomenon was described in the past by one of us as specific to borderline organizations (Paz, 1981). After a short silence, Maria said: ‘I don't know. Since I started the analysis, | have been thinking like crazy all the time. I don't know if this is normal, because the analysis has helped me a lot; this summer I was able to cope with difficult situations, and { owe it to the analysis’ (she was here referring to the fact that she had been able to travel abroad and live together with other adolescents). She went on: ‘Now I could talk about other things. and tell you about the summer, which is what I want to do, but afterwards | shall go home and feel very bad if | am not clear about what is happening to me. What is happening to me’, she said suddenly in a very anvious voice, almost erying, is that I cannot understand certain things and | am dying of despair—it is this business of control ‘The analyst told her that she was demanding to know what she could not yet understand and that she wanted ‘to take everything to the absolute limit’ as she had so often said. In demanding so much from herself, she would leave no place inside her to feel that her analyst and that they might might retain in her memory the things she told her, that she might remember these thi gradually come to understand them together. Changing her tone, the patient said: ‘Yes, the thing is that | went tothe cinema yesterday with my parents. Suddenly she was again overcome by intense anxiety and exclaimed in tears: ‘I don't know, the film made me ve CD and is copyright to the ¢ personal use of the owner of the PEP Archi oe WARNING! ted for th 7 SN an ed, Its illegal to copy. distribute or circulate it in any form whats Journal in which it originally appearfel ery uly." Then with another change of one of my analysis, used to think that he was nok sucking up to my mother, and Wie days at X and we got on well and we talked a lot about people uric eee ne WEE fhe or a ew tts ea retraite one on cto tata a, thnk Tow tise t,t el cep ere eal peron and make comments; my cousin Cal as als hing andor oe ‘For example, ‘ample, my cousin Diego: before, in the fist year The analyst interpreted that, although she had now felt good and got on with he talking about other people and taking abou psychology made her eel ey mesa oe ee because perhaps she felt confused withthe analyst. and being confsed inthis way fet that she ee see place and thoughts. That was why she was soaftad afterwards thatthe araye mish killher ocene nee right, that'right: inthe film there is a philosophy teacher—it was the Woody Allen film Another Homan. ana in the room next door is a psychiatrist and his patient. There isa grille in the wall through which you ean hear bout her based on what she overhears. In the end, she knows the patient everything, and this teacher is thinki ‘ell and this woman does not feel at all guilty about it. "Trememiber the time in the analysis when we saw that I wanted to read C's (a girlfriend's) diary and how guilty I felt and I did not know why, and I asked you why. [felt that one ought to respect other people's, intimacy, and now Lam very pleased that I did not read it, bt this woman, I don't know. My curiosity is good. 1 think, and I get confused (weeping); I would like to be more free, without so much guilt; everything gets mixed up for me.’ ‘The analyst interpreted that she wanted to be more free so that she could indulge her curiosity about the analyst without feeling so guilty. She was also expressing a bad conscience; the reason why she became ‘confused was that, in allowing herself to be curious, she also felt that her thoughts were being taken away from her, and perhaps this was the confusion she had felt inside her the other day when she had felt so attacked by her analyst when she had told her how much she lacked freedom and liberty. In a previous session, Maria had brought along a set of photographs, which included ten of the Statue of Liberty. That interpretation had triggered a paranoid-confusional state inthe patient, who had reproached the analyst along the lines ‘why did you have to say things like that” This time, when the above interpretation was ven, she smiled and said: ‘Today have reached this point; now I understand, and I shall go away more calmly. Of course | am confused, and when I feel like that, I feel very rushed and do not trust that you will tome. What I feel is that freedom arouses lots of fear in me. 1 want it on the one hand, but explain everythi on the other it makes me feel very afraid.’ These statements of Maria's clearly illustrate her fear of freedom, experienced as separation and loss. We. shall see below how she constantly sought extreme dependence, as is often the case in the analysis of borderline cases. both adolescent and adult. We consider this aspect to be very important, as we believe that its correct interpretation encourages discrimination and avoids strengthening the paranoid defence. ‘Next session she rang the bell as usual at her time, No sooner had she lain down on the couch than she sai: ‘Look. as I was coming up it occurred to me that if you did not open the door immediately (only a few seconds had elapsed), it would be because you wanted me to come in ata precise moment, Of course, if it had not been { would have waited, but that is what I thought, though I know itas a fantasy. Today I feel calmer, | have ‘1; | would like you to go on repeating tim realized my confusions, but look, today I would like to go on Tike a litt things to me, to make me more sure. We see here the persistence of the extreme dependence on the object and the fantasy of being reated like a robot. Her infantile functioning ‘vas also clearly evident, encouraged by the analyst's interpretive technique. This revealed the superimposition ‘in Maria of infantile and adolescent features, with the coexistence in her of oedipal levels tinged in turn with fantasies indicative of psychotic functioning, another characteristic phenomenon of borderline pathology. This Will be illustrated by what we regard as a typical episode 1d is copyright ro the WARNING! This text is printed for the personal use of the owner of the PEP Archive CD an arcs ENTane to copy. distribute or circulate it in any form whatsor Journal in which it originally appeared. It is illMaria had felt sexually attracted by her dancing teac! st etc as ree ihe ted reesei mea involved in an argument with her mother’—a method that Maria had diecevevog Raa ase 1 could prolong her exareme dependence. When alone, she had thought about how toll her mother, with a gun or by owen ner She had eventually emerged from her confusion and told herself: "These are all just ideas; | must control myself She was thus able not to choose the path of discharge or of tying herself affesh to her mother in her old sado-masochistic clinging. When she reported this episode in her session, she was able to say: ‘I feel more of a person’. ‘A year later, when she started the pre-university course, she felt very anxious; she found it very difficult to study because she could not concentrate, and was afraid of being unable to complete the course. When she tried to study, she would be invaded by all kinds of thoughts and bodily sensations which filled her with confusion, Ina session in October, she said: ‘T cannot study; so many thoughts are criss-crossing through my mind, 1 am very anxious. | feel very turned on and I cannot think.’ The analyst replied: ‘I wonder what those thoughts are that are criss-crossing through your mind, which you say tum you on so much that you cannot think.’ Maria said: ‘What you say sounds sexual. I feel very ashamed to tell you a dream I had a while ago, which | just remembered. I felt ashamed to tell you it, but now I shall. 1.go to the lavatory to do a business and what comes out is meatpies, some balls are completely whole, as if uneaten, It is very strange and there is a lot. They are on top of the white lid of the loo and I say: how strange, how can this be? I cannot understand wity they are whole and on top of the loo lid In the dream, the meatpies went in and came out undigested. Something like that would happen to her with words: they would go in through one ear and come out through the other; she was unable to digest them to allow them to be thought. In the transference, Maria showed her need for an analyst-as-lavatory who would help her to digest thoughts so that she could think them. In a later session, shortly before the Christmas holidays, she said she was afraid of being overwhelmed and starting off ‘on the same old rubbish as usual, and everything will snowball, The analyst commented: ‘Like in the dream of the meatpie balls? You are afraid that thoughts will go in and come out and you will be unable to keep hold of them and think’. The patient replied: ‘I think I do not know how to digest things and it is something I must learn. If things are not digested, you cannot live’. In our view, all this material illustrates a typically borderline phenomenon, the appearance of highly regressive dream material in the middle of a later conflict, associated with the possibility of a better analytic understanding of these primitive processes a short time later. In the last session before the holidays, mentioned above, Maria said: ‘I was chatting to my mother; we were talking about the gipsy (the dancing teacher referred to earlier) and this time I laughed a lot with her. 1 seem to trust my mother more now, I am not so distrustful. | thought that, when 1 feel like being nasty, instead of going on and on with her J will talk about it to my father. He is a bit like you, he is quiet and I can talk to him better. ‘Ah! Thad a dream: Teas playing hide-and-seek with you and we were at school and you were also sitting at a desk Last ‘year's chemistry mistress was now the literature teacher and she said: Ah, I know you are going out with Christian, No, that cannot be, or something of the kind. And I said: How did she find out? I turned round and you were not there any more and | thought that it was like the fairy godmother, there one minute and gone the next’ The patient went on: ‘It seems to me that the literature mistress is like the censorship; I turn to you and you are not there, but you are inside me. Now I am thinking of my trip to France, that | will take you with me and we will play’ ae Th ceoentahe tnvtheFrom this point on, significant changes began to occur in her symbol showed, the game of hide-and-seek indicated a beter elaboration ofher separsion ensey og ea ‘The patient was overwhelmed by paranoid and confusional anxiety; he exhibited confusions between subject, and objec, the internal and the extemal worl, fantasy and realty. He suffered from hypochondria and his ‘main sttence mechanisms were omnipotent control, spliting and projective identification, with denial, idealization orf imellectalization predominating. There were also failures of repression and he seemed to be overcome by Wn. His phobic symptoms (fears) concealed the phenomena just mentioned. ° depersonalization and derealizatior His identity disturbance went beyond the characteristic confusion of the adolescent process. Analytic process ‘Martin began his analysis at four sessions a week and continued on this basis throughout the six years ofthe analytic process. In the early sessions, moments of confusion, in which he felt ost, altemated with manifest phases of imtelleetwalization, In the transference he swung between an evacuative type of relationship. in search of @ Container. and moments of paranoid distrust. He had the following dream in the first month of analysis: vre. [think of my Vespa—the scooter I used 10 have—and that} will surely find that it 100 will have a puncture. When I reach the spot, both tyres really are punctured: Lam in a small town and I go 10a friend's house as his mother lives there, and I tel him that my vpwes are punctured and | am done for. I have to go to the university and I do not know how to get there, | ‘us queue to wait for the bus, and then I woke up." can't do it, and in the end I go and stand in the {'identity, his sexual confusion and other disintezrative phenomena. ‘1 see a car in the street and it has a punctured ty Other dreams illustrated his confusion 0 For instance: ‘1 dreamed that a girlfriend's father was interviewing me at X [the place where he had spent the summer], and that he put his finger, I don't know whether it was in my guts or up my anus, causing me to be sick’ Another example: ‘Last night I dreamed I had a severed head in one hand and a liver falling from the other’ 1 the following dream in a session three months into his analysis: In this climate, he brot “There is a globe and scientists have run the equator though with a screwdriver, I thought they were going tofinish off the world, and I said no, that cannot be, because ifthe scientists have thought about it, they‘ mote a goodsob of t. All of a sudden, Europe cracks apart and there is death and destruction. I seem 10 ‘and when a piece of Europe breaks off, | catch it in case it breaks’. He told this dream with a mixture of surprise and intense anviety. However, it must have had such an impact on him that he had to deny it afterwards, as he immediately switched toa different subject. saying: I was fh happened there’. Then, in response to the analyst's question, Martin said: “The at X for four days; not muc Wworid was being divided up to make more inhabitable land; as there are so many people, itis a of way of be outside, preventing a disaster’ “These in our view are typical dreams of borderline structures: they clearly show the boundary between that the screwdriver represented by analysis might loosen "the ore inhabitable (the madness and sanity, as well as the possibility screws’ (disaster) oF tighten them up, imposing order on his internal world and making itm use of the owner of the PEP Archive CD and is copyright Ce y form whatsoever WARNING! This text is printed for the personal aa: A an jeoal to conv. distribute or circulate it in amloneliness expressed in the previous dreams will be recalled), We consider the depersonalizations torbe fundamentally connected ‘hg underlying guil. flings, as the fantasies of growth implied cont cnith the separation feom the. methen sa "I want to tidy up my room, but the only thing in the way of this is my ane eee Marte er ea er, who does not want me to, T Twas with N [a girlfriend) and my friends were also there; I was getting my house re. myself getting worked up with N; I saw her undressed ao pady. but then I was by -7%0 with white knickers, and this new contact with her was very painful to me and I could not do anything: I felt ‘guilty, I don't know’. He immediately associated: ‘At the weekend | was with my parents at X and on Friday aftemioon I looked at myself in the mirror and began to feel something peculiar—nausea or like seeing this person (the one in the mirror) from afar. and in the evening it was worse: I did not know who I was. I did not go out, and on Saturday I felt the same, but in the evening I went to the cinema with my cousin and a friend’. This episode not only clarified his presenting symptom, nausea, but also once again illustrated the degree of his confusion. Note the contribution of his mother, who encouraged regressive behaviour by telling him: "Don't go out, you will feel unwell, stay at home with me’ On another occasion Martin said: ‘yesterday I noticed some interested, but | liked them a lot... and I went home with a funny feeling, I looked at myself in the mirror and 1 felt strange and began to get anxious ..." Here we have a telling illustration of how Martin responded to a characteristically adolescent situation with a borderline reaction, which, as shown, was intimately bound up with Is who were very nice. | never used to be his intense and complex bond to his mother. ‘The following comments clearly illustrate his violence and consequent fear: *... | don’t know, I don't like violence. A journalist was interviewing three murderers on the news and I became livid, almost having kittens. and switched off the television’. This was his stock response to situations of aggression. Later, he formed a relationship with a girl—whom we shall call Martha—who, however, left him after they hhad been going out together for a month. The day after this happened, he woke up in the middle of the night and began to feel different. ‘I felt different, I felt that I had my mother’s body from the waist up. I went to the mirror. went back to bed, and felt as if were a murderer, thinking of getting a knife. 1 said to myself: Martin, what is happening to you, and I called my mother to rock me to sleep. | was very afraid, but after a while I calmed down’. All this was recounted with intense anxiety. The analyst's interpretation was in terms of the feelings aroused in him by being abandoned: he had become depersonalized, felt murderous violence and also experienced his infantile need to be ‘rocked to sleep’ by his mother. Martin clearly. had difficulty in feeling depression at being abandoned, and-instead.experienced™n. disintegration, depersonalization and derealization, -He responded to object loss by first turning himself into the mother and then regressively seeking her. In this way Martin's reaction differed from that of @ normally developing adolescent. who, although he m momentarily not know whose body he was seeing in the mirror during puberty, would not experience such pronounced and repeated episodes of depersonalization as Martin. Other approaches to his intemal world are illustrated in the following dream, which he brought in a later session: ‘10 along for my session and you are in an old house, in an old part of the town: inside, the furniture is ‘modern, as itis now; 1 think I am coming with my mother, I come in and you are there. I say hallo, we are Sriends, we greet each other warmly; there is a dialogue between us and I have something important to te ou, | want to continue with what we were discussing in the previous session. I do nat remember what w: WARNING! This tex is printed for the personal use of the owner of the PEP Archive CD and is copyright© the me rs wNcas ts da amu Fem whatsOeVeFwere talking about yesterday {he had been taking about his mother} There ts also a small, dark-haired boy, with his mother. He leis schizophrenic and you greet his ‘There 54 spook 10 him, He goes op 'oyou and anDracas you an shan tha brat rece vess ie hee down ora id ond leaps on ma ond bes me. 1 2) out bacente i hars elo hare, onthe oles ofthe mat ec code piece of ini torn of | den! myself. my mother pros end | pl his hte, but area crm, he goes on biting me until he eventually gives way. You do nt have any ree sessions and im pase tuothink he snot there todo psychoanayss, and you go for a series of ha hour meetings see se ome ith him. You think you are going (0 help him, but, when you see how aggressive ei wae esrane We then goin the sexsion and there i aktchen; was dresed, bt I pu on a pair of 2 ett the ones sed im operating theares, 1am talking you and your husband comes clog: then ‘go away, but then [lie down on the ut Tcannor ell you anything any more because time is up. 1do not know what! have added from wr sar come thangs were definitely inthe dream: the vicious bites, the Kitchen .." ve was afraid that, Fhe were to show his violence, which he felt to be mad, him, Perhaps that is why he had brought his mother along t00 C(C was couch, b iy fantasy’, he continue ‘The basic interpretation was that h schizophrenic, the analyst would hesitate to treat Hie interrupted asking: ‘Am [the boy? But see him as deranged and in need of the psyehiowist Fe eeeisrite child poychiatrist who had treated him when he was 10). Well, fom what you tll me, now | ire retard something. {bring my mother along, for me itis a conscious wish, but, deep down, 1 do not want 'O- ane fen there isthe boy inthe dream who is schizophrenic, who takes the session away fromme, When | was aan tog was very unwell in need ofa psychiatrist. 1 fight with him, I hit him. 1 defend myself because he is damaging me and finally I manage to get to the session and have a dialogue with you. The whole thing is tatural, And me being undressed in front of you makes me think of my sexuality.’ ‘The analyst interpreted his desire fora dialogue with her as, on the one hand, a wish to understand the mad, violent child and the relationship with his mother, and, on the other, the wish to be with her. But if he was with her, he was afraid of her husband, and so he ran away, ‘After thinking for a while in silence, he said: "When | saw him once, | went away; now I remember a photograph of you naked, from behind, and I can see your nipples. This went through my mind, so I think you are right .." “There was obviously the violent, schizophrenic child, on the one hand, and the child in search of a mother to Jook after him when violence erupted, on the other. In addition to the mad child, there was also a very fearful cone. Similarly, there were signs of the oedipal adolescent in the triangular situation. Infantile and adolescent... Igvels were superimposed on each other, while his schjzophrenie part was clearly evident, with terrible oral Violence partly discharged on to himself throughout his life (as in his constant childhood illnesses) ‘on problem in this exposition, owing to its intense Note too that, although we have stressed the mother conflictuality, the figure of Martin's father was assuming an important place inside and outside the analytic process. We believe that ths relationship, of growing dialogue. represented a decisive step by tis patient, showing that the initial disintegration anxiety had substantially given way to castration anxiety ‘After many hours of analytic work, during which Martin became more and more able to discriminate and ceradually discovered a better identity, he had to terminate his analysis because the final deadline for his military service was approaching. the fluctuations in the process of working through and mourning were manifested in the final year of his analysis, Progress in the working through of his mourning at the forthcoming separation was accompanied by clear oedipal fantasies in which Martin was afraid of the figure of a clinging, seductive mother. Ina session after the Christmas holidays, he said among other things: ‘I have not been calm, | have had my clids | often used to have ... I found myself feeling old muscle spasms in the shoulder and the fluttering WARNING! This text is printed for the personal use of the owner of the PEP Archive CD and is copyright 1 eal Joumal in which it originally appeared. Its illegal to copy, distribute or circulate it in any form whatsoever.eee ‘with my general situation (having taken hs univeiy domes goes noe reer ot analysis, as well as Seca ser Sepe be sw ean rue ee et fel that the analysis is ending, hell! Itis really going to end. Teresa will stay Sasa Soe et fina be anv i edi Nell ely gine rd.‘ yan sal 99 Ta Christmas holidays.” ‘This was the first dream as he told it ‘Teome along to the session, Iam with you and itis the last one and you say to me: good, Martin has eominated. It is the last session and I'am pleased on one level. You give me your hand. | feel very grateful brace you. I give you two kisses On the cheek and then I leave, but I stay in the house. It isan ‘husband going past and people coming to their sessions. 1 see someone whom 1 vere is lots of light and I watch from an armchair. I see a woman go by and open dream: Martin, you realize that you cand I emi apartment and I see your recognize as your son. Thi the door, and I suddenly think im the are here and have terminated. and you are not leaving because part of you does not want to go. After then you arrive and put your hand inside thinking that, I leave. I take the lift and realize 1 am turned on: ‘ant to terminate, it makes me feel very sad my trousers and I come. It really is true: although Iw “Thad the second dream yesterday’ inthe ancient Roman eating posture; I give you my hard, and 1 it is the last session and I do a turn, I say nothing, but leave, and this remains behind. remember that handshake, I feel it very intensely. lysis, he then said; ending this relationship obviously have been thinking a lot about the end of the an dit out: Ihave spent a good 900 hours talking to you, makes me feel sad, after six years. Yesterday | worke ‘A few months later, in a session just before termination, Martin mentioned some plans on both the emotional —and professionally, and was also Ievel—he had had a more stable relationship with a girl for some two years: able to say: ‘I feel fuller: suffering does not overwhelm me as it used to, and I owe this to the analysis. am now functioning in a world that is more real and I find life exciting’ To end our case history, we reproduce below our patient's own account of the journey Twas at a bookshop. I had gone along to buy a book (to do with his profession) and I saw one by Someone called Bowlby Separation —and had a look inside it. One section dealt with infantile phobias, pseudophobias due to separation problems, After everything we have been analysing. it ‘seemed to be a portrait of me, and now I can understand what has happened to me. My fear of ‘separating from my mother, my history since my fist year at primary school, when I got ill and was and I found myself thinking that when I got depersonalized and went to the that lay behind him, unable to go to school mirror, it was because I wanted to separate. Losing my mother meant going mad. and I felt that | was distategrating: that is why I went t0 the mirror. This was the main thing that was happening to me. It was the same with my sickness—my first ‘attack of sickness atthe Viveros Gardens, and when I had to go on a trip and got ill, or when I came out of school and was always thinking about my mother ... well, what is happening now is that I feel very upset and it is because of saying goodbye to you. 1 feel like crying ... I have gained a lot on the ‘one hand, but on the other, | am also losing—yet there is also something that will remain behind for ever) Notwithstanding this elaborative possibility, it will be noted that Martin's muscle spasms remained, We consider this a typical symptom of borderline structures, which can in our experience persist alongside genuine elaborations and insight as the expression of a split off part of the personality deposited in the body. This may be a psychotic element in these personalities which is incapable of being elaborated, We also consider that during the analytic process Martin began to exhibit the essential stages of adolescent chive CD and is copyright to the WARNING! This text is printed for the personal use of the owner of the PEP At ate it in any form whatsoever Journal in which it originally appeared. It is illegal to copy, distribute or circulLe eee deerme aspect ac tase wicca te roes eo how he came tm we me yet ees Ob ing ah exer, nor spend a year concentrating on the mourning processes. ig one ease mace i poms a) REFLECTIONS AND CONCLUSIONS By virtue ofthe similarities between the symptoms of Maria and Martin and the experience of their analyses, we consider that both clearly display the characteristic features of borderline structures. These features ars agree in almost all respects with the descriptions and conceptualizations ofthe various authors covered by ae eview. However, there are significant differences in respect of serious acting out and behavioural Sheturbances such as sexual promiscuity, drug addiction and delinquency. Maria and Martin, as well as other cases of ours, compel us to draw attention to these differences. which be partly due to our therapeutic approach. how the importance of the process of separation, especially. fromthe, mother .Alhthe-~ this point.. The cases of Maria and Martin show us how two mothers, with different may _Bosh of our cases sh aust stuied concur on a re and Geren etaviours towards thet hitdren contributed 10 this form of pathological organization which adolescence makes manifesto shattering effect. “Te lineal material presented in our opinion clearly reveals how impossible i is for borderline patients 10. encree te adolescent crisis. Only in-depth analyses can help them to experience and then overcome they xi also work through their structural pathology. adalescent process ank sin gives us further evidence of the potential of the analytic technique with ‘At adolescent level, Mart borderline patients—a potential We have illustrated in the past in borderline adults (Paz et al., 1976-77). es illustrate the superimposition of the adolescent crisis and borderline pathologsig uring the analytic process, of essential stazes of adolescent development 's analysis shows how he overcame the most critical aspects of his In our view, these two cas They also demonstrate the beginning, into adulthood. The progress of Martin Cntastrophie adolescent crisis, while Maria's present development confirms the validity of psychoanalytic treatment in such cases. ur conclusion from this study is that borderline adolescents are a definite clinical reality, nonwithstanding, the questions that remain, The obvious differences between the borderline structures of Maria (depressive-guilty type) and Martin (schizoid-disintegrative type) suggest that there are different clinical subforms., This is in ‘sin borderline adults and with those of Grinker etal in their important 1968 paper agreement with our findi ‘The borderline syndrome We believe that the possibilities of psychoanalysis for the diagnosis and treatment of these adolescents are clearly illustrated by these experiences, In conclusion, we wish to emphasize the need for comparison of such experiences, with a view to the possible achievement of a better consensus on these structures and their analstic REFERENCES AULAGNIER, P. 1984 L’Apprenti-Historien et le Maitre-Sorcier Paris: Presses Univ. de France BION, W. R. 1965 Transformations: Change from Learning to Growth London: Heinemann, BION. W. R. 1966 Container and container transformed In Attention and Interpretation London: Tavistock, 1970 pp. 106-124 BRENAS, E. & LADAME, F, 1985 Les adolescents borderline: Diagnostic et traitement Psychiatrie de enfant XXVIII 485-512 FREUD, A. 1958 Adolescence Psychoanal. Study Child 13 255-278 FREUD, S. 1908 Creative writers and day-dreaming S.E. 9 WARNING! This text is printed for the personal use of the owner of the PEP Archive CD and is copyright ro he Journal in which it originally appeared. It is illegal to copy. distribute or circulate it in any form whatsoever