Borderline Personality Disorder-New Perspectives On A Stigmatizing and Overused Diagnosis

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Borderline Personality
Disorder
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Borderline Personality
Disorder
New Perspectives on a
Stigmatizing and Overused
Diagnosis
Jacqueline Simon Gunn and Brent Potter
Practical and Applied Psychology

Judy Kuriansky, Series Editor
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Copyright © 2015 by Jacqueline Simon Gunn and Brent Potter
All rights reserved. No part of this publication may be reproduced, stored in a retrieval
system, or transmitted, in any form or by any means, electronic, mechanical,
photocopying, recording, or otherwise, except for the inclusion of brief quotations in a
review, without prior permission in writing from the publisher.
Library of Congress Cataloging-in-Publication Data
Gunn, Jacqueline Simon.
Borderline personality disorder : new perspectives on a stigmatizing and overused diagnosis /
Jacqueline Simon Gunn and Brent Potter.
pages cm. — (Practical and applied psychology)
Includes bibliographical references and index.
ISBN 978–1–4408–3229–1 (cloth : alk. paper) — ISBN 978–1–4408–3230–7 (ebook)
1. Borderline personality disorder—Diagnosis. I. Potter, Brent. II. Title.
RC569.5.B67G87 2015
616.850 852075—dc23 2014025566
ISBN: 978–1–4408–3229–1
EISBN: 978–1–4408–3230–7
19 18 17 16 15 1 2 3 4 5
This book is also available on the World Wide Web as an eBook.
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This book is printed on acid-free paper
Manufactured in the United States of America
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Contents
Series Foreword by Judy Kuriansky vii
1 Introduction: The Borderline Personality Personified 1

The Scarlet Label 3
Mary 3
Andria 5
2 A Historical Anatomy of a Social Construction: “Wandering
Womb,” Hysteria, Psychiatric Disease 9
Antiquity: Maladies of the Feminine and the Feminine as Malady 10
Middle Ages: From Uterus as Endoparasite to Demonic Possession 16
Modernity: From Bedevilment to Brain Disease: Orgasm Therapy
and the Rise of the Respected Physician 20
Deliteralizing the Feminine: Dynamic, Developmental, and Social
Contextualisms 24
Contextualism Abandoned and BPD’s Formal Entry into the
Psychiatric “Bible” 27
3 The “Borderline” as a Human Person: Contemporary Perspectives 31
“Borderline” Is to Psychiatry as Psychiatry Is to Medicine 32
Contexts of Agony 34
An Experientialist Description of Being with “Borderline
Personality Disorder” 41
4 Chewed Up—Spat Out: Jane’s Story 49
5 Emotional Jungle Gym: Melanie’s Story 65
6 The Permeable Frame: Ethan’s Story 81
7 Watering Flowers: The Stories of Caroline, Violet, and Charley 97
8 Conclusion: Reflections, New Directions 109
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vi Contents
References 115
Appendix: Wellness and Recovery Resources 121
Index 157
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Series Foreword
From the moment I spoke to Dr. Brent Potter about his thoughts about what is
commonly called “borderline personality disorder,” I knew he had to write a
book.
I knew he had a new view of this “condition” that has long been a diagnosis in
the profession and becoming an increasingly used word in the public.
Little did I know how challenged I would be the more I read the manuscript
and talked to Brent about his approach.
For the coauthors Brent and his colleague Dr. Jacquie Simon, “borderline per-
sonality disorder” is a misnomer that sadly stigmatizes the people who suffer from
this complex of feelings and display confusing behaviors. They make a convinc-
ing argument about not using the word and about a new way to view and help
such people and patients.
Like so many others, I’m comfortable with labels. I’ve spent years in the field
using psychiatric diagnoses easily in writing, communicating, and teaching.
When barely out of college after majoring in psychology, I was swept into the
world of psychiatric nomenclature, working at the New York State Psychiatric
Institute with a team of esteemed psychiatrists on multimillion-dollar research
grants comparing British and American diagnoses of schizophrenia and depres-
sion. We’d show videotapes of patients and ask panels of the experts from the dif-
ferent countries to label the patient according to the prevailing classification of
disorders. The results showed that the same patient could be labeled differently
by experts on differing sides of the ocean. My immersion in diagnoses was made
more keen while still an “early career professional” in the 1970s, when I was hon-
ored to be invited to join a panel of experts led by Dr. Robert Spitzer, reframing
the classifications in the famous Diagnostic and Statistical Manual, which classifies
and describes the symptoms and names for the “mental disorders.” At that time it
was DSM-III, which has now morphed into further revisions to become DSM-5.
Then, when I wrote my book The Complete Idiot’s Guide to Dating, I even
included a chapter warning about personality disorders that are dating disasters,
like the Narcissist who cares more for him- or herself than you, and the
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viii Series Foreword
Passive-Aggressive type whose anger shows up in backhanded compliments that

are really digs.
The labels have increasingly crept into common language. I notice people
casually saying about themselves, “I’m bipolar” or about others, “He’s schizy.”
A guy suddenly sends venomous texts after declaring undying affection three
times a day, and the conclusion is: “He’s borderline.” A woman tricks her friend
into paying for a trip, leading to the assessment that “she’s borderline.” While
unstable stormy relationships, manipulation, labile moods, and irresponsible
behaviors are typical symptoms, it’s become all too easy to use the label.
American singer-songwriter Madonna even popularized the word “border-
line” in her hit song with that title word, as part of her “Virgin Tour” in the early
1980s. In the song, she is a prisoner who is “going to lose my mind,” who
bemoans to an anonymous lover that “When you hold me in your arms you love
me till I just can’t see . . . But then you let me down,” which to clinical ears is
typical of the “borderline” person who draws you in but then pushes you away.
It’s a challenge not to label, and then not to treat someone according to the
disorder.
My first powerful experience about this challenge was with a patient whose
case I was assigned to, during my internship in a psychiatric ward of a hospital.
She had been given the diagnosis of being “borderline” and had been in the
hospital for two weeks when she told me that she got a call to come on a job as
a production assistant on a movie. She was thrilled since that was the job she
loved and had before she was hospitalized. At the case review that next morning,
a famous psychiatrist, Otto Kernberg, was called to consult. His ruling was that
she should not be released because she was not through with treatment, and giv-
ing in to her request to leave would only feed her symptoms of narcissism and
manipulation, and would risk her not returning to the hospital. Though green
in comparison to the big guns with years of experience, I argued that why
shouldn’t she get a pass to go do what would help her feel good about herself,
and help her readjust in society. I argued from the opposing position of another
famous psychiatrist, Heinz Kohut, whose point of view maintained that treat-
ment should center on encouraging a patient’s narcissistic desires, wishes and
needs—to open up during the process of transference. It was a more humane
approach. I wanted her to get that job and build self-esteem, to work on her
“problems” from a stronger place. Alas, I was overruled and had to tell her that
she could not take the job. The next day, she attacked me in the hall. Proof,
I was told, that the decision was correct; she was unpredictable, aggressive, and
not prepared to leave the hospital. To this day, what happened haunts me.
This book revives all my reflections about that “case.”
I championed Brent and Jacquie to write this book because I knew it was a
brave effort to confront the prevailing trend to still use the label “borderline.”
In reading the manuscript at various stages, I was challenged—and welcomed
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Series Foreword ix
the stimulation—to open my mind, to watch my words, and to not think about a
disorder, a syndrome, or a disease.
Brent and Jacquie have presented an important book with a provocative new
view. I read with exceptionally keen interest about their own journey as profes-
sionals intermixed with intelligent accounts of clinical work with real people
struggling with difficult feelings and behaviors. The challenge they present
became most poignant when I asked them to include a chapter about how part-
ners can cope” with such patients. Yet Brent illuminated me that including typ-
ical advice about “How to live with . . .” is exactly antithetical to what he and
Jacquie are trying to communicate. The alternative is evident in every page of
their book, in the cases and in the references, which must be read and digested.
It’s about the person and their context, not the label, they convincingly pur-
port. You have to read the book to see how this unfolds, how much sense it
makes, and how you too can be challenged to rethink your view and approach
as to how and why people do what they do.
Judy Kuriansky, Series Editor
Practical and Applied Psychology
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1
Introduction: The Borderline
Personality Personified
[T]he psychology of women hitherto actually represents a deposit of the
desires and disappointments of men.
—Karen Horney (1993, p. 56)
When you are reading this book, be prepared to challenge your view of what is
called “borderline personality disorder” and even the way you see all “disorders.”
This is what we have done as coauthors. It has been a challenging road for us as
well. We may sound a little strong at times, but we really believe in what we are
presenting.
We will take you through exactly why we take this approach, give you histori-
cal context, and explain some experiences with real people who are suffering.
To this end, we will provide stories from clients along with a few narratives writ-
ten by clients themselves along the way. We insist upon sticking faithfully to the
experiences themselves rather than upon theoretical constructs and other
abstracted materials. Our approach is not experience-near, but experientialist;
we do not hypothesize, abstract, nor construct theories from human experience.
Here is the overview of the journey in store in this book. The fields of psychia-
try and so-called scientific, evidence-based psychology are as aware of their
historical-environmental context as a fish is to its being wet—they are oblivious;
the most obvious and necessary context eludes them. You will notice in every
book you pick up on “borderline personality disorder” that the authors assume
that it is a psychiatric syndrome/disease as outlined in the clinical literature.
None of them even look at the basic assumptions or historical, cultural, and
environmental contexts wherein the supposed syndrome or disease was invented.
You read this correctly: All of the mental illnesses outlined in the diagnostic guide for
psychiatrists and other mental health professionals, the Diagnostic and Statistical
Manual of Mental Disorders (DSM), are inventions. Said differently, there is no
biological evidence for any one of the disorders outlined in the DSM. There is
no blood test, mouth swab, hair sample, biopsy, spinal tap, x-ray, brain-
imaging, or any other sort of “We’ll have to send this off to the lab” way to diag-
nose or confirm psychiatric diseases—zero. The contents of the DSM are
2 Borderline Personality Disorder
constructed by committees of professionals, most with financial ties to the

psychopharmaceutical industry, and then voted upon.
That the diagnoses are diseases and/or syndromes reflecting a chemically
imbalanced or otherwise defective brain organ is a “given.” Yet the fields of psy-
chiatry and natural science psychology proceed as if their hypotheses, perspec-
tives, and diagnoses are facts, like wind or gravity. And, like wind or gravity,
diseases just happen. If brain diseases are like other medical diseases, they hap-
pen independent of other factors. They simply are due to this or that neuro-
chemical mishap and there is no need for any further investigation or thinking
outside the realm of biology. When varieties of human distress are understood
as diseases, critical thinking is off the hook. The phenomena are decontextual-
ized, stripped of context and any meaning outside of biological hypotheses.
It makes sense that clinicians, for the most part, accept this “given.” Psychol-
ogy students today learn that psychology is the study of human behavior, which,
in turn, is the exclusive product of the brain organ. Brain organ events produce
human behavior. The DSM categorizes anything that is considered defective or
maladaptive in such happenings. These are so “given” in the education and
training of mental health professionals that the presuppositions and contexts
are entirely ignored. These diagnoses are accepted as facts. Every clinician, for
example, knows that it is commonplace for clinicians to simply refer to a client
by his or her diagnosis: “the schizophrenic,” “the one with major depression,”
“the borderline,” or sometimes, “the borderliner.” While it is impossible to stand
outside our cultural-historical context, it is possible to examine some of the his-
tory, context, and philosophical assumptions inherent in our worldview.
This is one of the major challenges and accomplishments of this book: stick-
ing descriptively with the phenomenon itself without lapsing into established
opinions, ideas, and long-held understandings. We also do not deny that various,
typically expressed, forms of distress exist. People do become distressed, some-
times in long-standing ways. What is often labeled as mental illness varies in
degree, but not in kind, from what everyone experiences.
This work stands out as distinct from all other books written on “borderline
personality disorder” and other so-called psychiatric diseases. We do not assume
that BPD is what is outlined in the DSM and the literature on psychopathology.
At no time do we refer to it as a diagnosis or psychiatric disease. This is why you
will repeatedly see “borderline personality disorder” in quotation marks. It is not
a thing, like a disorder residing solely in the brain organ of an individual.
An individual takes up only possibilities disclosed to him or her by the
cultural-historical environment. To say otherwise would be to say that the indi-
vidual creates them out of nothing, which, of course, would be absurd. Since dis-
tressing states of mind are variations of common human experience, they are
expressed in typical ways. For these reasons, we do not consider “borderline
personality disorder” in a decontextualized fashion.
Introduction: The Borderline Personality Personified 3
Since we do not take up “borderline personality disorder,” nor any other phe-
nomenon of psychological life, in decontextualized, pathologized, literalistic, or
moralistic terms, there is no guide to how to contend with it, no workbook, no
advice on how to live with someone afflicted with the disorder, etc. Doing so would
only further the errant belief that it is an affliction with which one has to contend.
The causes and conditions of what is often labeled as “mental illness” are
known. There is no further need to research its origins. Though the literature
is unambiguous on this score, it is not popular; that is, it does not further the
financial interests of the psychiatric establishment. It is nonetheless true.
It is the aforementioned failures of psychiatry and psychology that demand
the writing of this book. The context provided herein is the story of how the very
fields charged with the care of distressed persons came to treat them in such stig-
matizing and reprehensible ways. Concurrently, it presents the meaning and
experience of people contending with developmental stress and trauma, which
is often labeled as “borderline.”
The fact that this work is heralded as controversial bespeaks the tsunami of
energy invested in maintaining and promoting the hegemony of understanding
“borderline personality disorder” as is—without context, history, compassion,
or truth.
THE SCARLET LABEL

The diagnosis Borderline Personality Disorder (BPD) strikes fear and loathing
in the hearts of most mental health providers. It is unquestionably one of the
most stigmatizing and overused diagnoses in existence. Often diagnosing some-
one with this label is a clinical punch in the gut to the client and also a means
of communicating warning to other clinicians. It is the twenty-first-century
version of the scarlet letter.
MARY
I’m not sure if I’ll ever be able to eat again. That last punch to the face made my jaw
instantly swell; and now I look like a boxer who just lost a fight. But was it hard enough
to pay my penance? I was too upset to know, so I just sat in my car on this hot July evening
with the windows up; I had sweat tears and mucus pouring into my—impossible to close—
mouth.
I was in the city suburbs looking at the house where my ex-therapist has her practice.
“Why do you hate me?!?” She used to make me tea when I was sad. Now I’m lucky that
she doesn’t know I’m here, otherwise she might send the men in white coats to straight
jacket me and drug me into submission.
Around an hour earlier she said I had to sign a waiver before our session. It stated that
no one was to sue her if I killed myself. She then asked me for my check, terminated our
therapeutic relationship, and asked me to never contact her again.
Three months before this evening she pushed me to try a relationship with a man who
had been pursuing me for over a year. I didn’t want to, but she said he wanted to be there
for me, and that I should try letting him in. I didn’t like or trust him, but she insisted—so
I did. I was afraid she’d stop seeing me if I didn’t. She felt that with his support I could get
off the Effexor—the drug that was hurting my body, clouding my judgment, and giving me
high blood pressure. So I did that too—got off the Effexor; I wanted to be a good patient.
I was in the process of withdrawing off the meds when the man I was dating suspected
I was cheating on him, and raped me to get back at me for it. When I came to her for help
she raised her fee to a price I would not be able to afford, and told me that I was responsible
for my decisions. Her raised fee was double the price, but she wouldn’t negotiate. It was a
business decision, and not open for discussion. I told her that she wanted to get away from
me because she didn’t think I was worthy of her practice. Judging from the note she made
me sign, I believed she didn’t think me worthy of being alive.
I stayed in the hot car that night for so long because I had forgotten how to drive; and
where would I go anyway. I wanted to make my ex-therapist happy and kill myself. With
all my heart—I wanted to die. Not just for her, but for the sake of everyone I had ever
loved. I wanted to release them from having to deal with the pain my existence causes
the world, but I was too chicken. So I punched myself again. This time in the stomach;
I punched myself with all the passion and hate those I love have for me. I was screaming,
“Why won’t you die!” I was begging myself to do it. I screamed so loud I lost part of my
voice, and the punches to my gut were hard enough to make me topple over and focus
on the physical pain. Finally some sort of relief. Will anyone ever love me? How can they
when a therapist won’t talk to me? I’m such a piece of shit I can’t pay someone to care.
How can I look for a new therapist? All they do is say “you really need help, but I can’t
help you” followed by giving me a phone number for someone who will eventually say
the same thing. What’s the point? My first month with any new therapist has been spent
dealing with the pain and rejection of looking for a fucking therapist. If they won’t/can’t
help me who will? I can’t help myself.
My jaw and stomach hurt; and I’m afraid; I want my mommy—is all I can think, but
she’s dead. All I can do is call the people in my life who I believe I have been there for, but
no one cares. One person is even angry at me. That’s ok—I punch myself a few more
times to show I agree; I deserve the verbal attack. If I sit here any longer she may see
me and call the cops so I call my ex—aka recent rapist. He’s kind on the phone, and offers
to talk to me while I drive to his place where he will make me a soft dinner and take care of
me. Like a zombie I head to him knowing it’s the only choice I have.
I’m glad I went to therapy with her because I learned a valuable lesson: You can’t pay
someone to care, but if you let someone fuck you, they will pretend to care from time
to time.
Since 1980, the year of the initial standardization of the criteria for personal-
ity disorders, all versions of the Diagnostic and Statistical Manual of Mental
Disorders have indicated that BPD is unequivocally more common in women
than men. For example, according to the Diagnostic and Statistical Manual of
Mental Disorders, 4th edition, text revision (DSM-IV-TR) (2000), there is a 3:1
female-to-male gender ratio. This is interesting, especially given that a study by
Grant et al. (2008) for the National Epidemiologic Survey on Alcohol and
Related Conditions found that BPD is equally prevalent among men and
women. According to the National Alliance on Mental Illness (NAMI, 2012)
a staggering 1 in 20 to 25 people, predominantly women, live with this condi-
tion. Despite contrary evidence, it is clear from the inception of the label up to
the present that there is something both frightening and feminine about this
label. BPD holds a critical place in the annals of diagnosis. It is the “hallmark”
personality disorder, the blueprint upon which the other personality disorders
are based. There are three broad criteria for making an Axis II (personality disor-
der) diagnosis: tenuous stability, adaptive inflexibility, and fostering vicious
cycles. Not all three have to be met. The presence of any one means that a
personality disorder diagnosis is probably merited.
ANDRIA
The soft spring wind rushing up my short skirt made me feel like a goddess as
I rushed up 4th Ave in Akron to my job interview. The anxiety of my failing relationship
had caused me to lose enough weight for guys to notice me; and for the first time in a year
I felt real. I’m almost at my interview when Brian calls me. I can hear in his voice that he’s
angry. He says he isn’t angry, but that he’d rather not speak to me for the rest of the day
and then he yells, “Goodbye” into the phone and hangs up. Although this was normal for
him, I’m confused for a moment at what had just happened. The world became dark and
there were no longer the sounds of the city streets. My legs feel weak, and although I’m not
sure I remember how to walk, I look for a place to sit down. A man rushes past me, brush-
ing my shoulder muttering, “Get out of the way asshole.” Although he barely touched me
I feel a sharp pain that starts where we had contact and spreads throughout my body.
I might as well have been shot; I wish I had been. I think, “Why does everyone hate
me,” as my legs go out, and I fall to the ground. I’m sobbing with anger and intensity,
hoping it will give me some release from the grips of the monster that is my own soul.
They were right no one is ever going to love me. Why did I have to be born? My existence
does nothing but cause those I love pain. If I were a better person, and not such a piece of
shit, I’d kill myself to relieve my friends and family of me.
A sweet woman kneels down next to me and says, “Are you ok?” I want to ask her to
help me, but I forgot how to talk. Her caring is very painful; I want someone who knows
me to care. If she knew me she’d hate me too. The small part of me that is aware of her
existence wishes she would just go away so that I could punch myself like I’m supposed
to do. Punching myself makes me feel like I’m doing right by those who hate me and giving
them a little of what I feel they want; maybe they will be a little happy. I can only faintly
hear her, but I retire to my fantasy life. My usual fantasy: my head in a meat grinder that
I churn with my right arm.
She sees my phone on the ground, where I had dropped it, and asks if there’s anyone
she can call. I look at my phone and see that Brian is calling me. I grab it and answer.
I hear him say, “Are you OK sweetie?” I feel a rush of warmth run through me strong
enough that I’m able to softly say the word “No.” He apologizes and speaks to me for a
few moments. In my mind, I’m in a dark room alone with his voice comforting me. I feel
like I’m being wrapped in a pink fuzzy blanket. He asks me to meet him, and I say, “Yes.”
The interview isn’t going to be able to happen anyway; I’ve been crying so hard I look like
I’ve had an allergic reaction; and I’m still not sure I know how to speak. Besides—if
I don’t go to him right now—he might get mad at me again, and then no one will ever
love me.
Why is BPD so frightening? Let’s look at the recent criteria first and then look
at the history behind the diagnosis, especially in regard to women who are per-
ceived as being emotionally and behaviorally out of control by society. Interest-
ingly, the American Psychiatric Association forbids citation of DSM and related
materials, asserting that such actions constitute a copyright violation. This is an
interesting protective strategy they employed in an attempt to manage the
massive criticism they were receiving prior to the publication of the latest
DSM. In any event, we are not allowed to cite, even if referenced properly, the
criteria listed in the DSM directly. For this reason, we will provide a general
description of the criteria without citing it directly.
Stated briefly, “borderline personality disorder” has remained substantially
unchanged from its appearance in the DSM-III up to the present edition, the
DSM-5. As an interesting side note, the American Psychiatric Association
moved from titling its diagnostic “bible” with Roman numerals to the common
(Hindu-Arabic numeral system), so they could add decimals, similar to computer
programs—something like the DSM-5, 5.1, 5.2. In any event, not only has
“BPD” remained substantially unchanged through the various versions of the
DSM, it has also remained largely unchanged over the last roughly 4,000 years.
The diagnostic criteria, whether it be the DSM-IV-TR or the DSM-5, refer to
pervasive, personality-encompassing patterns of relational volatility (lack of empa-
thy, hypersensitivity, intense, conflicted, mistrustful, needy, anxious, idealizing
and then hating), self-image instability (impoverished, regressive, self-critical,
empty, dissociated/psychotic under stress), affective dysregulation (baseline
pessimistic, fearful, apprehensive, threatened/threatening, affect disproportion-
ally strong to relational context/event, dramatic, uncertain, confused), frantic
attempts to avoid imagined or otherwise abandonment (paranoid, clingy, hyper-
dependent/icy, separation insecurity, worry of rejection, separation anxiety).
Other criteria include impulsivity (often acting in a kneejerk response to stimuli
without considering consequences), risk taking (often engaging in dangerous,
high-risk behavior without consideration of one’s own and others’ safety or con-
sequences). In one way or another, all of the aforementioned criteria paints the
picture of someone who is self-destructive, whether through successful suicide,
self-harm behaviors, or secondary lifestyle factors such as overeating, drug and
alcohol abuse/dependence, impulsive behavior, risk taking behavior, etc.
Theodore Millon (2004), perhaps the world’s leading expert on personality
disorders, goes farther, offering four subtypes of BPD: discouraged, petulant,
impulsive, and self-destructive. Upon reviewing the criteria, we do not suspect
that most people would want to meet this woman. She sounds like trouble.
Moreover, she sounds dangerous. Her chaotic behavior, effecting emotional
storms, devouring attention, and erratically putting her and others at risk,
reflects something more like a feral creature than a human person. Our philo-
sophical presuppositions about the feral feminine do not arrive in 2013 ex nihilo.
There is a history.
In what follows, we will outline the history of attitudes about the (perceived)
feminine gone awry. We will show that current diagnostic conceptions do not
bespeak a psychiatric disease of chemically imbalanced brain organs, but are
the logical outcome of long-standing attitudes about women through history.
We will not deny that there are patterns of experience typical of emotional
chaos, and we will demonstrate that men too suffer from distress presently
labeled as borderline. In order to stick with the experience itself, contemporary
humanistic and psychodynamic views will be presented as ways of re-visioning
BPD. Following this, clinical material will be presented to reflect lived experi-
ence of working with people struggling with some of the issues outlined. These
clinical narratives are presented also to provide clinicians, both new and experi-
enced, with concrete ways of taking up and relating to the experiences of those
distressed. Finally, it is our hope that someone suffering from intense emotional
states will find, without stigma, his or her experience reflected accurately in these
pages. If what is outlined in these pages seems to resonate with behavior of a
friend or family member, we hope this provides insight, a more open path to
compassion.
2
A Historical Anatomy of a Social
Construction: “Wandering Womb,” Hysteria,
Psychiatric Disease
[B]ecause women are weaker and colder in their nature; and we should look
upon the female state as being as it were a deformity, though one which
occurs in the ordinary course of nature.
—Aristotle (cited in Arthur, 1983)
As the “hysteric” was the prototypical patient of Freud’s era, so is the “border-
line” the problem patient of today. Six to 10 million Americans, roughly the
population of New York City, meet criteria for “borderline personality disorder.”
This is twice that of those labeled with bipolar and schizophrenia combined. Ten
percent of people diagnosed as “borderline” commit suicide. This number is
400 times higher than the general population, and young women with BPD have
a suicide rate of 800 times higher than the general population (Clearview Wom-
en’s Center for Borderline Personality and Emotional Disorders, 2013). And, it is
important to remember that this diagnosis often misses the clinical radar, since
most people with this kind of distress do not seek help and, when someone asks
for services, it is usually either misdiagnosed or simply missed altogether
(Paris, 2005; Phend, 2009; Ruggero, Zimmerman, Chelminski, & Young,
2010). So, stated differently, these are the people we know about. The real num-
ber is higher, perhaps considerably higher. And the story does not begin with
Freud. We have to go back in time, way back in fact, to find the origins of
recorded symptoms that would one day would be called borderline personality
disorder. These symptoms began being documented about 4,000 years ago.
No, this is not a joke, and do not worry; we will not give you a dissertation-like
account of what transpired during that time. We will, however, hit the high-
lights to provide cultural-historical context to the present-day phenomenon.
Either it is the case that the phenomenon today can be adequately understood
via an ongoing cultural-historical narrative about the female psyche; or it is the
case that, somehow, millions upon millions of chemically imbalanced brain
organs (almost exclusively in women) sprang into existence recently. If the
chemically imbalanced brain organs hypothesis is not correct, then where did
such a narrative come from, and why was it brought into being?
www.ebook3000.com
ANTIQUITY: MALADIES OF THE FEMININE AND THE FEMININE

AS MALADY
How far back were such symptoms documented? Surprisingly, the symptoms
that would one day become “borderline personality disorder” first appeared in
medical literature almost 4,000 years ago. An accurate description of hysteria
can be found in the second millennium BC and is the earliest description of what
we now understand as a mental disorder. Dating back to the ancient Egyptians in
1900 BC, the Kahun Gynecological Papyrus is the first to investigate the
cause of disorders in spontaneous uterus movement within the female body.
The Eber Papyrus (1600 BC) is the oldest medical document containing referen-
ces to a depressive syndrome. At this time in history, women’s emotional distress
was described somatically as seizures, with a sense of feeling suffocated and fears
of imminent death. The location of the uterus determined the type of therapeu-
tic intervention, with the goal being to return the uterus to the natural anatomi-
cal location in the body. The techniques used to return the uterus to its natural
location, and thus restore homeostasis to the body, was understood as the
method by which to reduce women’s psychological distress. Procedures that
now seem outrageous, such as placing malodorous and acrid substances near
the woman’s mouth and nostrils or scented ones near her vagina if the uterus
had moved upward, were implemented. When the uterus had lowered, the rec-
ommended treatment was placing the storical Anatomy 13 acrid substances near
her vagina and the scented ones near her mouth and nostrils (Cosmacini, 1997;
Sigerist, 1951).
While texts from Egyptian antiquity represent the first such medical docu-
mentation of feminine maladies, ancient Greece provided sustained thought
and writings on this score. Men were unambiguously the dominant gender
throughout Greek antiquity. Women’s social standing was far below that of
men. Men held political office and participated in the critical functioning of
the city-state or polis. Women were seen as being more susceptible to mood
swings and unpredictable behavior, and thus unable to make logical choices.
The male perspective of the time deduced that the moodiness and concordant
susceptibility to erratic thinking/behavior was due to female reproductive
biology, since it was a clear differentiating line between the genders. The word
hysteria is traced back to roughly 5 BC due, in large part, to a collection of writ-
ings known as the Hippocratic Corpus authored by a variety of anonymous men,
some of which were attributed directly to Hippocrates. Hippocrates is considered
to be the father of modern medicine; he was the first to search for explanations
for physiologic phenomena using empirical knowledge, rather than religion.
He is known for employing natural means to fight disease. The “wandering ute-
rus” became a term that was synonymous with hysteria, which reflected a belief
that movement of the woman’s reproductive organs was the root of her
A Historical Anatomy of a Social Construction 11
emotional and physical ailments. It followed, then, that controlling the uterus
was imperative to the physical and emotional well-being of women.
In the Classical Age, 500–336 BC, while Greek philosophy was in full bloom,
women still had very few autonomous rights and were still under the control of
men. Women were prohibited from holding political office or participating in
the polis; both were prohibited by the Greek philosopher Aristotle, who believed
women’s potential to suffer with hysteria made them unfit to participate in poli-
tics. The concept of a pathological, wandering womb was later viewed as the
source of the term hysteria, which stems from the Greek cognate of uterus,
Úστέρα (hysteria). In ancient Greece, the notion of a wandering uterus
was believed to be the cause for the dreaded female ailment—excessive
emotions or, more accurately, hysteria. Hippocrates—the first to identify this
syndrome—noticed that hysteria was common in women. Hetoo ascertained
the underlying causation was a displaced or wandering uterus. The term hysteria
was used to describe most of the physical and emotional female illnesses. And
because of this correlation, Aristotle did not address women in his philosophy
as he believed they were biologically defective. In his book Nicomachean Ethics,
he describes women to be unfit candidates for political participation because of
their menstruation and the corresponding emotional changes. Using this theory
of hysteria, Aristotle further argued that women should not have the opportunity
for participation or be allowed to partake in politics. These beliefs were not
solely Aristotle’s; they were the common social belief of the times.
Plato was writing at roughly the same time as the authors of the Hippocratic
Corpus, and both asserted, in their own ways, that the uterus was like another
living entity inside the woman’s body. This idea that the womb was an
animate-autonomous entity, “a living thing inside another living thing,” as the
second-century AD medical writer Aretaeus later wrote, was also a commonly
held belief (King, 1993, p. 26). Its best-known expression is perhaps in Aretaeus,
who purports that this autonomous wandering of the womb mostly afflicts youn-
ger women; he believed younger women to have a “somewhat wandering” life,
since their wombs were rhembodes (roving). Older women, in his estimation,
had most stable, situated wombs, hence their more stable comportment and ways
of being. This did represent a slight variation from Hippocratic theories, where
he tended to associate womb displacement with older women, as a result of his
belief that their wombs were lighter. It is at this point that Aretaeus describes
the womb as hokoion ti zoon en zooi, generally translated as “like some animal
inside an animal,” but which could be less emotively rendered “like a living thing
inside another living thing.”
Aretaeus may have based his theories on notions he picked up reading
Timaeus during his education. Some of Plato’s ideas are contended with in the
work of Soranus, who also wrote in the second century AD. Soranus, though, dis-
missed the womb as an internal animal or animal-like entity claim: yet he did
acknowledge that the uterus appeared to be responsive to cooling and loosening

medicine. He reinterpreted the therapeutic successes of therapies involving
enjoyable or awfully scented substances to attract or repel the womb; he believed
these worked as a result of the smell’s ability to produce relaxation or constric-
tion. This stands in contrast to the previous theory that the womb, being like a
wild animal, was attracted to the pleasant scents and took flight from the foul
ones. Galen, writing shortly after Soranus, rejected what he considered Plato’s
theory that the womb was a living creature. After quoting from Timaeus, he
wrote in his On the Affected Parts:
These were Plato’s words. But some added that, when the uterus during its
irregular movement through the body touches the diaphragm, it interferes with
the respiratory. Others deny that the uterus wanders around like an animal.
When it is dried up by the suppression of menstrual flow, it extends quickly to the
viscera, being anxious to attract moisture. But when it makes contact with the
diaphragm during its ascent, it suppresses the respiration of the organism. (King,
1998, p. 223)
At least by the second century AD, medical opinion was evidently split on
whether womb movement meant that the uterus was either a living thing or a
wild animal. The description of the womb in Timaeus should be interpreted in
the context offered by the preceding sections on the human physiology, where
he expresses analogies in which certain parts of the body are compared to semi-
autonomous living organisms. That part of the soul that was consumed with
physical desires was in the body “like a wild creature,” so a disease was purported
to be as being like a zoon (creature), insofar as it had a natural life span. At the
beginning of the second generation, all those who had demonstrated cowardice
or were otherwise unjust became women. It was then that the gods put into all
human beings a zoon, which was driven by desire for sexual union. In men, the
penis had a somewhat noncompliant and determined nature, “like a zoon,” and,
like the wild part of the soul, it also disobeyed logos (reason). The only difference
in the description of the uterus in this context was that it now not put beside the
zoon in a simile. For women it was not simply “like a living thing” as it was with
men, but as “a living thing desiring to bear children.” In both genders, what was
essential was that the organ moved autonomously of the logos, often in an uncon-
trollable or barely controllable fashion.
Aretaeus’s analogy stood out as an artifact being so uncharacteristic of
the medicine of his time. Plato’s medicine did share some similarities with
Hippocratic medicine but also offered many unique individual points. Galen
and Soranus held steadfast to the notion that the womb was not simply like a
creature, but instead was an animal. Soranus apparently thought that treatment
using scents as therapy implied that the womb was an animal. Soranus’s own
elaboration of why scent treatment worked implied that it was possible to

employ the intervention within an entirely dissimilar theoretical context.
Within these ancient manuscripts, there is very little written about women
relative to their male counterparts. It was the men who held political offices
and were broadly considered superior to women. “No Greek State ever enfran-
chised women. In Athens, they could not attend or vote at meetings of the
assembly, sit on juries, or serve as council members, magistrates, or generals”
(Blundell, 1995, p. 128). Often, one will find that women were “viewed as a spe-
cial case, a deviation from the masculine norm. This should serve to forewarn us
that there is an element in the medical treatises which runs counter to the writ-
er’s emphasis on empirically acquired knowledge, and which derives from an
ideological view of the physical nature of women” (Blundell, 1995, p. 98). In
the discussion of gynecology in particular, ideas about women’s physiology
reflected and reinforced ideas about their social and moral personhood.
Aside from gynecological theories of the time, the creation myth of women
was very telling. Pandora was the first woman in creation, according to Greek
mythology. She was formed out of clay by the gods. Women were created as a
permanent blight, an affliction, a punishment to mankind. Prometheus, whose
name means “forethought,” took and killed a sheep. He took all of the best parts
of the meat and wrapped it in the stomach, which was considered the worst
part of the sheep. He then took the bones and placed them in the fat, which is
where the best parts of the meat were supposed to be stored and was what burned
in a sacrifice. Prometheus took both bundles and presented them to Zeus, kind of
the gods and the cosmos, and asked him to pick one. Zeus knew he was being
tricked by Prometheus, who represented mankind. In retaliation, Zeus punished
man by taking away fire. Prometheus stole it back for humanity. Zeus, enraged,
lashed vengefully back at mankind by having a woman created who was given to
human beings. Zeus did not simply give this woman to mankind, but gave them a
kalonkakon (beautiful evil). She was one mankind cannot do without. Women were
beautiful, irresistible; but they made men work, so they were a bad thing. They
posed a threat not only because of men’s need for them, but also their overwhelm-
ing sexuality that could overpower men’s ability to control themselves. The first
woman, Pandora, was given a pithos (storage jar) and told not to open it. She did
anyway, and all of the evils of the world were let loose: pain, suffering, pestilence.
Too late, she closed the jar, leaving only one thing behind, hope. There is a link
from the creation myth of women to ancient Greek understanding of gynecology:
“In ancient Greece, gynecology originated in the myth of the first woman Pandora,
whose beautiful appearance was seen to cover her dangerous insides. Pandora repre-
sented to male humanity as beautiful, marriageable, threatens the work of the
healer because her outside is deceptive, concealing the fact that her body contains
a voracious womb-jar and the mind of a bitch” (King, 1998, p. 40).
Pandora’s dangerous insides are her womb. This can be related to writings
found in the Hippocratic Corpus, where the wandering womb was responsible
for all illnesses. Hysteria was the name given to a number of female illnesses.
“Hysteria has been a label used for potpourri of female ailments and non-
ailments alike since antiquity . . . The Greeks and Romans called almost all
female complaints hysteria, and believed the cause of all these female maladies
to be a wandering uterus . . . In various Hippocratic texts the term hysteria is
applied to a large variety of female complaints” (King, 1998, p. 206).
Aretaeus of Cappadocia, a contemporary of Galen, accepted the basic
Hippocratic doctrines about hysteria. “In the middle of the flanks of women lies
the womb, a female viscous, closely resembling an animal; for it moves itself
hither and thither in the flanks, also upwards in a direct line to below the carti-
lage of the thorax, and also obliquely to the right or to the left, either to the liver
or the spleen; and it likewise is subject to prolapsus downwards, and, in a word, it
is altogether erratic. It delights, also, in fragrant smells, and advances towards
them; and it had an aversion to fetid smells and flees from them; and, on the
whole the womb is like an animal within an animal” (as cited in Thompson,
1998, p. 34). Doctors prescribed a diverse mixture of remedies to entice the ute-
rus back to its proper position. It was common for women to be told to rub honey
on their vagina or chew cloves of garlic as potential solutions. The thought was
that the uterus would be either enticed back by the sweet smell of honey or
repelled by the scent of garlic. When the womb was discovered to have moved
toward the liver, doctors would push it down, tying a bandage below the ribs to
stop it from rising. Other prescribed remedies by Hippocratic authors involved
potions, fumigations, and either hot or cold baths. However, interestingly, sex
and pregnancy were understood to be the ultimate cures. The idea was that when
a woman did not have intercourse, her womb would become dry; and this dryness
was what made the womb vulnerable to displacement.
In Greek mythology it is believed that the birth of psychiatry, as a new
discipline, has its origins in the experience of hysteria. The physician Argonaut
Melampus is considered the originator: he placated the rebellion of Argo’s vir-
gins who refused to honor the phallus and ran to the mountains, as their behav-
ior was being reckoned as madness. Melampus used hellebore to cure these
women; he then encouraged them to unite carnally with young, strong men.
Melampus described the women’s madness as originating from a uterus poisoned
by venomous humors, as a result of a lack of necessary orgasms—“uterine melan-
choly” (Cosmacini, 1997; Sigerist, 1951; Sterpellone, 2002). Here we see the
emergence of the idea of a female syndrome that is related to a lack of a healthy
sexual life: In Timaeus, Plato purports that the uterus is miserable and distressed
when it is not joined with the male; and is equally sad when it does not have the
opportunity to experience new birth. Aristotle and Hippocrates agreed with
Plato on this position (Cosmacini, 1997; Sigerist, 1951; Sterpellone, 2002).
The Greek physician differentiates hysteria, which he clearly distinguishes

from epilepsy. He focuses on the differentiation between the compulsive move-
ments of epilepsy, originating as a disorder of the brain, and the aberrant move-
ments of the uterus that cause hysteria. He then follows the idea of an agitated
and traveling uterus and contends that the cause of the indisposition is due to
an inadequate sexual life. He proposes that a woman’s body is physiologically
cold and wet and susceptible to putrefaction of the humors (as opposed to the
dry and warm male body). Thusly, the uterus is more susceptible to illness, par-
ticulary if it is deprived of sex and procreation, both of which widen a woman’s
canals and stimulate cleansing of the body. As he progresses in his theory, he sug-
gests that a “bad” uterus not only produces toxic fumes, but also roams around
the body, causing a variety of distresses including anxiety, a sense of suffocation,
tremors, and occasionally even convulsions and paralysis. For this reason, he rad-
ically suggests that even widows and unmarried women are wise to be married,
so as to live a reasonably adequate sexual life within the bounds of marriage
(Cosmacini, 1997; Sigerist, 1951; Sterpellone, 2002). If the disease is recognized,
women are to take drastic measures by either consummating sex outside of
marital union or using fragrance fumigation techniques by rubbing scents on
her face and genitals, ultimately to push the uterus back to its natural position
(Cosmacini, 1997; Sigerist, 1951; Sterpellone, 2002).
Hysterical cures were completely transformed by Soranus (a Greek physician
from the first half of the second century AD). He wrote a treatise on women’s
diseases and was considered the founder of scientific gynecology and obstetrics.
He postulated that since women’s disorders originated from the work of procrea-
tion, their recovery was stimulated by sexual abstinence; he further purported
that perpetual virginity was the ideal condition. He found fumigations and com-
pressions ineffective; his treatment for hysteria was hot baths, massages, and
exercise (Cosmacini; 1997, Penso, 2002; Sigerist, 1951).
The term hysteria as originally derived from the Greek language is defined as
uterus or womb. In Greek medical historical writing, hysteria was understood as
an illness whose origin is in violent movements of the womb; therefore, hysteria
was specifically a problem of women. These writers, like those in Hippocratic
Corpus, believed that the womb was not a motionless fixed anatomical object,
but rather an organ that migrated throughout the body; this propensity to wan-
der throughout a women’s body was often to the unfortunate detriment of her
overall health.
The Hippocratics thought that the womb moved upward in the woman’s body
whenever it became hot and dry from overwork, or lack of irrigation from male
seed, searching for cool and moist places in an effort to restore its equilibrium.
As the womb tried to force its way toward the crowded places at the center of a
woman’s trunk, it wreaked havoc with her physical and mental well-being, caus-
ing her to faint or become speechless. Foul odors at the nose and sweet smells at
the vagina were prescribed to lure the uterus back to its seat (Rowlandson, 1998,
p. 340).
Most authors concur that the womb is an organ predisposed to wandering
movement throughout the body; this particular predisposition is experienced
most often in situations of cessation of menses, fatigue, insufficient nourishment,
sexual abstinence, extreme dryness, or weightlessness of the organ itself.
MIDDLE AGES: FROM UTERUS AS ENDOPARASITE TO DEMONIC

POSSESSION
After the fall of the Roman Empire, Greco-Roman medicine had its new hub in
Byzantium. During this time, physicians assimilated Galen’s theories without mak-
ing any significant changes in thought. Sometime prior, Bishop Nestorius had
brought with him awareness of classical science, which participated in the spread
of Greco-Roman medicine in these areas. The political climate of the early Middle
Ages created a rift between Christian Europe, in the hands of just a few scholars,
and the Middle East of the Caliphs, where, due to an atmosphere of tolerance
and cultural melding, the works of Hippocrates and Galen were translated and
commented on in Arabic, leading them both to become well known.
Within this framework, two prodigious scientists continued the legacy of their
work: Avicenna (Jacquart & Micheau, 1990; Vanzan, 2007) and Maimonides
(Iancu & Nicolas, 2009). Because of them, the legacy of Hippocrates and Galen
extended throughout Europe. Avicenna’s Canon of Medicine and Galen’s Corpus
were softened along with the Latin translations attributed to Gerard of Cremona.
Maimonides’s texts were distributed in the Jewish world, with other medical
texts, as a result of translations by the Ibn Tibbon family (thirteenth and
fourteenth centuries). The medical schools of Salerno and Montpellier were
responsible for the propagation of these works (Grmek, 1993). This was
how Hippocratic’s hysteria became well known in late medieval Europe
(Genet, 1999).
At this point, a sort of “talking cure” evolved that was being used alongside
the natural remedies. This “talking cure” was being practiced by Avicenna, and
also by Arnaldus of Villa Nova, who was recognized as medieval Europe’s great-
est physician (Laharie, 1991). There were numerous treatises spreading around
during the time—Constantine the African’s Viaticum and Pantegni, the Canon
of Avicenna, and Arnaldus of Villa Nova’s books—in which women were often
not illustrated as patients to be treated and cured; rather they were being
described as the cause of a particular human disease, an illness defined as amo-
rheroycus or love madness, unfulfilled sexual desire (Vanzan, 2007). A dialogue
of women’s health in the Middle Ages would be deficient without acknowledg-
ing Trotula de Ruggiero. Because she was a woman, she had limited stature and
status, but Trotula was the first female doctor in Christian Europe. Referred to
as Sanatrix Salernitana, Trotula was an expert in women’s diseases and illnesses.

She recognized women as more vulnerable than men, and she explained how
the travails related to women’s diseases were intimate; and because of the deeply
personal nature, women often felt a sense of shame that led them to hide
their discomforts from the doctor. Her best-known contribution, De Passionibus
Mulierum Ante in et Post Partum, gave thoughtful reflection to female problems,
which included hysteria. Although Trotula was faithful to the teachings of
Hippocrates, she did make efforts to break down the prejudices and moralism
of her time. She also offered techniques on how to mollify sexual desire. She
believed abstinence was a cause of illness; she suggested sedative remedies such
as musk oil, mint, and other herbals as treatments (de Ruggiero, 1994).
Hildegard of Bingen, German abbess and mystic, was also a female doctor.
The importance of her work rests on her attempt to reconcile science and faith.
Hildegard recognized Hippocrates’s “humoral theory,” as she attributed the ori-
gins of black bile to the original sin. According to Hildegard, feminine maladies
were defects of the soul, originating from pure evil; she believed that doctors
must accept these illnesses as incurable. She described melancholic men as
unsightly and perverse. Women were described as slim and tiny, unable to fix a
thought and infertile because of fragility of the uterus (Von Bingen, 1997).
In her theories, Adam and Eve shared responsibility with respect to original
sin; and she depicted them both as equal in the eyes of God (Mancini, 1998).
In contrast to Hildegard’s ideas, mainstream perspectives viewed women as
physically and theologically inferior. This notion was rooted in the Aristotelian
concept of male superiority and is reflected in St. Thomas Aquinas’s Summa
Theologica, which cites the Aristotelian belief that “the woman is a failed
man.” The inferiority of women was considered a result of sin, and the solutions
postulated by St. Aquinas’s reflection left no doubt as to what would overturn the
relationship between women and Christianity. The ecclesiastical authorities
tried to force celibacy and chastity in the clergy. St. Thomas’s theological
reflections regarding woman’s inferiority, possibly, laid the framework for the
beginning of a misogynistic movement in the late Middle Ages.
From the thirteenth century onwards, the Church aimed at unifying Europe
under its standards. Many manifestations of mental illness were understood as
obscene bonds between women and the devil. Hysterical women underwent
exorcisms; the cause of their maladies were discovered in a demonic presence.
In early Christianity, exorcism was perhaps undertaken as a cure instead of a
punishment. However, in the late Middle Ages, it was a punishment; and hyste-
ria had become misunderstood as witchcraft (Alexander & Selesnick, 1975).
The first humanist ideas threatened the status quo in Europe, and as a result,
the Church began escalating the regularity and intensity of inquisitions.
The climax was reached in 1484 with the Summis Desiderantes Affectibus—
Pope Innocent VIII’s bull—which established the witch hunt and a
responsibility to “punish, imprison and correct” heretics (Kramer & Sprenger,

1982). The German Dominicans Heinrich “Institor” Kramer and Jacob Sprenger
were attributed with the 1486 publication of the renowned Hammer of Witches,
the Malleus Maleficarum. Although not officially a Church manual, it held an
official tone as a result of the papal bull within the text. Interestingly, the title
itself reflected misogyny, as maleficarum (witches), not maleficorum (wizards).
This exacerbated the conviction of women as the progenitors of evil. Themes
of the devil were widely dispersed throughout the religious literature of the time.
The devil, with the aid of the witches, made men sterile, murder children, cause
famine, and spread pestilence. The compilers of the manual explored the rela-
tionship between witchcraft and human moods. Their incredulous descriptions
rivaled those contained in the best psychopathology guidebooks. The Malleus
Maleficarum sought to confirm the existence of demons and witches. It fore-
warned readers that anyone remaining disbelieving was too a victim of the devil;
and then it went further and described how to find and reprimand witchery. The
inquisitor believed the devil could successfully possess hysterics and, as a result,
found sin in mental illness. It was believed that the devil also deprived women
of confession and forgiveness, consequently leading to the belief in an increased
need to target and ruthlessly interrupt, interrogate, and intervene.
From this line of reason, single and elderly women were among the most com-
monly affected; usually these women were in mourning or victims of brutality.
Witchery became the scapegoat for every misfortune, and contributing factors
were also provided: for Sprenger and Kramer, the Latin word foemina was created
from fe and minus, that is, “who has less faith.” In this text was the most horrific
condemnation of hysteria as well as general disgusting statements about women
to be disclosed throughout the course of Western history. Until the eighteenth
century, thousands of innocent women were put to death as a result of “evi-
dence” or “confessions” that were forced through coercion. By the end of the
Middle Ages, journeys along the coasts of the Mediterranean Sea created
the possibility for rapid diffusion of Greek classics, preserved and dispersed by
the Arabians. The humanistic movement, beginning with Dante, Boccaccio,
and Petrarch, emphasized respect for the writings of antiquity. During these cen-
turies, a new realistic approach to the human being as a person emerged; this
fresh position was in complete opposition to the scholastics and introduced a
unique point of view about nature and man. Italian philosopher Giovanni Pico
della Mirandola advocated the value of free will, emphasizing that man had the
ability to determine his own fate. This humanistic perspective conceived that
only man was capable of recognizing his ideal; and most times this ideal was
acquired through education (Alexander & Selesnick, 1975).
The sixteenth century was an era of significant medical developments,
as shown by the writings of Andreas Vesalius’s 1543 text, De Humani Corporis
Fabrica, and French surgeon Ambroise Paré. These authors’ research became
the foundation of modern medical science. Additionally, the Cartesian philo-

sophical revolution, during which time René Descartes described how the
actions attributed to the soul are actually linked with the organs of the body, cre-
ated an atmosphere for modern science to be born. Physician Thomas Willis’s
timely disclosure of studies on the anatomy of the brain also greatly contributed
to this forward movement. Willis’s introduction of a new etiology of hysteria
explained that the condition was not generally caused by the uterus, but rather
related to the brain. In 1680, another English physician, Thomas Sydenham,
published Epistolary Dissertation on the Hysterical Affections, which used a histori-
cal panorama to support his own beliefs that hysterical symptoms simulated
almost all forms of physiological diseases. Sydenham’s writing did reveal a
back-and-forth thought between somatic and psychological explanations (Wing,
1978). He contended that the uterus was not necessarily the principal root of
diseases, as he compared this to hypochondria. Sydenham’s work challenged
traditional thought, and for this reason it was very revolutionary; however, it
still took many decades for his work to fully infiltrate cultural beliefs and
for the theory of uterine-caused pathology to be critically rejected (Duby &
Perrot, 1991).
The historical records of the time report many outbreaks of hysteria, the most
famous of which occurred in the village of Salem, Massachusetts, in 1692. In one
documented event, a slave, originally from Barbados, spoke about some girls hav-
ing fashioned a circle of initiation. This assembly was purportedly comprised of
teenaged unmarried women. The act of forming a circle of initiation was morally
opinioned to be a public desecration of the precepts of the Puritans. The docu-
mented symptoms afflicting these young women were staring and barred eyes,
wild noises, and sudden movements. The local doctor, William Griggs, unsure
how to treat these woman, referred the problem to the priest. The slave and
two other women were summoned to see the priest, and the former admitted to
practicing witchcraft and making pacts with the devil. As the atmosphere
became more frenzied, the girls started to accuse each other. The unfortunate
result of these events was that 19 women were hanged, believed to be witches;
an additional 100-plus women were kept in detention. It was only when the girls
accused the wife of the colonial governor as being a participant in this circle that
the arrests and trials abated. Marion Starkey, at the end of World War II,
explored the events surrounding the Salem trials and compared them with con-
temporary events. She believed that classical hysteria was an illness that mani-
fested itself in young women who were repressed by Puritanism; the condition
was grossly aggravated by the intervention of Puritan pastors and ultimately led
to dramatic consequences. The incident created a strong argument for hysteria
being seen as a function of social conflicts (Wing, 1978).
Social conflicts were not exclusive to closed societies; they also occurred in
more open and vibrant societies. In 1748, Joseph Raulin published a work in
which he described hysteria as an affection vaporeuse (vaporous condition).

He postulated that it was a disease caused by the filthy air and chaotic social life,
which were characteristic of large cities. Theoretically, he argued, the disorder
could afflict both sexes, but women were more susceptible as a result of their
being lazy and irritable.
In 1775, the physician-philosopher Pierre Roussel published the Systeme Phy-
sique et Moral de la Femme which had been greatly influenced by the thoughts of
Jean-Jacques Rousseau. For both authors, femininity was an essential nature, and
the hysteria could be understood as a nonfulfillment of natural desire. The afflic-
tions, illnesses, and wantonness of women resulted from the breaking away from
the normal natural functions. Following the rationale put forth by ideologies of
natural determinism, doctors’ prescriptions for those afflicted were to confine
women within the borders of a precise role; she was mother and guardian of vir-
tue (Duby & Perrot, 1991). In this context, the woman-witch appeared more and
more as a facade to protect and preserve social order.
MODERNITY: FROM BEDEVILMENT TO BRAIN DISEASE: ORGASM

THERAPY AND THE RISE OF THE RESPECTED PHYSICIAN
During the era of Enlightenment, an increasing rebellion against misogyny
and sorcery was evolving; this became a problem for psychiatrists. The Encyclopé-
die said that sorcery was preposterous—ignorantly credited to the incantation of
demons. Mental illness began to be understood within the “scientific view.” Hys-
teria was described in the Encyclopédie as one of the most complicated diseases.
The last “witch” was put to death in Switzerland in 1782, a decade after the pub-
lication of the latest editions of the Encyclopédie. This woman’s name was Anna
Göldi, and her memory was revived in 2008 (Hauser, 2007). In the eighteenth
century, hysteria started (again) to become slowly associated with the brain
instead of the uterus; this trend in thought opened the door for the emergence
of ideas surrounding neurological etiologies.
The German physician Franz Anton Mesmer in studying the body, identified
a fluid called “animal magnetism.” He thought that the mesmeric action of the
hands on diseased parts of the body could help ailing patients by having the
hands interact with the fluid within the body; his method, which he established
in both group and individual modalities, was popularly called “mesmerism.” It
was only later that it was discovered that the success of his treatments was more
likely due to the power of the suggestion itself. Mesmerism had succeeding devel-
opments in the study of hypnosis (Zanobio & Armocida, 1997). The French
physician Philippe Pinel, believing that kindness and sensitivity toward patients
was vital for good care, freed the patients held in Paris’s Salpêtrière sanatorium
from their chains. Extrapolating from ideas linked to the French Revolution,
Pinel’s theory declared specifically that “mad” was not substantially different
from “healthy.” However, Pinel did consider hysteria a purely female disorder
(Pessotti, 1996).
Jean Martin Charcot, the French founder of neurology, committed himself to
a systematic study of mental illnesses. In particular, he explored the effectiveness
of hypnosis on hysteria; from 1870 onward, hysteria was distinguished from other
illnesses of the spirit. Charcot strongly contended that hysteria originated from a
hereditary degeneration of the nervous system, and he also considered it a
neurological disorder (Bannour, 1992; Haule, 1986; Leff, 1981; Mitchell, 2004;
Pérez-Rincón, 2011). During the Victorian Age (1837–1901), women tended
to carry a bottle of smelling salts with them. This trend was popular at the time
because women were inclined to faint when stimulated emotionally; it was
common belief that, as Hippocrates had suggested, that the wandering womb dis-
liked the strong odor and would return to its place, thus affording women re-
cover. Despite new ideas and trends regarding medicine and the body,
Hippocrates’s theories remained a point of reference for centuries.
French neuropsychiatrist Pierre Janet, with Charcot as his sponsor and sup-
porter, opened a laboratory in Paris’s Salpêtrière. He convinced doctors that
hypnosis was a very successful method for investigation and therapy. He recog-
nized that the patient’s own thoughts about pathology was translated somati-
cally, becoming a physical disability. Janet studied the hysterical symptoms of
anaesthesia, amnesia, motor control diseases, and disorders of character. For
him, the etiology of hysteria was in the idée fixe (fixed idea), that was to be found
in the subconscient (subconscious). Janet’s ideas clearly lay the foundation for the
early theories of Freud, Breuer, and Carl Jung and therefore are paramount to the
foundation of the field of modern psychiatry (Pérez-Rincón, 2011).
Here we arrive at a critical point in the “evolution” of what was to become
borderline personality disorder. Notice that here, in the early nineteenth cen-
tury, hysteria became a point of convergence and synthesis of the theories and
practices of hypnosis and formal psychiatry. For roughly 25 centuries, hysteria
had been understood as a conglomeration of confused and confusing symptoms
ascribed to the afflictions of (from the male perspective) an incomprehensible
gender. Around the sixteenth century, there were attempts at sustained, objec-
tive, and systematic studies of this mysterious feminine ailment. For example,
there was the Traite de l’Hysterie published in 1859 by the French physician Paul
Briquet, head of the ward of hysterical patients in the Hopital de la Charite in
Paris. His observations led him to believe that the phenomenon of hysteria had
not been properly taken up at all. Over the course of a decade, he studied 430
hysterical patients and came to classify hysteria as a brain disease, “a neurosis
of the brain, the manifestations of it consisting chiefly in a perturbation of those
vital acts which are concerned with the expression of emotions and passions”
(as cited in Ellenberger, 1970, p. 142). Of the 430 cases observed, Briquet noted
only 20 male hysterics, which he attributed to a basic emotional vulnerability
and gullibility inherent in women. Significantly, he broke with traditional

notions of hysteria being founded in sexual cravings and inhibitions; rather,
he situated the roots of the disease in heredity. Moreover, he found hysterical
disease to be prominent among the poor and rurally situated people. Along with
heredity, he found the disease to be exacerbated by traumatic emotions,
sustained grief, family struggles, and strained relationships.
While Briquet was attempting a rigorous empirical study of hysteria, hypno-
tists were synthesizing the various magnetic diseases under the name “hysteria.”
The massive synthesis of the various diseases under the phenomenon of hysteria
was done for three reasons. First, magnetists and hypnotists observed a number of
similar features underlying both hysterical and nonhysterical persons. In 1787,
for example, Petetin asserted that catalepsy, considered a medical condition
characterized by trance or seizure states and concordant loss of consciousness/
sensation and bodily rigidness, was simply a subset of hysteria. During fits of cata-
lepsy, people demonstrated states of ecstasy, lethargy, hallucinations, sleepwalk-
ing (somnambulism) and a host of other symptoms. More dramatically, multiple
personalities became associated with hysteria and were considered the result of a
fit of lethargy or other ailment of magnetic source. Second, hypnotists felt com-
pelled to include various disturbances of mind and body to hysteria because
hypnosis itself could evoke such states. At this time, hypnotists convincingly
demonstrated that they could produce states of sleepwalking, ecstasy, lethargy,
the aforementioned aspects of catalepsy, hallucinations, and even shifts in per-
sonality. Third, hypnotists could show some measure of progress or even cure of
hysterics utilizing their techniques. Magnetizers too had obtained seemingly
miraculous cures of hysterical paralysis through hypnotic induction and sugges-
tion. As a matter of fact, it was this sort of demonstration that gave Charcot
his juggernaut medical reputation.
While Briquet was striving to move toward a more empirical scientific view of
hysteria, notions of it as the result of thwarted erotic desires and passions
continued unabated in popular culture, the fields of gynecology and neurology.
Charcot, who was greatly influenced by Briquet, took to heart the notion that
hysteria may not be solely sexual in origin, though he also did not dismiss it.
According to Charcot, while eroticism may not be the origin of hysteria, it did
assume a central role in the lives of hysterical women. This is outlined in some
detail in the study of grande hysterie taken up by Charcot’s eminent student, Paul
Richer. Richer noted that hysterical episodes were reenactments of past trau-
matic events. While some hysterical attacks reflected themes, for example, of
running from a dangerous animal, more often than not the themes of the epi-
sodes were sexual in nature (e.g., attempted rape, scenes of overtly sexual activ-
ity, etc.). Richer noted too that such themes tended to emerge during hypnosis
that were denied during waking consciousness. For example, one of his patients
expressed sexual desire for a man whom she had only seen a single time during
hysterical delirium of which she denied to herself in waking consciousness

(Ellenberger, 1970).
This trajectory of hypnotists consolidating numerous symptoms under “hyste-
ria” and the overall shift to understanding hysteria as a brain disease continued.
By the end of the nineteenth century, attempts were being made to combine the
sexual theory of hysteria with emerging notions of dualities in the psyche.
In 1887, Binet announced, “I believe it satisfactorily established . . . that the
two states of consciousness, not known to each other, can co-exist in the mind
of an hysterical patient.” Later, in 1889, he continued, “The problem that I seek
to solve is, to understand how and why, in hysterical patients, a division of con-
sciousness takes place” (as cited in Ellenberger, 1970, p. 144). Many profes-
sionals sought to explain the link between the sexual theory of hysteria and the
increasing observations of bifurcations in the mind. One gynecologist of the
time, A. F. A. King, asserted that the human psyche organically rested upon
two physiological areas of organization and action that he dubbed “the depart-
ment of self-preservation” and “the department of reproduction.” Civilization,
he postulated, deprived women of gratification in the department of reproduc-
tion, thus setting into motion a process of repetitive hysterical symptoms. Stated
differently, since women could not enact and satisfy their primal sexual urges,
the failure to achieve this binds them to a state of hysterical repetitive crises.
It is this sort of thinking that led to the “treatment” of inducing, often forcibly,
orgasms in hysterical women who were hospital inpatients and outpatients. It is
noteworthy here, among other things, to notice that the husbands and lovers of
the women escaped unscathed from criticism of not satisfying their partners.
If it is the case that hysteria was essentially a function of being sexually deprived,
then it would stand to reason that if hysterical women had satisfying partners,
the matter would not emerge at all.
During the nineteenth century, physician-assisted paroxysm (orgasm) was the
standard normal treatment modality for hysteria. Relative to the usual modalities
employed by doctors (e.g., bleeding patients), genital massage did seem to alleviate
some hysterical symptoms or, at least, women seemed to feel better following a
treatment. Physicians, generally not respected until this time, finally gained atten-
tion, credibility, and trust. Women, in large numbers, returned regularly to their
doctors for the procedure. Unfortunately, physicians treating hysteria found them-
selves with sore, cramped hands and complained bitterly, even in medical journals,
about how physically taxing such procedures were. Hand fatigue often interfered
with the doctor’s ability to maintain the treatment long enough to produce, repeat-
edly, the therapeutic effect. Less successful procedures meant less money, too. Achy
hands and less revenue was unacceptable, and so doctors began seeking mechanical
means to offset the manual labor. Necessity drove technology and “physician-
assisted paroxysm” paraphernalia emerged: water-propelled contraptions (the fore-
runners of showerheads/water massage devices), steam-driven dildos, and every
variety of pumping massage devices. Most of these devices were unwieldy, messy,
unreliable, and occasionally dangerous. Toward the end of the nineteenth century,
electricity began flowing into homes. More than a decade before the appearance of
electric fans, toasters, hot water kettles, sewing machines, irons, and vacuum clean-
ers, the English doctor Josephe Mortimer Granville patented the electromechanical
vibrator. It was a hit. Physicians, previously afflicted with chronic hand fatigue,
now applauded the arrival of the device that reliably and more quickly produced
satisfactory paroxysm events (Maines, 1999).
If it seems that notions of hysteria seem humorous, bizarre, or tragic, it is at least
in part due to the strenuous efforts to which the dominant male psyche of the times
went to biologize, scientize, and pathologize something that was clearly a social
construction moving through cultural-historical indexes. But equally clear were
the telling signs and symptoms of the mind attempting to give form to the personi-
fied notion dubbed hysteria. “Other” to the male psyche was the feminine. Femi-
nine ways of knowing and being with the masculine that were experienced as
unpredictable, overly emotional, erratic, or strange were interpreted as forms of
sickness. Stated differently, if they did not bump up against, as it were, the mascu-
line mind in a way that was deemed distasteful, they would not be meaningful at
all. If these ways of knowing and being were experienced by the masculine mind
of the times as pleasant, they would likely be praised and encouraged. But this com-
plex synthesis of interweaving, moving, and shifting signs and symptoms was
broadly construed as an affliction. All theories, from wandering womb through
brain disease, situate hysteria in the woman’s body. It was fundamentally, neces-
sarily, physiologically rooted in her body. Moreover, what is really telling is how
the masculine mind sought to content with this malady: control at all costs. Hyste-
ria was inescapable, somehow programmed, wired into the woman’s very physio-
logical and genetic constitution. Of course, the same sustained vigorous effort was
never applied to the male psyche whatsoever. Hysteria as a constitutional, deter-
ministic, feminine affliction was taken as a given. Such concepts set the foundation
not only of what would become known as “borderline personality disorder,” but of
what would become the field of psychiatry. Ideas pertaining to this social construc-
tion were the primary backdrop for formulations of Janet, Breuer, Freud, and Jung.
The hysteric and the scientist-physician mutually forming, informing, in each
other’s psyche the mirror image of itself. Up until now, though, the masculine
analytic lens was never turned back upon himself. Along came Sigmund Freud.
DELITERALIZING THE FEMININE: DYNAMIC, DEVELOPMENTAL,

AND SOCIAL CONTEXTUALISMS
Freud took issue with the practices of hysterical paroxysm and, more impor-
tantly, with notions that hysteria was biological in nature. From Charcot, Freud
adopted the notion of a trigger or provoking event that provoked hysterical fits.
He added, though, that such provoking agents (triggers) were themselves symp-
tomatic, pointing to something deeper. Triggers were not found in heredity,
but in experiences in infancy and childhood. Hence, from Freud’s perspective,
hysteria was not fundamentally linked with feminine physiology, somatic, or
genetic predetermination. As a matter of fact, the feminine was not a necessary
condition at all. Men were susceptible to hysteria, too. Hysteria, then, was a form
of distress bespeaking disturbed or disrupted experiences in parental upbringing,
education, and social interactions as a child, with adults and other children.
Thus Freud dismissed hysteria as a brain disease and situated it in social context.
For the first time, the lens, so to speak, was turned back upon itself. Not only
did Freud take up “male hysteria,” but he wrote in 1897: “After a period of good
humor, I now have a crisis of unhappiness. The chief patient I am worried about
today is myself. My little hysteria, which was much enhanced by work, took a
step forward” (as cited in Tasca, Rapetti, Carta, & Fadda, 2012). In 1889, Freud,
with Joseph Breuer, published his Studies on Hysteria. Although the influence of
childhood sexual fantasies and the influence of the unconscious mind had not
yet been formulated, they were already implicit in his writing of this text. Freud
would later develop the concept of his (now) famous Oedipus complex, which
emerged through his study of male hysteria. These original studies focused exclu-
sively on female hysteria. Male hysteria and the arising Oedipal issues developed
after this treatise. We see here a very critical point historically: until Freud, it
was purported that hysteria was the result of the lack of conception and mother-
hood. Freud reversed the standard: hysteria was a disorder caused by deficient
libidinal evolution and the failure of conception was not the cause of the disease,
but contrarily, the result of it. This implies that a hysterical person was unable to
maintain a mature relationship.
Furthermore, Freud also identified the psychic process of “secondary gain.”
The hysterical symptoms emerged as a result of frustrations in the fulfillment of
the sexual drive—because of reminiscence of the Oedipal conflict. The symptom
thus is a “primary benefit,” insofar as it allows the discharge of the urge—the
libidinal energy connected with sexual desire. Secondary gain—as Freud termed
it—is the side (implicit) advantage of providing the patient the opportunity to
manipulate the environment and other people to serve his or her needs. Essen-
tially, this accounts for the implicit notion that the woman had no substantial
power, and the best she could do was manage her environment by trying to use
others in subtle ways to achieve hidden objectives (Loughran, 2008).
Freud was faced, though, with an interesting question. If most neuroses were
the result of early (imagined or real) sexual cause, then how can they be differen-
tiated? Here, Freud seems to fall back upon the biases of earlier thinkers.
He asserts that if the early erotic encounter is experienced as pleasurable and
with some sense of active presence, then it is “masculine.” The cognitive and
behavioral patterns will manifest in an obsessional neurosis. In contrast, if it is
experienced with a sense of passivity or disgust, then the mind will become
wrought with hysteria. It was reasoned by Freud that the passive internalization
of early sexual fantasy or events was “feminine,” since women were passive in
sexual acts. It is important to note that, for Freud, feminine passivity (and its
hysterical manifestations) and masculine active presence (and its obsessional
manifestations) were states of mind independent of physical gender. Clearly,
Freud made strides in moving away from a predominantly female definition of
hysteria and situated it in psychology and society. However, as we also see, it still
retained some of the misogynist elements of those coming before him. To be fair,
though, much of psychoanalysis saw hysterical phenomena in terms of dynamics
of the psyche rather than in gender, whether physical or psychological in nature.
Dynamic movement of the mind implies the movement and relationships
between at least two aspects of the mind. Moreover, the question of how such
aspects relate in the mind as well as how they manifest in relationships became
a topic of much interest. Thus, the interest in psychic borders invariably
emerged.
Freud (1964) introduced the topographical model of the psyche:
In thinking of this division of the personality into an ego, a super-ego and an id,
you will not, of course, have pictured sharp frontiers like the artificial ones drawn
in political geography. We cannot do justice to the characteristics of the mind by
linear outlines like those in drawing or in primitive painting, but rather by areas
of color melting into one another as they are presented by modern artists. After
making the separation we must allow what we have separated to merge together
once more. You must not judge too harshly a first attempt at giving a pictorial rep-
resentation of something so intangible as psychical processes. It is highly probable
that the development of these divisions is subject to great variations in different
individuals; it is possible that in the course of actual functioning they may change
and go through a temporary phase of involution. (p. 79)
Freud introduced the notions of id (libidinal energy), ego (the sense of “I” one
has) and the superego (the moral agent). They were considered as basic struc-
tures of the mind for men and women alike. Freud and early clinicians noticed
many common ways in which the ego organizes experience, dubbed “defenses.”
Two common defenses noted were splitting and repression. Throughout the
course of one’s life, clinicians noticed, one engages in behavior unbecoming to
oneself. There are also stressful, anxiety-provoking, or even traumatic events
that occur to one. In a variety of different ways, people sought to ignore,
suppress, or repress such things. This became problematic as one sought to essen-
tially seek to deceive themselves, often in a variety of ways, to split off the unsa-
vory aspects and to highlight the pleasurable ones. The problem arose as the
severity of such action created a split in the personality. Depending upon the
severity of the attempts to shove down such material, one typically would
develop neurotic or psychotic symptoms. This was called the return of the
repressed. Repressed material could not be ignored forever, since it was the truth,
and often returned with a strong emotional charge. Split-off aspects of emotional
life, memories, and past events tended to return, accompanied by feelings of
threat or signal anxiety. Psychoanalysts after Freud developed the idea, writing
of fear of “annihilation” (Klein, 1946), “nameless dread” (Bion, 1970), “disinte-
gration” or “agony” (Winnicott, 1958) or, interestingly, “blankness” (Green,
1969). It was within this context of finding, defining, and delimiting boundaries
and borders within the mind that the term “borderline” sprang.
The psychoanalysts Adolf Stern (1938) and, a little later, Knight (1953) first
introduced the term “borderline” into the body of literature to describe the ten-
dency of some patients to regress into “borderline schizophrenic” states. In its
practical use, though, it was used to describe a broad range of symptoms of emo-
tional instability, transient psychotic episodes, self-hatred, etc. found mostly in
women. Otto Kernberg (1967) gave sustained attention to “borderline personal-
ity organization,” noting it as a broad, general phenomenon defined by the primi-
tive defenses of splitting, projective identification, identity confusion/diffusion,
and sketchy reality testing. Many of the early formulations of borderline
personality pathology continue to this day, such as the notion of their “stable
instability” (Schmideberg, 1959), frantic need to affix themselves to others
as transitional objects (Modell, 1963), distorted sense of self and others,
dependence upon splitting, and intense fear of abandonment.
CONTEXTUALISM ABANDONED AND BPD’s FORMAL ENTRY

INTO THE PSYCHIATRIC “BIBLE”
Through the 1960s, psychoanalysis was becoming increasingly seen as passé,
being replaced by biological psychiatry and psychopharmacology. Being consid-
ered more “modern” and “scientific,” these approaches held the promises of more
efficient and less costly interventions. Where psychoanalysis often required a lot
of work, lengthy treatment, and substantial sums of money, medical psychiatry
and psychopharmaceuticals promised a brief consultation and quick chemical
relief. With the decline of psychoanalysis, so too went with it the social contex-
tualization and dynamic understandings of emotional distress. Now, with
psychopharmacology assuming hegemony, a concerted effort was applied to ren-
der an empirical understanding of an already established disorder. Roy Grinker
and his colleagues published The Borderline Syndrome (1968), establishing it as
a fixture in empirical psychiatry and a legitimate object of scientific inquiry.
Other seminal writings followed (e.g., Gunderson & Singer, 1975) and in
1980, it was formally entered in the so-called “Bible of Psychiatry,” the Diagnostic
and Statistical Manual of Mental Disorders (3rd ed.; DSM-III). The establishment
and rise of biological psychiatry brought with it many of the biological literalisms
and assumptions of more than a century earlier, sans psychodynamic and social
contextualization. In a formulation that Briquet and his colleagues would have
applauded, Robert Spitzer, chairman of the DSM-III task force, presented a
multiaxial diagnostic, empirically sound work of classifying mental disorders
firmly rooted in the tradition of psychobiology. Spitzer asserted that “mental dis-
orders are a subset of medical disorders” (as cited in Mayes & Horwitz, 2005).
The taxonomy supposed that each constellation of symptoms in a category
reflected underlying, likely neurological, pathology. The DSM-III was heralded
in the United States and abroad as a revolutionary advancement in psychiatry.
This was quite an edition for BPD to make its formal diagnostic appearance.
Borderline personality disorder is mentioned on the first page of the section of
the DSM-III dedicated to personality disorders, which were classified (and still
are) as an Axis II disorder. The section starts by defining personality disorders
as personality traits that “are inflexible and maladaptive and cause either signifi-
cant impairment in social or occupational functioning or subjective distress” and
“are typical of the individual’s long-term functioning and are not limited to
discrete episodes of illness” (American Psychiatric Association, 1980, p. 305).
The next portion of the text directs the reader to the section “Disorders Usually
First Evidence in Infancy, Childhood, or Adolescence” and provides a brief list.
To the left of “Borderline Personality Disorder” is the corresponding pediatric
psychiatric diagnosis, “Identity Disorder.” So, BPD, which can only be diagnosed
at and beyond the age of 18, has a corresponding diagnostic category in disorders
first evidenced in infancy, childhood, or adolescence—identity disorder.
Identity disorder was defined on page 65 as code 313.82 in the classification
system. This mental illness that is, as already mentioned, first evidenced in
infancy, childhood, or adolescence, is described as a “subjective distress regard-
ing inability to reconcile aspects of the self into a relatively coherent and accept-
able sense of self . . . including long-term goals, career choice, friendship
patterns, sexual orientation and behavior, religious identification, moral values,
and group loyalties.” By their own criteria, this infant, child, or adolescent may
experience conflict regarding career choice as expressed by an “inability to
decide on a career or as an inability to pursue an apparently chosen field.”
Distress regarding friendships may be manifested as an “inability to decide the
kinds of people with whom to be friendly and the degree of intimacy to have.”
In regard to values and loyalties, the infant, child, or adolescent may experience
“concerns over religious identification, patterns of sexual behavior, and moral
issues.” Briefly stated, “the disturbance is epitomized by the individual’s asking
the question ‘Who am I?’ ” At least one or more of these symptoms must last
for at least three months and impair social/occupational functioning. If the indi-
vidual was age 18 years or older, the diagnosis of BPD may then be merited
(American Psychiatric Association, 1980, pp. 65–66).
This diagnosis was not only clinically unhelpful and irrelevant due to its
global descriptions of most adolescents alive, but was self-evidently ridiculous.
The supposed standing of this particular tome as being the pinnacle of empirical
taxonomy only makes it stand out all the more. It was as if the task force was not
even trying on this one. Sure enough, this diagnosis was quietly deleted in the
following editions (DSM-IV and DSM-IV-TR) and replaced with the light,
hardly present, “identity problem” of the same code, 313.82. In the next, most
recent edition (DSM-5), the barely present “identity problem” is absent. Why
was this diagnosis in the DSM at all, and why was it specifically linked to BDP?
Since the diagnosis itself was abjectly meaningless, it can only be assumed that
it was meant to be structurally in place to bespeak and accent the potentially
lifelong nature of this mental illness. Identity disorder and the lightweight iden-
tity problem apparently served as a kind of pediatric placeholder in the diagnos-
tic lexicon for BPD, which could only be diagnosed at age 18 or older. The other
thing that can be gleaned from these (non-) diagnoses is that, like BPD, they
serve as a vague conglomeration of loosely knit signs and symptoms clinically
present in some ways, but elusive in others.
Borderline personality disorder (code 301.83) appeared on page 321 of the
DSM-III. Bracketing the contributions of psychoanalysis, which had now been
stripped, it is interesting to note the DSM-III characterization of BPD in light
of the history of hysteria provided up to this point. (As an interesting side note,
the famed psychiatrist and psychoanalyst of the 1960s and 1970s, R. D. Laing,
noted similarities between the DSM-III and the Malleus Maleficarum.) The essen-
tial feature highlighted was instability in many dimensions of living, including
interpersonal behavior, mood, and image. “No single feature is invariably
present. Interpersonal relations are intense and unstable, with marked shifts of
attitude over time.” Behavior in the person afflicted with BPD was “impulsive
and unpredictable” with mood as “often unstable, with marked shifts from a nor-
mal mood to a dysphoric mood or with inappropriate, intense anger or lack of
control of anger.” With this condition, one’s “identity disturbance may be man-
ifested by uncertainty about several issue relating to identity, such as self-image,
gender identity, or long-term goals or values. There may be problems tolerating
being alone, and chronic feelings of emptiness or boredom” (American Psychiatric
Association, 1980, p. 321).
People suffering from BPD frequently have features of other personality disor-
ders: schizotypical, histrionic, narcissistic, and antisocial. These people often vacil-
late between dependency and assertiveness, they are generally pessimistic, and,
during periods of exceptional stress, transient psychotic episodes may be present.
The criteria are clear that the “disorder is more commonly diagnosed in women”
and its prevalence deemed “common” (p. 322). No significant changes were made
to the fundamental criteria through later editions (DSM-IV and DSM-IV-TR) up
to the present edition (DSM-5). It should be noted, though, that in the current edi-
tion, the DSM-5, substantial charges were made structurally. All mental disorders,
including personality disorders, are enumerated in Section II of the manual. More-
over, the DSM-5 lists alternative criteria, based upon trait research, in Section III.
Substantially, though, there is no change in the tenets that BPD represents chronic,
unremitting psychiatric illness predominantly found in women and characterized
by irrational fear of abandonment, emotional instability, chaotic interpersonal rela-
tionships, a tenuous grip upon reality, an unstable sense of self, and a host of con-
current features (anxiety, depression, bi-polar affective disorder, narcissistic,
histrionic, antisocial, etc.).
It is not surprising that there have been little or no substantial changes in
BPD conceptualization and formulation between the various versions of the
DSM because there have been no considerable departures in hysteria for the past
roughly 4,000 years. Given, today it is not considered a disease of the womb; but,
in a very similar way to more than a century ago, it is considered a disease of
likely neurological origin afflicting women. In some ways, the introduction of
BPD into the DSM only solidified its place in the parlance of clinical psychopa-
thology and lent it further credence as a psychiatric disease meriting scientific
investigation.
3
The “Borderline” as a Human Person:
Contemporary Perspectives
When a man finds that it is his destiny to suffer . . . his unique opportunity
lies in the way he bears his burden.
—Viktor Frankl (1959, p. 86)
Looking back over the historical context of the “borderline,” we find an interest-
ing moment with Freud. He contextualized and deliteralized the phenomenon,
framing it in the context of early formative relationships and emphasizing the
dynamic, fluid nature of the psyche. However, as we noted, he too fell into the
hegemony of thought present in his own social-historical context. Moreover,
criticisms of him upon the grounds of being, at times, misogynistic, moralistic,
scientistic, and literalistic are merited. Despite his own conscious and uncon-
scious errors, he returned a humanistic sensibility to the “hysteric” of his times.
Sadly, tragically even, his contributions were largely covered over biological psy-
chiatry, which became dominant. To add to the confusion, there were literalisms
in the translation and interpretations by some of his followers. Noted child psy-
chologist and expert on psychoanalysis Bruno Bettelheim (1983) noted some of
these literalisms and misinterpretations, stating bluntly, “The English transla-
tions of Freud’s writing are seriously defective in important respects and have
led to erroneous conclusions, not only about Freud the man but also about
psychoanalysis” (p. vii). Of these, Bettelheim point out that Freud utilized the
word seele, which translates from the German as soul; not psychic apparatus, as is
so often translated into English. Clearly, there is a universe of difference in the
meaning and context afforded between the two.
Freud, despite some flaws, did represent a vital break from the long-standing
views of feminine psychopathology. These findings, implicitly and explicitly,
have found new expressions in contemporary psychology. Such things may have
been foreshadowed by Freud, but they may also be due, in part, to the fact that
scientistic, mechanistic views of the human person as diagnosis and diseased
brain organ simply have not worked. Running in tandem with biological psy-
chiatry is its partner, psychopharmacological remedy. Both have been brought
under considerable criticism due to their mutually reflective, highly lucrative
financial partnership and failures of diagnostic credibility/validity as well as the
safety/efficacy of medication interventions. The summary blow dealt to these

conjoined industries has sparked interest in what does work with understandings
of how to take up distressed states of mind. And, as we stated earlier, in contex-
tualizing so-called “borderline personality disorder,” we are not denying that pat-
ternings of negativistic, attention-seeking, emotional chaos, manipulation,
black-and-white thinking, suicidality, self-destructive behavior, ongoing pat-
terns of living in and promoting crisis, etc., exist as typical ways of contending
with distress. They do exist; yet they are not almost exclusively found in women,
they are not the manifestations of a maneuvering uterus or diseased brain organ,
and they cannot be neatly boxed into a diagnostic label—nor is a human person
reducible to this or any other psychiatric label. The “borderline” has a name, a
unique character and calling, and a cultural-historical context, as all of us do.
All elements of so-called “borderline personality disorder” are signs and symp-
toms, not the phenomenon itself.
“BORDERLINE” IS TO PSYCHIATRY AS PSYCHIATRY IS TO MEDICINE

As we are contextualizing “BPD” here, so too have others contextualized
psychiatry. There is a growing body of literature dedicated to this topic. Perhaps
the most sustained and exhaustive accounts of psychiatry from its beginning to
the present are provided by Robert Whitaker (2002, 2010). Without diving into
an exhaustive history, it is interesting to note the criticisms being leveled at the
most recent DSM, the DSM-5. In 2011, the British Psychological Society (BPS)
documented their serious concerns over the (then) upcoming DSM-5. In the
United States, the Society for Humanistic Psychology (Division 32) of the
American Psychological Association decided to formulate an open letter to
the DSM-5 Task Force outlining its own grave concerns. The letter concludes
in agreement with the BPS:
• “. . .clients and the general public are negatively affected by the continued and con-
tinuous medicalization of their natural and normal responses to their experiences;
responses which undoubtedly have distressing consequences which demand helping
responses, but which do not reflect illnesses so much as normal individual
variation.”
• “The putative diagnoses presented in DSM-V are clearly based largely on social
norms, with ‘symptoms’ that all rely on subjective judgments, with little confirma-
tory physical ‘signs’ or evidence of biological causation. The criteria are not
value-free, but rather reflect current normative social expectations.”
• “. . . [taxonomic] systems such as this are based on identifying problems as located
within individuals. This misses the relational context of problems and the undeni-
able social causation of many such problems.”
• There is a need for “a revision of the way mental distress is thought about, starting
with recognition of the overwhelming evidence that it is on a spectrum with
The “Borderline” as a Human Person: Contemporary Perspectives 33
‘normal’ experience” and the fact that strongly evidenced causal factors include
“psychosocial factors such as poverty, unemployment and trauma.”
• An ideal empirical system for classification would not be based on past theory
but rather would “begin from the bottom up—starting with specific experiences,
problems or ‘symptoms’ or ‘complaints.’ ” (as cited in Division 32 Open Letter
Committee, 2011)
The letter criticizes the DSM on the grounds of being scientistic, moralistic,
literalistic, pathologizing, medicalizing, stigmatizing, and stripping distressing
psychological states of their context and meaning. Essentially, the letter
protests the process of applying dubious psychiatric disease labels instead of the
application of science and contextual understanding.
In light of the growing empirical evidence that neurobiology does not fully account
for the emergence of mental distress, as well as new longitudinal studies revealing
long-term hazards of standard neurobiological (psychotropic) treatment, we believe
that these changes pose substantial risks to patients/clients, practitioners, and the
mental health professions in general. (ibid.)
The letter bravely calls for ousting the DSM altogether and “to explore the
possibility of developing an alternative approach to the conceptualization of
emotional distress” (ibid.).
The president of the division at the time, David Elkins (2012), reflects:
“On Oct. 22, 2011, the open letter was quietly posted at a petition website with-
out publicity or fanfare, inviting professionals to read the letter and, if they
agreed with it, to sign the petition. The results were unexpected and overwhelm-
ing.” Prior to the posting, the open letter received two endorsements from the
Society for Community Research and Action: Division of Community Psychology
(Division 27) and Group Psychology and Group Psychotherapy (Division 49).
Within days of the post, the open letter received more than 1,500 signatures
from mental health professionals along with numerous mental health organiza-
tions. Allen Frances, MD, chair of the previous DSM Task Force (DSM-IV)
joined the effort. News of the letter cascaded into more than 100 media outlets
around the world including USA Today, ABC News, the New York Times, the
Washington Post, the San Francisco Chronicle, Fox News, the Chicago Tribune,
the Huffington Post, the Wall Street Journal, Nature, Scientific American, and
Psychology Today. At the time of this writing, the open letter had 15,218 signatures
from individual mental health professionals; 50 mental health organizations,
including the numerous divisions of the American Counseling Association; the
British Psychological Society (50,000 members); and 15 divisions (including all
clinically oriented segments) of the American Psychological Association. So not
only is BPD controversial within DSM categories, but psychiatry and its so-called
“psychiatric bible,” the DSM, is controversial in the medical community.
CONTEXTS OF AGONY
We have gone through the social-historical narrative of “BPD” as a social
construction, showing some of the things that it is and is not. While it is not a
psychiatric disease, we do not deny that it is one kind of emotional distress.
There are, in fact, people (men and women alike) whose distress manifests in
attempts to avoid real or perceived abandonment, who report challenges main-
taining interpersonal relationships (including alternating between hating and
idealizing), who exhibit childlike ways of organizing experience (tantruming,
pouting) and/or a transient sense of self. This tenuous sense of self can include
one being immersed in fantasy where perceived deficits, lacks, and limitations
of oneself is “filled in” by imagined events, accomplishments, etc. There is, in
varying degrees, a disparity between what the individual experiences as “real”
and what others report as being “real.” The tenuous sense of self may also mani-
fest as a heightened fear of others, situations, things, or places. This tenuous
sense of self leaves some feeling “depersonalized”—that is, one is not entirely a
part of what he or she is experiencing. The experience of time tends to be a
heightened awareness and thinking about the past, feeling bored or understimu-
lated in the present with either worries or grand fantasies about the future. Peo-
ple with this kind of distress often feel compelled to engage in dangerous
tension-relieving experiences such as illicit drug use, alcohol consumption, gam-
bling, sexual enactments, overeating, and self-cutting. They also report feeling
emotions very intensely at times but tend to have negative moods and irritability
as “normal.” The pessimistic outlook often manifests in biting sarcasm, passive-
aggressive comments, or “jabs” at others in conversation. Interestingly, it is not
uncommon for someone who is in the presence of (or in relationship to) a person
with this disturbance to experience some of the same states of mind. It is as if the
distressed person is able to communicate, both verbally and nonverbally, with
sufficient force some of the suffering he or she is enduring. (More on this curious
dynamic later.) Some or all of these things, even when being expressed franti-
cally, decrease or cease altogether with the return of someone whom the person
considers to be a caregiver or supporter.
We want to reiterate that these are descriptions of experience, not signs,
symptoms, or criteria pointing toward an underlying disease. The question natu-
rally arises: If it is not a disease, then from where does this kind of disturbance
come? The aforementioned descriptors emerge from and are constellated around
trauma.
We don’t need a stitch more research . . . This stuff is painful and therefore we dare
not look at it in ourselves and therefore we don’t open to its existence in others and
then we have to look for all kinds of other reasons. If you deny pain, going to early
experience and early loss and early trauma, then the world becomes very compli-
cated and justifies all kind of complicated explanations. Yet if we see that a child
has certain needs and, if you meet those needs, that child will be just fine and, if you
don’t, he’ll have to adapt somehow and those adaptations are the basis of dysfunc-
tion late on. That’s really simple. They call it simplistic. It’s not simplistic, it’s sim-
ple. The world is really very simple. We make it complicated because of our
denial . . .
We have the evidence. It’s just that the evidence is not incorporated. So when
they talk about evidence-based practice, they are looking at a very specific kind of a
very narrowly defined sense of evidence. If you actually look at the science—it’s not
that the science doesn’t exist—we know how the children’s brains develop, we
know how the chemistry of the brain develops, we know how behaviors occur
as a response to either nurturing or emotionally impoverished environments.
We don’t need more research. (Maté, 2012)
It is equally true that trauma is an organic part of life. The word “trauma” comes
from the Ancient Greek τραμα, meaning “wound, damage,” which is akin to
θραU ~ ω, “to break, break in pieces, shatter, smite through.”
Who has not had an experience that left one feeling wounded damaged, bro-
ken to pieces? As Epstein (2013) points out in The Trauma of Everyday Life, it is
rare, if not impossible, for someone to go through life without experiencing a
trauma. Trauma does not simply occur to the so-called mentally ill or to a hapless
few; it is woven into the very fabric of human existence. Death of a beloved pet,
strained family relations, loss of a loved one, sexual concerns, grief, illness,
breakups/divorces, financial woes, academic stressors, injury to self or a loved
one, pregnancy, business readjustment, moving, employment woes—anyone
could add to the list ad infinitum. We have all experienced, to greater or lesser
degrees, one or more of these things.
As a thought experiment, imagine one of these events that has occurred in
your life. Perhaps recall the death of a family pet early on in your life. If it is
not too uncomfortable, think of the loss of a loved one, a good friend or beloved
family member. As you remember this, recall some of the feeling you had—
probably surprised, worried, sad, depressed. Many people, for some time after
the event, find themselves unexpectedly tearful or angry or somehow suddenly
in a powerful mood. Along with this, many people report sudden recollections
of the event and at how “out of control” one feels during grief. Often people
unexpectedly find themselves irritable, agitated, feeling guilty, or, the opposite,
numb, disconnect, slightly disembodied, unable to feel. It is not uncommon at
all to experience some amalgamation of these things in a confused and confusing
fashion. The experience has an uncanny feel to it—whether encountered with a
numbing or hypersensitivity—as if the event or loss “haunts” ongoing life. If the
traumatic even involved loss of some kind, it is as if the absence of the person
“haunts” our minds and environment. We come home and he or she is not there.
Something extraordinary good happens and, in reflex, we call our friend—he
or she is gone. Traumatic events happen to everyone in the course of life.
If you think about it, no one is spared. Rich or poor, irrespective of ethnicity or
background, old or young, male or female, something like one of the aforemen-
tioned traumatic events has happened and will likely happen again. Stick with
the experience for a moment; recall what it felt like to go through such an
experience in your life.
Now imagine what would happen if there were multiple recurrent events such
as the one you recalled. Imagine if the event you recalled were exponentially
worse. Imagine, if you can, what it would be like to have multiple recurrent
events, such as the one you imagined, with varying degrees of impact. Imagine
this beginning early in one’s life and continuing through adulthood. One does
not need a degree in psychology to intuit that such a person’s experience of life
would be one in which pain, neglect, invalidation, shame, guilt, anxiety, sus-
pense, and terror would become “normal.” Trauma would be the primary context
for most of their existences.
Childhood loss and trauma cause not only “borderline personality disorder,”
but most, if not all, other forms of psychological distress—addictions, socio-
pathic and criminal behavior, depression, anxiety, psychoses, and relationship
problems—and they also contribute to the manifestations of a host of physical
diseases. Having said this, childhood loss and trauma does not always cause
such distress, but, when disturbance is present, so too are early childhood loss
and trauma. Said differently, the more experiences one encounters of early
loss and trauma, the more exponential risk one has for developing an emotional
or physical illness. Now, those of you who have taken a Psychology 101 class will
recall the dictum, “correlation does not prove cause and effect.” This is true,
technically speaking, but the research findings on this matter are clear and
unambiguous. To say otherwise would be like saying that chronic cigarette smok-
ing does not necessarily cause lung cancer, other cancers, and an array of other
health ailments.
Of the countless studies available, a few of note are The Collaborative Longitu-
dinal Personality Disorders Study (Gunderson et al., 2000) and the Centers for
Disease Control and Prevention (CDC) and Kaiser Permanente’s (1998) Adverse
Childhood Experiences (ACE) Study. The ACE Study is an ongoing cooperative
research project shared by the CDC and Kaiser Permanente. The coprincipal
researchers are Robert Anda, MD, MS, with the CDC, and Vincent Felitti,
MD, with Kaiser Permanente. One of the remarkable features of the study is
the staggering 17,000þ Kaiser Permanente patients who volunteered to be par-
ticipants. The data generated by their participation continues to be analyzed
and reveals concrete proof of the health, social, and economic vulnerabilities
resulting from childhood trauma. This is one of the largest studies ever con-
ducted to investigate the correspondence between childhood maltreatment and
its consequences upon health and well-being later in life. Childhood loss, abuse,
neglect, and exposure as well as other traumatic stressors, dubbed adverse
childhood experiences (ACE), are common. Almost two-thirds of the partici-

pants reported at least one ACE, and more than one in five reported three or
more ACE. Without question, the short- and long-term outcomes of ACE expo-
sure manifest a multitude of health and social struggles. This study utilizes the
ACE Score, which is the count of the total number of ACE participants
reported. This ACE Score is then used to assess the total amount of stress during
childhood. As the ACE Score increases, so too, often exponentially, does the risk
for the following:
• Alcoholism and alcohol abuse

• Chronic obstructive pulmonary disease (COPD)
• Depression
• Fetal death
• Health-related quality of life
• Illicit drug use
• Ischemic heart disease (IHD)
• Liver disease
• Risk for intimate partner violence
• Multiple sexual partners
• Sexually transmitted diseases (STDs)
• Smoking
• Suicide attempts
• Unintended pregnancies
• Early initiation of smoking
• Early initiation of sexual activity
• Adolescent pregnancy
There are 10 types of childhood trauma measure in the ACE Study. Five are
personal and include physical abuse, verbal abuse, sexual abuse, physical neglect,
and emotional neglect. The other five pertain to other family members: an alco-
holic parent, a parent who is the victims of domestic violence, an incarcerated
family member, a family member diagnosed with a mental illness, and the disap-
pearance of a parent through divorce, death, or abandonment. Each of these
types of trauma counts as one. Also, the ACE Study focused only on these kinds
of traumas, not others. It is likely that other ACE not outlined in the study
would amplify one’s risk for chronic physical and/or psychological distress. The
more ACE, the higher the ACE Score. The higher the ACE Score, the higher
the risk of disease and of social and emotional problems. A startling two-thirds
of the 17,000þ participants in the ACE Study had an ACE Score of at least 1,
and of these, 87% had more than 1. With an ACE Score of 4 or more, things
become gravely serious. For example, the likelihood of COPD increases by
390%; hepatitis, by 240%; depression, by 460%; and suicide, by 1,220%.
Again, the ACE Study notes, “other types of trauma exist that could contrib-
ute to an ACE score, so it is conceivable that people could have ACE scores
higher than 10; however, the ACE Study measure only 10 types” (CDC & Kaiser
Permanente, 1998). So, while the ACE Study does a brilliant job in regard to the
10 types of trauma they study, they do not account for other kinds of trauma. It is
important to note one very important kind of trauma that has received little
notice in the literature, but is just as impactful and destructive: unremitting gen-
eralized environmental stress. The 10 types of trauma accounted for in the ACE
Study and in other studies are the kind of traumas that are objectively present.
One can observe and quantify the events outlined in this study, which makes
sense because a study is at its best when able to quantify the phenomenon in
question and analyze the data. However, this does not account for other kinds
of objectively present trauma as well as qualitative trauma such as unremitting
generalized environmental stress.
Bateson et al. (1956) did investigate this kind of trauma. They described dis-
tressed states of mind, primarily schizophrenia, as originating in impossible
demands placed by parents, particularly the mother, on children. According to
these researchers, there is a network of communication in the family that is con-
fused and confusing, thereby creating an environment in which one or more
children are constantly experiencing stress. The example is given:
A young man who had fairly well recovered from an acute schizophrenic episode
was visited in the hospital by his mother. He was glad to see her and impulsively
put his arm around her shoulder whereupon she stiffened. He withdrew his arm
and she asked, “Don’t you love me anymore?” He then blushed and she said, “Dear,
you must not be so easily embarrassed and afraid of your feelings.” The patient was
able to stay with her only a few minutes more and following her departure he
assaulted an aide. (p. 251)
In extremely toxic homes, anything the child does in accordance with the
wishes of one parent concurrently upsets the other. The child becomes caught
up in an impossible task in which there is no chance of success. The 11 families
Laing and Esterson describe in Sanity, Madness and the Family (1970) fit this
model. While this description may be criticized as, more or less, blaming the
parent, especially the mother, it is still important to note the phenomenon of
the double-bind and other “no way to win” communications and relational
dynamics that produce stress and trauma. Walking on eggshells, so to speak, is
the everyday atmosphere of this family system. It is not uncommon for people
coming from these households to say, “I grew up never knowing when the other
shoe would drop,” “Anything could happen at any time,” “I’d never knew what
to expect when I’d got home,” or “A good day was a day without many
explosions.”
This is reminiscent of the kind of environments articulated so well by such
programs as Adult Children of Alcoholics (ACAs) and, clearly, one does not
need to be the child of an alcoholic to be raised in this kind of environment.
Of note, ACAs encapsulate this confused and confusing communication net-

work with the phrase, “Don’t trust. Don’t talk. Don’t feel.” Obviously, it is natu-
ral for children to want to trust caregivers and others. When this is violated,
children learn to associate trust with vulnerability and/or being hurt. This is dis-
tressing because the child is caught between the natural desire to trust and bond
and the mutually conflicting fear of being vulnerable or hurt. One can easily
imagine the “internal” conflict that erupts: “Is it me? Am I bad? Did I do some-
thing to deserve this? Are my parents bad? If so, what do I do?” The emotional
tension and turmoil can be brittling. Learning through multiple letdowns that
parents are untrustworthy can leave the child feeling criticized, judged, belittled,
and shamed. An invalidating, emotionally inconsistent environment is not con-
ducive to fostering a sense that the child can share his or her emotional experi-
ence. If sharing one’s feelings with the family is not always safe, then the child
learns that it is probably better to never share than to continue being vulnerable
and hurt. So, along with “don’t trust” goes “don’t talk.”
Keeping one’s feeling entirely private means safety on the one hand, but pro-
found loneliness and disconnectedness on the other. One sacrifices personal con-
nectedness for safety and survival. What is worse is that others may not even
pick up on how lonely and disconnected the child feels. By definition, the child
is keeping his or her emotional life extremely private. Keeping everything stuffed
down, as it were, can take on many forms, not just silence or withdrawal. Some
children learn to keep intensely private by using humor or charm to deflect.
The name of the game is not being seen, so the child may employ a number of
defensive maneuvers to keep others off track. So this child or teen may be quite
charming, gregarious, and seemingly masterful in relationships, and dying emo-
tionally. Or the child or teen may withdraw, isolate, or retreat into a fantasy
world. In both directions, the “tone” is stress, and the effect is traumatic. Aside
from the unremittingly stressful home environment, one has the added pressure
of maintaining a private, safe self and the other “self” utilized to keep others at
bay. The unpredictable, unstable, stress-inducing home environment leads to
an “internal” bifurcation in the child, the “self” that is private and protected
and the “self” others see. To add another layer, the more one invests in these
two selves, the more one needs to invest in them. Emotional life and relatedness
with others can only be evaded for so long. With the shutdown of the ability to
communicate one’s true self, comes emotional shutdown.
Emotional shutdown, “don’t feel,” is another self-protective maneuver. What
is really occurring is a brittling of one’s sense of self and quite a bit of emotional
anguish.
However, it is impossible to simply target and eliminate the particulars caus-
ing pain—abandonment, loneliness, desperation, deprivation, guilt, remorse,
anxiety, shame, anger, resentment, depression, dread. An attempt to kill the
pain is an attempt to kill off all of emotional life. A useful metaphor to
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understand this may be the body’s use of fever as a defense mechanism for killing
off infection. In some instances, the fever response is quite effective in killing off
the infection, but it is not always effective at returning to a safer baseline temper-
ature. The body’s natural response to a threat may, in and of itself, prove fatal to
the whole. Shutting down one emotion means shutting down the others as well.
This strategy, while beneficial or even lifesaving in the short term, has long-term
consequences. Learning to shut down emotional life in childhood atrophies the
capacity to relate to self and others, to have a felt sense of connectedness,
embodiment, and attunement.
There is a vapid and vacuous sense that grows as one drifts from a feeling of
being continuous in time and in a shared world with others. Along with empti-
ness grows a frightening realization of one’s inability to connect with others, to
be spontaneous and perhaps suspicious of others’ motives or a tyrannical “inter-
nal critic.” Protecting the private self through voiding feeling comes at the price
of psychological and social growth and aliveness. Later in life, one may have lost
sight of shore, so to speak, unable to articulate or even remember how one shut
down emotional life. Problems crop up and one is unable to differentiate or
understand what one is feeling. Or the “warning signals” of emotional life may
not be sent at all. The logic in fantasy seems to be: If feeling is the issue and feel-
ings do not exist, then my problems do not exist. The “Don’t trust. Don’t talk.
Don’t feel,” established early on are now working in tandem, and effectively so.
As Friedenberg (1977) noted, “These patterns . . . become very complicated
networks of slow and tormented human strangulation” (p. 18).
Such patterns, though often not as objectively present as those outlined in the
ACE Study, are no less devastating in the toll they take in later life. Qualita-
tively present and quantitatively present trauma are quite destructive on their
own. When combined in varying ways, they form a juggernaut of destructive
impact upon later life. The manifestations of what is called “borderline personal-
ity disorder” are not only easily understood relative to these kinds of trauma, but
are the logical outcome. It is as if people exposed to these kinds of trauma stand lit-
tle chance at all. And, by the way, the 17,000þ participants in the study do not
represent, for the most part, the populations most exposed to the most egregious
and protracted forms of trauma; that is, nonwhite populations and/or those living
in grinding poverty. “The study’s participants were 17,000 mostly white, middle
and upper-middle class college-educated San Diegans with good jobs and great
health care—they all belonged to the Kaiser Permanente health maintenance
organization” (CDC & Kaiser Permanente, 1998). One can only assume, quite rea-
sonably, that the impact is much greater on these vulnerable populations.
Given the historical narrative of “borderline personality disorder” as a social
construction as well as the unambiguous research outcomes on the long-term
effects of childhood trauma, we have arrived at a clear understanding of the
human person so affected. Through the elucidation of these contexts, we find
the person. The person, especially if a woman, has been set up through
4,000 years of historical trauma and then, within that context, exposed to one
or numerous different kinds of childhood trauma. Frantic efforts to avoid real
or imagined abandonment? Haunted by an impending sense of separation or loss?
Sensitive to environmental changes? Feeling fundamentally “bad,” as if someone
he or she deserves these things? Self-defeating and/or self-destructive thoughts
and feelings? Unstable, intense relationships? Difficulty with reality testing?
Transient psychotic episodes? Irritable and sometimes agitated? Depressed,
anxious and moody? Attention-seeking? Sometimes paranoid? No wonder!
How could a person be otherwise under the aforementioned circumstances?
AN EXPERIENTIALIST DESCRIPTION OF BEING WITH “BORDERLINE

PERSONALITY DISORDER”
How does a mental health professional experience someone labeled with
“borderline personality disorder”? The answer is simple: The same way most
others do. They can be challenging, but then again, so can other kinds of clients.
Why all of the historical and contemporary clinical defensiveness against this
kind of distress? “Borderline” clients scare us mental health professionals. They
can be assaultive, suicidal, homicidal, loving one moment and cruel the next.
They can be litigious, attention-seeking, elated, and then vapid and vacuous.
One has the sense that the “borderline” is the Grand Canyon and the therapist
has a trowel with which to try to fill the void. It is often difficult to tell when they
are sincerely suicidal or using that to relay a sense of needing to be seen. Some-
times these things come in combinations, such as someone who attempts to com-
mit suicide as a cry for help and is accidentally, impulsively successful. Given the
shifting, permeable, fragmented “self ” that they often have, who dies when they
threaten or commit suicide? Are they killing off the “don’t trust, don’t talk, don’t
feel” self-preservation system? Maybe they are getting back at the perpetrator(s)—
“I’ll show them!”
Fantasies of others at the funeral, for example, can serve as a kind of fuel for
solidifying one’s sense of self and worth. Maybe they are murdering the “pain
self.” Especially if they are engaging in therapy or some process of growth, maybe
they are afraid of the self that will emerge through the process. A new or emerg-
ing self is an unknown self, and hence dangerous, since that “person” may too be
a perpetrator or abandoning. Maybe a suicidal gesture or ideation reflects an
attempt at self-mastery—“At least I can control this!” Anger, rage, resentment,
and hate can shore up the personality—“I am not weak, I am strong!” Maybe
shame, guilt, hurt, confusion, and emptiness are a part of the environment, so
to speak, a kind of “background radiation” of the surround and suicidal thoughts
and actions are ways to configure these environmental “givens.” This can be
scary stuff to a clinician.
Most clinicians have experienced or have had a colleague experience some-

one labeled “borderline” who successfully completes suicide. This often occurs
when the clinician goes on vacation. The client is there and then gone, just like
that. This is scary stuff for most mental health professionals. The typical response
to a “borderline” is more limits and boundaries. And, as with most areas of life,
when one is acting fundamentally out of fear, things do not go well. While some
limit and boundary setting is appropriate, it is dangerous to fall into the fantasy
that somehow enough of them will replace the catastrophic circumstances lead-
ing up to the present situation. An analogous example is addiction. It is as if
many health care professionals and treatment centers (mostly unconsciously)
operate on a philosophy that if only enough limits and boundaries were set,
the addict would somehow snap out of his or her addiction, see the light, take
responsibility, made a good decision, “get his/her shit together.” Like the
“borderline,” people with addictive processes can be unpleasant to work with,
repeatedly relapse, and hurt those around them. This brings about a lot of anger
and resentment on the part of those sincerely trying to help. Knowingly or
unknowingly, it is tempting to stigmatize and punish these individuals.
Along with limit and boundary setting goes punishment. Of the various kinds
of punishment applied, the worst is probably social alienation. Whether it is
addiction, “borderline personality disorder,” or some other variety of distress,
the solution seems to be to stigmatize them, kick them out of society. Of course,
it is ridiculous to assume that, with enough boundary setting and punish-
ment, someone who is chronically distressed will one day say, “Oh, I didn’t get it
before but, thanks to your being stringent with me, I am going to straighten out
and fly right.” If such a thing were so easily accomplished, the institutions of the
criminal justice system, case management, psychiatry, psychopharmacology,
psychotherapy, drug and alcohol in- and outpatient treatment centers, etc., would
be rendered obsolete overnight. It seems that, operating primarily out of fear, no
amount of limit and boundary setting, stigmatizing, and punishment work.
To the contrary, these industries continue to grow unabated along with a
staggering number of people diagnosed “borderline,” among other things. What
do we do? How can one be with someone so distressed? We can start by, as we have
done, understanding the history and traumatic contexts. Next, we can do some-
thing quite simple: listen.
Limit and boundary setting, stigmatizing, and punishment cover over the
possibility of listening. Said differently, acting out of fear is a defensive posture.
If the “borderline” acts in a fashion that is okay with me and in accordance with
the treatment plan, then the “condition” is improving, “responding well to treat-
ment.” If he or she is not, then the person is being “treatment non-compliant.”
If the individual leaves, he or she is “aborting treatment.” As mentioned previ-
ously, if that “borderline” in my life is acting in accordance with the ways I like
to be treated, then the diagnostic label does not even come up. Only when he
or she is not and seems unstable (i.e., is bothering me) can the instability be
labeled as “borderline” or something similar. More simply, think about someone
with whom you have had an argument or who you simply do not like. The other
person offends you somehow and, now insulted or hurt, your guard goes up. You
are going to defend yourself and probably take your own jabs in process. If you
stick with the experience, you are really not listening or, perhaps, you are listen-
ing to the degree that you can find a hole in the other’s argument or for an entry
point to insert your own opinion. But you are not really listening. This is analo-
gous to the comportment the mental health system has with “borderlines.”
Now, having said that, this is not to say that all mental health professionals oper-
ate in such a fashion. There are many caring and dedicated clinicians out there
doing the best they can. Some clinicians do not know better. Many are educated
and trained to believe that “borderline personality disorder” is an unremitting
condition, most likely the result of a chemically imbalanced or otherwise mal-
functioning brain, and that they are to be avoided. And the vast majority of
them do avoid “borderlines.” We are speaking about how things are historically
and generally in the present. In any event, defensiveness and operating out of
fear precludes the possibility of listening to the “borderline.” How do we listen?
This may seem like a self-evident, silly question. Then again, it is assumed
that most mental health professionals listen to their “borderline” clients, which
is not the case. We can listen to distressed people by paying attention to our
own feelings before, during, and after encountering him or her. It is not at all
uncommon for clinician and non-clinician alike to how powerful feelings, usu-
ally of anger or hatred, before, during, and after talking to someone suffering
from this kind of distress. For some reason, “borderlines” are quite effective at
producing strong, often tormenting, affective states in others. It is not uncom-
mon for someone to feel like, “I can’t believe I am so angry! I can’t stop thinking
about it!” It’s the kind of anger or other emotion that lingers long after the
encounter, leaving one with confusion as to how and why it is so long-lasting.
At other times, others are surprised at how angry and impulsive they are in the
moment. “I can’t believe I said that! I can’t believe how furious I was!” Some-
times the fantasies that pop into one’s mind are surprisingly strong. “I wanted
to punch so-and-so right in the face!” Given, such reactions are not limited
to conversations with someone who is distressed, but they can be especially
pronounced. Why is this?
Melanie Klein (1946) offered the seminal notion of projective identification
to denote the process whereby the self can split off unwanted aspects and project
them, often with violent force, into the mind of another. This mechanism repre-
sents a primitive level of psychic functioning whose purpose is to simultaneously
rid the personality of unwanted aspects and to also experience them in another.
Projecting them into someone else allows the self to have visitation rights, so to
speak, with those unacceptable parts of the self. Notice that the aspects are not
projected “onto,” but “into” the mind of the other. One fantasy underlying this
process is one of controlling the other, working him or her like a puppet. This
process, being primitive, is necessarily unconscious. One on the receiving end
of the projection may suffer a loss of identity and insight, increased general con-
fusion, a sense of tiredness as he or she is caught up in the manipulation by the
other person’s fantasy. The recipient may even lose all sense of self and become
reduced to a projective-receiving receptacle. The feelings, attitudes, and other
contents of the projections can be good or bad, enlivening or deadening. For
example, hope may be projected by a client into their clinician, when they can
no longer consciously feel it themselves. It is as if everything but “x” emotion
is being experienced by the client, thus producing it in the clinician. The parts
experienced as good or ideal may be projected, leading to dependence or
identification. Feelings that cannot be consciously accessed are defensively pro-
jected into another person in order to evoke the thoughts or feelings projected.
Projective identification is a potent means of interpersonal communication.
We can listen to the “borderline” by being attuned to our own feelings. They
are communicating, but we are either not really listening or, if we are, we do not
understand them correctly. There are some important insights here. According to
Klein, there is a means by which people who are distressed communicate their lived
experience to others. It is as if they are unconsciously sending distress signals, SOSs
from the depths of suffering. This is done to communicate distress to others, to give
others a “dose” of what it is like to be them 24/7. This also helps describe how it is
that others suddenly, with force and often unexpectedly, are feeling what the other
person is experiencing. It also explains some of the other effects such as confusion,
tiredness, being surprisingly “out of it.” This phenomenon explains, in part, why
some clinicians fall asleep during a session. The “borderline,” like all of us, wants to
know that he or she occupies a living space in the mind of another. We all want and need
this, but it is especially exaggerated with people suffering from this kind of distress.
Some go as far as killing themselves to configure, to give shape to, to produce this
experience. But there are some things that are problematic with Klein’s theory. It
relies heavily upon a theoretical structure, a metapsychology that postulates two in-
dependent minds that mysteriously interact with one another and does so in an
almost magical way. How exactly does one evacuate an aspect of the mind into that
of another? And yet, there is no denying the lived experience. We can take to heart
some of the felt experiences and discard the unnecessary metapsychology. More-
over, this is not a magical process; it can be described concretely. What is called
projective identification really is not a phantasmagorical function of two isolated
minds, but an intersubjective experience.
Robert Stolorow, George Atwood, and Donna Orange (2002) sought to give a
more descriptive, less theoretical account of projective identification. They stick
with the lived experience of the phenomenon, rather than relying upon mysteri-
ous theoretical constructions.
We have come to regard the doctrine of projective identification—the objectified

image of one mind entity transporting its contents into another mind entity—as
faithfully diagnostic of Cartesian isolated-mind thinking . . . (p. 89)
In addition to the errors of objectification and tautological circularity, there are
other problems with the use of the concept of projective identification to explain
the analyst’s visceral states. There is, for example, the mistake of inferring causa-
tion from correlation. Because the analyst feeling something that is also in the
patient’s experience in a not-yet-articulated form (correlation), it does not follow
that the latter has produced the former (causation). It is equally plausible that there
is a conjunction—an intersubjective correspondence—between regions of the
patient’s less articulated and the analyst’s more articulated worlds of experience,
a conjunction that creates the possibility of affective attunement. (p. 91)
The process is relational, not the product of two isolated minds with a magical
theory explaining the connection-transmission point. Further, consistent with
the current research, Stolorow (2011) finds the antecedents of affective commu-
nication in early trauma. Developmental trauma is experienced as “threats both
to the person’s established psychological organization and to the maintenance of
vitally needed ties. Defenses against affects become necessary.” Rather than
interpreting the long-term manifestations of trauma as the product of a diseased
or chemically imbalanced brain organ (psychiatry), or as a malfunctioning or
poorly defended ego (Freud, Klein), it is seen as a disjunction or rupture within
a relational system. Trauma does not happen within a vacuum. It occurs funda-
mentally within a relational system. “Painful or frightening affect becomes trau-
matic when the attunement that the child needs to assist in its tolerance,
containment, and integration is profoundly absent.” From this perspective, emo-
tional pain cannot find a relational “home,” so to speak. In the cases where there
is a relationally responsive environment, injurious childhood experience need
not be traumatic. “Pain is not pathology. It is the absence of adequate attunement
to the child’s painful emotional reactions that renders them unendurable and
thus a source of traumatic state and psychopathology” (p. 27; emphasis in origi-
nal). Complex neurological or Cartesian psychodynamic explanations do not
stick descriptively with the experience distress emerges.
Clearly, we are fundamentally social beings. We always already find ourselves
within a social context, a relational network. Even the extreme example of one
who chooses to become a hermit is a way that he or she takes up his or her social
nature. This relational element is found in the earliest stages of human life and
continues throughout the course of life. Humans seek relationships, physical
and emotional closeness, from the beginning. Relationship between mother
and infant carries on into other relationships, maintains familial ties, and builds
communities. There is a complete dependence upon infants and children upon
nurturing caregivers. Physical and emotional pain are distress signals to call
one or more caregivers to his or her aid. The presence of a nurturing caregiver
gives the physical or emotional pain a “home” in the relationship, hence sooth-
ing. The infant or child can also experience a physically present, yet emotionally
unavailable caregiver. In such circumstances, there is a misattunement wherein
the infant or child will attempt to reconnect to the parent. Even adults raised
in more nurturing environments can recognize the distress or discomfort in being
in a relationship with someone who is physically present, but psychologically
absent. The absence of a nurturing caregiver at these stages of life leaves one’s
pain unmet, thrusting the original distress back upon the infant or child with
the added stressor of knowing that no one is coming. The distress cannot find a
“home.” No one is going to help. You are on your own with pain. These are some
jagged pills to swallow early on. These conditions explain, relationally, the force
with which some in later life, verbally and nonverbally, communicate their
pained and chaotic lived experiences to others. Diseased or imbalanced brain
organ theories and disparate ego dynamics are not only unnecessary; they are
not accurate descriptions of the lived experience. We are fundamentally social
beings, fundamentally communicative beings.
Distressed or otherwise, we are always already communicating our experience to
others, implicitly or explicitly. We can think of the phenomenon of “projective
identification” by “borderlines” as an amplified version by some much wounded,
uncared-for persons of what all people do all the time. Said differently, it varies in
degree, but not in kind, from all people’s relational and communicative experience.
What the so-called “borderline” is seeking is love and belonging; but these very
things, early on, were traumatogenic (i.e., trauma-producing). This is a double-
bind, immense and essential, to both be relational where relational is understood
as the “cradle,” the source of agony. Maté (2009) describes one such person whom
he had in his care as a physician. She was a 27-year-old sex-trade worker who medi-
cated her early trauma with heroin. “ ‘The first time I did heroin,’ she told me, ‘it
felt like a warm soft hug.’ In that phrase she told her life story” (p. 165).
Given 4,000 years of cultural narrative about women and what we now know
about the long-term effects of developmental trauma, we have arrived at a
salient understanding of the phenomenon today called “borderline personality
disorder.” Clearly, there is much suffering produced by this phenomenon, both
to the distressed individual and to those in his or her relational field. Some peo-
ple, like the aforementioned sex-trade worker, die as a result of lifestyle or
remain in a state for the duration of their lives. They often do not know that
wellness is possible, since the very system treating them does not believe it is pos-
sible. In stark contrast to this, we assert that achieving centeredness, wellness,
and success—as the person defines these things for him- or herself—is possible.
It is possible to find a relational “home” for the early unreflected emotions, the
trauma, and the pain. Perhaps it is not possible to recover from trauma, as if it
never existed; but it is possible to give it a “home” and to learn to take it up in
different ways. No matter how grave the trauma, there is always hope.
Viktor Frankl was an Austrian neurologist and psychiatrist when the Nazis took
power. Being Jewish, he and his wife were sent to concentration camps. Included in
the camps to which Frankl was sent was the most horrible, Auschwitz. His wife died
while interned at another camp, but Frankl survived. He emerged to write about his
experience in the classic, Man’s Search for Meaning (2006), and to establish the
form of therapy called logotherapy. Surely, this man knew something of trauma
and how to emerge from it. One of his conclusions is that there is meaning in every
moment. Even when surrounded by seemingly impossible circumstances, torment,
and death, there is a choice—however small—about how to respond. He con-
cluded too that life is not merely the summation of our past experience, but it is also
the ability to choose. He noted that one’s ability to survive and even thrive was
directly proportional to the degree that one has hope. To find meaning in extreme
suffering is the key. Frankl gave the following as an example:
We stumbled on in the darkness, over big stones and through large puddles, along
the one road leading from the camp. The accompanying guards kept shouting at
us and driving us with the butts of their rifles. Anyone with very sore feet supported
himself on his neighbor’s arm. Hardly a word was spoken; the icy wind did not
encourage talk. Hiding his mouth behind his upturned collar, the man marching
next to me whispered suddenly: “If our wives could see us now! I do hope they are
better off in their camps and don’t know what is happening to us.”
That brought thoughts of my own wife to mind. And as we stumbled on for
miles, slipping on icy spots, supporting each other time and again, dragging one
another up and onward, nothing was said, but we both knew: each of us was think-
ing of his wife. Occasionally I looked at the sky, where the stars were fading and the
pink light of the morning was beginning to spread behind a dark bank of clouds.
But my mind clung to my wife’s image, imagining it with an uncanny acuteness.
I heard her answering me, saw her smile, her frank and encouraging look. Real or
not, her look was then more luminous than the sun which was beginning to rise.
A thought transfixed me: for the first time in my life I saw the truth as it is set
into song by so many poets, proclaimed as the final wisdom by so many thinkers.
The truth—that love is the ultimate and the highest goal to which man can aspire.
Then I grasped the meaning of the greatest secret that human poetry and human
thought and belief have to impart: The salvation of man is through love and in love.
I understood how a man who has nothing left in this world still may know bliss,
be it only for a brief moment, in the contemplation of his beloved. In a position
of utter desolation, when man cannot express himself in positive action, when his
only achievement may consist in enduring his sufferings in the right way—an
honorable way—in such a position man can, through loving contemplation of the
image he carries of his beloved, achieve fulfillment. For the first time in my life
I was able to understand the meaning of the words, “The angels are lost in perpetual
contemplation of an infinite glory.” (pp. 56–57; emphasis in original)
Surely there is hope and not simply the kind of hope that seeks to manage
something like an incurable, unremitting psychiatric disease. What is called
“borderline personality disorder” is basically untreated trauma. It is possible to

find a relational home for the trauma and to choose to find meaning, even if
agony is present. It is possible not simply to be symptom-reduced, but (hopefully)
to live a fulfilling life; one that is centered, well, and successful. In what follows,
we will describe a handful of experiences we have had with people who have
come to us for assistance. We will show some moments of progress and some
moments of struggle. This will hopefully provide another layer of descriptiveness
and deepen even further the understanding of the phenomenon.
4
Chewed Up—Spat Out: Jane’s Story
“Look at this!” Jane’s hands were shaking as she waved a dismembered photo in
front of me. “Look at it!” she raised her voice; I could hear the rage beneath
her thin veneer of composure. She leaned in and finally placed the photo on
my desk. I moved my body away from her, my stomach fluttering; I thought she
might hit me. Her rage was palpable.
One of the best tools clinicians have when trying to understand those who
suffer from a borderline pattern is themselves; this, however, is what makes work
with borderline clients so challenging.
After Jane placed the photo on my desk, she leaned back into her chair.
I released a deep breath; I could feel a thin layer of perspiration on my forehead.
Trying hard to be inconspicuous, I brought my hand to my brow and wiped.
I then looked down to observe her photo. There were two people in the picture,
the head of one was gone; it had been cut out, leaving only an empty circle
where the face should have been.
I was thinking. Sometimes a quick moment—a necessary hesitation in
therapy, something I call “the therapeutic minute”—can feel like an eternity.
Jane was particularly sensitive to theses minutes. “Are you looking?” she cracked
her knuckles, barely giving me seconds to think.
“Yes, yes Jane, I am looking,” I responded, making sure I met her eyes despite
my own discomfort. I was still perspiring, “I’m sorry; I am just taking a moment to
really observe what I am seeing.”
Because of errors in reality testing that many people suffering from borderline
personality disorder experience, I always try my best to be honest, clear, and
straightforward. I wanted Jane to know that I was not ignoring her panic—her
pain; I did not want to leave her feeling emotionally abandoned. Even the slight-
est misperception would send Jane into abandonment panic; I was hoping to
avoid this. I was successful this time, but that was often not the case.
“What is there to think about?!?” she raised her hand to her head and pulled
at some tiny wisps of hair, “My . . . my Mother cut me out of the picture! She said
that I looked ugly in the photo, so she cut me out!” “She has done this in many
other photos,” her shoulders dropped as she began to shake. Her eyes were moist
as she continued; “I can bring more in if you want to see.”
I had seen enough, Jane was decapitated. And I knew she was riddled
with shame. “Thank you for sharing this photo with me, Jane,” I leaned forward,
“This must be so painful. I am truly sorry.” And I meant it.
Silence. And then . . .
Jane started crying; pools of tears were pouring out of the creases of her deep
blue eyes. She had black mascara running down her cheeks. She was trying to
talk but was having difficulty catching her breath. It was only my sixth session
with Jane, and I already knew how labile her emotional expression could be; Jane
could switch from rage to sadness and then back again within minutes. It was
also very hard to know what could trigger her dramatic mood shifts; I felt like
I was walking on eggshells all the time with Jane. I really wanted to help her;
she needed and desperately wanted help, but her difficulty establishing any trust
in the therapy relationship made things very difficult. As our relationship
unfolded, the dynamics felt very chaotic.
Jane’s historical narrative focused on the toxic relationship between her
mother and her. She described her mother as cold, aloof, and emotionally
unavailable. “My mother is a former model and appearances are all she cared
about,” Jane shared matter-of-factly in one of our first sessions. “My sister was
always the pretty one; she looks just like my mother and I am the ugly one,”
she shared, her voice flat and monotone. “I never got any attention, unless . . .”
Jane’s eyes welded up, “Unless . . . she was telling me how repulsive and worthless
I was.” Jane was sobbing. I leaned forward and handed her the tissue box. I sat
with Jane in her tears; it was nearly unbearable.
As horrible as her mother’s attacks on Jane were, she did describe wanting to
be close with her. “I just wanted her to love me, but she doesn’t. I know she
doesn’t. I am disgusting!” Jane’s emotions shifted to rage. I could feel my own
body become tense. I could always tell when Jane was about to rage—my should-
ers would become stiff and I would feel tightness across my chest. I eventually
noticed an emotional pattern while working with Jane—I would vacillate
between feeling a deep, awful abyss of sadness and intense physical symptoms
including chest pain, knots in my stomach, facial grimacing, and back and
shoulder tightness.
Although I have experienced a broad range of emotions when working with
clients, this particular oscillation is something unique to my work with people
struggling with “borderline personality disorder.” I have never been faithful to
diagnostic categories or labels. My understanding of people struggling with
borderline personality disorder does not rely on the symptom profile described
in the DSM. However, through years of clinical work, I have learned that there
are behavior patterns; and recognizing certain patterns can facilitate a better
conceptual understanding of a person’s lived experience. More astute conceptu-
alization fosters more effective treatment; however, it is always important to
Chewed Up—Spat Out: Jane’s Story 51
remain open and flexible—using discretion whenever thinking about the unique
lived experience of an individual.
Historical narratives filled with stories of stormy relationships, a lack of self-
possession, despite obvious strengths, and apparent affective instability—
particularly deep dysphoria and rage—usually signals a borderline pattern. But
what I have come to know is that what really suggests underlying “borderline
personality disorder” dynamics is the way one feels when engaged in a relation-
ship with someone suffering from borderline personality disorder.
Sensitive clinicians can expect to be filled with a painful, variable array of
affect states. The physical symptoms I experienced with Jane were a manifesta-
tion of my own surmounting, unexpressed rage. These somatic experiences are
horrible, but also work as effective clinical radars; if I feel this way, I can usually
predict that I am in the presence of someone really suffering from “borderline
personality disorder” behavior patterns, and that the course of our treatment is
going to be challenging.
I worked with Jane for close to one year in twice-weekly therapy. Each stage
of our relationship offered different obstacles. As much as Jane wanted treat-
ment, she was equally apt at undermining every step of the process. Jane came
in to therapy following the breakup of a five-year relationship. This is often what
brings people into therapy.
During our first session, Jane described her tumultuous relationship with Dan;
her thoughts were fixated on the day Dan finally ended the relationship—just
one week before our first appointment. As I listened closely to her story and
attended to my own emotional state while listening to her, I knew that this
was not Jane’s biggest problem. Jane was in a state of complete and utter panic;
she felt abandoned, and despite her clinical presentation of dysphoria, Jane
wanted revenge.
I was trying to gather a little background information during that first session;
she was making it very difficult; she was angry, shaking, and in a panic. “He’s not
going to get away with this!” Jane’s voice was raised and her cheeks were bright
red as she described the day Dan threw her out of his apartment, ending their
relationship. “He was abusive. I should have left him. How could he leave me?”
her chin was trembling as her rage turned to tears, “He’ll come back. How can
I get him to come back?” Then rage—her mouth clenched, “He left because
I’m ugly. My mother told me I could never keep a man!” Jane’s eyes were welded
up with tears as she placed her head in her lap and sobbed. When she finally
looked up, she appeared so small and vulnerable. Although it was only our first
session, I already felt totally beaten down; but when she looked at me with such
deep sorrow, my heart went out to her. Jane was really suffering.
Eventually, albeit not easily, I was able to piece together some information
about Jane’s relationship with Dan. Jane was 35 years old. Dan was 10 years
her senior. The two had met at a hotel bar in downtown Manhattan where Jane
was working as a bartender five years before our first session.
Jane described Dan as the pursuer. When I inquired what this meant, she
raised her voice and cracked her knuckles. She stared at me venomously, her
eyes wide, “He chased after me! Don’t you get it?!? Aren’t you listening to me?!?”
I wanted to know more, but was afraid to ask. Jane could be so nasty, and the
malevolent quality of her expression often caused me to withdraw. I found that
abundant validation, platitudes that felt very inauthentic, were the only way to
get Jane to open up. This style of interaction made me very uncomfortable—it
felt superficial—the antithesis of how I usually relate—but it was the only way
I could get Jane to calm down and actually talk to me.
“I slept with him the first night when I got off work. He got me drunk and
seduced me,” she stated.
“What a jerk!” I responded, hoping to hear more.
“He swept me off my feet,” she was finally engaging in some dialogue.
“Dan wanted the relationship. He brought me to expensive restaurants, sent
me flowers, love letters, and within a month he invited me to move in with
him. First he gave me a small drawer for when I stayed over. Then my own key;
and then he asked me to move in. Within one fucking month that piece of shit
asked me to move in,” she was flailing her arms and screaming. “This is his fault;
all of it. He promised he would stay with me forever and he fucking left me; threw
me out of our apartment! He had this planned from the fucking beginning!”
Jane covered her face with her hands. She was sobbing and repeating, “Why
does this always happen to me? Why does this always happen to me? Why . . .”
and then she looked up with such hatred in her eyes and coldly stated, “Fuck
him. I’ll get him, that fuck! I’ll get him.” These moments—when I could feel
the depth of Jane’s rage—took my breath away. Sometimes I would not even
realize that my breathing was shallow until Jane left, and I would release a long
gasp of air and sink down into my therapist’s chair exhausted.
During the first six months of our therapeutic journey, I witnessed Jane’s des-
perate attempts to get Dan to be with her. She was calling him incessantly.
Sometimes she would plead for him to meet her for a drink to “talk” or let her
move back in; other times she was raging and threatening him.
After Dan asked Jane to leave, she had to move in with her sister temporarily;
she had nowhere else to go. Jane really envied her sister, Patty. “She has all her
shit together; she has the perfect little life,” Jane stated, pursing her lips.
She always had the same hard, overcontrolled expression when talking about
Patty. Jane was fraught with such sadness and rage during those first six months,
our session time was nearly intolerable. And slowly and insidiously, the dynamics
between us became very hard to manage.
Jane’s relationship with Dan was the most recent of a string of turbulent inti-
mate relationships. While listening to Jane’s stories about the men in her life,
I found myself associating Jane to a tempest; she felt like a storm that blew
through wreaking havoc and chaos everywhere she went. The aftermath was
always a mess of shattered hopes and dreams; and with each relationship failure,
Jane was more and more broken.
Jane was practically always in a relationship. I was quite struck by Jane’s
inability to be alone; those six months post-Dan was the longest time Jane had
been out of a relationship since she was a young high school girl. “I just feel so
empty,” Jane shared one session, as she drew her limbs in close to her body. “I feel
so lost without a man; it is like I am nothing; I am nothing,” Jane curled her body
up, as she sobbed uncontrollably. She hated being alone.
Jane’s parents were divorced when Jane was 9 years old. Jane and Patty lived
with their mother and spent every other weekend and some holidays with their
father. Following the divorce, Jane’s mother was involved with numerous differ-
ent men. Jane shared that her mother always had a man in the house, but none of
them stayed very long. And there was always conflict; yelling and cursing were
commonplace. As were passive displays of hostility.
Jane’s mother was more invested in her personal life then she was in taking
care of Jane and Patty. There were times when there was very little food in the
house. When Jane would complain, her mother would say things like, “You’re
fat anyway; you don’t need to eat a big dinner.” Other times without obvious rea-
son, Jane’s mother would cook large elaborate dinners and expect Jane to sit and
finish everything on her plate. Her mother would state, “I made this for you and
you are going to eat the whole thing; don’t you have any gratitude Jane? I did this
for you; you had damn better appreciate it.”
One horrible day when Jane was 12 years old, her mother caught her trying on
makeup. Her mother hollered at her, stating “What do you think you’re doing,
missy? You will never be beautiful; take that crap off; you look like a clown; don’t
embarrass me; take that shit off.” “Never mind, I’ll do it for you!” Her mother
then took the coarse edge of a sponge and roughly scrubbed the makeup off Jane’s
face. Jane said that her mother was so forceful that she had patches of exposed
sensitive pink skin on her face for a week.
I knew Jane was overwhelmed with shame; her mother criticized and attacked
her on a regular basis, rendering Jane incapable of establishing any secure sense
of herself as a worthy, lovable person. Jane felt that she was bad; and this emo-
tional experience of herself as bad and unlovable was all-encompassing. This
fundamental sense of shame was so painful that Jane had no words to describe
it, which made processing her feelings in any constructive manner difficult.
Instead, Jane experienced constant feelings of emptiness and chronic rage.
The years of shame and rage took a toll on Jane. It was apparent on her
face; her skin was gray, lacking any vibrancy; she did not look healthy. Despite
the intensity of her emotional presentation, Jane looked like she was dying; the
shame and self-hate was eating away at her from the inside out. Jane was an
attractive woman by traditional standards, but I noticed that sometimes I had a

hard time looking at her; it felt painful to see her. And I knew that this was
how Jane felt about herself; the thought of Jane living every day with such
self-disgust made me sick to my stomach.
It was during the sixth month of our treatment journey when I began to notice
subtle indications that I was the next victim of Jane’s tempestuous rage. This is
when the treatment started to feel unmanageable. Trying to contain and validate
Jane’s feelings while having to control my own surmounting anger was dreadful.
I was feeling tightness across my chest nearly every session; some days the tightness
would begin early in the day with agonizing anticipation of our session time.
Despite the intensity of Jane’s rage, I did feel empathic toward her. But as the
treatment unfolded, Jane’s responses toward me challenged this empathic
regard—confusing and compromising my own emotional experience. I was never
sure how Jane would react to empathic responses. Sometimes genuine empathic
discourse would cause Jane to become more enraged; I found myself feeling
attacked and helpless; I felt cornered and shamefully defensive.
This is an awful feeling; sitting with an incredibly distressed person who is
“asking” for help while experiencing one’s own rage is a clinical nightmare.
Trying to successfully navigate through this dynamic is one of the greatest chal-
lenges in working with people exhibiting borderline personality disorder symp-
toms. During our sessions I often imagined myself holding up a metal shield
and moving it all around attempting to protect myself from malicious assaults.
It really felt like Jane was trying to kill me, and in a metaphorical sense, she was.
Jane so desperately craved warmth, nurturance, and validation, but these
responses felt so uncomfortable—unfamiliar. Essentially any sort of kind, empa-
thetic—good—response, challenged Jane’s way of being; she recognized bad as
normal and any other response was experienced like a foreign object, threaten-
ing her sense of herself in her world. For people struggling with “borderline per-
sonality disorder,” warm empathic exchanges can feel like a growing
malignancy; a seeping toxin that needs to be dis-guarded. People with borderline
personality disorder need to “chew up and spit out” all that is good. Acting in any
other manner would shatter their sense of reality.
When I would think about Jane in between sessions, my heart was heavy;
when I could let my metal shield down, I could really feel the depth of her pain.
It was around the six-month treatment mark when rage became a common emo-
tional experience for me while I was with Jane. Intellectually, I understood that
in order to help Jane, I had to compartmentalize my own rage and maintain my
empathic connection; but emotionally, this was very, very hard.
Often times, people with “borderline personality disorder” say one thing, but
then, through subtle and insidious interactions, communicate something
entirely different. This creates a sense of chaos in the therapy relationship; the
constant drama and turmoil are what feels normal for people with borderline
personality disorder, and they are masters at creating this normative in the thera-
peutic relationship. It feels as if one is being thrown around in all different direc-
tions on a constant and ongoing basis; it is being caught in an emotional
hurricane with no refuge. When genuinely engaged with someone struggling
with “borderline personality disorder,” one can expect to feel a relentless whirl-
wind of emotional disorder and disarray; eventually, this can lead to questioning
one’s own reality testing. When this happens, one begins to understand on a
deeply emotional level how people with “borderline personality disorder” feel
on a daily basis.
Jane was yelling about Dan, “Why won’t he call me back?!?” She had been
trying to get Dan to respond to her; over the last couple of months, he had stop
returning her calls. Later that week when Jane called him, she discovered that
Dan had changed his phone number. Jane came storming into the session, shak-
ing. “Why would he do this? Why won’t he talk to me? I bet he never loved me!
Lies, all lies. That man used me. He just wanted me for cooking and fucking.
That’s all. That’s all men ever want—a fucking hole to stick their dick in!”
Jane stopped her diatribe momentarily, cracked her knuckles, and then . . .
“You don’t give a flying fuck either!” she was screaming. It took so much for-
titude to hold eye contact; but I wanted Jane to feel heard, so I looked at her,
unwaveringly. “Sometimes it takes you hours to call me back. You’re my thera-
pist; I’m in major crisis, I call you and you don’t call right back. I bet you do that
shit on purpose. You say you want to help me, but you don’t act like it!” Jane’s
face was contoured—her eyes were wide showing the whites, and her lips were
tight. She grabbed her hair and started pulling, her hands shaking. Jane displayed
an unsettling mix of rage and desperation.
I was rubbing my hands along my arms and biting my lower lip. I looked over
at the clock; I was floundering, “Jane, I do . . . I do care and I do want to help you.
I, umm . . . Hmm . . . sometimes I can’t call you right back, because I am in other
sessions or don’t have the privacy to talk.” I bit my lip harder.
“Well what about this past weekend? I called you at 8:30 a.m. and you didn’t
call me back until 5:19 p.m. You can’t tell me that you didn’t have even a few
minutes to call me back before then!” Jane was picking a fight. I could feel myself
wanted to retaliate and start hollering back. I felt attacked and provoked. Jane’s
most comfortable way of relating was in heightened conflict—hollering and
screaming back and forth—I was resisting the urge to engage in this. It was not
easy; my chest was tight and my shield up, but I maintained my equanimity.
I was not sure how to respond. My immediate emotional reflex was to react
defensively, but I knew this was not in Jane’s best interest; this would be my
retort based on my own feelings. I knew I needed to hold steadfast to a more
objective clinical position, instead of engaging with a spontaneous reaction to
my own emotional experience. I needed to proceed cautiously—remaining
cognizant of the pull to react, without reacting.
My inner dialogue was complicating the situation. My wheels were spinning

in an array of uncertainty. In reality, Jane was right; I could have called her back
sooner. Although I did not consciously decide to wait until later in the day to
return her phone call, her attack caused me to question my own intention.
It was the weekend; she wasn’t in imminent danger, and I was busy. I waited until
I had amble time to talk so I wasn’t rushing her off the phone. At least this is what
I was telling myself. Did I purposely wait? Did I feel Jane’s call to be an imposition?
An impingement on my own time? Was I attempting to assert my own boundary?
Or was Jane correct—was I angry and passively expressing myself by making her wait?
I was beginning to question my own reality.
I needed to remain mindful of the truth, but the truth started to feel blurred;
my perception was very different from Jane’s, which made my own sense of what
was happening tenuous. I decided to validate Jane’s feelings; her truth. “Jane,
I am so sorry that you feel I don’t care,” I was being careful. I was internally cring-
ing. I was biting my lip again, but I continued, “It must really be horrible to feel
like no one cares about you.”
“Well, no one does,” Jane swallowed hard, her voice soft and small. She
brought her knees to her chest and folded her arms. She was crying. I believe
Jane felt heard; I took a deep breath in and blew out hard; “Puffff,” I sighed relief.
Jane spent the rest of that session and the few following mourning the loss of
Dan. This was progress. Jane was describing how abandoned she felt every time a
relationship ended. She was able to explore—albeit, infinitesimally—how her
fears of losing someone might cause her to react in a manner that could push
someone away. Jane’s mood was quite dysphoric, but she was calmer and actually
seemed to be gaining some insight. But then a few weeks later, her behavior
began to escalate.
Jane often called outside of the session hour; these calls typically occurred
when Jane was in crisis. During the first six months of treatment, the calls were
sporadic. After Dan changed his phone number, Jane’s calls became more
frequent. At first she was calling a few times during the week, but soon she was
contacting me nearly every day and sometimes more than once a day. I started
to feel both overwhelmed and angry.
I tried to address the phone calls during our sessions. It was complicated.
I wanted Jane to feel she could call me if necessary—in an acute emergency.
But Jane’s normal emotional state was to be in crisis, which in her mind war-
ranted the ongoing influx of phone calls. We were spending a lot of our time in
session engaged in convoluted dialogue surrounding the calls; the hostility
between us was increasing. Some days it took all my inner resources not to blow
up at her. I felt like a sizzling volcano about to erupt.
There were times in session when Jane would be somewhat self-reflective,
even insightful, and appear more stabilized. I would feel hopeful and optimistic
about Jane’s ability to progress and grow from therapy. But these pockets of
stabilizations were short lived; these times were akin to the eye of a storm; they
were moments in time when it seemed quieter and that things might pass, only
to be ominous forewarnings of impending chaos.
Another challenge was the ever-evolving double-bind; these are situations
when no matter how well thought out a response or intervention may be, it is
destined to fail. These are essentially circumstances created in the interpersonal
dynamic that are lose-lose situations. If I responded to Jane’s phone calls
promptly, she would call more often in escalating crisis; if I attempted to assert
boundaries—only calling back during certain hours, which were outlined in
session—she would call more often. No matter what I tried, and I was trying very
hard, Jane’s attempts to engage me in convoluted and conflictual dynamics were
relentless.
Jane only knew how to relate in heightened conflict; this was normal for
Jane; when Jane attached to someone, she unconsciously persisted in creating a
relationship riddled with conflict. I found myself pulled so forcefully into Jane’s
chaotic interpersonal world. I had fantasies of retaliating; yelling, screaming,
and displaying hostile responses toward Jane vividly played out in my mind.
Jane had been emotionally abused by her mother, and I felt myself being
pulled to occupy her mother’s role in our relationship. I wanted to verbally abuse
Jane; I did not rationally want to hurt Jane; I wanted to help her. I could feel her
deep distress; her emptiness, loneliness, abandonment fears, her sense of shame
and self-hate—I could feel them all. And yet, sometimes I just felt a pool of rage
simmering—the feeling was so deep and pervasive, it was completely envelop-
ing. And my retaliatory fantasies persisted alongside my empathic experience
of Jane’s pain. Although it was painful—my emotions felt twisted—through
acknowledging my own emotional state, I knew exactly how Jane felt. And it
was utterly horrible.
I began to wonder what Jane thought she was getting out of therapy; I wanted
to know what Jane believed she was in therapy for. I felt Jane had more insight
since we began our journey together, but aside from that, Jane was as distressed
as she was the first day she walked through my door. I thought about this for a
while, and one day I decided to ask her. I thought perhaps my question would
encourage her to be curious about how she imagined therapy should be. In addi-
tion to encouraging curiosity, I thought it might shift our dynamic toward
collaboration.
I leaned forward. “Jane, I am curious, what do you want from our work here?
How do you see therapy helping you?”
Jane was a smart woman and a very talented artist; I so wished she could see
that. I observed her thinking. Still leaning toward Jane, I waited for a response.
“I don’t know,” she stated, gazing around the room. She seemed to really be
thinking about my question. She paused for a few moments and then continued,
“I guess I want to find a man and get married; but my relationships never work
out; they always leave me. And I don’t want to feel depressed anymore; I am so
fucking sick of feeling depressed; it sucks; every day sucks. And I want to pursue
my art work; I haven’t painted in months; I just don’t feel like I was getting any-
where with it.”
After that session, Jane was able to stay focused on some of the themes that
she wanted to change in her current life circumstances. The next few months
were filled with tearful sessions where Jane was exploring how feelings of being
worthless were contributing to frustrated attempts to move her life forward in
the direction she wanted. She was still calling outside of the session hour, but
the contacts were less frequent and less frantic. But then during our ninth month
of treatment, she met Julian; he was like the wind, quickly moving the storm
clouds over our heads once again; and this time, it was even worse.
Jane met Julian serendipitously one evening in the grocery store. Jane, now
36 years old, was immediately attracted to Julian’s warm, cheerful demeanor.
The two exchanged cell phone numbers and met for a few drinks the very next
evening. Julian was a 29-year-old artist living downtown, not far from Patty’s
apartment, where Jane was still staying.
Jane was bubbly when describing her date with Julian; I had never seen Jane
cheerful before; her cheeks were beaming, and she was chattering nonstop. For
the first time, there was liveliness to her comportment, but I was concerned that
it was ill fated; I had the feeling that Jane was aware of the emotional risks she
was taking and, deep down, knew she was too fragile. Jane’s outward presentation
revealed excitement and hope, but I could feel the shallowness to her expression;
I had the sense that she was falsely elated; her happiness was completely depen-
dent of Julian’s responses to her. I knew this meant trouble.
After only a few dates—one being a sleepover—Jane was convinced Julian
was going to ask her to move in with him. I was worried, but Jane was “in love,”
and I knew trying to encourage any curiosity with a love-struck person was futile.
So I stayed with Jane in her growing infatuation, remaining vigilant of any
emerging opportunities to have Jane explore her emotional dependency.
A month later, there was an explosion.
It was early on a Sunday morning when I woke up to a string of missed calls
from Jane. My body became tense and my chest tight; I knew before I even lis-
tened to her messages that I was waking up to a mess. Jane’s first message was
at 5:00 a.m.; she was hysterical. From what I could make out, Julian had “thrown
her out,” making it clear that he did not want to see her anymore. There were
four messages following the first, all within about 15 minutes of each other;
Jane was crying; I could hear the panic—her voice sounded shaken. She was
desperate.
It was now close to 9:00 a.m.; I was still in bed. As I heard Jane’s last message,
I sat up, jolting out of my morning slumber. I was rubbing my hands up and down
my arms as I stood up and began pacing. I hated my first thought: I can’t do this
anymore; I just can’t do this. This was not the first time I felt this way with Jane,
but every time I thought of giving up on her—terminating our treatment because
it was too difficult—I hated it.
I could hear Jane unraveling on my voicemail. She went from crying, to
hyperventilating in a panic, to rage. As Jane’s panic escalated, so did her
impulsivity.
Jane was going to stand on the ledge of Patty’s fifth-floor apartment; her trem-
bling voice reporting that she “might” jump. I began pacing faster. “Why haven’t
you called me back?” she panted, “I need your help now!” She was literally asking
me to talk her off the ledge. Her last message was a threat: “If you don’t call me
back, I am going out on the ledge and I . . . I . . . think I might jump. I swear
I might!”
The thought of Jane jumping, her body smashing on the hard concrete,
flashed through my mind. Jane had made similar threats before; these always
seemed to happen when Jane was feeling emotionally abandoned; she wanted
my attention, and if I did not respond immediately, she was going to provoke
me. The helplessness and rage I felt during these incidents were indications of
how Jane was really feeling; through her actions, Jane was able to show me just
how much emotional pain she was in.
My clinical understanding of this dynamic process did not make my in-the-
moment experience any easier. Despite my alarm, I knew from experience that
Jane’s genuine intention was to get me to respond quickly—not to actually jump.
But I always remember one supervision session early in my clinical training when
I first encountered a client threatening self-harm under duress. My supervisor
had stated, “You always need to consider how impulsive your particular client
is when making these types of threats; even if he/she doesn’t intend to harm him-
self/herself, he/she could do so accidently or in a rage react impulsively without
intent.”
With this guidance in mind, my heart racing, I went to call Jane back
immediately. But then my phone rang—my caller ID registering Jane’s phone
number. I took a deep breath in, releasing a long air-filled, sigh and picked up
the phone. It was just after 9:00 a.m. on a Sunday morning, and Jane was scream-
ing at me.
“Where were you? Why didn’t you call me back? I’m fucking freaking out!”
Jane was on a tirade. “Did you even listen to my messages? I was standing outside
on the ledge and I was about to jump. If you even care!?! I came in to call you
one last time; I swear if you didn’t pick up the phone, I was going back out there.”
Her speech was pressured and accelerated.
I bit my lower lip so hard, I started bleeding. I felt tightness across my chest as
I began digging my nails into the palms of my hands; I was angry and trapped in a
double-bind. Even if I wanted to set a boundary surrounding early Sunday-
morning phone calls, the intensity of Jane’s escalation, combined with her threat
of jumping off a ledge, made it impossible; essentially, I had to call Jane back.
Although not of completely conscious intent, Jane knew that; and this made
her actions feel manipulative. I was still digging my fingers into my palms trying
hard to contain my own anger. The tightness across my chest made my breathing
feel shallow. In order to intervene in a clinically constructive manner, I had to
hold my own feelings in abeyance, and this was very uncomfortable.
I began pulverizing my pillow; grinding my fingernails deep into the cushion-
ing, exercising all of my self-control in an effort not to retaliate. As Jane was
bludgeoning me on the phone, my thoughts were racing; I was thinking about
the best way to respond to her. I used my own feelings to inform my response.
I felt a horrible mix of helplessness and rage; I knew that was only about a tenth
of what Jane was feeling.
“Jane, I am so sorry about Julian; I know how much you love him. I can hear
how helpless and angry you feel,” I stated slowly and calmly. I was hoping the
tone of my voice with the content of my statements would soothe Jane.
Jane began to sob; I heard her trying to catch her breath as she tried to speak.
Her voice quivering in between heaves, Jane responded, “H—H—help me;
I . . . I feel like I am dying.” And as I listened, my anger dissipated leaving me
with all-encompassing feelings of sadness; I was heartbroken.
Jane assured me that she would not go out on the ledge again. She did warn
me that she intended to stay in bed all day. “I just want to curl up and die.
I promise not to hurt myself, but I just wish I would die . . . get hit by a bus or fall
and crack my skull open or something . . . Anything to make the pain stop,” Jane
shared, still crying. “The only time it doesn’t hurt is when I am sleeping. This
always happens to me; there is something wrong with me; I hate myself . . . I just
hate myself,” she added.
Jane agreed to come in for a session the next day; I looked at my schedule and
was able to move her Tuesday appointment to Monday. She was very sad when
we hung up, 30 minutes later, but she sounded calmer; she had stopped crying
and said she was totally “exhausted and going to bed.” When we ended our
phone call, I crawled back into bed for an hour; I felt worn out.
Jane came in looking beaten down; she had dark circles under her eyes, her
face was white as a sheet, and her shoulders and back were slouched. Her long,
dark hair was pulled back in a tight ponytail; there was a thin scarf tied around
the top of her head and she was dressed in all black; her clothing wrinkled. She
looked like she was going to a funeral; and metaphorically, she was.
Jane spent most of the session crying or attempting to fight off her tears so that
she could talk. “Why does this always happen to me? Why? Why?” she repeated
numerous times throughout our session, her hands covering her face. I did not
want Jane to blame herself for the breakup with Julian; she was already wracked
with shame. Jane did not have the inner resources at this point for the type of
self-reflective curiosity this sort of question required. I also recognized that
understanding her role in these relationship dynamics was essential for her
recovery.
The next few months of our treatment vacillated between Jane breaking
down in tears, asking for help, and episodes of explosive rage. I was working hard
to contain her feelings and offering some concrete behavioral techniques to help
her in-between sessions. The treatment was hard, but started to feel more man-
ageable. Then one Monday morning, I received a frantic voicemail from Patty.
Patty sounding exasperated, left a message that her sister was out on the ledge
of her apartment and was threatening to jump. Patty was asking for a call back.
Jane had ambivalent feelings toward Patty, and I knew that there would be con-
sequences if I decided to call Patty back. Jane had not signed a consent form
allowing me to speak with Patty. However, Jane’s suicidal gesture was considered
a “threat to herself,” and this waved her right to privacy. I could ethically call
Patty back, but I knew this could complicate an already delicate therapeutic
alliance.
With Jane’s safety in mind, I called Patty back. Patty went into her bathroom
to talk to me; she was whispering. Jane—in from the ledge—was now in the bed-
room crying. Patty did not want Jane to hear the conversation; the walls of the
bathroom were causing an echo on the line; I was straining to make out every-
thing Patty was sharing.
I was on the phone with Patty for close to half an hour. When we hung up,
I felt totally disorganized. Jane had been stalking Julian. I knew that she was still
obsessing over him; she was making sporadic late-night phone calls pleading him
to take her back or raging at him for not returning her calls. We were discussing
her calls to Julian in session. But Patty informed me that Jane was standing out-
side of his apartment at night looking to see if he was with another woman.
On Sunday night, Julian spotted her and demanded that she leave him alone.
Jane was clinging on to him, begging for another chance—or an explanation for
why he abruptly ended their relationship. Jane told Patty that Julian shoved her
into a bush; Jane reportedly fell backward scrapping her elbows as Julian threat-
ened to get a restraining order if Jane did not stop bothering him. Jane came
home to Patty hysterical; Patty stayed up with her for most of the night, and
when they finally went to bed at 4:00 a.m., Patty thought Jane was okay. Then
at 8:30 a.m., Patty awoke to Jane calling to her from the ledge. Patty ran to the
window and convinced Jane to come back inside.
The conversation with Patty left me very confused. Despite interpersonal
challenges with Jane, I had never questioned her narrative; whatever Jane
described in her story, I assumed was the truth. It was her reality, but her report
was not a shared experience of the actual circumstances.
Jane described Patty as selfish and uncaring, but she was neither; she was
actually deeply concerned and trying to help. Jane spent many sessions describ-
ing Patty’s insensitivity. I believe Jane truly experienced Patty in this way, but
my experience of Patty revealed a worried, loving family member. Jane came to

situations anticipating rejection, and this is exactly how she experienced peo-
ple—Patty included. People were cold, indifferent, and ultimately abandoning.
Patty also told me that in four weeks, Jane would be moving in with their
mother. Patty had taken a new job and was leaving the city. Jane’s mother lived
in Salt Lake City, which meant that Jane would be terminating our treatment.
Jane had not intimated anything about this—not even a hint.
I was worried about Jane moving in with their mother; she had created an
image of her mother as an abuser. I asked Patty about the decapitated photos;
Jane would periodically bring in one of those photos to share with me. Patty’s
story was different from Jane’s; a proverbial variation of the truth. Patty’s story
was that it was Jane who said that she looked ugly in the photos; and it was Jane
who begged their mother to cut her out. Their mother did not want to, but Jane
pleaded with her. Jane was relentless; finally their mother conceded; she was cry-
ing the entire time she was cutting the photos. She was asking Jane to please stop
talking about herself in such a debasing manner.
I thanked Patty for the information she related to me. I informed her that I
would be sharing our conversation with Jane; I felt it was important to be honest
with Jane and disclose that I had spoken with Patty. Patty said she understood;
she thanked me for my time, and we hung up. I plunked down into my soft cush-
ioned chair, coffee in hand, and sat in my stupefaction; I had a vague sense of
uneasiness; I felt dazed while thinking it all through, and attempting to process
and integrate everything I learned. I was also trying to figure out how best to
approach Jane with this information. I knew our next session was going to be
uncomfortable. And, I was not looking forward to it.
Jane’s safety was a priority. So, I began our session with a firm stipulation. If
Jane wanted to continue treatment, she could not go out on the ledge anymore.
She hesitated for a moment, but soon agreed. After some thought the previous
evening, I decided to ask Jane directly about her forthcoming move.
“Hmmm . . . Jane,” I was leaning toward her, “I am curious why you didn’t tell
me you were moving?”
Jane’s eyes were drifting; she couldn’t make eye contact. I sensed she was
ashamed. Finally staring at a spot just above my head she responded, “I . . . I . . . ,”
she gazed downward. She continued, “I . . . umm . . . I was afraid to tell you.” She
looked at me. I encouraged her to keep going, “Oh—I am sorry to hear that Jane.
Can you say more?” “I . . . umm . . . well . . . umm . . . I guess I thought if I told
you that you would stop therapy with me. I thought you would terminate with me
because I was moving. I didn’t want that to happen.” She looked so sad, and then
she added, “I was going to tell you. I swear I was.”
Jane thought if she told me, I would abandon her. “Jane, that would never
happen,” I responded. I decided not to confront Jane about the pictures. We only
had about seven sessions left before her move and I believed it was more
important to explore her feelings about this transition as well as the termination
of our relationship. We did briefly discuss the Sunday-Julian incident superfi-
cially. Jane disclosed her stalking behaviors, but made it clear she was done hold-
ing on to fantasies of reuniting with Julian, and did not want to explore it any
further. I knew it made no sense to pursue the issue. Jane would be leaving
treatment soon, and we definitely did not have ample time to make any clinical
headway there. So, I let it go and focused in the present—here and now—
circumstances.
We spent the last month of treatment preparing Jane for her move; she was
anxious, but also hoping it might offer opportunities for a better future. Her
mother had agreed to pay for Jane to go back to art school; this inspired a sense
of optimism. Jane almost seemed hopeful. I admittedly was somewhat relieved
that Jane was moving. I hated thinking that, but it was the truth. I would not
have ended our treatment, even though I had fantasies of doing so. But the emo-
tional chaos I experienced with Jane made the work very hard. And sometimes
I was not even sure I was helping her.
Apparently, I was. Approximately a year after Jane moved, prematurely end-
ing our treatment journey, I received a letter in the mail. Jane was in art school,
back in therapy, and living in her own apartment. She was even having family
therapy sessions with her mother, and she was on her own—without a man—
and feeling “independent” for the first time in her life. She thanked me for
“putting up” with her, which sounded very insightful. It was the first time I heard
any sort of recognition of the effect her behavior might have on another person.
I closed the letter feeling full of hope. That letter made all of the frantic phone
calls, alarming threats, chest pains, and spirals of complicated feelings worth it.
5
Emotional Jungle Gym: Melanie’s Story
I met Melanie in the waiting room the afternoon of our first session. We greeted
each other as she slowly stood up from her chair to come into my office. Her
movements were stiff, seeming unnatural and contrived, as if she was thinking
about her every move instead of reacting spontaneously. Her eyes were vacant,
and I felt a real disconnect; it seemed she was looking past me, not at me.
When we finally sat down to begin our session, I almost had the sense that
I was alone in the room. Melanie felt like a vacant shell; her physical body was
present, but she was emotionally absent. And our interpersonal exchanges
lacked any sense of connection. Her voice was slow, labored, and monotone.
And despite her exceptional physical attractiveness, she lacked any vitality.
Melanie was deadened, and I was having a hard time staying focused; her story
was filled with intrigue, but I noticed that I was struggling to pay attention.
Melanie was a runway model. A tall and thin, 31-year-old beauty, Melanie
had the longest legs I had ever seen. Her pale blue eyes stood out next to her
olive complexion and black hair, but they were empty. She was gorgeous, but
her slouching shoulders and poor eye contact gave me the sense that she lacked
any real confidence or self-possession.
Melanie came into therapy following the abrupt ending of a two-year rela-
tionship. Although she had never been in psychotherapy before, she had a long
history of intense romantic relationships; they always started quickly, becoming
serious almost immediately. The relationships would feel like a whirlwind
romance, would last anywhere from six months to three years, and would always
end “badly,” leaving Melanie feeling totally depressed. Melanie at 31 years old
finally began to wonder if this was a pattern. “I want to know if I am doing some-
thing wrong. My friend said I should talk to a therapist and so here I am,” she
stated looking at the floor, with her teeth clenched; her mouth was practically
closed as she spoke.
I could tell that Melanie’s engagement in any therapeutic process was tenu-
ous; she did come in and was in distress, but I had the sense that she was not sure
she wanted to be in therapy. Developing a firm therapeutic alliance would be an
important first obstacle to overcome. I also felt something; I intuitively sensed
immense sadness and rage beneath her overcontrolled veneer. Melanie’s
ambivalence about entering treatment, combined with her unexpressed deep

distress, forewarned a challenging therapeutic journey. It only took a few sessions
to realize just how complicated our work together was going to be.
The first few sessions were painful; it was hard to get Melanie to speak openly.
I wanted her to guide the direction of the sessions, but the only way I could get
her to engage in dialogue was to ask her questions. Around the fourth session,
when I encouraged Melanie to elaborate on the demise of her most recent
relationship, her emotions began to surface.
“Please Melanie; tell me more about what happened with Peter; I want to
really understand what happened between the two of you,” I gently inquired,
hoping she would open up. She gazed downward as we sat in silence for a few
moments. It was an uncomfortable few minutes, but I waited, leaning forward
to try to get her to engage with me. Her lower lip began to quiver, and when
she finally looked up, she was crying. Still leaning toward Melanie, I sat with
her in her tears, waiting for her to speak. Melanie declined the tissues I offered
her and instead wiped her eyes with the arms of her sweater. I could see her strug-
gling to stop her tears. “It is okay to cry, Melanie; it is normal to cry when we lose
an important relationship and it sounds like you went through a lot with Peter,”
I tried to soothe her. She nodded her head, placed her face into the palms of her
hands, and cried harder.
Tears were still seeping out of the corner of her eyes as she took a tissue and
blew her nose; regaining her composure, she began to talk. “My mother told
me my whole life never to let anyone see me cry. My mother is all about being
poised, graceful, and in control. Crying was not allowed in our house, not even
when I was a little girl. If I cried, she would yell at me until I stopped.
I guess . . . ,” she paused and looked down again. I encouraged her to keep going.
And she continued, “I guess I learned to hold everything in at least when I am
around other people.” She lowered her voice to a whisper as if she about to tell
me a secret, “Sometimes when I’m alone I cry hysterically for hours. Sometimes
I don’t even know why I’m crying.” Her eyes looked hollow again as she contin-
ued, “I have been crying constantly since Peter left me. I just don’t know what to
do or even who I am without him. I just feel so lost and empty.”
“I am so sorry Melanie; this is a horrible way to feel; I’d really like to hear all
about it,” my heart went out to her. I really wanted to hear more about her
mother and their relationship. I had the sense that this was at the origin of her
difficulties, but I also knew that this type of emotionally laden material was much
harder to talk about. Exploring these types of dynamics too early in therapy could
send a client running out the door; it often threatened the core of one’s person-
hood, one’s way of being. Besides, Melanie had come into therapy to discuss her
romantic relationships; this was her presenting problem. I knew eventually,
if Melanie had the wherewithal to stay in treatment long enough, we would
have the opportunity to explore and process her relationship with her mother.
Emotional Jungle Gym: Melanie’s Story 67
With the aforementioned in mind, I held off on asking about her mother.
Instead, I actively expressed interest in her relationship with Peter.
Melanie spent hours of session time talking about Peter. Her thoughts sur-
rounding their relationship had an obsessive, ruminative quality. She described
debilitating depressive symptoms since the breakup. “I can’t eat; I can’t sleep;
I don’t want to work or see friends; sometimes I lay in bed all day thinking about
him; I think about why he left me; I don’t even know who I am without him;
I don’t even remember what I used to do or enjoy doing before I met him,” she
trembled while talking. I could see her shivering as she grasped at the ends of
her sweater sleeves, struggling to fight off tears. She raised her voice, squeezed
her shoulders, and affirmed, “I don’t know who I am anymore; I just don’t know
who I am without him.” No longer able to fight off tears, her shoulders quivering,
she sobbed, “I . . . guess . . . maybe I . . . maybe I never feel like anybody without a
man; maybe . . . ,” she dropped her shoulders in defeat, “I just don’t know
anymore.”
Melanie met Peter, a photographer, at a photo shoot a little over two years
ago. There was immediate chemistry and within one week, the two were dating
exclusively. “I loved him instantly,” Melanie shared. “I thought for sure he was
the one; I had finally found my man.” One month into the relationship, Peter
moved into Melanie’s large two-bedroom apartment. For the first six months or
so, they did everything together. “I was so happy when I was with him; I can’t
remember ever being so happy; I felt important . . . like he really loved me,”
she beamed. Melanie always seemed vibrant when she discussed the early stages
of their relationship.
Melanie described conflicts arising within their relationship when she started
to feel Peter “pulling away sometimes.” I inquired what she meant by this. “Can
you say more, Melanie; what do you mean pulling away?” I had already generated
a few hypotheses at this point about Melanie’s personality organization. I had the
sense that she did not have an integrated sense of self and that her sense of iden-
tity was based purely upon whoever she was in a relationship with. She only
existed within the context of her relationships; without someone to depend on
for her identity formation, Melanie felt like she was nothing; she felt as though
she did not exist.
Her response to my question confirmed my other hypothesis—“When he
wanted to do things without me, I felt like he didn’t love me anymore; I would
feel totally rejected and abandoned.” Melanie felt abandoned. Melanie came to
situations anticipating being abandoned. Because of this underlying way of
experiencing her world, abandonment was the inevitable result. Any attempt
on the part of the other to assert independence was experienced as abandonment
by Melanie. And Melanie felt abandoned by everyone in her life. As I had
speculated after first meeting Melanie, our therapy together was going to be
complicated; we had a lot of work to do, and it was not going to be easy.
Melanie and I spent months in twice-weekly sessions exploring her relation-

ship with Peter. I was trying to keep her focused on his “pulling away,” how she
experienced it, and what it meant about her experience of people. This was very
difficult; Melanie experienced the world as abandoning; this was her reality. So it
was very hard to get her to consider other possibilities. In addition, I began to
notice subtle indications that Melanie was beginning to experience me as
an abandoner as well. I knew things were going to become increasingly
complicated.
It was around six months into our therapy journey when we had a small thera-
peutic explosion. Melanie was finally working again. She was doing some maga-
zine shoots, but she hated it. In fact, Melanie hated being a model. She was
starting to discuss how she had wanted to go to college and study law; Melanie
had wanted to be a criminal defense attorney, but her mother would not have
it. Instead, her mother—a former model—insisted that Melanie, her only child,
become a model. Ida—Melanie’s mother—called in all her favors, and just
after Melanie’s high school graduation, Melanie landed her first modeling job.
Melanie was beginning to explore the possibility of going to college in her ses-
sions; this was tremendous progress; Melanie was connecting to her own real
desires; to her wants and needs, which suggested the emergence of some
integrated sense of self.
But then I had to disclose an untimely vacation; four weeks before a two-week
vacation, I shared with Melanie that I was going to be away. It felt like we were
sitting with a ticking bomb, waiting for it to go off; and when it finally did, we
were sitting in the aftermath for weeks. It was the second vacation I had taken
since Melanie and I began our work together. The first one was early on in our
therapy relationship; it was before a firm alliance had been established, and
Melanie was still detached from both me and the therapeutic process. This vaca-
tion was different. Melanie was attached and invested. Her growing connection
with me left her feeling vulnerable; and my two-week absence was experienced
as a personal departure from her. Once again, Melanie felt abandoned.
When I shared that I would be going away for two weeks, Melanie tried to
appear disengaged; her eyes glazed over and her response, “okay, I hope you have
a nice trip,” was tight-lipped and contemptuous. I encouraged her to share her
feelings about it, but she said she had none. “You have a life, right? You’re going
on a vacation. No biggie,” she scoffed, her lips curled.
The rest of the session felt artificial—she was making small talk as this huge
pink elephant sat between us. I knew something was going to happen, but I was
not sure what. I was thinking a lot about it after our session hour and into that
evening. There is no way she is going to be able to sit with all of those painful feelings
without saying something. And then—or acting on them; gosh, I hope she doesn’t
leave treatment.
Melanie called and cancelled our next session, leaving a cavalier—“Sorry,

I got a last minute photo shoot”—message on my voicemail. She said she would
see me the following week; but then she cancelled the next session too. I knew
Melanie was communicating her feelings through her actions, but I was not sure
what the best way to handle it was. I wanted her to have the space she needed,
but I was also afraid if I let it go for too long without responding, she would feel
even more abandoned. After some thought, I decided to call her back. Our con-
versation was awkward and curt, but Melanie said she would come to our next
session, and I believed her.
Melanie came in; I could feel the tension in the room as she slowly sat down
in her patient chair, crossed her legs, and folded her arms across her chest.
She was looking at me, but not speaking. I kept looking at the clock and fiddling
with the hem of my shirt; nearly five minutes of discomfited silence. Finally,
Melanie spoke, “I had a dream a couple of nights ago. In fact, I had two, right
in a row, I think. I remember you saying that if I had any dreams I should write
them down and bring them in. You said they could help the therapy; sometimes
they give new information?”
“Yes, yes, Melanie; yes, this is true,” I was nodding, as Melanie unfolded her
arms and reached into her bag, retrieving a small spiral note pad. She looked
up at me, her eyes softened, “Should I just start? Should I just read both of them
to you?”
“Let’s start with the first one; you can read what you wrote down and then tell
me about it. Sound good?” I asked her. Melanie nodded and flipped through the
pages for a second, found her spot and began to read.
“I was in a fashion show; I was in the dressing room getting ready, but the
dressing room looked like my house growing up. The makeup artist put too much
makeup on me; I didn’t like the way I looked. I told her, but she just kept putting
more and more on. You came in the door; I saw you and called out; I wanted you
to tell the makeup artist to stop, but you ignored me. It seemed like you worked
there; I think you were curling another girl’s hair. I was staring at you, trying to
get your attention, but I couldn’t for some reason. When I looked at myself in
the mirror again, I had no lips. My mouth was gone. I wanted to scream—I was
scared—but I had no mouth, so I couldn’t. I was trying to scream with my eyes.
I wanted you to help me; I got up and started walking toward you, but you were
gone. Like you disappeared or something. And then I woke up.”
“Wow, Melanie that is a very powerful dream; thank you for sharing it with
me. Let’s explore what it might mean,” I was captivated by the content.
“Wait, can I tell you the second one? I fell back to sleep and had the second
one right after this one. It’s short; can I read you that first?” she inquired, her eyes
wide and pleading.
“Of course, sure, tell me about your second dream,” I leaned toward her.
www.ebook3000.com
“In the second dream, I came to your office for our session, but you weren’t
there. The door was opened so I looked inside and all your things were gone.
I was standing in your empty office. It seemed like I was in there for a while, in
the dream. And then I began to melt—just like the wicked witch in The Wizard
of Oz. Maybe it was because I had watched part of The Wizard of Oz right before
bed. I don’t know, but I began to melt away until there was nothing left of me
except my black sweater. And then I woke up.”
Melanie shivered and then crossed her arms over her chest, “Scary. Right?”
I had associations running through my mind, but I wanted to hear Melanie’s
thoughts first. “Hmm . . . yes, Melanie, I could see how those dreams were scary;
they sound more like nightmares. How did you feel when you woke up?”
I wondered.
Melanie took a moment to think. She was rubbing her hands up and down her
arms and looking at the floor. When she finally looked up, her eyes were blank
and her voice hesitant. “I . . . umm . . . I felt kind of angry after the first one,”
she grumbled. She raised her voice and stared me squarely in the eyes, “When
I was trying to go back to sleep I kept thinking about how pissed I was at
you.” I felt a deep chill down my spine; I could feel her rage; and it was disquiet-
ing. I had the sense that she was teetering on the edge of verbally letting me have
it. And my intuition turned out to be right.
Whenever I felt Melanie’s rage, I would temporarily lose my ability to empa-
thize with her distress. This is a major challenge that therapists encounter when
being the direct target of a client’s rage. As much as we would like to assume
some omnipotent inoculation against our own ugly feelings, we therapists are
human too; and the more empathically connected we are to a particular client,
the more vulnerable we are to experiencing our own painful affects.
If we are to effectively help client’s struggling with “borderline personality
disorder,” we need to remain empathically connected, even if that means sitting
in one’s own rage; often times, I will feel rage for hours after being a casualty of
my client’s wrath. Authentic empathy requires an openness and accessibility to
both another person’s feelings as well as to one’s own. If we are not allowing a
metaphorical interpersonal boundary to be crossed—such that we actually can
access and experience the other’s feeling state—then we are simply being com-
passionate, not empathic. As confusing and often times disorienting it is to
empathize with a deeply distressed client, it is a crucial element for the treat-
ment; it is the only way to truly understand, on an emotional level, what a client
is feeling, and therefore, the only way to help them garner access to their own
unprocessed and chaotic emotional world.
My legs were crossed, and I was shaking my right foot. I was hoping to process
the content of Melanie’s dreams; there was so much clinically relevant material
that could be explored from the dreams. But Melanie’s response indicated that
she was ready to share her feelings more directly. I had tightness across my chest
as I looked Melanie in the eyes, nodded my head, and responded, “Yes, I can hear
that Melanie; you are very angry with me. I think it’s important for us to talk
about it.”
I was taking deep breaths as I waited for her response. Melanie’s eyes were
wild; her pale blue irises looked black; her pupils dilated. “I was asking for your
help in the dream and you were ignoring me; I felt invisible, like I didn’t matter
to you, like you didn’t care at all. And you were taking care of another person
while paying no attention to me! And I needed your help,” she was banging
her foot rapidly against the floor and her hands were shaking. She continued,
“When I woke up all I could think about was that I was just a pay check to
you; you don’t really care about me; you act like you do, but you’re only doing
that so I will keep coming in and paying you!”
Tears were streaming down Melanie’s cheeks; her shoulders were now shaking
too, and her head was bobbing, “No one cares about me, not Peter, not my
mother, not even my own therapist; I feel so invisible. It is just like the second
dream, you were supposed to be there for me, in your office, but you weren’t.
And it made me disappear; just melt away until I was nothing but a piece of
clothing. That’s all that was left of me once I realized you were gone.” She was
crying harder as she continued with a disturbing mix of desperation and rage,
“You just don’t care! No one does. How am I supposed to live like this? When-
ever I start to trust . . . to believe that someone actually gives a shit, they do
something that proves they never cared at all!” Melanie moved from her chair
to the floor; she lay on her side, curled her legs up to her chest, in the fetal posi-
tion, and sobbed uncontrollably.
My momentary lapse in empathy quickly remedied itself. When Melanie
moved onto the floor, she seemed like a helpless infant crying for her mother;
I felt devastated. And I was not sure what to do—how best to respond. I knew
Melanie was having a reaction to my impending vacation. And the feelings that
my temporary absence was bringing up were at the core of Melanie’s emotional
difficulties. Now was not the time to explore any historical connections, even
though these associations were very important in the long term. I needed to stay
present in the here and now with Melanie, to be with her in her feelings as they
related to me.
Based on what I knew of Melanie’s history, her responses to me, and the
content of her dreams, I was able to surmise that not only did Melanie feel aban-
doned by me, but she also felt that in my absence she would disappear; she felt
she would “melt away.” If she was able to process her feelings about my vacation,
it could help her understand her experience of others in her life.
I decided to use my own feelings of devastation to inform my response. I was
also trying hard to maintain my composure; I could feel tears forming under my
own eyes and my throat felt tight. I swallowed hard, hoping my voice would
not crack, “Oh Melanie, I am so sorry that this is so painful; I can really feel
how devastated you are.” It was good—in an ironic way—that Melanie was on
the floor and not looking at me. I had just enough time to take a tissue and wash
away the silent tear running down my cheek before Melanie sat up and made eye
contact.
She was sniffling. She was wide eyed and childlike when she asked if she could
continue the remainder of the session while on the floor. “I have a headache
now. I think if I lay down it will help,” was her alibi. “Sure, Melanie, if you will
feel more comfortable,” was my response. I knew Melanie’s desire to stay on
the floor had a deeper significance. It was quite unusual, and the session was so
intense. It was definitely not a good time to explore something like this, so
I did not question her. I did speculate that being on the floor reminded her of a
time in her childhood when she and her mother were always together. This
was a time when they were physically enmeshed—nearly inseparable. Despite
the fact that this eventually caused Melanie much conflict, she did describe
times from her childhood when her mother’s overbearing presence was soothing.
I wasn’t sure—her positioning felt regressive—but my sense about Melanie’s
request to stay on the floor reminded me of these times when she found comfort.
Melanie was on her back and facing me when she shared her feelings about
my vacation. Her voice sounded childlike: “I didn’t think I cared at first, but after
I had those dreams, I realized that it feels like you are leaving me. It seems weird
because I sort of know you’re not, but it feels like you are. And I am worried that
I might fall apart while you’re away; I’m worried that you might decide you don’t
want to be my therapist anymore while you’re away; Maybe I am using you to fill
this void I have; I don’t know. I’m just upset that you’re going away and then I’m
upset that I’m upset. None of this makes a lot of sense to me. It’s just how I feel.”
We spent the little remaining time we had left exploring Melanie’s feelings of
being left—abandoned by me. In fact, most of our session time leading up to my
vacation was spent with Melanie on the office floor exploring why she experi-
enced my vacation time as both a rejection—an indication that I did not care
about her—and abandonment. The sessions were difficult; Melanie fluctuated
between intense affect and defensive disengagement. And the amount of suffer-
ing my vacation was causing Melanie left me feeling guilty; the guilt caused me
resentment. I was spending much of my personal time thinking about Melanie;
it was all a lot to contain. By the time I was on the airplane headed toward my
holiday destination, I was emotionally exhausted.
I did leave Melanie with something to think about in my absence. She was
trying so hard to sort through the incongruence between her thoughts and feel-
ings. “Melanie, I know this is all very confusing for you; emotions are not always
rationale; sometimes we can intellectually understand something so completely,
but our emotions make us feel something entirely different. But our perception is
everything; it’s our truth. If you anticipate abandonment, you will find it,”
I explained. And then I added, “Does this make any sense, Melanie?” She was
squinting her eyes, listening intensively, “I think so; I need to think about it.”
She took out her little spiral notepad, jotted down a few lines, looked up at me,
and said, “I will think about it.”
When I returned from my vacation, Melanie was a blond. Her new platinum
locks changed her whole appearance; I was a bit taken aback at first; the change
was rather dramatic. I could tell she was waiting for me to notice—to acknowl-
edge her personal alteration. “Wow, look at you, Melanie; a blond now; what a
change. You look really striking,” I was so curious about her decision. I knew
her mother was blond, and Melanie envied her mother’s blond hair; I wondered
how much this may have influenced the change. I wanted to know what had
prompted her decision. I waited to see if she would offer me an unsolicited
answer. She giggled like a schoolgirl, but her eyes looked intense, “My mother
made me do it; I was feeling depressed while you were away and she said,
I needed a change. So I did it.”
“Hmm . . . okay . . . ,” I wasn’t entirely clear. “So, your mother ‘made’ you do
it? Did you want to do it?” I wanted to understand if Melanie had made her
own decision. Melanie described her mother as completely overbearing, dictat-
ing much of the direction of Melanie’s life. When Melanie wanted to go to col-
lege, her mother insisted—not taking “no” for an answer—that Melanie
become a model. Melanie was afraid if she pursued her own desires, her mother
would abandon her; so Melanie almost always did whatever her mother told
her to do. We had been working on helping Melanie separate and form healthy
boundaries with her mother prior to our vacation-related emotional-jungle-gym
experience.
I imagined that Melanie’s decision to go blond was complicated; and I was
waiting for her answer. Melanie slouched into her chair and looked away from
me momentarily. When she met my eyes again, I tilted my head to the side,
“Melanie?” She cupped her face with her hands and bowed her head, “I don’t
know; I just don’t know.”
“It’s okay Melanie,” I wanted to reassure her that I wasn’t sitting in judgment,
but rather trying to help her. “I’m not judging your decision. I just want us to talk
a little bit about it. Is that okay for you?”
“Yes . . . yes, it’s okay,” she mumbled. She elaborated, “I can’t tell really;
I mean, my mother brought it up and it seemed like a good idea; I always wanted
to see what it felt like to be a blond; so when she said it, it seemed like a good
idea; like something I did want; but now, I’m not sure. I mean, now that I did
it, I’m not even sure I like it. Do you think I should dye it back?”
I was not going to fall into that trap; I wanted Melanie to make her own deci-
sion. “Melanie, rather than answer that, let me help you figure out if you want to
dye it back; let’s explore what you want. I want to know what you want and
I trust that you can make the right decision for yourself,” I leaned toward her
and raised my eyebrows with a questioning gaze.
Melanie released a deep exhale and smiled, “I hate it. I want to dye it back.
See I was afraid I would lose focus while you were away. I never should have done
it. I’ll make an appointment with my stylist as soon as I leave here and color it
back,” she smiled harder. “Pheewee,” she released a long sigh of air.
After that session, Melanie—once again, a stunning brunette—seemed to
have a bounce to her step. She described feeling hopeful for the first time in a re-
ally long while. With Melanie feeling more stabilized and emotionally stronger,
we were able to explore her relationship with her mother in more depth. Melanie
was an only child. Her parents divorced just around Melanie’s second birthday.
Melanie lived with her mother, but her parents shared joint custody, so she did
get to spend a lot of time with her father. She described really enjoying her time
with him. Although he was a reserved and reclusive “writer-type”—her father
being an author—Melanie found comfort just being around him. “He doesn’t
talk that much, but he is very warm and I always feel calmer when I am with
him,” Melanie smiled when she spoke of him.
Melanie described her mother as the direct opposite of her father. “She is the
life of the party,” Melanie shared with a caustic tone. “There were always tons of
people around; and my mother . . . well, she lo-o-oves attention,” she was shaking
her head and wrinkling her nose. “Sometimes she made me want to throw up.
She puts on a good act for everyone—sickening, really.” Despite Melanie’s
obvious distaste, she also said that her mother and she were “very close”; so close
that Melanie often described her mother and her as inseparable. Melanie both
loved and hated this; her feelings toward her mother were totally ambivalent.
From Melanie’s narrative I was able to appreciate the depth of the conflict
with her mother; I also came to understand how this relationship grossly affected
Melanie’s feelings about herself. Her mother was domineering, never allowing
Melanie any room to grow as an individual person. For Ida, Melanie existed
purely as an extension of herself; she never listened to anything Melanie wanted
or did not want. She was entirely incapable of allowing Melanie to think for her-
self or foster any of Melanie’s strengths as a whole person. As a result, Melanie’s
sense of herself was underdeveloped and fragile; this created a circumstance in
which Melanie was dependent upon others for self-definition. Without another,
Melanie had no idea who she was or what she wanted.
In one unforgettable session, Melanie sat on the floor crying while describing
how her mother told her she was “nothing but a pretty face.” Whenever Melanie
showed interest in any extracurricular activities or investment in her education,
her mother would tell her she was not good enough or smart enough. Melanie
wanted to join the high school soccer team, but her mother was not having her
porcelain-doll daughter “running around kicking a ball like a boy.” “Nooo
Melanie, you listen to me! Are you listening? I won’t have it. I will not have
it! Besides you have no talent in sports; you’re not athletic; you’re nothing but
a nice pair of legs and a pretty face.” By the time Melanie finished telling me this
horror story, she was crying so hard her words were barely audible. As a result of
Ida’s relentless efforts to stop Melanie from doing anything that would enrich
her life or afford her any new experiences, Melanie now—as an adult—felt
completely worthless.
“I know . . . I know . . . it can’t really be true. It can’t, right?” she was rocking
back and forth, and weeping. “I know I must have more to me than being pretty.
But I don’t feel that way. I just don’t. I actually hate when people tell me that
I am pretty or beautiful. I hate it! I want people to like me for me, not because
of how I look. But then I don’t know what there is to like. I say I want people
to like me for me, but . . . but, I . . . I just don’t know who I am anyway. This feels
so confusing,” Melanie stopped rocking, began pounding her hands on the floor,
and sobbed for over five minutes. She kept repeating, “I just don’t know. I can’t
take feeling like this. Please, please help me. Please help me. I can’t take it any-
more. Please, please help. Please . . .”
When she finally calmed down, she looked exhausted. Melanie’s emotions
were so raw, I could feel her pain; she was so desperate. I felt tortured and com-
pletely agonized while sitting with her in the dreadfulness of her story. I wanted
to hug her and tell her everything was going to be okay. Instead I responded
with, “I am going to help you Melanie. I promise.” And I meant it.
My thoughts associated to my first encounter with Melanie; the day of our first
session was floating around in my mind. My feeling sitting with Melanie during
that first day was that she was an empty shell. And this is exactly how Melanie
felt about herself. Her mother’s commanding presence over her development
coupled with her assaultive attacks on any emerging self, left Melanie feeling
that she was “nothing but a pretty face.” And now at 32 years old, Melanie was
in a career where her most important attribute was how she looked.
Despite the fact that Melanie was in a storm of emotion and pleading in des-
peration for help, as soon as the session was over, she got up, collected her things,
and waltzed out my office completely composed; she carried herself with the
poise and grace of a professional ballet dancer. This was the way Melanie
lived—she would be engrossed in a gale of chaotic emotion and then in a snap
pull herself together, seeming as if it never happened. She had learned how to
detach herself from her feelings in order to survive the imperious presence of
her mother.
Melanie did possess an uncanny strength that made our therapy together
more effective; she was able to articulate her feelings, even in the midst of some
of the most powerful storms of chaos. Her ability to be curious and verbalize her
conflicting feelings, even when she felt confused, helped her to begin integrating
an internal sense of self. This was going to save her from more years of tor-
menting internal havoc.
The next few months were filled with painful stories surrounding her mother’s
assaultive comments and suffocating nature. Melanie was really struggling to
understand what it all meant to her. She was able to understand how her
mother’s behavior toward her left her feeling worthless and empty. It was more
difficult for Melanie to reconcile her concomitant desire to remain close with
her mother. I offered some guidance: “Melanie, of course you want to maintain
a close relationship with your mother; she is your mother and as difficult as your
relationship is, she is the person to whom you feel the closest.” Melanie, listening
attentively, wide eyed and hanging on my every word, nodded that she
understood.
Melanie had been trying to “change” her mother’s reactions to her; she was
attempting to garnish her mother with the insights she had garnered through
our therapeutic work together; she was not getting anywhere. The failing efforts
left her in a tortured fury. Some sessions her rage would be so intense, I had to sit
all the way back in my chair, physically moving away from her—it was too much
to bear. There were days when I had fantasies of running out of the office and
getting as far away from the squall of rage as I could. But, I stayed with Melanie;
I promised her I would. And I intended to keep my word.
One session when Melanie was calmer, we were able to discuss the possibility
that her mother was never going to change. I had been holding my thoughts
about this in abeyance, waiting for an opportune time to share them—a moment
during session when I thought Melanie could hear me. “Melanie, perhaps we
have to look at this from a different perspective. I don’t like seeing you so angry
and frustrated by your mother’s failure to hear you,” I leaned toward her. Melanie
leaned in putting her elbows on her knees. She was biting her lower lip and
waiting.
I swallowed hard and continued, “Melanie, I know this is very hard; I really
do; but I don’t think your mother is going to change; at least not in the way
you imagine or would like; so all we can do, is help you change how you respond
to her; and continue to help you feel better about yourself, so that her harsh
words don’t hurt so much; or so that you can see that her words aren’t the
truth—for example, you aren’t just a pretty face; you are so much more than that.
The more you realize this, the less impact her comments with have.”
Melanie leaned back in her chair and squinted, “Hmm . . . yes . . . I see.”
“Melanie,” I continued, “Remember a while back we were working on setting
new, better, clearer boundaries with your mother? We were discussing that you
might want to go to college. Remember, it was before my vacation?” “Yes,
yes . . . I do,” she said, leaning toward me again, elbows to her knees. “I still think
about that; about going to college, I mean.”
“Good, Melanie, we will work on that. And that is a good example of what
I am saying. We can’t let your mother stop you from pursuing things that you
want for your own life; you aren’t a little girl anymore; you are a woman and
you can choose to live your own life now—not live hers. Does this make sense?”
I sat back in my chair, giving Melanie time to think about everything I just said.
“Umm . . . yes, it makes sense,” Melanie started taking notes. She looked up
from her little spiral notepad and asked, “What if she stops talking to me or
leaves me or doesn’t love me anymore? I’ve always been terrified that if I don’t
listen and do what she says that she would leave me—you know, not want any-
thing to do with me. She always said, ‘it’s my way or the highway’; what if this
is true?”
Melanie was biting her lip again; she was gnawing at it so hard, she started to
bleed. I was thinking about how to respond to Melanie’s question; it was a hard
one. And while I was taking a therapeutic minute, I remained acutely vigilant
of how anxious Melanie was; despite her bleeding lower lip, she was still biting
down; I was worried she would chew it off in angst if I did not respond quickly.
Then I remember her mother’s response when Melanie told her she wanted to
go college. Hmm . . . Feeling relief, I responded with a question: “Melanie, do
you remember your mother’s response when you told her you might take some
college classes?”
“Yes . . . yes . . . I do,” she paused for a quick moment; she was thinking.
“She told me, she thought it was a bad idea and she wouldn’t help me pay for
it. But she couldn’t stop me . . .” she paused again, this time for a bit longer.
She was rubbing her hands together and then chuckled to herself before she con-
tinued. Still giggling to herself, “Oh, yeah, right . . . then she said, ‘you can ask
your father for the money; since he went to college maybe he will think it’s
important enough to pay for.’ ”
“I feel better about what you said now. I guess maybe I can try to do more
things that I want. Maybe in time she will understand?” she half-laughed. “One
can only hope, Melanie,” I smiled, using humor—as Melanie did—to lighten
the moment. I think we both knew that Ida was way too stubborn and entitled
to ever change.
We were about a year into our therapeutic journey, and Melanie was doing
much better; she was more stable and emotionally integrated. I knew she was still
fragile, but she had more access to her strengths and emotional resources. She was
taking two classes at a small liberal arts college, for which her father was paying.
In order to support her somewhat lavish lifestyle—one to which she had become
accustomed—she continued her modeling. And she wanted to start dating again.
When we had started our treatment, I had suggested that Melanie may want
to take a sabbatical from men; I did not insist, but I suggested that since she was
worried that she maintained a dysfunctional intimate relationship pattern, begin-
ning a new relationship could complicate our work together. At the time, Melanie
was so broken by Peter; she stated, “Trust me the last thing on my mind is a new
man; I don’t know that I’ll ever get over him; he was the love of my life.”
We were just beginning to explore the possibility that Melanie was ready to
meet a new man. But, then the storms of chaos struck again when right before
her midterm exams Melanie ran into Peter at a photo shoot.
Melanie arrived to our session looking uncharacteristically disheveled; she

always looked so effortlessly put together—like a model. But on this particular
day, Melanie was a mess. Her hair was knotted, as if it had not been brushed
for days; she had dark circles of crusted makeup under her puffy eyes, and she
appeared to be wearing pajamas. I was unsure if in fact she was wearing her night
clothes, but her flannel shirt was wrinkled giving the impression that she had just
rolled out of bed. As we began our session hour, I came to learn that Melanie
had, in fact, rolled out of bed—where she had been for the past two days—just
to come to session.
Melanie was hysterical; she came in, sat in her chair, folded herself in half—
her upper body lying across her legs—and sobbed. I had no idea what was the
cause of Melanie’s distress, so I sat with her in her tears and waited. I was just
about to offer a soothing comment, when Melanie sat up and, with a pained
stare, made eye contact. She was still catching her breath as she began to speak:
“I . . . I have been in bed . . . for . . . for two days . . . I . . . I . . . slept . . .” She shook
her head and paused looking downward; she was coughing as she tried to clear
her throat. Finally, her voice still a little shaky, she began to describe the awful
details of her run-in with Peter.
Melanie walked into her photo shoot and immediately saw Peter. It had been
months since the dreadful day Peter ended their relationship. “Melanie, you are
suffocating and overly emotional; I’m sorry but I just can’t do this anymore. I’m
leaving,” and just like that Peter packed up his things and walked out on her.
Melanie was devastated. She had tried on numerous occasions to reach out to
Peter and get him to give her another chance, but he was unresponsive. In one
final phone call, Peter requested, “Melanie please stop calling me; I don’t love
you anymore.” Melanie was in bed for weeks after that.
When Melanie saw Peter, he smiled hard and instantaneously came toward
her offering a warm hug. Melanie described having butterflies in her stomach;
she felt nervous and awkward, but she was really happy to see him. They
exchanged some flirtations during the six-hour shoot; and afterward, Peter asked
Melanie if she wanted to “grab a drink and catch up.” One drink led to two, then
three; and the next thing she knew, they were back at his new apartment having
“wildly passionate sex.”
Melanie shared that Peter “missed her.” “At least that’s what he told me while
we were having drinks; he said he missed me and still loved me,” she was banging
her hand against her head. “That’s what he said and I believed him. I believed
him! I’m so stupid,” her eyes welled up with tears as she continued. “I never
would have gone home with him if I thought for one second he was lying! I’m
so stupid! I can’t believe I gave myself to him after everything he did to me!”
she was screaming, her rage escalating. “I thought he wanted me back; I really
did. I thought . . .” Her voice trailed off as she began to weep, “I really thought
he wanted me back . . .”
After their “hours of wildly passionate sex,” they both passed out, exhausted.
In the morning, Melanie was in the kitchen making coffee while Peter was still
sleeping when his cell phone went off. It was a text message. “I knew I shouldn’t
really be reading his text messages, but his phone was right next to me; I just
couldn’t resist,” Melanie cried. “And . . . and the message was from a woman—
Penelope—that’s what the caller ID said—Penelope K. And . . . and,” Melanie
started banging her head again.
Melanie remembered the message verbatim: “Hey sexy, my parents are meet-
ing us at 12:00 for brunch, instead of 11:30. I’ll come by around 11:45. Can’t wait
to see you. xo.”
“I woke him up, shoved the phone in his face and asked ‘What is this?!?
Who is this?!?’ ” Melanie’s cheeks were turning bright red as she telling me what
happened. Peter rolled over, lazy-eyed from sleep, and carelessly said, “She’s my
girlfriend.” Without emotion he added, “Well you didn’t ask if I was seeing any-
one. Mel, I was going to tell you.” Melanie in a fury went in the bathroom, took
Peter’s long shirt off, tried to flush it down the toilet and then put her clothes on
from the night before. She then went into his kitchen and smashed a bunch of
dishes and glasses all over the floor. He was trying to calm her down, “Mel,
please; please, calm down. Let’s talk about it.”
“I am through talking to you Peter. Through! I never want to see you again!”
Melanie said. She was screaming and crying as she took his cell phone threw it
on the floor and crushed it with her boot. “I guess you won’t be texting Penelope
K back anytime soon.” She was just about to slam his door shut when she heard
Peter scream, “You’re crazy. This is exactly why I didn’t want to be with you
anymore!”
Melanie was scrunched over with her face in her hands crying, as she shared
Peter’s last crushing statement. It took months for Melanie to totally recover
from her last encounter with Peter. She was blaming him for most of what
happened, but the most painful part was that she was also blaming herself.
Underneath her rage and contempt toward Peter, Melanie believed what he said.
Melanie believed it was her fault that he left her.
Melanie’s shame and self-hate were nearly debilitating following the incident
with Peter. She was able to push herself through her midterms half-heartedly.
But she was barely working and basically spending most of her time in bed
watching television or sleeping. With time, and with many sessions mixed with
tears and rage, Melanie recovered enough that we were able to process what hap-
pened with Peter constructively. We were able to work on the connection
between her underlying shame, her abandonment fears, and the assaults to her
personhood during her childhood.
About a year and a half into her therapy, Melanie met a new man—Wayne—
an art history graduate student attending the same college as she. The two met in
the library and quickly started dating. Melanie is much more aware of her
anxieties surrounding any healthy separation from Wayne; and she is working
very hard in therapy to maintain her independence and to be able to be with
Wayne while also being able to be with herself. It is still a challenge for Melanie,
and her abandonment fears still surface, albeit with much less frequency and
intensity. Her plan is to finish her college degree and possibly pursue her dream
of going to law school. She has whispered to me in session, “I want to be married
to Wayne too; but I know, I know . . . in time, right? Right now, I have to pay
attention to myself. I am really trying. I am.” And she is.
And I am hopeful for Melanie.
6
The Permeable Frame: Ethan’s Story
It was our first session, and Ethan was describing episodes of feeling “out of it”
and in a “weird fog.” His expression blank and his voice flat, he shared, “At least
twice a week, I find myself with my dick in a hole in the wall and some anony-
mous man sucking on it; I feel like I just find myself there and it’s like I didn’t
decide to go there—you know, to the porn shop; I didn’t decide to go . . .” he
drifted off momentarily. And then continued, “I am just there; I sort of know
I am there, but I’m really out of it. But when I leave and realize what I did, I feel
horrible . . .”
During our initial phone contact, Ethan reported that he had serious marital
problems, and he was afraid if he did not get help, his wife was going to leave
him. She had given him an ultimatum—either he seeks therapy, or she takes
their two young daughters and leaves. He was seeking treatment to prevent this
from happening.
I was surprised by Ethan’s clinical presentation and overall way of being when
we met for our first session. He sounded angst-filled on the phone; his voice was
shaky and hesitant, and he was fumbling with his words. I imagined him being
uneasy and apprehensive during our initial meeting; but he was not as I expected.
Instead, he interacted with childlike playfulness, while simultaneously feeling
disturbingly void of emotion. And his narrative—told with pronounced detach-
ment—was filled with terrible stories of dysfunction and abuse. There were
moments—eerie flashes in time—when Ethan seemed to be in a trance.
During our first session, I learned that Ethan’s wife found out about his visits
to the porn shop. It had been close to a year ago when she happened to be driv-
ing past and saw Ethan walking out. He reported that he was really trying to stop
going in, but he could not. “It feels like I just find myself there; I’m not planning
it; and next thing I know I’m just there,” he stated, his eyes vacant. He crossed
his legs, sipped a coffee he brought with him and continued, “I have to stop or
she’s really going to leave. She’s fed up; she thinks I may be gay, but I’m not;
I really am not. I just don’t understand why I keep going in there. I hope you
can help me figure this out.”
I nodded, listening intently to his every word, while also observing the incon-
gruence between his narrative and his expression. He sounded like he was
rambling off a grocery store list—he was so disconnected from the content of his
story. I knew this observation was clinically relevant—likely the reason he did
not feel in control of his actions, why he felt “out of it”—but it was too early to
observe this with him. I was about to validate his need to “understand” his
actions when he just talked right over me and continued. “My half-brother
sexually abused me when I was a kid; maybe this has something to do with my
problem,” Ethan seemed as if he was talking to himself.
He paused for a moment and reached over, pulling a cupcake out of his jacket
pocket; he opened it up and began to eat. He began describing a long history of
sexual abuse; he was speaking between chews. The juxtaposition between his
story and his casually eating and sipping his coffee, his legs comfortably crossed,
gave me the sense that he felt like an observer of his own life; it felt as if he was
watching a movie, rather than explaining events that he personally experienced.
During the early stages of our therapy journey, Ethan spent most of the session
hours going over the particulars of the abuse he experienced. His accounts had a
wordy, ruminative quality; he would describe incidents with such detail, but he
was rambling, trailing off, and detached from the content. It felt like he had no
emotional relationship with anything he was saying. And he did not.
The amount of information he disclosed surrounding the abuse was also strik-
ing. It is unusual for a sexual abuse survivor to divulge intimate details of the
events with such detail so early in the treatment. Typically, there is so much
shame and conflicting emotions regarding the abuse that clients have a difficult
time talking about it; often times it takes months, sometimes years, to piece
together the traumatic events that occurred.
I was not sure how to handle discussions about the abuse. Ethan was clearly
traumatized; and I knew eventually we needed to explore the gross disconnect
between his thoughts and feelings. Because this usually happens much further
along in the treatment—when trauma survivors finally begin talking about the
abuse—I felt that I should wait. Despite the ease with which Ethan appeared to
be discussing the abuse, I knew his propensity to dissociate indicated deep unre-
solved trauma. With this in mind, I decided that my role—for the time being—
was to listen and bear witness to his story.
Ethan was 40 years old and had been married for 11 years. His marriage had
been falling apart for years before his wife finally discovered his frequent visits
to the porn shop. Ethan stated that his wife, Sylvia, was continuously dissatisfied
and often complained that Ethan seemed absent from the marriage; he was emo-
tionally unavailable. Ethan had been engaging in oral sex with men throughout
their marriage; and he was hiding his extracurricular activities from her. This—
I imagined—created a lot of distance between them; Ethan had a whole other
life—a secret life—to which Sylvia was not privy. Additionally, Sylvia refused
to engage in any sexual intimacies with Ethan until she knew he was no longer
having relations with men. Ethan complained that Sylvia’s withholding of sex
The Permeable Frame: Ethan’s Story 83
was causing him to act out more; it made his visits to the porn shop more
frequent.
Ethan reported anxiety and distress regarding his marital problems. “I don’t
feel comfortable at home anymore; she’s watching me like a hawk and she’s
always mad about something. I keep telling her that she’s making everything
worse. But she won’t listen. She says it’s all my fault; I guess, maybe it is. But she’s
not making it any easier for me to get better,” Ethan’s brow furrowed as he
talked. It was the first time I observed Ethan in any overt emotional discomfort.
I knew the treatment was going to be challenging. And then there were the hor-
rors of Ethan’s past; he had deep scars from the severe and consistent violations
he experienced. It was hard to bear.
In his characteristic detached manner, Ethan—in session after session—
described an atrocious series of traumas from his past. Ethan was raised by his
parents as their only child until he was 5 years old, when his half-brother—his
father’s son from his first marriage—came to live with them. Mario was 10 years
old at the time and was a “bad seed.” I asked Ethan to elaborate on what being a
“bad seed” meant. He stated, between sips of his usual tall coffee, “You know, he
was getting into trouble at school—he used to bully other kids in the school yard.
And he never listened to his mother; she couldn’t control him. My dad is tough;
when I was a kid, I was afraid of him. If he says something, you listen. So Mario’s
mother sent him to live with us. You know . . . to whip his ass into shape.”
Ethan and Mario shared a room. Mario had only been living with them for a
couple of months when one night he crawled into Ethan’s bed with him. Ethan
described rolling over, half asleep and finding Mario next to him. “He was rub-
bing my dick,” Ethan sipped his coffee, leaned back, casually crossing his legs.
His eyes were wide but vacant as he continued, “I sort of knew it was wrong,
you know, that he shouldn’t be touching me there, but it sorta felt good. So
I didn’t stop him. Or maybe I was afraid to stop him; he was so much bigger than
me. It’s confusing to me when I think about it. But anyway, I didn’t stop him.
And he kept doing it.”
After a few months, Mario began performing fellatio on Ethan during their
evening encounters. And then after some more time had passed—Ethan thought
it was about a year after the abuse started—Mario started taking Ethan’s head
and pressing it gently downward toward his genitals. He was encouraging Ethan
to pleasure him. At first, Ethan resisted, but then Mario began to push Ethan’s
head harder; he held Ethan’s head so hard and he would not release him; Ethan
felt he “had to give in.” “I didn’t know what else to do. Mario said that it was
my turn. His dick was in my face and he wouldn’t let go of me. I didn’t know
what else to do . . .” Ethan trailed off; he seemed absent for a moment and then
he repeated, his voice soft, “I just didn’t know what else to do.”
About three months into our twice-weekly therapy, Ethan began to wear
T-shirts and sweatshirts that had emblems of various superheroes. After a few
weeks, I decided to observe his choice of apparel with him—bring it into the
room. I was wondering what it might mean; and I also thought the question
might encourage him to be more present. I wanted to create a more reciprocal
dialogue, hoping this would cultivate a greater awareness of the existence of a
relationship between us; and perhaps this would lessen Ethan’s profound
detachment.
I leaned forward, raised my eyebrows and gently stated, “Ethan, I notice you
like shirts with superheroes on them.” He looked at me, his eyes wide and child-
like as he nodded, “Yes, yes, I do.” I leaned in a little closer, “I’m curious, Ethan,
do you have thoughts about superheroes? Do they hold any personal significance
for you?”
Ethan moved from the patient chair—where he usually sat—to the couch; he
plopped down, sinking into the cushion; reached into his backpack; and pulled
out a muffin. He unwrapped it, and began eating. Pieces of muffin were flying
out of his mouth as he was speaking, “That’s an interesting question Doc. I’m
not sure.” I encouraged him to think more about it: “Ethan try telling me what
comes to mind. What are your thoughts about superheroes?”
Ethan crossed his legs at his ankles and began swinging them; the expression
in his eyes was a combination of childlike innocence and the curiosity of a kit-
ten. He was still eating his muffin, as I observed the shift in his demeanor and
waited for him to respond. “I have always liked superheroes; when I was a kid
I would imagine that I was a superhero; I can remember spending hours day-
dreaming that I was a superhero—that I had special powers. If I was a superhero
then no one could hurt me; I would have special powers . . . powers that would
keep enemies from hurting me . . . I guess . . . ,” he drifted off in thought. He
rubbed his hands over the front of his Spiderman T-shirt, “I guess, I always
wanted to have their power; their special and superior powers; yeah, to me,
superheroes have all the power. They can always save themselves—protect
themselves—and the world too . . . That’s what comes to mind Doc.”
He paused, swallowing the last bit of his muffin, and washing it down with a
chug of coffee. He looked straight at me, as if it was the first time he really
noticed me. Then he asked, “What does that mean Doc? Does that mean any-
thing?” I took a sip of my own coffee—giving myself a moment to think. I was
chewing on my lower lip. I was about to take a leap with Ethan; I was going to
answer his question with an interpretation. I wasn’t sure if it was timely. Is it
too soon? He’s finally engaging; am I going to scare him? Will he disengage again?
I thought his question coupled with his genuine curiosity offered a window of
opportunity; and I decided to take the risk.
I leaned toward him, speaking in a soft, soothing tone, “Ethan, I’m thinking
that you felt very powerless when you were a kid. From your stories it sounds like
you felt very unsafe; and you weren’t safe—even in your own house. I’m wonder-
ing if imagining yourself as a super hero—with their super powers—helped you;
the fantasies offered you temporary relief from feeling scared all the time—they
gave you a sense of feeling powerful, and in control of your environment and
all the bad things happening to you?”
Ethan raised his eyebrows; he was blinking rapidly and swinging his crossed
legs. He pulled a bag of M&Ms out of his backpack and began eating again. He
appeared so childlike. I was associating his manner to Ethan as a boy. Ethan’s
youth was stolen from him; and I had the uncanny sense that in these moments
Ethan’s expression was him as a boy—that in some ways he was stuck there—his
emotional development arrest.
I tilted my head to the side, “Tell me Ethan—do you have thoughts about
what I just said?”
“I think you’re right Doc,” he leaned in toward me. “I never ever felt safe at
home . . . especially after Mario came to live with us. My father was always scary
to me; he was always yelling at me for something. I was so afraid of him; I tried so
hard not to upset him; but I never knew what he was going to get angry about.
Sometimes he just went off screaming at me and sometimes he screamed at my
mother too . . . I just never felt safe with him, you’re right. When Mario moved
in things just got worse. And then when I told on Mario my life was hell.”
I still sensed some guardedness from Ethan, but as he was speaking, I noticed
that he was much more engaged with me and to the content of his narrative.
He revealed a greater range of emotions, too; I felt more depth in his emotional
expression. This was definitely progress, but Ethan’s porn shop visits were
increasing in frequency and his last visit almost got him arrested. This was going
to take a lot of hard work.
“You know Doc,” Ethan had more to say, “I still feel totally powerless. I think
you’re right, pretending I was a superhero was the only time I felt powerful. And
that is a great feeling. Maybe I am still trying to get that feeling. If I really think
about it, I usually wear my superhero shirts when I feel the most powerless or the
most afraid. And this time—right now—I am afraid I will lose my family; and
I am afraid that I can’t stop acting out with men; and I am afraid that I just can’t
get a hold of myself in general. I feel very unstable, fragile and powerless. Doc, I
know this probably sounds weird . . . maybe it is weird . . . but I actually still wish
that I was a superhero. I really do.”
When Ethan was 9 years old and Mario was 14, Ethan told his mother that he
and Mario and he were having oral sex. The abuse had been going on for four
years, and as Ethan began to notice girls at school, he began to realize—with
greater clarity—that what he and Mario were doing was wrong. He tried to get
Mario to stop, but Mario refused. In fact, the harder Ethan tried to get Mario
to stop, the more aggressive Mario’s sexual overtures became. He even started
punching Ethan, forcefully making him continue. Ethan, wanting Mario to stop,
reached out to his primary caregiver—his mother—for help. One day, Ethan
started at the beginning and told his mother the whole awful series of events.
I had heard Ethan’s story many times; he often spent the session time rumi-
nating about the abuse. The next part of the story was the crushing blow that left
Ethan broken. And it was always the hardest to hear. I could feel myself cringing
whenever I knew he was about to retell what happened the day he told his
mother.
Ethan described wanting to tell his mother about the abuse since the first
night that Mario—uninvited—entered his bed. But Mario warned Ethan not to
tell, stating from the very first night that it must remain their secret. He told Ethan
that they would both get in “big trouble.” Ethan believed him and also feared him,
so he decided that he better not tell anyone. In one session, Ethan explained,
“I wanted to, but I couldn’t; I was really scared that we would get in ‘big trouble.’
I was so little when it started and the whole thing felt so confusing at the time.
So I just found ways to survive it. Like sometimes I could rise out and above my
own body. It’s like I wasn’t really in my body anymore. I looked down on the scene.
It was like it was me, but it wasn’t at the same time. Does this make sense?”
Remembering my own sense that Ethan often seemed like an observer of his
own story, I responded, “Yes, yes, Ethan this makes total sense. And is a very
common survival mechanism for victims of sexual abuse. You felt like an
observer. I wonder if you still feel like this now.”
Ethan—that day eating a white frosted donut—sat back in his chair and
winced. “Yes, I do Doc. I feel like that all the time; like every day. Sometimes
I snap out of it, but I do feel like I’m outside of my body all the time. I do. That’s
exactly how I am when I find myself in the porn shop; it’s like I am there, but not
there. It’s all still so confusing.” Ethan released a gasp of air and then looked
down, picking at the frosting on his donut; he appeared so boyish as he was
licking his fingers.
Ethan finally decided to tell his mom when one of his teacher’s noticed a dark
bruise on Ethan’s arm. Mario had punched him really hard the night before,
practically beating him, until Ethan finally surrendered and gave him a blow
job. His teacher asked about the bruise and Ethan lied. He told her that he was
playing football with his brother and fell. He insisted that he was okay. His
teacher finally conceded and stopped asking questions. Ethan described knowing
at that moment that he needed to tell his mother. He was afraid she might discover
the truth on her own and that he would be in even more trouble for not telling.
He left school that day determined to reveal the whole ugly story to his mother.
Ethan walked home from school rehearsing the whole scene in his head; he
was preparing what he was going to say and imagining his mother’s response.
He thought she might be angry, that she might even yell at him; but he also
envisioned her as his savior; he thought of her rescuing him from the wrath of
Mario. And these images of his mother helping him, assuaged his fears as he
slowly opened his front door.
Ethan shared this part of his story over and over; the images “flashing”
through his mind on a daily basis. Ethan and his mom were having cookies and
milk in the kitchen; this was a frequent afterschool activity that they shared.
He reported the story to his mother. “Most of the details, not all, but most,” he
reminded me many times during our sessions.
Ethan remembers his mother dropping her glass, and milk splattering all over
the kitchen floor. At first she was crying. “She didn’t say anything at first she was
just crying; I was scared. My mother almost never cried,” Ethan often repeated
this. The tenacity with which he repeated this line gave me the sense that he
was practically reliving it.
Then she began screaming at Ethan. Ethan described a “scary” look in her
eyes when she was screaming at him. Then suddenly she stopped screaming, bent
down, grabbed Ethan’s face, squeezed his cheeks together until they were burn-
ing and stated, “This is a lie, Ethan.” Ethan was so scared that he could not move.
She pushed his cheeks harder and started yelling again, “Ethan, this is a lie;
I didn’t raise you to be a liar. How dare you say this! Mario is your brother;
how dare you, you little liar! Never ever repeat this to anyone and I never want
to talk about this again young man. Do you understand? I never, ever want to
hear this come out of your mouth ever again!” she released his cheeks and ran
off into her bedroom. Right before he heard her door slam she, hollered one more
thing, “And clean the milk off the floor, you filthy little liar.”
After that day Ethan was never the same. That scene, which Ethan played
over and over in his head, left a permanent scar and changed his life forever.
Ethan’s father was emotionally abusive; and his half-brother was sexually and
physically abusive. Ethan was living in a private hell for years, but his mother’s
reaction to his disclosure about the sexual abuse remained imprinted in his mind
as the day that ended any sense of safety or stability. He had always imagined her
as his private ally—his protector, his superhero—but after that day, he experi-
enced her as a perpetrator. Any sense of security was scattered, and Ethan recalls
feeling distant and disconnected from that day on. His perception of his world
was altered and he began to experience himself as a perpetual victim—a
wounded causality for others to prey upon.
As a 40-year-old man, Ethan found himself in a marriage where he was being
controlled and manipulated by his wife. She was withholding any intimacy;
Ethan was not even allowed to sleep in the same bed with her anymore. And
she was always hollering at Ethan; she blamed him for all of their marital prob-
lems and for her own dissatisfaction and unhappiness. Despite her constant
tirades of “Ethan, I never should have married you; you have caused me nothing
but pain; I really should take the girls and leave you; you are all fucked up,” he
described still loving her and wanting to work things out; he really wanted to
make their marriage work.
As a result of his childhood experiences of abuse, Ethan was disconnected

from his feelings. His thoughts and emotions existed as separate entities in his
mind. One of the reasons that Ethan could talk so openly about the abuse he
experienced was because he had detached the thoughts about the abuse from
any emotions. He either felt nothing, void of emotion; or he experienced numb-
ness, fogginess, and a sense of being out of it. These were all ways of being that
Ethan learned to use to survive what was happening to him.
Ethan’s visits to the porn shop reenacted the abuse he experienced. Without
insight or forethought, Ethan would find himself in situations with men that
replicated the abuse. Because he was unable to process his feelings regarding
the sexual abuse, he continued to repeat the actions; it was painful and maladap-
tive, but it was helping him keep his thoughts and feelings isolated from each
other. In this way, it functioned as a way to protect himself from the damaging
psychological and emotional consequences of the violations he experienced.
Conceptualizing Ethan’s way-of-being-in-the-world helped me organize Ethan’s
inner world; it facilitated an understanding of Ethan’s personality organization and
what was happening for him in his life. But understanding and empathizing with
Ethan was not going to make our treatment journey any easier. I knew Ethan and
I had a long rocky road ahead, but I was determined to help him; I was prepared
to combine different psychotherapeutic interventions to do this.
After—what I began to refer to as “doomsday”—the day Ethan told his
mother about the abuse, Ethan acquiesced to all of Mario’s advances. He felt
totally defeated and powerless, having lost his one rescuer; the desire to fight
back, in any way, lost all meaning. Ethan lay helpless as he let Mario do what-
ever he wanted.
About a year later, Mario moved back in with his mother. The circumstances
regarding Mario’s departure remain a mystery to Ethan. He came home from
school one afternoon to find all of Mario’s stuff gone. He asked both of his
parents what happened. And they both replied that it was time for Mario to go
back to his mother. Ethan tried to get more information, but they both resisted.
And that was that; Ethan was afraid to ask any more questions. I speculated that
perhaps Ethan’s mother did rescue him. Was it possible that she found a way to get
Ethan’s father to ship Mario back to his mother? It all seems so secretive and suspicious.
Something must have happened?
We were about six months into our treatment journey when I received a fran-
tic phone call from Ethan. He had been arrested. I was worried that this was
going to happen; he had almost been arrested just a couple of months ago.
I was trying to help him reduce his porn shop visits; we were working on putting
words to the feelings behind his actions, but it was not helping; his acting out
actually appeared to be escalating. I knew I needed to try something different
with Ethan, but I was not sure exactly what. He was a very challenging client;
as much as I liked him, he was very resistant.
Ethan was distressed on the phone, but when he came into session the day
after his arrest, he was disturbingly calm. When Ethan began visiting the porn
shop he was just 20 years old. For the first few years, his visits were very sporadic.
His narrative surrounding the evolution of his porn shop visits was sketchy; but
from what I could piece together, his visits became more regular after meeting
Sylvia when he was 24 years old. I had speculated that the intimacy between
Ethan and Sylvia triggered feelings related to his past; unable to process these
emotions, Ethan began acting out. I had wondered about this with Ethan, but
he could not corroborate. Intellectually, he thought it made sense, but emotion-
ally, he just was not sure.
At the time of his arrest, Ethan was frequenting the porn shop about twice a
week. His routine was always the same. He would find himself there and go into
a private viewing room. All of the rooms had small holes in the wall that con-
nected to the adjoining rooms. He would watch a film until he was aroused and
then he would stick his penis into one of the holes and wait for someone to start
sucking on it. As soon as he finished, he would run out to avoid any additional
contact with the anonymous mouth on the other side.
This visit followed his usual routine until the nameless man came outside run-
ning after him. The man was asking for Ethan’s cell phone number; he wanted to
hang out with him again. Ethan said no, but the man was persistent. According
to Ethan, the man was becoming agitated and would not take no for an answer.
Ethan remembers feeling intimidated and bullied by the man. He felt this for a
quick moment when, without conscious intent, he punched the guy in the face,
hopped into his car, and drove off. The next thing Ethan remembers is being
pulled over by a police car.
Ethan was arrested for assault and he had to call his wife to pick him up. He
tried to tell her a more innocuous version of the truth, but the police had already
informed Sylvia of what had transpired. Sylvia’s resolve was to give Ethan six
months to “get his shit together” or she was throwing him out. Ethan said she was
livid; he had never seen her so angry before. Although he appeared relatively com-
posed, he said that he was terrified of losing her. He reported that if she left or threw
him out, he thought he would kill himself. “I can’t live without her; she is my life;
I wouldn’t even know how to live if I wasn’t with her,” he leaned back with a deep
sigh and rubbed his hand down his Spiderman shirt. Ethan looked tired.
After this session, I realized that despite the fact that Sylvia was one of the
causes of Ethan’s distress, she was also his lifeline. She was the glue that held
the broken pieces of Ethan together, and without her, Ethan would either kill
himself or break apart totally destroyed. I did not think Sylvia was going to leave
or throw Ethan out. I imagined her just as enmeshed and invested in their
marriage—irrespective of the dysfunction—as Ethan. But I also knew that any-
thing was possible, and if she did decide to dissolve their marriage, we were going
to have big problems.
I decided to implement a few new techniques in an effort to help Ethan gain

control over his impulsivity. I knew visiting the porn shop was only a symptom
of much larger issues, but I wanted to try to help Ethan gain control over his
behavior while also working through the deeper problems.
I referred Ethan to a Dialectic Behavior Therapy group as a supplement to our
twice-weekly sessions. Ethan was reticent when I first mentioned the group to
him, but I insisted that he attend; it was nonnegotiable—it was mandatory—so
he finally agreed. I thought the added support would be containing; and that
the emphasis on identifying emotions that preceded his destructive behaviors
would enhance the work that we were doing in our sessions. In addition,
I thought the experience of being in a group with people who had similar strug-
gles might increase Ethan’s ability to engage with others.
I then created an exercise program with Ethan. He used to be an avid cyclist
but had not even been to a gym in over a year. As part of our treatment plan,
Ethan was to begin cycling at least three times a week for 30 minutes. And he
would attend yoga, lift weights, or run on the fourth day; he said he enjoyed all
of these activities, too, so I left it up to him to choose. I asked him to log the
workouts and bring them in to our Monday sessions. I was hoping the increased
physical activity would help alleviate some of his anxiety; if Ethan felt calmer,
perhaps his impulsivity would lessen. Ethan was actually enthusiast about begin-
ning his training again; he thanked me for “forcing” him back “on the horse.”
After some thought, I decided to also employ a technique that I thought quite
possibly would open up new challenges, particularly in the dynamics between
Ethan and me, but I felt it was worth the risk. At this point in our treatment,
we had an established rapport, and I believed if any difficulties arose between
us, we would be able to work through them. Something more active needed to
be done to help Ethan; with this in mind, I opened the frame and dove in.
“Ethan, I would like us to try something different; something that I think may
help you control your visits to the porn shop. But I want us to discuss it a bit first.
I want to make sure you are comfortable with it. And that you feel it may be
helpful,” I put my elbows on my knees and leaned toward him.
Ethan, wide eyed, leaned in toward me. He seemed physically closer to me
than usual as he responded, “That sounds great, Doc. Hit me . . . ha . . . I mean
tell me. You know the kids use that expression now. It means tell me.” Ethan
chuckled, “I hope you don’t think that was a Freudian slip or anything. Please
tell me Doc, I really need help. I have got to get this under control.”
“I know you have said that you just find yourself in the porn shop, like you
didn’t mean to go there, but just wind up there.” I was trying to be very clear—
I needed to be very clear. I continued, “But I wonder if there is a moment, even
a second that happens before you go in when you feel aware of what you’re
doing?”
Ethan pursed his lips and looked up at the ceiling. “Umm . . . Yeah, Doc . . . if
I really, really think about it, I don’t like to admit it, but yeah, there is a flash of a
minute; it usually happens right after I park my car, Doc,” he looked at me for a
second and then looked up again.
I had set up a new email account just for Ethan. “Ethan, I want you to start
paying close attention to those quick moments when you’re parking your car.
Do you think you can do that?” I asked, with unwavering eye contact. Ethan
met my eyes and nodded, “Yes, Doc, yes I will pay attention from now on.”
“Before you go in, I want you to look in the mirror. Either buy a small compact
mirror or you can use a mirror in your car. I want you to look at the time, and
then look at your reflection in the mirror for five whole minutes. Can you do
that?” I asked. “Yes, Doc, yes, I can do that,” his pupils were dilated as he nodded,
gesturing yes.
I had used this technique before to help other clients with impulse control
problems—particularly binge eating—and it often helped. It creates space for
“reflection”; it provides an opportunity to think before acting. And by using a
mirror, it inherently presents a chance for “self-reflection” and contemplation.
I thought this might help Ethan. And if it did not result in cessation of his acting
out, it would at least give him a pause before he acted. Over time, this would
implicitly teach him what it felt like to wait, and help him to feel that going into
the porn shop was a decision—an action he had volition over. He would begin to
feel more in control of himself, which ultimately could render him able to stop
his destructive behavior.
The second part of this intervention was more precarious. I gave Ethan an
email address that he was to use after he looked in the mirror for five minutes.
He was to send an email to me that was a stream of consciousness—a free-
flowing thought process—account of everything he was feeling. After sending
me the email—which I would not respond to, but promised to read and hold
for session—he was to turn around and go home.
I did clarify that I always worked from a harm reduction model, which essen-
tially means that I recognize and fully accept that relapsing into destructive
behaviors is part of the process. It often happens, and it does not mean he failed;
we were working on a process of recovery, and if he did go into the porn shop,
it was okay. I just wanted him to be honest and forthcoming about it, and
together we would continue to work at it.
I added the emailing to the intervention for two reasons. First, I thought the
in-the-moment writing would help Ethan gain awareness of the feelings that
triggered his acting out. Second, I decided to have him email it to me as a non-
verbal communication that I was going to “hold” his feelings for him. I thought it
might work to provide the emotional experience that I—holding his feelings—
was containing him. Essentially, Ethan would feel metaphorically held.
Because Ethan felt so fragmented and broken in pieces, I knew there was a risk
that if I opened the frame, providing him more access to me, it could lead to
needing and wanting more out-of-session contact. Typically, using emailing as
a clinical technique is with clients who had a firm sense of identity and a more
solid personality organization, and therefore could maintain appropriate bounda-
ries regarding the emailing. I was not quite sure if Ethan could do this, but I really
thought it was going to help him. Sometimes as anxiety-producing as it can be,
we as therapists have to leave our own comfort zone and try something different
with our clients. We need to be creative and come up with unique ways to help
people, especially for clients like Ethan who do not respond to more traditional
psychotherapeutic techniques.
The new frame was set, and I waited—remaining vigilant of the complexity of
the situation—to see how the circumstances would unfold.
Ethan was doing better. It had been 4 months since his arrest and about
10 months since we began our treatment together. Since the establishment of
our new frame, Ethan had been able to avoid going into the porn shop. It was
very hard, but he was doing it. His ability to use his inner resources gave him a
new sense of confidence and helped him to feel more in control over his life
and his choices. He was also becoming more apt at identifying his feelings; he
was putting words to his actions for the first time. He seemed freer and more
engaged during our sessions too. But Sylvia was relentless; and I was afraid she
was going to push Ethan—who was still fragile—into a relapse.
Despite Ethan’s progress, Sylvia insisted that he still had problems; she did
not totally believe that he had stopped going to the porn shop, and Ethan had
no way to prove it to her. Over the years, the trust, if there was any to begin
with—I was not sure about this—had deteriorated. And Sylvia had declared that
she could not believe anything Ethan said. I had the feeling that Sylvia had her
own intimacy problems but blamed Ethan for everything, never taking owner-
ship over her own role in their dynamic. If Ethan got better, she would be forced
to confront her own demons. Deep down, this terrified her, so she resolved—
albeit unconsciously—to keep Ethan “sick.”
Since Sylvia was not my client, all I could do was help Ethan contemplate the
possible reasons Sylvia reacted toward him in such an abusive manner and help
him manage his own feelings around it. I had a private fantasy that Sylvia might
concede to Ethan’s numerous requests that she seek her own treatment, but this
did not seem to be happening. Sylvia insisted she was fine, and that all her
problems were Ethan’s fault.
The further along we got in our treatment and the more Ethan could separate
his own identity from that of Sylvia’s, the angrier he became. Anger was a very
unfamiliar emotional experience for Ethan; he had been repressing his emotions
for so many years. But as he became more aware of his feelings, his rage started
seething. As attached as he was to Sylvia, and as afraid as he was to lose her,
he started to feel furious with her. He started to worry that he might “lose it”—he
was afraid he would go into a vengeful tirade, or perhaps even hit her. Ethan was
scared of his own impulses once again. And then his taste for sweets—which
I had been curious about since the start of our treatment—became another
problem.
Since the beginning of our treatment, Ethan almost always brought coffee and
a snack to our therapy sessions. There were numerous instances that he was
actually late for our appointment, indicating that he had stopped on his way over
to pick up something to eat. I had been curious about this and asked Ethan on
numerous occasions about the snacks. He always shrugged it off stating that he
was hungry. A few times I even observed with him that he was late for our session
because of his snack-stops, but he would always state the same “Sorry I was
hungry” excuse.
I did not believe Ethan; I accepted that this was the truth as Ethan experi-
enced it, but there was a compulsive quality to his snacking, and I was convinced
that it held a more significant meaning. Eventually, I began to hypothesize that
the sweets and coffee were a way that Ethan soothed himself; they possibly
reminded him of fond memories, and the comfort he felt while sharing cookies
and milk, after school with his mother, before “doomsday.”
As Ethan was becoming more aware of his feelings and he was no longer fre-
quenting the porn shop, I began to notice that Ethan was bringing even more
snacks in. And his nibbling was accelerated; he was chewing so fast that during
one session, he ate an entire donut in two big bites. Finally, during one session,
Ethan disclosed that he felt his eating was “out of control.” He had been to the
doctor for the flu when he learned that he had gained 10 pounds over the last
year. “I have always had a sweet tooth, Doc, but lately I feel like I can’t stop
eating sugar,” Ethan shared following his doctor’s appointment. I learned that
Sylvia was prone to binge eating and had been going to Overeaters Anonymous
for years. Ethan was wondering if he should go, too.
As we began to explore Ethan’s eating habits, it became clear to him that he
was using high-sugary food in an attempt to self-soothe. “Yeah, Doc . . . yeah,
I think I crave sweets when I am uncomfortable, lonely or I dunno . . . maybe
confused too. I was never able to make this connection before. I remember you
asking me a bunch of times; honestly, I thought it was a weird question, but
now it makes sense. I eat to calm down. But I have to stop doing this. I’m blow-
ing up,” Ethan rubbed his hand over his distended belly. “With Sylvia causing
me all this stress I think I’m eating even more,” he rested his hands across his
stomach and crossed his fingers.
We discussed the possible connection between eating cookies with his mother
as a kid and looking for that same comfort in the present through food. Ethan
thought about it and then nodded, “Yeah that seems right to me, Doc. Those
times with my mother, you know, before doomsday are some of my best
memories.” He started swinging his legs seeming very childlike, “Even now
whenever I go visit my mother she’s always trying to make me eat more. Maybe
it’s an Italian thing. She always has so much food; there are always lots of pas-
tries.” Ethan drifted off in thought. “Ah, those times with my mother . . . those
were some good times,” he gazed at the floor.
Ethan then began to discuss more detailed memories of some of the “good
times” in his childhood. It was the first time Ethan described recollections
of the closeness he felt with his mother. He had made it clear, to some extent,
that he shared an intimacy with her that was special. But it was the first time
that I realized how enmeshed their relationship was, and how he lost a part of
himself on the now-infamous doomsday. I felt really sad as Ethan was
reminiscing.
These descriptions did help me understand the entanglement with Sylvia.
Ethan was trying to replicate his early relationship with his mother—for better
and for worse. The simmering rage he was holding toward Sylvia was also dis-
placed anger toward his mother—anger that he had kept buried since doomsday.
I asked Ethan if he was aware of any anger toward his mother, but he was not
ready and responded with a steadfast “no.” He projected all his toxic feelings
onto Sylvia and reported, “I feel sad about what happened with my mother,
not angry. I think she couldn’t help it. My father was so mean to her. I think
she had to react the way she did; if my father found out the truth about his son
then he might have taken it out on her. She didn’t have a choice. I can tell
now—it’s a look in her eye when she sees me—I can tell now that she believed
me. She just can’t say it.”
Ethan, the superhero, was also protecting his mother. He had to shelter her
from his father and also from his own rage. Ethan was not ready to confront this;
and I knew better then to shatter this image with any strong confrontation.
Ethan needed to shield himself from knowing this, at least for now, and I hon-
ored his need for self-protection; at this point in our treatment, I understood
his resistance as self-preservation.
Ethan wanted to go to Overeaters Anonymous with Sylvia. I thought perhaps
it was a sign of their enmeshment; her problem was also his problem—he could
not distinguish between the two. But when they began going to twice-weekly
meetings together, it seemed to be facilitating better relations between them.
I also employed the same tactic with Ethan regarding his sugary snacking; he
was to look in the mirror for five minutes whenever he felt he was about to
eat in an out-of-control manner. After that, he would email me a narrative of
feelings.
Ethan was working really hard to identify and process his feelings instead of
acting on them, but his rage was so intense and he just did not know how to
manage it. I knew he was at risk for an explosion; I could feel his emotional
instability becoming worse again. I was trying to contain him, but Ethan did not
yet have the inner resources to soothe himself constructively. We had just agreed
to move our sessions up to three times a week when Ethan lost control at a family
dinner and wound up in the hospital.
It was Christmas, and Ethan’s parents had their yearly celebratory dinner.
As a result of Ethan’s growing awareness of his feelings when his father went
off on one of his typical Ethan-bashing diatribes, humiliating Ethan, all the years
of split-off emotions came rushing out, and Ethan found himself in a screaming
match with his father. His father’s verbal assaults escalated and Ethan turned
to his mother—once again—for support. But she did not protect Ethan. Instead
she told him to “stop yelling at your father.” Ethan felt a wave of rage, but then
reverted to his familiar detachment to cope. He then found himself in the bath-
room with a knife, his wrists slit, and blood everywhere.
After Sylvia found him bleeding in the bathroom, she called 911, an ambu-
lance picked Ethan up; and Ethan was admitted to the psychiatric ER. The resi-
dent called me and informed me of the details. Ethan had denied any previous
suicide attempts or hospitalizations during our intake session, but when I went
down to the ER the following day to meet with the treatment team, I discovered
that Ethan had been hospitalized after slitting his wrists twice before. The first
time was during his first semester of college, the first time he was separated from
his mother—I thought; the second was following the break-up with his first seri-
ous girlfriend when Ethan was 21. The treatment team decided to admit Ethan
into the hospital for stabilization, and then to place him in six months of day
treatment. Ethan was reporting suicidal ideation with a plan, and we all agreed
that he needed a more secure treatment setting.
When I visited with Ethan, he asked if we could still talk while he was in day
treatment and if we could resume our work again once he completed the pro-
gram. My response was that he could call to update me on how he was doing,
but that we should not engage in ongoing dialogues. I did not want to set up an
opportunity for Ethan to “split,” basically; I did not want our relationship to
interfere with his ability to form attachments—which could help him—with
the therapists he would be working with at the day treatment facility. Ethan
and I agreed that we would see how he felt once he finished the program; coming
back to our work was a definite possibility, but one that needed to be determined
following the completion of his program.
Two months later, I received a phone call from Ethan. He sounded calm.
He was still in the day treatment and said he was “taking it one day at a time.”
He and Sylvia were getting marital counseling, and he was still going to Overeat-
ers Anonymous—he reported that he was still binging on sweets but was getting
better. “I am trying as hard as I can, Doc; this is some hard stuff, but I am doing
it,” Ethan sounded sincere.
Four months later, Ethan called again to inform me that a month ago, he had
gone into the porn shop—again. This time, he left before he did anything with
anyone, but “finding himself in there” left him feeling so worthless and hopeless
that he immediately went home and, without forethought, slit his wrists and was
put back in the hospital. He is now in day treatment indefinitely; that was five
months ago and, as of this writing, the last contact I had with Ethan.
7
Watering Flowers: The Stories of Caroline,
Violet, and Charley
The label “borderline personality disorder” conjures up nightmarish images of
interpersonal chaos and emotional storms. Descriptions of unmanageable rages,
threats of self-harm, and exhausting therapy dynamics have become the proto-
type for “borderline personality disorder.” But beneath the mask of disorientation
and confusion—behind the scarlet label called “borderline personality
disorder”—exists a human being, and one who is struggling tremendously.
A common feature for people suffering from “borderline personality disorder”
is a lack of self-possession; this is an inability to maintain an internal organiza-
tion that affords one the ability to proceed forward with life goals. It is a great
tragedy, as a clinician, to be able to discern a person’s remarkable strengths while
simultaneously knowing that they are unable to use them. Everyone is endowed
with unique strengths; it is truly a misfortunate when one is unable to access
them.
The chaotic world of the borderline makes it difficult to remain cognizant of
these unique strengths—for both therapist and client. Often times, the primary
focus of the treatment is the management of emotional instability and contain-
ing constant storms of crisis. But in order to really help clients with “borderline
personality disorder,” clinicians need to remain mindful of a person’s strengths
and slowly help them integrate and use them.
Caroline was crying. She was trying to explain how stupid she thought she
was, but it was hard to understand what she was saying between her deep heaves.
I just keep hearing the words, “I am stupid; very stupid,” her voice audibly louder
when repeating this phrase. Caroline was an emotional cutter; she used self-
deprecation as a form of self-harm. Caroline was not stupid; in fact, she was bril-
liant, talented, and really funny. There were moments between episodes of rage
and chaos when I could see Caroline’s remarkable character attributes; and
I was determined to help her see them, too.
When Caroline began therapy, she was living in a small studio apartment
with her ex-boyfriend, Timothy. Neither one of them could afford to move
out; so despite the ongoing hostility and resentment between them, they
remained roommates. It was around the second month of our twice-weekly
therapy that I observed a clear pattern to Caroline’s emotionally cutting.
When she was enraged at Timothy, she said nothing to him, but rather directed
the toxic hate toward herself and became consumed with self-contempt. She had
fantasies of thrashing her body against a wall, cutting her wrists, and poking her
eyes out with a fork. Fortunately, she never acted on these fantasies; but meta-
phorically, through her self-deprecation, she was beating, cutting, and
poking herself to death. Caroline’s presenting complaint when she began therapy
was to “Get the hell out of the situation she was in; get a real job and tell
Timothy to shove it.” Now, after 13 months of therapy, Caroline was still living
with Timothy, working as a temp and drinking every night to numb her pain.
Caroline was 36 years old and a college graduate. She had aspirations, but she
never seemed able to follow through with any of her goals. She was unfocused
and disorganized; her goals were always changing; and she never stuck with
anything that seemed to require persistence. As soon as anything required
wherewithal, she would revert to “I’m stupid” statements and give up. But I knew
Caroline could be persistent and determined. I could hear it in some of her
narratives, and I could see it in her self-expression.
I needed to figure out what was stopping Caroline from garnering strengths
that could actually help her meet her goals. Caroline had worked as an advertis-
ing consultant following college; she was very creative. One session, she brought
in her portfolio to share some of her work with me; and it was very impressive.
She described wanting a career in advertising; but every time she organized her-
self enough to begin searching for her desired employment, a crisis would occur,
and she would fall apart. Ruminative self-hate and fantasies of self-harm would
consume her, and she stopped working toward her goal.
Through her narrative, it became clear that she was terrified of rejection.
Caroline did feel “stupid”; she believed she was unworthy of the career she really
wanted. So every time she got close, she undermined her progress and instead
focused on interpersonal dramas and chaos. This made garnering her strengths
challenging. Whenever we would begin working toward aspirations, a crisis
happened that superseded working toward constructive goals.
It took months, but eventually I was able to create windows of time for
Caroline to be curious about how and why this happened. When Caroline felt vul-
nerable to rejection or abandonment, she created obstacles preventing her from
getting what she wanted; this then reaffirmed her feelings of being unworthy and,
in her mind, confirmed that she was stupid. I slowly began to address Caroline’s
feelings about herself. Although painful, the “I’m stupid’s” actually created a mal-
adaptive shield for Caroline. As long as she maintained these false beliefs about
herself, she had an alibi for avoiding the risks of working toward higher goals.
I used our relationship to help Caroline. When Caroline wanted something
from me—for example, a change in session time or a return phone call—she
was relentless. I often found myself giving in to Caroline’s demands; she would
Watering Flowers: The Stories of Caroline, Violet, and Charley 99
break me down to the extent that sometimes I was doing scheduling gymnastics
just to meet her requests. Gently, remaining vigilant of Caroline’s propensity to
feel harshly judged, I helped her notice her ability to be persistent with me.
This determination was also evident in her relationships with men. Caroline
was able to win over men with an ease and charm that almost seemed award wor-
thy. She was quite attractive; she had gorgeous, flowing long blond hair, full lips,
deep brown eyes, and two adorable dimples that lit up her face when she smiled.
But it was not her physicality that allured men. When she met an eligible pros-
pect, she was determined to “get him.” Often after the chase was over, Caroline
became bored and disinterested, wondering what she saw in him in the first
place. But based on her narrative, it was a rarity for Caroline not to get her man.
Caroline needed to integrate her strengths and begin to use them construc-
tively; instead of using it to be interpersonally manipulative, she could strive
toward goals that would give her life meaning. As an alternative to feeling
deflated, she could feel energized as she moved forward to reach her potentials.
Because of the storms of chaos and crisis, this technique took months and
months of hard work. But I never lost sight of Caroline’s strengths—even when
she was at her most broken. Eventually, Caroline showed signs of using her
strengths more constructively. And the more she was able to access these forces,
the more control she felt over her life; and the better she felt about herself. The
positive affirmation led to a greater ability to confront her fears, take risks, and
leave the comfort of her dysfunction.
After nearly two long years of twice-weekly sessions, Caroline got her dream
job. She was hired as a consultant as at huge advertising agency. The pay was
lower than she had anticipated, but it was a foot in the door, and she was grate-
ful. Using these same strengths, a few months later, Caroline moved into her
own studio apartment; it was very small—“like a closet”—but it was her own,
and she felt good about it. She closed the door on Timothy and began slowly
moving forward toward constructive life goals.
According to Karen Horney, given “an atmosphere of warmth,” one has the
opportunity to grow toward one’s potential; to move forward in life and pursue
constructive goals with congruity of feelings and thoughts. She eloquently states
(Horney, 1950, p. 17):
You need not, and in fact cannot, teach an acorn to grow into an oak tree, but
when given a chance, its intrinsic potentialities will develop. Similarly, the human
individual, given a chance, tends to develop his particular human potentialities.
He will develop then the unique alive forces as his real self: the clarity and depth
of his own feelings, thoughts, wishes, interests; the ability to tap his own resources,
the strength of his will power; the special capacities or gifts he may have; the fac-
ulty to express himself, and relate himself to others with his spontaneous feelings.
All this will in time enable him to find his set of values and his aims in life.
Although Horney never directly addresses character pathology—she uses the

umbrella term “neurosis”—her emphasis on growth can be applied to the treat-
ment of “borderline personality disorder.” She describes all human beings as
being endowed with innate and unique strengths; she contends that neurotic char-
acter evolves when these strengths—“constructive forces”—are blocked, causing
the person to be unable to grow and move forward in any authentic and meaningful
way. The aim of therapy for Horney is to activate, foster, and cultivate these
strengths so that people have the opportunity to dispense with neurotic ways of
being and strive toward growth. She states, “Beyond this aim there looms an
entirely new therapeutic goal, which is to restore the individual to himself, to help
him regain his spontaneity and find the center of gravity in himself.”
Because the treatment of “borderline personality disorder” can be incredibly
challenging and emotionally chaotic for therapists, the emphasis on the person
behind the disorder is often lost. If one is “to restore the individual to himself,”
then one must integrate the focus on strengths and innate inner resources into
treatment plans with borderline clients. This will also reduce the stigma associ-
ated with “borderline personality disorder” by offering a perspective that includes
the whole person.
Violet was consumed with rage. She was obsessively preoccupied with vindic-
tive fantasies of retaliation against those that hurt and abandoned her; and her
plans for revenge were very detailed and elaborate—scary elaborate. Her most
recent victim was her ex-boyfriend Marshall, who cheated on her and then left
her for the woman with whom he had the affair.
Violet came in for therapy just following their breakup. For the first six
months, she devoted most of our session time to discussions about Marshall and
how he had betrayed her. Her rage drove her obsessions; she would read about
him on the Internet. And, having figured out his password, she would violate
his privacy by logging into his account and reading his private emails. Because
Marshall had betrayed her after a three-year relationship, Violet believed she
was entitled to infringe upon his privacy. “I am the victim here, not him!” was
her response whenever I tried to confront her.
Violet’s historical narrative revealed a long list of people who had deceived,
hurt, and/or abandoned her. According to Violet, she was a perpetual victim;
this was Violet’s reality. And she was torn up and completed broken down as a
result. Her resolve was to spend months and years fantasizing and imagining
revenge scenarios. Violet had no history of physical violence, and she assured
me she would never act on her fantasies, but the amount of energy she spent
thinking about them was very self-destructive; despite the satisfaction she was
getting from these ruminations, they were very painful and were stopping her
from living.
I had a mild aversion toward Violet. Her rages and obsessive fantasies made it
difficult to experience and empathize with her pain; her despondency,
helplessness, and shame lay buried, and I had to work tirelessly to remain mind-
ful of the pain beneath the rage. It was exhausting.
Violet’s propensities toward obsessive ruminations were a maladaptive shield
for deep feelings of shame and worthlessness. Her rage protected her from feeling
entirely powerless. I needed to help Violet figure out constructive ways to feel a
sense of power and control over her life. This was not easy; it felt like I was trying
to move a huge boulder off a narrow trail. But I persisted, digging it out slowly
with breaks in between.
Violet was enrolled in an MBA program, but she was on a temporary sabbati-
cal after nearly flunking out. Her preoccupation with her victimhood and
revenge fantasies were interfering with her schoolwork. This much Violet was
aware of, but she believed it was Marshall’s fault. He was the cause of her thought
spirals and fantasies.
Violet had above-average intelligence. She was very skilled at research, her
attention for small details was remarkable, and she could be very determined.
These skills would be an asset in the business world, if she could redirect her
energy. After a year in once-weekly treatment, I began to explore this with her.
It is an arduous task to help a client who has the experience of being a victim
take control over their life. If one believes that one is a victim, then getting the
person to experience themselves otherwise involves a shift in identity. One’s way
of seeing themselves and their world must shift, and this takes an enormous
amount of time and effort.
The entire second year of therapy together felt like a battle. Every time Violet
seemed to be making progress, she immediately reverted back to her ruminative
world. She was clinging desperately to her victimhood; she was terrified of letting
go of this way of being. It was during the beginning of our third year of treatment
when I began to notice Violet becoming curious when I would point out her
strengths. Instead of raging at me, she began to listen to what I was saying; it
seemed that for the first time, Violet was actually hearing me. She was finally
able to take in and absorb that she had strengths and talents, and that she was
worthy and deserving of living a more meaningful life.
Through the consistent and unwavering observation of Violet’s strengths, she
finally was able to hear me. Even when she would rage or brush me off, or when
I was enraged at her, I never lost sight of her as a whole person. One session we
were exploring how to assimilate and apply her strengths toward her goal of
finishing her MBA when I suddenly had the association of watering a flower.
Violet was a flower, and I was gently nurturing and watering her, helping her
to grow. I have often thought back to that moment with Violet. Cultivating
and fostering a client’s strengths and innate endowments is much like watering
flowers; it is equally as essential for each respectively to grow.
Violet did return to her MBA program and is currently attending classes.
She still reverts back into the safety of her rumination, albeit not as frequently.
Now the fantasies feel incongruent; they are uncomfortable for Violet, and she
works hard to stop them whenever they emerge. Violet continues to move
toward living a fuller, more meaningful life and I continue to water her strengths,
fostering continued growth toward her potentials.
One of the most fundamental and important aspects of psychotherapy is the
relationship that is formed between therapist and client. In the didactic litera-
ture on psychotherapy, one learns that the initial phases of therapy are focused
on establishing therapeutic rapport. In order to get to a place where fostering
strengths is possible, there must be a relationship between therapist and client.
I think one mistake that is often made when treating people with borderline per-
sonality disorder is assuming too much, too soon. For people struggling with
storms of emotion, the rapport-building process takes longer and often feels like
two steps forward, one step back. But if one is sensitive, intuitive, and able to
remain empathically connected, a relationship will evolve and constructive
forces will emerge.
It is at this beginning stage—when there is an opportunity for a budding rela-
tionship to grow—that one must remain astutely vigilant of the propensity to use
labels. Labels are used to reduce fear; when one feels the abyss and ambiguity in
the initial meetings, it is not uncommon to revert to diagnoses to help make
sense of what is happening in the room. The problem with this is that diagnoses
create assumptions; and since everyone is unique, these initial suppositions are
often false. When it comes to borderline personality disorder, the label also leads
to stigma; this then instigates additional fear and blocks the budding relationship
from growing. Clients can feel the silent label one is holding onto, and this will
exacerbate their shame and self-loathing.
When there is a budding flower, it needs water to grow. If one assumes that a
flower is “sick” and unable to grow, is one going to nurture the budding flower’s
growth? Will one still take care of the bud in hopeful anticipation of its emerging
growth into a beautiful flower? If one thinks about someone struggling from emo-
tional chaos from a Horneyan perspective, one finds hope and the concomitant
possibility for growth and change—just as one sees the metamorphosis from
bud to flower. If one wants to make a difference in the lives of people struggling
with emotional chaos, it is useful to use this as an organizing principle for treat-
ment rather than a relying on a diagnostic straightjacket.
Charley came to our first session, sat down, making no eye contact, and
immediately took a spiral notepad out of his backpack and began reading. “I have
borderline personality disorder,” he said in a flat monotone voice. I was looking
at him, my eyes wide with curiosity, but I am sure he did not notice. He did
not look up; instead, he kept his eyes glued to the ruffled pages of his spiral pad.
He then proceeded to go through the entire list of diagnostic criteria for
borderline personality disorder—the complete list of symptoms from the Diag-
nostic and Statistical Manual of Mental Disorders (DSM). After each symptom,
he stated, in the same constricted tone, either “Got that one,” or “Not this one.”
I sat listening, noticing how mechanical and disconnected he seemed, and won-
dering where he obtained this information. Did he learn this from a mental health
professional? Through his own research? Or his medical doctor? Hmm . . .
The experience of listening to his laundry list was disquieting, partially
because he was so disengaged, but more importantly, because Charley thought
this was the most important thing he had to tell me about himself. Initial ses-
sions can be quite uncomfortable for clients, but it is always interesting—and
telling—to observe how one begins. This was not the first time I had a client,
in a first session, tell me he was diagnosed with borderline personality disorder.
But it was the first time I sat with someone who went through each symptom
and appeared to be really invested in carrying the diagnosis.
I let him finish going through the list. It must be important for him, I thought.
And I waited to see if he would pause afterward, wanting a response from me;
I also wondered if he would make eye contact once he was done reading. I lis-
tened and waited. Finally he finished, looked up, and made eye contact for the
first time, stating, “So that’s why I’m here.”
I leaned slightly forward in my chair. I wanted to engage Charley, to show
him I was listening, but not to be intrusive; I could sense his discomfort. Two
questions were looming: where did he get this information, and what was he
communicating by starting the session with this particular material. I decided
to ask the first question; it required less self-reflection (so it was less threatening
for a first session), and I thought the answer to “where” might naturally lead to
“what.”
In a soothing tone, I began, “Thank you for sharing this with me, Charley.
It seems very important to you. I am wondering . . .” I paused for a moment;
Charley’s body was tight, he looked stiff—unnatural—and his eyes had a terrified
look on them. “Are you okay, Charley? First sessions can be scary.”
“I’m okay,” he gazed downward for a moment and then continued, “It’s just . . .
uh . . . It’s just . . . I have been to four therapists before you . . . uh . . . umm . . . and
none of them wanted me as a patient. I know it’s because I have borderline person-
ality disorder. No one wants to work with me. And my two previous therapists left
me. They . . . um . . . they . . . um . . . told me that they couldn’t work with me any-
more. I was too high-risk because . . . um . . . um . . . sometimes I feel suicidal.
I never hurt myself. But sometimes I want to.”
Charley’s eyes were now wide and pleading. He seemed so vulnerable—
childlike. I could feel his distress, and my heart went out to him. “I’m so sorry
Charley. This all sounds terrible. I would like to hear more,” I shifted my inquiry
to meet him where he was.
“I wanted to give you my diagnosis and all the information about my mental
illness before we go any further. I started doing that. I figured . . . um . . . I . . . um
. . . I figured this way you can tell me right away if you would be my therapist.”
“I understand, Charley. This must be very difficult for you; feeling like no one
will work with you—how awful. Let’s discuss this together. First, I am wondering
where you learned about borderline personality disorder?” I sensed the opening.
He looked down for a moment; he seemed to be thinking. I tilted my head to
the side and waited. He looked up and shared, “Ummm . . . My first therapist . . .
she, um . . . she was the one . . . she told me my diagnosis and then went through
this list of symptoms and we discussed which ones I had. She said it would help
me understand what I was going through.”
“And did it?”
“Umm . . . well . . . umm . . . maybe at first . . . yeah, at first a little bit. But then
when I started to read about it . . . you know, to inform myself . . . when I started
to read about it and talk to a few people about it, I . . . um . . . um . . . I started to
feel hopeless and more depressed. There is no cure . . . and no one wants to help
me. No one wants to work with borderline personality disorder.”
Charley seemed so defeated, and I did not blame him. I had heard the “there
is no cure” statement from quite a few clients struggling with emotional chaos, as
well as clients who were family members or in a relationship with someone diag-
nosed with borderline personality disorder.
After some further discussion, Charley and I agreed to work together. I knew
the treatment was going to be challenging. It was not clear what had led to the
terminations of his previous therapies, but whenever I hear stories about prema-
ture termination(s), I know they hold significance. And they are usually indica-
tors of impending complicated relational dynamics.
During our early sessions, it was difficult to help Charley describe exactly
what he was seeking therapy for. He was clinging to the diagnosis of borderline
personality disorder; when I would inquire about his personal distress, he used
the symptoms from the DSM to explain his experience. It felt like he had lost
himself; his own voice had vanished as he came to understand himself only
through the very limited diagnostic criteria.
I was able to gather some historical information that helped me understand
Charley’s inclination to use this criterion to explain his emotional world.
Charley grew up in a small rural town. He was the youngest of six siblings, all
girls excepting Charley. His family was always struggling financially, and both
of his parents worked a lot of hours to help support the family. Charley, being
the youngest, was often left to the care of his two oldest sisters.
Charley described feeling lonely and isolated during his childhood; I could
hear a deep longing for parental attention and acceptance in his narrative.
As an adult, Charley understood that his parents had to work; but as a young
boy, he felt very abandoned. Charley’s only relief during his childhood was play-
ing music. He described spending hours lost in his own world, playing his guitar,
singing, and songwriting.
Charley, now 30 years old, was a very talented musician. He could not organ-
ize himself enough to navigate the harsh music industry, so he had not released
any of his music publicly. But he did send me a download of some of his work,
and it was absolutely breathtaking. The few friends Charley had were always
encouraging him to actively pursue his music as a career, but Charley was
afraid—petrified.
Through more intense exploration and over time, I came know that Charley
felt he had no voice. When he was a boy, he felt no one listened to his needs.
He described his family life as chaotic and noisy. The house was small and every-
one was on top of each other, and yet there was very little actual relating to each
other. Charley was quite precocious; as a deeply sensitive and intelligent child,
he tried to speak to this experience, but his family would brush him off. “You’re
too sensitive,” his father would say with frequency. “Oh, stop being such a baby,”
was also something he heard regularly. Eventually, not being heard, Charley
stopped talking; he ceased voicing his feelings.
Charley also described an event when he was 9 years old, which I believe was a
defining moment. It was a beautiful summer day. Charley had been riding his
bicycle through the vast woodsy area behind his home when he fell off, breaking
his left arm. His sister rushed him to the local hospital where he was treated
for his injury. His mother came rushing home from work; she was so concerned
about his recovery that she decided to take a week off from work to take care of him.
Charley remembered, in vivid detail, how nurtured and loved he felt during
this week, having received the attention of his mother—the attention he craved.
The experience became an emotional imprint that unfortunately led Charley to
associate being hurt or sick with getting his needs met. Following this event,
Charley reported a long history of illness and minor injuries. And as a young
man, Charley appeared fragile, sickly—prone to illness.
Charley was unable to make this connection during our first year of treat-
ment. It had come up numerous times as he often canceled sessions as a result
of illness; he was asthmatic and also complained of chronic gastrointestinal prob-
lems. Although he sought medical attention, the doctors found nothing wrong
with his stomach, prescribing antacids, which Charley said did not help.
A complicated and frustrating dynamic began to emerge around our one-year
mark when Charley would cancel session due to feeling unwell. If I did not call
him back to see how he was feeling, or if I assumed (which was set up in our
therapy frame) that I would see him at our next scheduled appointment, his
symptoms would escalate, and he would call saying he thought he was dying.
Or he would describe being in so much physical distress that he wanted to kill
himself. “I can’t take the pain anymore, maybe I should kill myself. If I kill myself
the pain will go away,” was a voicemail message he would frequently leave
for me.
This placed me in a double-bind. If I responded to his sickness with added

attention, I was colluding. This would likely lead to increased emphasis on physi-
cal distress. If I did not respond, I was ostensibly leaving Charley feeling aban-
doned. As the frequency of the dynamic increased, I began to image that this
was what led to the previous treatment terminations. I had fantasies of terminat-
ing—my own rage simmering. But I stayed with Charley; I knew this dynamic—
this way of relating—was maladaptive, but it was the only way Charley could
communicate. He could not voice his needs, so he created a different way of
communicating. I needed to hear him, so I persevered.
Since Charley’s inclination to somatize—to communicate psychological dis-
tress physically—was unconscious, I began to focus on his strengths. Somatic
symptoms can be extremely resistant to psychological insight. And pushing
and/or confronting someone, to encourage insight or curiosity, when one is
expressing somatic symptoms is very delicate. If one pushes too hard, it can lead
one’s client to feel completely alone and invalidated. The physical distress
feels very real, and clinicians must remain mindful of this. Having tried a few
times to be curious with Charley without success, I knew I needed to shift the
clinical focus.
Since Charley felt he had no voice—and even after a year of twice-weekly
sessions, he could not really describe his emotional distress—I asked him to tell
me more about his song lyrics. Charley was a brilliant writer; his intelligence
combined with his keen sensitivity was expressed in the voice and tone of his
lyrics. At first he brought in a small book of lyrics and read them aloud during
sessions. There were themes of loss, isolation, humiliation, self-hate, and longing
for love.
I probed Charley, creating curiosity and providing an opportunity for deeper
exploration of his words. I noticed that when discussing his songs, he was able
to put words—giving vivid and descriptive accounts—to his emotional experi-
ence. Eventually after a few weeks, Charley brought me a gift—a large hardcover
binder filled with his writing.
It was evident that Charley could describe his emotions with deep perspicuity
when he was writing; this was a tremendous strength. But when it came to talk-
ing directly to his experience, he seemed at a loss; he could not find words, and so
essentially, he had no voice. I observed this with Charley: “I notice, Charley,
that you are able to articulate your feelings with such clarity in your music.
I wonder what happens when you try to speak about your feelings without
writing them down first. Do you notice that happening?”
“Yes,” he replied; his eyes were darting around the room. Despite the fact that
we had been working together for over a year, Charley still had difficulty making
eye contact. He often stared at a spot on the wall directly in front of him. I could
feel his guardedness; and I tried to remain vigilant and not push him to hard.
“Can you say more Charley?” I used my most gentle tone. I would often feel
Charley’s thinly veiled rage; the rage I heard loudly when he called incessantly
outside of the session hour wanting—demanding—a call back. But during ses-
sions, he masked his rage, and although I could sense it, the more predominant
experience was his fragility.
“I . . . uh . . . I . . . umm . . . umm . . . I know you brought this up before and I
didn’t really understand it at the time. And I . . . um . . . I still don’t totally under-
stand it, but I think it’s because—like you said once—no one listened to me
when I talked at home. Everyone was always talking, but no one really listened.
I remember . . . um . . . I remember we discussed this a little awhile back and I
have been thinking more about it lately, especially after going home for the hol-
idays. I think I became afraid to talk. No . . . um . . . more like I almost forgot
how. It makes me sad to think about it; angry too.”
Using his music as a vehicle into his inner world was helping Charley gain
access to his feelings. It was remarkable; Charley was beginning to speak to me.
In a session a few months later, Charley was able to describe how terrified he
was when he began to speak about his feelings in session. “I thought you might
not want to hear it. Or . . . um . . . or maybe I wouldn’t say it right. I was . . . umm
. . . umm . . . afraid . . . No one really ever told me to talk . . . or . . . um . . . to talk
about anything that mattered to me . . . when you were asking me to talk about
feelings, I am embarrassed to say this now because I know it’s not true, but . . .
umm . . . when you were asking me a while ago, I thought you might be tricking
me . . . Like . . . um . . . um . . . like it was a way to get me to say something that
might . . . um . . . that might make you want to end our therapy. I know that’s
not true now. I know that’s not true now though.”
About 18 months into our treatment journey, I took out my metaphorical
clipboard. I had been holding one of my first questions in abeyance. I wanted
to know what brought Charley into therapy; I wanted him to describe his distress
to me without relying on the scarlet label. I wanted to hear the phenomenon of
his distress as he experienced it.
By focusing on Charley’s strengths—his intelligence, sensitivity, creative self-
expression, and proficiency at articulating his feelings through the written word
—he was beginning to show the capacity for curiosity and insight. His emerging
ability for curiosity—an important precursor for therapeutic success—allowed
for more in-depth self-reflection. And his increased insight afforded him the
capability to formulate associations, rendering him a fuller understanding of
himself and the meaning of his emotional struggles.
I explained the gross limitations of diagnostic criteria. I emphasized my desire
to know him personally and to understand his struggles just as he experienced
them. It was not easy for Charley; he had been identifying with the DSM symp-
tomology for a long time, but through persistent efforts, relying on his strengths,
he slowly began to put words—spoken words—to his feelings. Charley found his
voice. One day, he actually described feeling liberated.
There is still much work to be done. Charley’s new goal is to pursue his music
career. When he began therapy, he did not even envision this as a possibility.
That Charley now visualizes an opportunity—a potential that did not exist
before—shows the progress he has made. Through the fostering of Charley’s
strengths, he shows increased energy, more organized volition, decreased physi-
cal symptoms, and a more positive self-concept. Charley’s petals are opening as
he slowly grows, revealing, to me, a beautiful flower.
8
Conclusion: Reflections, New Directions
In this chapter, we want to present some overview, and some ideas about the
future. In thinking about the entirety of what we have presented, it occurs to
us to mention a client. This client came into and spoke about a nightmare he
had the previous night. He described in great detail a terrifying monster, some-
thing like a dinosaur, ravenous, with savage bladelike claws perusing him
through a dense jungle. The creature issued eardrum-splitting screams as it tore
through the thicket. The man ran frantically, but the steps of the giant were rap-
idly catching up. Realizing he could not outrun the beast, the man stopped and
turned around to face the fiend. Upon realizing the pursuit was over, the beast
stopped and said, “I’ve been trying to get your attention! I am hurt. Help me.”
The man suddenly noticed that the creature had a gash in its leg that required
attention. The man tended to the wound, and the nightmare ended. There is a
lot packed into this tiny dream. There is a wounded aspect of the man’s psyche
that, being unattended to, becomes other, monstrous, inhuman, tyrannical. This
wounded aspect of himself, now taken as alien and frightening, elicits a fear
response from the man. He flees, setting in motion the archetypal chase. It is
not until he simply stops and faces this aspect of himself that he is able to give
it the attention it deserves and move toward healing.
The dream is analogous to the backstory of “borderline personality disorder.”
It is quite a historical narrative extending back roughly 4,000 years, with
elements of it that have shockingly remained unchanged into the present.
The “other” of man is woman and men, who have essential held hegemony since
antiquity, have been frightened of the aspects they did not understand about
women. Specifically, there was a lot of fear over (what was perceived to be) extreme
states of emotion and also unexplained bodily ailments of women. What essentially
differentiates men and women is their physiological gender, so the uterus bears the
brunt of men’s fears and concordant projections. Like the monster of the client’s
dream, the uterus is personified as having an almost autonomous and tyrannical
nature. It is personified in many ways, none of them pleasant, as an internal
creature-like being that produces emotional chaos, bizarre symptoms and mysteri-
ous symptoms. This wandering, discontented internal creature took the visage of
hysteria in the ancient Greek world. It was another reason why women were
relegated to being second-class (or lower) members of society. The womb was “like
some animal inside an animal.” Qualities of this line of thinking are vividly por-
trayed in the Greek creation myth of women. Pandora opens her pithos (a womb
symbol) to unleash all things tormenting upon the world of men. She is sent as
an affliction, an eternal punishment to the world of men. She cruelly leaves hope
as the single remaining thing in her storage jar.
During the Middle Ages, the pathologies of the female “other” shifted from an
internal wild creature to demonic possession and witchcraft. Manifestations of
hysteria were interpreted as an obscene link between the feminine and the devil.
Whereas things such as exorcism were previously seem as a cure, they were now
utilized as a punishment for witchcraft or consorting with the devil. Pope Inno-
cent VIII’s Bull blessed the witch hunt and its obligation to “punish, imprison
and correct” the heretics. Shortly thereafter, in 1486, the Dominicans Heinrich
“Institor” Kramer and Jacob Sprenger were credited with the publication of the
Hammer of the Witches (Malleus Maleficarum), a diagnostic guide for how to iden-
tify witches. Interestingly, much like the current DSM, it included being uncon-
vinced of criteria as criteria itself. The righteous one utilizing the manual could
assess, “diagnose,” and contend with witchery. Armed with unquestioned
authority, the righteous ones found copious numbers of bedeviled women and
dispensed their brand of holy justice upon them. Since women were prone to
hysteria and were generally considered weak, there was (by their logic) a height-
ened need to intercept, interrogate, and intervene with them. Until the eigh-
teenth century, countless women were killed, often in grisly ways, for witchcraft.
During the Enlightenment, witchcraft became seen as passé and ignorant, but
the belief that women were essentially weak and prone to disturbance lost no
ground. Feminine emotional instability and beguiling hysterical symptoms were
upgraded from demonic to disease origins. The term hysteria was used again,
but now in association with female neurological dysfunction. Some of the old
views of the uterus held, but most people of medicine prided themselves on the
contemporary progress of science. It was during this time that mesmerism and
hypnosis were born. These fields crossed with neurology and came to be utilized
as a form of treatment, even cure, for hysterical symptoms. Theories of feminine
sexuality became popular. Many theorists discussed similar views of the feminine
psyche somehow being split, as if there were a rational side and an irrational, sex-
ually driven side. The outcome of this sort of logic was that women were essen-
tially deprived of their bestial sexual drives by the demands of civilized society.
Not able to satisfy their base sexual urges, they were bound to hysterical repeti-
tive crises. Continuing this line of thinking, the men of medicine arrived at
the modality of intervention: orgasm therapy (physician-assisted paroxysm).
This modality was well received by women, and physicians began their ascent
to a respected position in science and society. This also mobilized technological
advances, such as the invention of the vibrator. The invention has been a hit
Conclusion: Reflections, New Directions 111
ever since. Today, 53% of women report having used a vibrator in their lives.
Fifty-one percent of women are married, which means that women are more
likely to have a vibrator than a husband. Interestingly, 45% of men report having
used a vibrator as well (LiveScience, 2009).
In any event, Freud came on the scene and deliteralized the phenomenon of
hysteria. Said differently, he moved hysteria and other phenomena of psycho-
logical life away from biological literalisms and into historical and developmen-
tal contexts. He also deliteralized the notion of hysteria as a uniquely feminine
pathology. Freud introduced the topographical model of the mind and also gave
a considerable amount of attention to the boundaries delineating psychological
and waking life. This line of thinking was taken up by post-Freudians as well as
the long-standing interest in hysteria. Out of this, the word “borderline” emerged
in the field of psychiatry and psychoanalysis. In 1938, the word “borderline”
came into the formal literature and stuck. By the 1960s, psychoanalysis’ standing
diminished as chemicals were developed that held the promise of curing psychi-
atric dysfunction. Drugs, it was believed, would replace the painstaking and
expensive process required in psychoanalysis. Along with psychoanalysis went
understanding “borderline” phenomena in terms of historical and developmental
contexts. Said differently, the field reverted back to brain disease understandings
based on an unwavering faith in medical science’s ability to offer a quick fix
in pill form. In 1968, Grinker and his colleagues published their landmark
The Borderline Syndrome, establishing it as a legitimate psychiatric disorder mer-
iting scientific inquiry. In 1980, “borderline” pathology was entered into the
DSM, where it has remained, substantially unchanged, to the present day.
While what is called “borderline personality disorder” is largely a social con-
struction with a long history, we do not deny that people do suffer from states of
emotional distress. Clearly, such states are not the result of a malfunctioning brain
organ. We know, today, that such states are largely, if not exclusively, the result of
developmental trauma. Given 4,000 years of cultural narrative about women and
what we now know about the long-term effects of developmental trauma, we have
arrived at a rich and more accurate understanding of “borderline personality disor-
der.” Clearly, there is much suffering produced by adverse events in childhood,
both to the affected individual and to those in his or her relational nexus. Some
people die as a result of lifestyle or suffer for the duration of their lives. In contrast
to the predominant understanding of “borderline” as a chronic, unremitting psychi-
atric syndrome or disease, we assert that wholeness and wellness are entirely possible.
From this, approaches most appropriate to contending with trauma need not focus
on attempting to managing, as if it were an incurable disease. We dispose of
approaches and assumption that treat “borderline” and other forms of distress as
incurable, progressive, and potentially fatal “diseases.” We emphasize that achiev-
ing centeredness, wellness, and success—as the person defines these things for
him- or herself—is not only possible, but should be sought, if the client wishes it.
No matter how grave the trauma, there is always hope. Surely there is hope, and
not simply the kind of hope that seeks to manage something like an incurable,
unremitting psychiatric disease.
What is called “borderline personality disorder” is basically untreated trauma.
Here we do not mean that “untreated” means that one needs to go to treatment,
although it may include this. We mean “treat” in the original sense of the word.
In its original Latin, tractare, it means some like to “manage, handle, deal with,
conduct oneself toward” (Barnhart, 1988). It is possible to find a relational teme-
nos for the suffering and to choose to find significance and meaning. It is possible
not simply to be symptom-reduced, but (hopefully) to live an enjoyable and
rewarding life. Like the man running terrified from the tyrannical, terrifying
monster, one has but to summon the bravery to stand for a moment, turn toward
what is frightening, and treat the wound. Hopefully, one day, sacrosanct psychia-
trists and other mental health professionals, purportedly in the service of allevi-
ating psychological suffering, will muster the bravery and humility to face their
fear of “borderline personality disorder” or, at a minimum, discontinue demoniz-
ing what they have not taken the time to understand.
The psychological nomenclature surrounding “borderline personality disor-
der,” particularly the neatly packaged taxonomy provided by the DSM, reduces
this human struggle to a list of concrete symptoms. This diminishes the human
being behind the diagnosis as well as takes complicated human behaviors out
of context. Furthermore, it begets a formula of psychopathology, which leads to
recipes for a concise method of symptom reduction.
What one learns from reading clinical narratives is that there are countless
intricacies that may reveal themselves with the unfolding of each unique therapy
relationship. It is the hope of the authors that through experiential disclosure of
borderline patterns, within the context of therapy, one will have a greater under-
standing of what the phenomena we now term “borderline” is; and that through
creative and flexible psychotherapeutic processes, people struggling with such a
whirlwind of chaotic emotions can be helped to live fuller more meaningful lives.
A few salient themes emerge through the clinical vignettes that are of funda-
mental importance. The first is the contention that “borderline personality disor-
der” is essentially untreated trauma. When the authors speak of trauma, we are
referring to micro-traumas as well as larger more obvious traumas such as the case
with Ethan—who is a survivor of severe emotional and sexual abuse. Traditionally
when one thinks of “trauma,” one is reminded of these larger, more pronounced
event(s); but all human beings experience some level of developmental trauma—
what we, the authors, call micro-trauma(s). When one is engaged with someone
suffering from “borderline personality disorder,” it is of utmost importance to under-
stand what event(s) felt traumatizing; how one’s illusion of safety and security in
one’s environment was shattered to the extent that their world feels unsafe, and
all relationships feel precarious.
Conclusion: Reflections, New Directions 113
One pronounced example of this happens when one experiences losses.

In order to survive—to live—with the unpredictable and vulnerable condition
of human life, we find ways to divert our attention, avoiding or defending against
our inherent helplessness and lack of control over our environment.
When a loss is experienced, one’s ability to avoid this truth becomes tenuous
at best, and sometimes it leaves one completely broken—disintegrated—and
unable to put the pieces back together. When this happens, one’s entire way of
being is to live in a state of panic, just trying to hold onto to something—
anything—in fearful anticipation of the next traumatic event. When one lives
in their world in such a way, even the smallest “unpredictability”—for example,
not having your therapist call you right back (as we saw in Jane’s story)—feels
totally disorganizing and shattering.
The behavior pattern(s) that are demonized, and that often frighten mental
health professionals, are really the person’s attempt to create the sense of safety
and control that has been lost. This understanding leads to the second basic
tenet, which is the ability to remain empathic in the face of emotional chaos.
Through clinical examples, we have shown the challenges that one is confronted
with when successfully engaging with “borderline” patients, one of the greatest of
which is the compromises in empathy.
There is no doubt that sensitive clinicians and family members experience
their own spectrum of painful feelings; and rage—which is the most common
—creates a situation in which empathy may be temporarily suspended. As men-
tioned in the clinical narratives, this is a sort of “nightmarish” therapeutic
atmosphere. To feel enraged with someone you are trying to help is quite painful.
Acknowledging one’s own feelings while simultaneously remaining vigilant and
ever mindful of how much this person is suffering can help one through these
tough patches, ultimately leading to growth for client and therapist alike while
also deepening the trust in the therapeutic relationship.
Another important and related principle is the importance of clinicians’ abil-
ity to use their own emotional responses to better understand their client’s expe-
rience and further to inform the therapy process. Each therapeutic relationship is
a unique context in which two people come together and a new world is created.
Clinicians always experience thoughts and feelings that arise and unfold based
on the distinct nature of each relationship. This happens with all clients, but it
is the most confusing and disorienting when one is engaged in a world with a
borderline client. As we learned through the clinical narratives, acknowledging
one’s own feelings is tantamount for therapeutic success.
Often times, clinicians will have painful visceral experiences, such as
chest tightness, back pain, and jaw clenching, as we see with Jane. When Jane
is enraged, we understand her pronounced pain on a bodily level. Other times,
it may arise as more of an intuitive sense in which one has a nagging feeling that
something more than is being said is happening. A latent process transpires in
the room that is beyond wisdom and reason; it is a felt sense that our client is
experiencing something that is beyond words. In both situations, astute atten-
tion to one’s own processes can provide information about the client’s world
and can be used to better understand what our clients are experiencing on a more
unconscious level. With this type of emotional clarity, clinicians can engage in
therapeutic processes that are guided by greater perspicuity and, thusly, facilitate
greater awareness and personal understanding for clients.
The next significant precept is the importance of maintaining a flexible,
malleable frame that changes based on the individual needs of each client.
Traditional therapeutic approaches to treatment of clients with “borderline per-
sonality disorder” typically emphasize very structured, well-defined frames. The
authors suggest that although this may be temporarily containing, it creates a
sterile therapeutic environment, and one that ultimately Band-Aids the deeper
emotional chaos. It also inherently purports that all those who struggle
with emotional chaos are the same, which—as we learned from the clinical
narratives—simply is not true; everyone is different. Therapy can be unpredict-
able and even messy at times; to be effective, clinicians must treat each client
differently, bending and changing to meet the client’s needs in the moment.
The final salient feature, and perhaps the most important, is attending and
cultivating client’s strengths. Identifying and fostering attributes that allow peo-
ple to live more meaningful lives is integral to any therapy. Historically, psychol-
ogy has placed greater emphasis on a pathology model and psychotherapy on
symptom reduction, and less on nurturing a person’s strengths. The authors high-
light the importance of integrating these unique strengths into treatment plans
for individuals suffering with “borderline personality disorders.”
Because of the emotional chaos that characterizes much of the therapeutic
dynamics while working with borderline clients, this emphasis on strengths is
all but forgotten. Through clinical narratives of people diagnosed with “border-
line personality disorder,” one observes that beneath the scarlet label exists a
whole person, and one who has much strength; unfortunately, these attributes
are often lost as clinicians struggle to simply manage the chaos.
With years of clinical experience, the authors concur that all “borderline” cli-
ents have strengths, and that they are often some of the most interesting, cre-
ative, intelligent, and talented people. As a result of internally chaotic worlds,
they often lack the type of self-possession that enables one to use these traits in
pursuit of satisfying lives. It is our job as clinicians to remain vigilant of these
forces and move clients toward recognizing, integrating, and ultimately activat-
ing them in pursuit of more balanced, meaningful lives. People struggling with
emotional chaos deserve to be treated as whole people and not be reduced to a
label that leaves them stigmatized—as untreatable outliers—and demonized
within the psychiatric community.
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Appendix: Wellness and Recovery Resources
We are pleased to offer this resource guide. Of course, it is impossible to provide

a complete list of all resources. Our hope is that, in the following pages, one will
be able to find one or more resources that will aid in the process of wellness and/
or recovery. Finding a psychiatrist or other prescriber is quite easy these days.
It is far more challenging to find non-medication resources. We are not anti-
psychiatry and do not oppose people taking medications. We also do not recom-
mend that one discontinues medication (of any sort) without proper medical
supervision. However, for those who may be interested in nonpsychiatric
approaches, the following appendix will prove helpful.
We do not believe that any single approach is necessarily more superior to
another. Recovery and wellness are intensely personal experiences. Sometimes
a single approach works well, sometimes a few different approaches, sometimes
a combination of approaches, etc. As mentioned throughout the book, there
are often secondary forms of distress, constellating around untreated trauma
(e.g., substance use). We have included resources that address such areas. After
reading this book, if you feel that you personally relate to some of the material
or perhaps know a friend, family member, or coworker who may, hopefully some-
thing provided in this appendix will help. We feel confident that if you do not
find assistance here directly, a resource listed here will point you in the right
direction. As Jung said, “The shoe that fits one person pinches another; there is
no recipe for living that suits all cases.” No matter where you are on your path,
do not be discouraged. If one thing does not work, try another. Take what is
useful to you and discard the rest. Try something new and do not lose hope.
RECOVERY AND WELLNESS ORGANIZATIONS

Animals as Natural Therapy
http://www.animalsasnaturaltherapy.org/
“Animals as Natural Therapy (ANT) empowers individuals of all ages to build
honest mutually respectful relationships with our animal partners. Participants
122 Appendix: Wellness and Recovery Resources
are challenges to expand their possibilities in a safe, nurturing environment.

They develop essential life skills, with the support of mentors, beside horses
and other animals. These skills will positively impact all aspects of their lives:
self-management, determination, social intelligence, gratitude, hope, awareness
and curiosity.”
National Empowerment Center

http://www.power2u.org/
“NEC staff and consultants bring unique experience in organizing and develop-
ing consumer-run organizations, and helping individuals and groups develop
the knowledge and ability to transform the mental health service system toward
a more recovery-oriented and consumer- and family-driven approach. Each has
experience running organizations, nurturing the process of recovery in individ-
uals and groups, and strong skills as educators. This team is available to individ-
uals, organizations, service systems, and family members looking for a speaker or
for technical assistance, training, and consultation.”
PsychRights
http://psychrights.org/
“The Law Project for Psychiatric Rights (PsychRights) is a non-profit, tax
exempt 501(c)(3) public interest law firm whose mission is to mount a strategic
legal campaign against forced psychiatric drugging and electroshock in the
United States akin to what Thurgood Marshall and the NAACP mounted in
the 40’s and 50’s on behalf of African American civil rights. The public mental
health system is creating a huge class of chronic mental patients through forcing
them to take ineffective, yet extremely harmful drugs.”
Recovery Innovations
http://www.recoveryinnovations.org/
“Our Mission: To Create opportunities and environments that empower people
to recover, to succeed in accomplishing their goals, and to reconnect to them-
selves, to others, and meaning and purpose in life.”
Recovery Opportunity Center

http://www.recoveryopportunity.com/
“Welcome to the Recovery Opportunity Center! Thanks for check us out. We
are the training and consulting wing of Recovery Innovations, and as you’ll
see, we have lots of information, material, training, and consultation available
for you. Our intent is to spread the message of recovery world-wide by offering
tools that you can easily use to promote recovery and resilience.”
BOOKS
Marcia Angell
– The Truth about Drug Companies: How They Deceive Us and What to Do about
It (2005)
Peter Breggin
– Brain Disabling Treatments in Psychiatry: Drugs, Electroshock and the Psychopharma-
ceutical Complex (2007)
– Drug Withdrawal: A Guide for Prescribers, Therapists, Patients and Their Families
(2012)
– Medication Madness: The Role of Psychiatric Drugs in Cases of Violence, Suicide and
Crime (2009)
– Psychiatric Drug Withdrawal: A Guide for Prescribers, Therapists, Patients and Their
Families (2012)
– Talking Back to Ritalin: What the Doctors Aren’t Telling You about Stimulants and
ADHD (2001)
– Talking Back to Prozac: What Doctors Aren’t Telling You about Today’s Most
Controversial Drug (1995)
– Toxic Psychiatry: Why Therapy, Empathy and Love Must Replace the Drugs,
Electroshock and Biochemical Theories of the “New Psychiatry” (1994)
– Your Drug Might Be Your Problem: How and Why to Stop Taking Psychiatric
Medications (2007)
Paula J. Caplan
– They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s
Normal (1996)
– Bias in Psychiatric Diagnosis (2004)
Jose Cardona
– Psychiatry: An Industry of Greed, Misery and Death (2010)
James Davies
– Cracked: The Unhappy Truth about Psychiatry (2013)
Seth Farber
– The Spiritual Gift of Madness: The Failure of Psychiatry and the Rise of the Mad Pride
Movement (2012)
Joan Gadsby
– Addiction by Prescription (2001)
Peter Gotzsche
– Deadly Medicines and Organised Crime: How Big Pharma Has Corrupted
Healthcare (2013)
David Healy
– Let Them Eat Prozac: The Unhealthy Relationship between the Pharmaceutical Industry
and Depression (2006)
– Pharmageddon (2012)
Jack Hobson-Dupont
– The Benzo Book: Getting Safely Off Tranquilizers (2006)
The Icarus Project

– Harm Reduction Guide to Coming Off Psychiatric Drugs (2012)
Bliss Johns
– Benzo-Wise: A Recovery Companion (2010)
– Recovery and Renewal: Your Essential Guide to Overcoming Dependency and Withdrawal
from Sleeping Pills, Other “Benzo” Tranquilizers and Antidepressants (2012)
Irving Kirsch
– The Emperor’s New Drugs: Exploding the Antidepressant Myth (2011)
Peter Lehmann
– Coming Off Psychiatric Drugs (2002)
E. Robert Mercer
– Worse Than Heroin (2008)
Gary Null
– Death by Medicine (2011)
Gwen Olsen
– Confessions of an Rx Drug Pusher (2009)
Matt Samet
– Death Grip: A Climber’s Escape from Benzo Madness (2013)
Ann Blake Tracy

– Help! I Can’t Get Off My Anti-Depressant! (CD, 2010)
– Prozac: Panacea or Pandora? The Rest of the Story of the New Class of SSRI Antidepres-
sants: Prozac, Zoloft, Paxil and More (1991, 2001)
Robert Whitaker
– Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Rise of Mental Illness
in America (2011)
– Mad in America: Bad Science, Bad Medicine & the Enduring Mistreatment of the
Mentally Ill (2010)
DOCUMENTARIES
Brian Baxter
– Benzo Withdrawal: Welcome to Hell (2009; YouTube)
Kevin Miller
– Generation Rx (2008)
Gary Null
– Death by Medicine (2011)
– War on Health: The FDA’s Cult of Tyranny (2012)
WEBSITES
– Alice W. Lee, MD, ABIHM, Holistic Psychiatrist (http://holisticpsychiatrist.com/)
– Alto Strata (http://survivingantidepresants.org)
– Beyond Meds (http://beyondmeds.com)
– Bliss Johns (http://recovery-road.org/)
– The Council for Evidence-Based Psychiatry (http://cepuk.org/)
– Dialectical Behavioral Therapy (http://www.dialecticalbehavioraltherapy.net)
– Diane Speer (http://www.dianespeeryogameditationwellness.com/)
– Drug and Label-free Site for Parents (http://ablechild.org)
– Foundation for Excellence in Mental Health Care (http://www.mentalhealth
excellence.org/)
– Icarus Project (http://www.theicarusproject.net/)
– International Coalition for Drug Awareness, Dr. Ann Blake Tracy (http://www
.drugawareness.org)
– Law Project for Psychiatric Rights (http://www.psychrights.org)
– Mad in America, Science, Psychiatry, and Community (http:/www.madinamerica
.com)
– Madness Radio with Will Hall (http://madnessradio.net)
– Meaningful Online Therapy (http://www.meaningfulonlinetherapy.com/)
– Mike Adams (http://naturalnews.com)
– MindFreedom (http://mindfreedom.org)
– Mindfulness Therapy Associates (http://mindfulnesstherapy.org/dbt/)
– National Association for Rights Protection and Advocacy (http://www.narpa.org)

– Open Paradigm Project (http://www.openparadigmproject.com)
– Psychiatric Drug Facts, Dr. Peter Breggin (http://breggin.com)
– Recovering from Psychiatry (http://recoveringfrompsychiatry.com/)
FACEBOOK ONLINE SUPPORT PAGES/SUPPORT GROUPS

– 100,000 Plus Who Realize the Great Harm That Psychiatry Does to People
– Alternatives 2012
– Antidepressant/Antipsychotic/Benzodiazapine Withdrawal Recovery
– The Anti-Psychiatry Movement
– Benzo Withdrawal Christian Support Group
– Benzo and Psych Med (BPM) Withdrawal Group
– Benzodiazepine Addiction Needs Awareness (BANA)
– Bloom in Wellness (Bliss Johns)
– The Dangers of Antidepressants
– Free Thinking about Psychiatric Drugs
– Healing from Psych Drugs
– Healing Voices
– The Icarus Project
– International Coalition for Drug Awareness
– Irish Network of Critical Voices in Mental Health
– Lives Destroyed by SSRI Antidepressants
– Mad in America
– Madness Radio
– NARPA
– Occupy Psychiatry: Discussion Group
– Prescription Drug Dangers
– Protracted Withdrawal Syndrome from Benzodiazepines and Anti-Depressants
– Psych Truth Seekers
– Psychiatric Drugs Destroy Life
– Psychiatric Revolution
– Psychiatric Survivors
– Psychotic Psychiatry
– Psychs
– Recovered Memories of Sexual Abuse (for psych survivors)
– Recovering from Psychiatry (Laura Delano’s page)
– Repealing Mental Health Laws
– Speak Out against Psychiatry
– Stop Psychiatric Diagnosis Harm
– Stop the Psychiatric Drugging of Children (Fight Psych for Children’s Rights)
– Stop the Psychiatric Drugging of the Elderly
– Un-Diagnosing Emotional Distress
MINDFREEDOM INTERNATIONAL DIRECTORY OF ALTERNATIVES1

(HTTP://WWW.MINDFREEDOM.ORG/MFDB/MFDB-SEARCH-FORM)
Australia
Irwin, Janet
Archer Counselling
87 Bishopsgate St. Carlisle
Perth, 6103
Australia
04 1692 5596
janet@counselling-perth.com.au
Services Provided: Individual Counselling. The therapeutic environment on
offer is calm, safe and respectful. Fundamental to my approach is the develop-
ment of a nourishing therapeutic relationship. My approach involves working
together to find particular ways in which you can change your relationship to
whatever problem or difficulty you are facing. I am especially interested in incor-
porating the unique skills and knowledge you have cultivated during the course
of living your life, in your own context, and in your own way.
Is a sliding scale available? No
Service Rates: $110 per hour session.
Thiecke, Gabriela
Artemisia Natural Medicine
38 Central Avenue
Sherwood, 4075
Australia
07 3716 0513
vt_501@hotmail.com
Services Provided: Dietary strategies plus nutritional (orthomolecular) and
herbal support
Service Rates: See website for details.
Alberta
Hagen, Brad
Associates Counselling Services
239 12B St. N
Lethbridge, Alberta T1K0N1
Canada
1
Used by permission of MindFreedom International
403-381-6000
brad.hagen@uleth.ca
Services Provided: I am a registered psychologist and counsellor who offers
counselling services. My counselling practice is part-time (one day a week); the
rest of the time I am a professor who teaches in a faculty of health sciences at the
University of Lethbridge. I strive to offer a safe and respectful counselling relation-
ship for people, particularly those people who may be facing struggles with over-
whelming sadness, grief, anxiety, and/or experiences like hearing voices. In
particular, I try to offer counselling services free of destructive labels (e.g., the
DSM categories), and offer support for people who are seeking alternatives to the
traditional psychiatric system of diagnosing and/or medicating people.
Is a sliding scale available? Yes
Service Rates: They are normally between $100 [and] $150/hour, but people
in certain circumstances may qualify for subsidized counselling and/or insurance
coverage. On occasion, I do offer services on a sliding scale, and occasionally
provide “pro bono” (no charge) services as well.
Arizona
Botham, Jenn
Miles Naturopathics
2111 E. Broadway Rd, Suite 7
Tempe, Arizona 85282
United States
480-252-4683
jenn@milesnaturopathics.com
Services Provided: Holistic, natural, mental health care, Homeopathy,
shared decision making
Service Rates: First two initial visits, approximately $500–$600; follow-up
visits, $100–$175
Edmonds, Sarah
Relational Alchemy
201 North Alarcon Street Suite C
Prescott, Arizona 86301
United States
928-830-4661
sedmonds@cableone.net
Services Provided: Psychotherapy, psychological evaluations
Service Rates: $85–$145/session. In exceptional cases, I will consider lower-

ing my fee further
Murphy, Lyle
Alternative to Meds Center
40 Goodrow Lane
Sedona, Arizona 86336
United States
800-359-9698
steve@alternativetomeds.com
Services Provided: Our services are residential, and are geared toward an
individual finding stability without or minimally using medication. We find that
many persons have accumulated toxins/neurotoxins that interfere with brain
chemistry function and create imbalances. We perform blood and urine testing
of heavy metal toxicity, essential mineral elements, hormones, and the thyroid.
We do a comprehensive metabolic testing as well. Once a client’s situation is
assessed, whole/organic food and targeted supplements are implemented. Our
doctors are experts at medication tapering. Our chelation program allows for
the removal of accumulated neuro-toxins. Our program consists of sauna, acu-
puncture, yoga, ionic foot-baths, massage, educational trainings, personal exer-
cise training, smoking cessation, amino therapy, animal husbandry (caring for
domestic animals), and luxury-type home accommodations with meals. Life
coaches work 1:1 with clients and in groups. Our focus is primarily alternative
mental health.
Service Rates: Full residential program with lab testing is $20,900 for the first
four weeks, and $16,900 for the second four weeks. Outpatient programs are
available at a reduced cost.
British Columbia
Cormack, Bryhre
Heart-Sense Counselling
2-4925 Marello Rd.
Nelson, British Columbia V1L-6X4
Canada
250-505-3448
bryhresboyz@yahoo.com
Services Provided: I provide client centered solution focused counselling at
either my office in Nelson or in Slocan. I am open to discussion regarding meet-
ing in the community or at client’s homes if that is helpful and possible. My focus
is on helping people create their own solutions to the problems that interfere
with their lives. I have worked with clients on issues relating to relationships, life
transitions, trauma and/or substance misuse, body image, loss and grief. I work
from a stance that seeks to reframe pathologizing experiences and to find alterna-
tives to traditional medical model views of mental illness. I work from an under-
standing that trauma is often one of the factors that underlies mental illness
which is seen as biological in origin (i.e., manic depression, schizophrenia)
Service Rates: My service rates are $25–$65/session
Zsange, Kemila
Kemila Zsange Hypnotherapy & Counselling
West End
Vancouver, British Columbia V6G 2Y2
Canada
604-687-4325
kz@kemilahypnosis.com
Services Provided: We provide information on hypnosis used for therapy and
healing; it offers services that help you, through hypnosis, to find wisdom within
to interrupt patterns, to learn from the depth of your own being and how to be
the best you are meant to be. We have successfully treated men, women and
children around issues such as anxiety, depression, insomnia, fear and phobia,
weight-loss, Past Life Regression. We offer 30 minutes free consultation. Hypno-
therapy is an exceptionally gentle and effective way of making lasting changes
with ease. It can also facilitate healing in the body and help to dissolve illness
and dis-ease. These amazing transformations are achieved through the use of
hypnosis, or direct communication with the subconscious mind. The subcon-
scious is that part of the mind in which habits and behaviors are formed and
maintained. It controls our emotions, beliefs, self-esteem, immune systems, and
bodies. It influences what we think, how we feel, the choices we make, and the
actions we take.
Service Rates: $95/hour. $400 for a package of five sessions.
California
Buck, Eric
Eric Buck Psychotherapy Associates
777 Campus Commons Rd #200
Sacramento, California 95825
United States
530-400-3275
Eric@ericbuckmft.net
Services Provided: Individual Psychotherapy, Couples Psychotherapy, Fam-

ily Therapy, Consultation, Job Coaching, and Training
Service Rates: $110–$150. Also Skype sessions available when appropriate.
Davis office location as well.
DelMonte, Dawn
395 Taylor Blvd., Suite #115
Pleasant Hill, California 94523
United States
510-704-3105
office@mindfreedom.org
Services Provided: Consultation, Psychotherapy, EMDR, Hypnotherapy,
Advocacy, with a client-centered, non-pharmaceutical, pro-nutritional
approach to mental health.
Service Rates: $60–$100/hr. I am on a few health insurance panels and can
provide a monthly statement for those who wish to request reimbursement from
those I am not on.
Dorman, Daniel
450 N. Bedford Drive #306
Beverly Hills, California 90210
United States
310-276-1474
ddorman8@yahoo.com
Services Provided: Psychotherapy for any so-called diagnosis, including
schizophrenia and other psychoses.
Service Rates: $225 per hour
Groome, Robert
Psychoanalysis Los Angeles California Extension
1223 Wilshire Blvd. #1514,
Santa Monica, California 90403
United States
323-913-1650
PLACE@topoi.net
Services Provided: Lacanian Analysis (complete description at: www.topoi.net)
Service Rates: This depends on the economy of the person.
Metz, Craig
740 Front Street, Suite 360
Santa Cruz, California 95060
United States
831-334-8499
therapy@craigmetztherapy.com
Services Provided: Individual and group psychotherapy for adolescents,
adults, couples and families.
Service Rates: $100 per session. However, I have never turned anyone away
for lack of funds and I am dedicated to working with clients to make my services
affordable.
Morrissey, Matthew MFT

Private Practice
2538 California St.
San Francisco, California 94115
United States
415-435-7599
mattmorr21@yahoo.com
Services Provided: Psychotherapy for adults, teenagers, and children.
Service Rates: $120 per 50 minutes. I also am a participating provider with
Anthem Blue Cross, Blue Shield of California, Cigna, Aetna, and MediCal.
Muranko, Karen
Anxiety Wellness Mentor
1109 S. Atlantic Blvd. Unit C
Alhambra, California 91803
United States
626-289-4835
Karen@AnxietyWellnessmentor.com
Services Provided: Personalized phone mentoring sessions nationwide for
people living with anxiety-related disorders. Services especially helpful for peo-
ple who may be home-bound due to their anxiety.
Service Rates: $40 for 1/2 hour. $80 for 1 hour.
Paris, Mary Jean

760 Market Street Suite 945
United States
415 9798767
mjpphd@gmail.com
Services Provided: Psychotherapy
Service Rates: $165/session with a sliding scale. Insurance accepted.
Popper, Mark
Sequoia Psychotherapy Center, Inc.
1065 North Fulton Street
Fresno, California 93728
United States
559-266-5200
mdpphd@comcast.net
Services Provided: Adult Day Treatment, Medication-free psychotherapy,
Individual and group psychotherapy, Psychological Assessment, Forensic Serv-
ices State Disability Evaluations
Service Rates: $180 per hour $120 per hour $60 per hour
Shepard, Gil
2665 Pine Knoll Drive #12
Walnut Creek, California 94595
United States
925-937-3337
gilshep@pacbell.net
Services Provided: As a licensed Marriage and Family Therapist in California
I provide help for teens through adulthood through Psychotherapy and Family/
Relationship Therapy. My intent is to help you recover from overwhelming
experiences that have left you unable to function fully due to stress, anxiety,
depression, addictions and other “diagnoses.” These may be recent or from early
childhood and may include being molested, beaten or abandoned, they may
come from observing abuse of others, marital conflict, rape, violence, war or loss
of loved ones. Or they may come from being unemployed, divorce, family con-
flicts, workplace bullying or not finding a fit in life. I am certified by the
International Society for the Study of Trauma and Dissociative to treat Dissocia-
tive Identity Disorder (DID or Multiple Personality) and am experienced in this
field. I am trained and experienced in Hypnosis, EMDR and EFT. My goal is to
help you experience safety, peace and stability.
Service Rates: Sliding Scale
Simmons, Joshua
Individual Psychotherapy and Couples Counseling
3821 23rd Street
United States
415-820-1554
drsimmons@sftherapy.info
Services Provided: Individual psychotherapy, couples counseling
Service Rates: $80–$160
Sweet, Grace
Average Miracles
349 Franklin Lane
Ventura, California 93001
United States
805-876-6367
grace@averagemiracles.org
Services Provided: I provide Education and Inspiration to workers in Mental
Health Government Agencies and Private Agencies wherever I am invited. A 3
Level Certification Course called Laughter Bridges is offered for Clinicians, Peer
Support Specialists, Counselors, Therapists, Administrators, Peer Family Advo-
cates or anyone else involved in, or providing care for mental health clients. It’s
about why & how laughter heals mental illness, along with many physical condi-
tions as well. The participant receive a certificate to lead therapeutic laughter
groups and one-to-one coaching sessions for clients and staff at mental health facili-
ties. My vision is the upliftment and the continued creation of inspiration for our
Mental Health System People and the Client. This is quite purposeful for the sus-
tainability and longevity of systems employees, and ultimately contributes signifi-
cantly toward the quality of care administered to the clients, and to the bottom
line to the organization, which keeps the system functioning.
Service Rates: I’m a Trainer/Consultant for the National Association of State
Mental Health Program Directors (NASMHPD), who entirely funds the Laughter
Bridges Certification Course. There is little or no cost for the training to an Agency
within the U.S. who requests the training from their State Mental Health Commis-
sioner. Contact Grace Sweet to learn how to go about making a request.
Williams, Paris
Private Practice
711 D Street
San Rafael, California 94901

United States
415-289-6655
pariswilliamsphd@gmail.com
Services Provided: Psychotherapy for individuals and couples.
Service Rates: $90/hour, but slide down depending upon income
Wu, Angela
Angela P. Wu, LCSW Therapist and Coach
123 Dogwood Lane
Aliso Viejo, California 92656
United States
949-933-9146
angela@therapistandcoach.com
Services Provided: Psychotherapy, counseling, and coaching for children,
teenagers, adults, couples, and families.
Service Rates: $150 for 50-minute session. I offer a few lower-cost slots when
available.
Yates, Kristina
3124 Linden St.
Oakland, California 94608
United States
510-496-6000, ext. 555
Services Provided: Counseling/psychotherapy. My background is in person
centered (Carl Rogers) therapy and Re-Evaluation Counseling (a form of peer
counseling). I believe people heal themselves when they are able to receive pos-
itive attention. Resources are inside the client not outside. For good emotional
and physical health I think it is very important to have in place a strong self-
care program including a healthy diet, exercise, outlets for creative expression,
support network of friends, and ways to contribute to making the world a better
place.
Service Rates: $50–$100/hour. I accept MediCal.
Zaejian, Jasenn
19744 Beach Blvd. #215
Huntington Beach, California 92648
United States
949-371-3997
drjz@relatedness.org
Services Provided: Existential biophysical psychotherapy with individuals,
couples, and groups. Forensic Testimony as a defense witness in insanity defense
cases, criminal trials and competency in states of licensure: California, New York
and Nebraska.
Service Rates: Psychotherapy: $150 per session (session ¼ 50 minutes to
1.5 hrs.). Forensic Testimony: Interview, record review and report writing:
$200 per hour. Court and deposition testimony: $300 per hour. Forensic Case
and Trial Consultation: $300 per hour.
Colorado
Santana, Pepe
90 Madison St. Suite 402
Denver, Colorado 80206
United States
720 272-0565
pepe.santana.phd@gmail.com
Services Provided: I am a licensed clinical psychologist specializing in the
treatment of psychological suffering without the use of any dehumanizing prac-
tices or substances such as drugs, psycho-surgery, or other procedures that
“reduce symptoms.” I have worked in this type of dynamic therapy since 1999,
when I began my training under Dr. Kevin McCready. I have experience work-
ing with children, adolescents, adults, seniors, and couples. I also have worked
with various “forensic” populations. I am a psychodynamic psychologist, with a
Jungian orientation.
Service Rates: Full fee: $120. I currently do not take insurance or Medicare/
Medicaid
Sherman, Miranda
Mind of Hope Neurofeedback
6005 Delmonico Drive
Colorado Springs, Colorado 80915
United States
719-694-6113
mindofhope@live.com
Services Provided: Neurofeedback is a drug free alternative that offers

improved brain functioning for Autism, ADD/ADHD, Post-Chemotherapy, Post
Traumatic Stress Disorder, Mild to Moderate Brain Injuries, Addiction, Anxiety
and Depression and many other challenges. Our clinic uses Low Energy
Neurofeedback (LENS), which is very mild yet very effective in treatment.
Service Rates: We offer a free initial consultation. Neurofeedback sessions
are $65 per hour.
Van Pelt, Mary Elizabeth

2202 Stockton Street
Alamosa, Colorado 81101
United States
mary@maryvanpelt.com
Services Provided: Advocacy, education, consulting, and peer support.
I have 30 years’ experience recovering from a severe and persistent psychiatric
disability. I understand the dual role problems encountered by Peer Specialists
working in the community mental health setting. My focus is on sustainable
and meaningful employment for people with psychiatric disabilities.
Service Rates: Professional consulting $50 per hour with a sliding scale avail-
able for low-income people. No charge for the first phone consultation.
Connecticut
Shulman, Richard
Volunteers in Psychotherapy
7 South Main Street
West Hartford, Connecticut 06107
United States
860-233-5115
ctvip@hotmail.com
Services Provided: Volunteers in Psychotherapy (VIP) is an IRS-approved
nonprofit charitable program that provides only one service: strictly private
psychotherapy that our clients participate in voluntarily. We don’t speak to nor
communicate with anyone else about our clients—so that they are in complete
control of all other relationships and decisions in their lives.
Service Rates: VIP’s program allows clients to earn their therapy in exchange
for volunteer work they provide, privately and independently, for the charity,
nonprofit or government agency of their choice. There is an option to pay a par-

tial fee and do less volunteer work (at the client’s prerogative)—but more than
95% of VIP sessions have been earned strictly through volunteer work. We spe-
cifically designed a program with no third party payers (managed care or insur-
ance) so that our clients would not be denied access to therapy, and so that no
one else could demand reports or psychiatric labels regarding our clients. VIP’s
system is as private as Connecticut law allows.
District of Columbia
Marr, Christine
The Natural Psychotherapist
Connecticut Ave NW at Albermarle
Washington, D.C. 20008
United States
917-547-4173
christinemarr.lmft@gmail.com
Services Provided: Holistic Psychotherapy, collaborative, respectful, human
potential focused approach. Methods available: Nutritional information/educa-
tion for optimal mood and mental health, and targeted amino acid therapy edu-
cation. EMDR, hypnosis, biofeedback, breathwork, meditation and mindfulness,
yoga for mood and mental health. Special Populations, Adults and Children
seeking optimal health and functioning, chronic pain and illness, trauma, sub-
stance abuse recovery. Collaboration with integrative doctor when appropriate.
Public talks on nutrition and mental health, focus, behavior.
Service Rates: $150/session Limited sliding scale slots available: After meet-
ing in person at least once, I offer sliding scale to a limited number of people for
telephone therapy with in person sessions as necessary.
Florida
Sengelmann, Inge
Creative Choice Counseling
7600 Red Road Suite 215
Miami, Florida 33143
United States
305-788-6857
inge.sengelmann@gmail.com
Services Provided: Assisting individuals, couples and families cope with and
adjust to problems in living through individual, couples and family counseling;
providing body-centered psychotherapy for trauma resolution (Somatic Experi-

encing) and mindfulness-based skills to reduce symptoms of eating disorders,
addictive impulses, depression and anxiety, and conditioned traumatic stress
responses.
Service Rates: $125 per 50-minute session
Sengelmann, Inge
Creative Choice Counseling
7600 Red Road Suite 215
Miami, Florida 33143
United States
305-788-6857
inge.sengelmann@gmail.com
Services Provided: Assisting individuals, couples and families cope with and
adjust to problems in living through individual, couples and family counseling; pro-
viding body-centered psychotherapy for trauma resolution (Somatic Experiencing)
and mindfulness-based skills to reduce symptoms of eating disorders, addictive
impulses, depression and anxiety, and conditioned traumatic stress responses.
Service Rates: $125 per 50-minute session
Sheen, Brian
Florida Institute of Complementary and Alternative Medicine
12 NE 5th Ave
Delray Beach, Florida 33483
United States
561-272-3733
Drbriansheen@yahoo.com
Services Provided: Training and Personal therapy in the field of Complemen-
tary and Alternative Medicine to help individual heal and develop greater inner
strength and ability to live a medication free life of peace and well-being.
We utilize meditation, yoga, Bioenergetics, Formative Psychology, Quantum
Psychology, hypnotherapy, NLP,
Acupuncture, Homeopathy, Chinese Medicine, Nutritional Counseling,
Hellinger Constellations, shamanic practices and Purifying breathwork. I have
developed the Clearminded Children’s Program that works directly with chil-
dren and their parents to get them off their ADD/ADHD medication as laid
out in my book, Educate Don’t Medicate.
Is a sliding scale available?: Yes
Service Rates: Our ongoing classes range from $12 to 15 each, Deep healing
Workshops are approximately $279 for a seven week 16 hour group healing pro-
gram and private session rates range from $150 to $195 per hour.
Simon, Laurence
15300 Jog Road Suite 109
Delray Beach, Florida 33446
United States
561-252-2779
laurence.simon@me.com
Services Provided: Individual and group psychotherapy
Service Rates: $125
Georgia
Lynch, Jayme
Peer Support and Wellness Center
444 Sycamore Drive
Decatur, Georgia 30030
United States
404-371-1414
wellnesscenter@gmhcn.org
Services Provided: We offer 24/7 respite for up to 7 days to any individual
who prefers to avoid a psychiatric hospitalization. We also offer daily Wellness
Activities and a 24/7 Warm Line.
Service Rates: All our services are free. We are a project of the Georgia Men-
tal Health Consumer Network in partnership with the Consumer Relations and
Recovery Section of Georgia’s Department of Behavioral Health.
Whitfield, Charles
Private Practice
3462 Hallcrest Drive
Atlanta, Georgia 30319
United States
404-843-3585 9:30 a.m. to 6:00 p.m. seven days a week
c-bwhit@mindspring.com
Services Provided: Evaluation, getting off drugs, psychotherapy, group
therapy, trauma psychology, alternative medicine and psychiatry
Service Rates: $150 per 50-minute session; $230 per month (4 sessions) for
group therapy.
Illinois
McNatt, Matthew
McNatt Learning Center, Inc.
101 W Illinois Ave, Suite 5
Morris, Illinois 60450
United States
815-433-9500
matthew@mcnattlearningcenter.com
Services Provided: The McNatt Learning Center of Morris, Illinois, helps
extraordinary people do ordinary things, improving attention, reducing stress in
learning, and discovering ease in movement. Our mission is to match each per-
son with practices that make learning and living more efficient and sustainable,
then to help him, her or, perhaps, you to implement those practices. We support
the informed choice to use—or not to use—psychiatric drugs, but helping people
wean off them is beyond our scope of practice. Instead, we help people develop
reliable habits of thinking and moving. Since we see behavior as communica-
tion, our focus isn’t on labeling people, prescribing medicine, or changing behav-
ior: it’s on listening to and empowering our clients to find safety, security,
dignity, and grace—and with these, the freedom to be who they want to be.
Our modalities include HANDLE, 8 Questions Coaching, Interactive Metro-
nome, Feldenkrais, and various cognitive training approaches.
Service Rates: Rates vary by service but are generally between $65 and $100
per hour. Sometimes, we can accept post-dated checks for payment.
Indiana
Schultz, Daniel
Clinical Psychology Center
15 Franklin Street Suite 230
Valparaiso, Indiana 46383
United States
219-462-4770
clinicalpsychologycenter1@frontier.com
Services Provided: All clinical psychology services including psychotherapy,
marital therapy, and evaluation. My evaluations are often for attentional and
school problems but my objective is to find out what is going on. I do not believe
in ADHD and want to know functionally what is causing the problems for the
child. I am a member of ISEPP and subscribe to all of its principles as well as the
principles of MFI. I am a client-centered therapist and use this as my primary
modality. I also use hypnosis as an adjunct to therapy and to provide a non-
medicinal means of anxiety reduction.
Service Rates: Intake, $135; Psychotherapy hour, $110
Kansas
Westwind, Sue
Natural Mind
3115 W. 6th Street
Lawrence, Kansas 66066
United States
785-331-9630
sue@naturalmindwellmind.com
Services Provided: I’m trained as a Holistic Mental Health Coach and hypno-
therapist. I’ve done extensive work with individuals and groups integrating a trans-
personal approach that takes spirituality into account in understanding the whole
person. I have a private practice and offer classes on drug-free approaches to mental
wellness. I prefer to do coaching or therapy in nature—peaceful or invigorating set-
tings where the person receiving care feels safe and free. I also make house calls.
The courses utilize integrative mental health practitioners such as naturopaths,
nutritionists, and fitness and meditation experts to do the teaching.
Service Rates: $60 per hour, but will do portions of an hour. I also do distance
coaching via telephone.
Maine
Feintech, Ronald
The Couples Center
222 Auburn St., #201
Portland, Maine 04103
United States
207-878-3141
couplescenter@maine.rr.com
Services Provided: Integrated Sex and Marital Therapy, individual psycho-
therapy, Information on alternatives to Psychotropic Medication
Service Rates: $125/hour
Maryland
Morrigan, Brooke
Private Practice
1015 Spring Street, Suite 201
Silver Spring, Maryland 20910
United States
202-329-7160
Services Provided: Individual psychotherapy with adults, adolescents, and
children.
Service Rates: Standard fee is $120 per 50-minute session. A few reduced-fee
openings are available from time to time.
Ruby, Chuck
The Pinnacle Center
603 Post Office Rd., Suite 210
Waldorf, Maryland 20693
United States
301-705-7593
docruby@verizon.net
Services Provided: Individual psychotherapy adults.
Service Rates: Initial Interview Meeting 50 minutes, $165. Subsequent ses-
sions, 50 minutes, $150. Telephone contacts, 15-minute increments, $35. Slid-
ing scale only in certain cases of financial need.
Silver, Ann Louise

Columbia Academy for Psychodynamics
4966 Reedy Brook Lane
Columbia, Maryland 21044-1514
United States
410-997-1751
annlouisesilver@yahoo.com
Services Provided: Psychotherapy; psychoanalysis; prescribing to patients in
therapy with me, where the objective is to keep these to a minimum and
simplified.
Service Rates: $200 for a 50-minute session.
Massachusetts
Bliss, Jeff
Windhorse Associates
211 North Street Suite 1
Northampton, Massachusetts 01060
United States
413-586-0207, ext. 333, or ext. 103, or ext. 113
admissions@windhorseassociates.org
Services Provided: Windhorse Associates is an innovative therapeutic com-
munity approach to recovery for individuals experiencing serious psychiatric dis-
tress. The services at Windhorse Associates are individually tailored in close
communication with each client and family, and represent a wide range of inten-
sity and structure. Services range from a clinical mentorship through to a sup-
ported apartment household in the local community.
Service Rates: From $20 per day to $595 per day
Cohen, Oryx
National Empowerment Center
599 Canal St., 5th Floor
Lawrence, Massachusetts 01840
United States
(413) 561-3269
oryx@power2u.org
Services Provided: Toll Free Information/Referral Line available 9:00 a.m. to
4:00 p.m. EST, M–F, Training Online Bookstore
Service Rates: Trainings are negotiable
Grossberg, Chaya
Freedom Center
75 West St.
Northampton, Massachusetts 01060
United States
917-974-1876
ngrossberg@yahoo.com
Services Provided: Instruction in yoga and meditation. Writing groups. Peer
Counseling. Reiki. Nutritional and herbal consults. Intuitive readings.
Service Rates: $60/hour, or equivalent. Barters enthusiastically welcome.
Pittenger, Sol
888 Purchase St 303
New Bedford, Massachusetts 02740
United States
508-991-7010
Services Provided: Individual psychotherapy, biofeedback for relaxation/self-
regulation
Service Rates: $80 per session
Weaver, Anne
1051 Beacon St
Brookline, Massachusetts 02446
United States
617-583-2348
anneleithweaver@gmail.com
Services Provided: I am a licensed mental health counselor and have been
practicing recovery-based psychotherapy since 2003. My work with my clients
is based on the principle that recovery from mental health crises and conditions
is possible. My own lived experience of mental health crisis directly informs my
work and my commitment to supporting and validating others who may have
been poorly served by the conventional mental health system. I do not work
from a medical model perspective and believe that recovery is best achieved
through a non-pathological and trauma-informed model of practice.
Service Rates: $75 per client hour. I am also a provider for Blue Cross/Blue
Shield.
Michigan
McCarthy, Elizabeth
1463 E 12 Mile Rd., Bldg. 1
Madison Heights, Michigan 48071
United States
248-875-4977
emcc@wowway.com
Services Provided: Psychotherapy. My practice includes helping children,
adolescents, and adults resolve emotional distress related to attachment and
trauma, anxiety and depression, chronic pain, iatrogenic drug dependency and
withdrawal (especially benzodiazepine withdrawal), as well as more extreme

states of consciousness.
Service Rates: Sessions billed at $75–$125. I reserve a few spots for reduced
fee when need can be demonstrated. I do not accept insurance.
Minnesota
Langsten, Nels
400 Selby Avenue, Suite G-4
St. Paul, Minnesota 55107
United States
646-752-2078
n.langsten@comcast.net
Services Provided: Psychiatric Consultations; Psychotherapy (psychody-
namic and cognitive-behavioral); Medication reduction and discontinuation;
Treatment of all people with emotional problems with special interest in persons
with trauma related problems and with psychotic symptoms.
Service Rates: I accept most insurance. Sliding scale fees for uninsured per-
sons with range of $200 to $300 for initial consultations and $100 to $200 for
follow-up consultations.
New Jersey
Danco, Jeff
American Institute for Counseling, Inc.
1952 Rt. 22
Bound Brook, New Jersey 08805
United States
732-469-6444, ext. 100 or ext. 115
jeffdanco@optonline.net
Services Provided: General counseling and psychotherapy
Service Rates: Most insurance networks; for private payers: $90–$150 per session
Ross, Lloyd
Private Practice
45 North Broad Street Suite 402
Ridgewood, New Jersey 07450
United States
201-445-0280
lloydross1@worldnet.att.net
Services Provided: Psychodynamic Psychotherapy for children, adolescents

and adults. I have been working without medication for the past 32 years in
full-time private practice because psychotropic medication interferes with real
treatment.
Service Rates: $175 per session.
Wetzel, Norbert
Princeton Family Institute
166 Bunn Dr. Suite # 105
Princeton, New Jersey 08540
United States
609-921-2551, ext. 2
wetzel@princetonfamily.com
Services Provided: Psychotherapy for families, couples, individuals. Also:
psychological evaluations, advocacy for families faced with deportation; expert
witness at court; divorce mediation; family network therapy, family business con-
sultations, family group therapy etc. Please note: Our group of highly experi-
enced practitioners consists of family therapists with years of training and
teaching family therapy. We are a culturally and ethnically diverse group provid-
ing culturally sensitive services for people from diverse backgrounds according
to race, culture, gender identity, sexual identity, age and “psychiatric
labels” . . . We privilege the expertise of the client!
Service Rates: $125–$205. Depending on the situation we make sure that
everyone who contacts us will be connected with a counselor within a short
time. There are counseling agencies in town that are publicly funded.
New York
Arenella, Jessica
Private Practice
80 East 11th Street Suite 207
New York, New York 10003
United States
917-304-5901
arenellaphd@jesspsychologist.com
Services Provided: Individual psychotherapy
Service Rates: I accept Medicare, Medicaid, HIP, Oxford and UBH health
insurances. Session rates are $80–$180, discounts may be available for daytime
hours and multiple sessions per week.
Dardashti, Niloo
Integrative Psychotherapy of NYC
5 West 86th Street, Suite 1C
United States
646-789-5113
PsychHealth@gmail.com
Services Provided: Integrative Psychotherapy and Holistic Alternatives
Heimowitz, Daniel
441 West End Ave., Suite 1B
United States
917-257-9621
danheimowitz@gmail.com
Services Provided: Individual, family and group psychotherapy
Service Rates: $60 and I take most insurances
Keilhofer, Isolde
Private Practice
412 Sixth Avenue, Suite 605
United States
212-726-0558
ikeilhofer@yahoo.com
Services Provided: Individual psychotherapy and psychoanalysis for adults.
Service Rates: I offer moderate fees. A sliding scale is available depending
upon need.
O’Loughlin, Michael
Private Practice
15 Laurel Drive
New Hyde Park, New York 11040
United States
5164144438
michaeloloughlinphd@gmail.com
Services Provided: Psychotherapy, Child Psychoanalysis, Child Psycho-

therapy, Adult Psychoanalysis.
North Carolina
Ford, Susan
EEG Centre for Neurofeedback LLC
2512 Lynn Rd., Suite No 1
Tryon, North Carolina 28782
United States
828-859-1220
eegcentre@charter.net
Services Provided: Neurofeedback for attention, anxiety, behavior, and sleep
problems
Service Rates: $250 for initial consultation, inclusive of diagnostic testing. $1,700
for a package of 20 sessions. Some insurance companies will cover the training.
Stone, William
Healing Connections
309 West Weaver Street Suite 200
Carrboro, North Carolina 27510
United States
919-618-3207
stonewil2@gmail.com
Services Provided: Psychotherapy, Homeopathy, and Bodywork with holistic
approach.
Service Rates: Free initial session. Basic rates are posted on my website, but
depending on insurance and need, I can be flexible.
Oregon
Birney, Rodney
Self & Soul Center
9820 Wagner Creek Road
Talent, Oregon 97540
United States
541-535-3338
sscenter1009@qwestoffice.net
Services Provided: Consultation and integrative psychotherapy. In an initial

consultation I listen and try to understand the person who I am meeting with,
their strengths and challenges. I find their goals and have a dialogue about what
may be helpful. In psychotherapy I help them learn self-regulation skills to be
able to meet life’s challenges. I use an integrative approach, meeting the client
where they are (pre contemplative, contemplative, action or maintenance
phases of therapy). Together we create a relational field that allows for growth
and maturation. I listen, teach skills from cognitive, depth, humanistic psycho-
therapies and contemplative practice.
Service Rates: Non insurance discount, initial consultation $150
(60–75 minutes), ongoing psychotherapy $125 (45 minutes). Insurance, initial
consultation $200, ongoing $165.
Birrell, Pamela
Private Practice
261 East 16th, #4
Eugene, Oregon 97401
United States
541-687-0041
pbirrell@gmail.com
Services Provided: I offer psychotherapy especially for people who have a his-
tory of trauma—child sexual abuse, physical abuse, or abuse at the hands of the
mental health system. I use a respectful relational approach with the goal of
safety in relationships so that my clients can fully engage in authentic relational
growth.
Service Rates: $100 for a 50-minute session. Sliding scale ($50) available on
some occasions.
Elliott, Travis
Dr. Travis J. Elliott
1305 SW Stephenson St
Portland, Oregon 97219
United States
503-206-7773
travis@drtraviselliott.com
Services Provided: Naturopathic medicine with a focus on emotional compo-
nents of chronic disease. I have a very unique perspective on the way that emo-
tions and the physical body interact and am able to quickly help my patients heal
underlying wounds and belief systems that are driving their current symptoms.

Service Rates: I offer free initial consults. I will listen to your story and let you
know if I think that I can help you. I also accept many insurance plans. “Fee at
time of service” is $90 per appointment. Most people experience significant
change in symptoms within 3–6 visits.
Hall, Will
Private Practice
2456 NW Raleigh St. #201
Portland, Oregon 97210
United States
413-210-2803
will@willhall.net
Services Provided: Counseling and coaching from my Portland Oregon,
office and by phone and skype internationally. I am a leading advocate, organ-
izer, and educator in creating alternatives to the traditional mental health sys-
tem. I co-founded Freedom Center, host Madness Radio, am on the collective
of The Icarus Project, and am Director of Portland Hearing Voices. I have more
than 9 years’ experience with people struggling with emotional crisis and
extreme states of consciousness, and am currently completing my master’s degree
in Process Oriented Psychology, a somatic and Jungian approach to therapy and
social change. My areas of specialization are: voices, delusions, paranoia, and
psychosis; extreme mood states called “mania” and “depression”; emotional
trauma including psychiatric abuse; spiritual practice and awakening; alterna-
tives to diagnostic labeling; working with families; reducing/coming off medica-
tions; conflict resolution; social oppression and rank; holistic health; and living
with mental diversity.
Service Rates: $80 per hour
Malecek, Stefan
Neah-Kah-Nie Counseling Associates
P.O. Box 776
Manzanita, Oregon 97130
United States
503-368-7747
phoenix@nehalemtel.net
Services Provided: I offer both office and telephone consultations. I provide
client-centered psychotherapy with a focus on: reframing shame; traumatic
memory integration; unresolved childhood issues reverberating into the present;
advanced recovery from substance abuse and other addictions; resolving
retraumatization by contact with the current psychiatric system; holographic

therapy (how the outside world mirrors one’s inner world); physical illness as
metaphor for unresolved emotional experience.
Service Rates: Free Initial Consultation. Insurance, $150/hour (No OHP or
Medicare); Self-Pay, $75/hour; Sliding Scale minimum, $45/hour
McNabb, Gary
Adaptup: Advanced Brain Readiness
1524 Willamette St., Suite 200
United States
541-343-2525
garymcnabb@adaptup.com
Services Provided: I provide behavioral practices that refocus important regula-
tory areas of the brain. People often feel relief, from a host of symptoms, within the
first 15 minutes of our initial meeting. I have worked in rehab medicine for many
years and have helped people with physical and behavioral health challenges by
mobilizing the deep strengths of our brain. I also help people learn how to “read”
what their brain needs from them and how to bring it. This regularly helps reduce
medications to optimal levels and limits unnecessary side effects.
Service Rates: When people have health insurance my charges are $125 per
visit.
Mendenhall, Elissa
Emerge Health
8512 SE 9th Ave 852 SW 21st Ave
Portland, Oregon 97202, 97205
United States
503-239-8181
dr.elissa@yahoo.com
Services Provided: Naturopathic care for mental health and addiction issues.
I approach treatment on a multifaceted level, because being human is a multifac-
eted experience. Approaches may include alternative diagnostics of underlying
physiologic conditions, deep listening, biofeedback and other stress management
techniques, nutritional counseling and identification of food toxins, orthomolec-
ular psychiatry, amino acid therapy, classical homeopathy, and energetic body-
work. I can also work toward reduction/elimination of medications or
reduction of side effects of medication. Initial intakes last around two hours
and follow-up visits are typically an hour.

Service Rates: $140 for the initial visit, $85 for follow-up. Can bill most
insurances that include naturopathic coverage.
Turnbull, Flora
Creative Energy Therapy
1034 Lawrence St.
United States
458-205-9921
flora@creativeenergytherapy.com
Services Provided: I offer a private psychotherapy practice for adults, adoles-
cents, and families, integrating transpersonal psychotherapy, expressive arts
therapy, and energetic healing within a holistic context. I also hope soon to offer
workshops and on-going groups.
Service Rates: I charge $90 per hour and also have a sliding scale rate avail-
able of $50–$80 per hour.
Unger, Ron
1257 High St. Suite 7
United States
541-513-1811
4ronunger@gmail.com
Services Provided: Recovery oriented counseling. I specialize in a respectful
cognitive therapy approach to helping people with experiences like voices, para-
noia, unusual beliefs, and helping people heal from trauma and reduce the stress
that drives people to extreme states.
Service Rates: Normal fee is $90 per 50-minute session. Also sliding scale
based on what you can afford, minimum $35 for a 50-minute session.
Walter, Bill
Golden Apple Healthcare
492 E 13th Ave, Suite 200
United States
541-342-4520
contact@goldenapplehealthcare.com
Services Provided: Naturopathic primary and specialty care for adults, with
prescriptive authority for most drugs Biofeedback and stress management
training Massage, bodywork, and joint manipulation Lifestyle counseling (diet,

exercise)
Is a sliding scale available?: No
Service Rates: Depends on service rendered. Average is about $300 per hour.
A 30% discount is offered if paid at time of service.
Pennsylvania
Spanier, Cyndie
Psychological Health and Behavioral Medicine
225 Penn Avenue
Pittsburgh, Pennsylvania 15221
United States
412-849-4755
cyndiespanier@aol.com
Services Provided: Clinical and Trauma Psychologist providing telephone
consultation, assessments, and psychotherapy. I specialize in traumatic stress,
posttraumatic stress disorder, anxiety, depression, relationships, grief and loss,
and stress related illnesses in the mind-body connection. I help with coping
and regaining normalcy.
Service Rates: My fee is $50 for 30-minute sessions; $75 for 45-minute ses-
sions; and $100 for 1 hour. I accept credit cards primarily (the most secure),
and also check or cash. My phone number is 412-849-4755.
Rhode Island
Sparks, Jacqueline
University of Rhode Island
2 Lower College Rd.
Kingston, Rhode Island 02881
United States
(401) 874-7425
jsparks@uri.edu
Services Provided: Individual, family, and couple counseling.
Service Rates: Sliding scale.
Texas
Breeding, John
5306 Fort Clark
Austin, Texas 78745
United States
512-326-8326
john@wildestcolts.com
Services Provided: Office and telephone counseling and consultation for
individuals, couples, families and groups. I am also available for public speaking
and workshops on personal growth, human transformation, parenting, working
with young people, and liberation from psychiatric oppression. http://www.
wildestcolts.com/counseling.html.
Service Rates: $125 for an hour; $165 for an hour and a half.
Vermont
Morgan, Steven
Another Way
125 Barre St.
Montpelier, Vermont 05602
United States
802-229-0920
anotherwayvt@gmail.com
Services Provided: Another Way is a nonprofit drop-in center providing peer
support, information, advocacy, and various social services to psychiatric survi-
vors and current/past users of mental health services. We provide a free commu-
nity meal on Friday evening from 5:00 to 7:00. Coffee and food are available on a
daily basis, as well as arts and crafts. Another Way also has showers, cooking
facilities, telephones, limited transportation, and Internet access. We have a
Housing Coordinator on staff to help people find stable housing, and we provide
advocacy as needed to navigate social services.
Service Rates: Free
Virginia
Irwin, Matt
1240 North Pitt Street
Alexandria, Virginia 22314
United States
703-780-1261
drmattirwin@yahoo.com
Services Provided: Primary Care/Family Medicine, Family Counseling,
Wholistic Healthcare
Service Rates: Initial visit, 60 minutes, $190; follow-up visits, 30 minutes, $95
Wisconsin
Watson, Toby
Associated Psychological Health Services
2808 Kohler Memorial Drive, Suite 1
Sheboygan, Wisconsin 53044
United States
920-457-9192
tobywatson@abcmedsfree.com
Services Provided: APHS is a Full Service Outpatient Mental Health Clinic
and Doctoral Training Program, supporting a patient’s choice NOT to rely or use
psychotropic drugs. Dr. Watson is also an expert in the psychotropic medication
verses non psychotropic medication outcome studies, whereby he successfully
stops and overturns forced medicating commitments. The clinic offers tradi-
tional psychotherapy, domestic violence and anger management groups, parent
skill training and full psychological testing services. Dr. Watson is the incoming
Executive Director of the International Center for the Study of Psychiatry and
Psychology and frequently lectures upon the topics of patient rights, false pillars
of the biological model of mental illness and working through dysfunctional
thoughts, feelings and behaviors (e.g. what we call symptoms).
Service Rates: $0 to $180 per hour. Dr. Watson donates 100% of his time to
the clinic; however, fees are charged to insurance carriers and patients on an
ability to pay basis. Dr. Watson does travel throughout the United States; how-
ever, fees must cover costs of travel, lodging and missed appointment income
for the clinic. Individuals wishing to come to the clinic with no ability to pay
are welcomed. Dr. Watson does not contract with any HMO, Managed Care
companies or the State of Wisconsin, as he would rather lower the fee to $0 than
have to diagnose and permit confidential information to be given to outside
parties.
SPIRITUAL COMMUNITIES
• 12-Step Programs (http://www.12step.com/12stepprograms.html)
• Al-Anon Family Groups (http://www.al-anon.alateen.org/)
• Alcoholics Anonymous (AA) (http://www.aa.org/)
• Centers for Spiritual Living (http://csl.org/)
• Narcotics Anonymous (NA) (http://www.na.org/)
Index
Abandonment, 51, 56, 59, 67, 68, 100; as scarlet label, 3, 97, 107, 114;
childhood, 73, 104; efforts to avoid, subtypes, 6
6, 34, 41; fear of, 41, 49, 62, 67, 72, Borderline Syndrome, The (Grinker),
73, 79–80, 98; by therapist, 49, 62, 27, 111
68, 69, 71–73, 106 Boundary setting and punishment, 42
Adult Children of Alcoholics (ACAs), Brain disease, 15, 19; from bedevilment
38–39 to, 20–24; BPD and, 32, 43, 111;
Adverse Childhood Experiences (ACE) DSM and, 1–2; hysteria as, 15,
study, 36–38, 40 19–21, 23–25, 30, 110; mental
Affective dysregulation, 6 disorders as, 2, 9, 33, 46, 111
Andria, case of, 5–6 Briquet, Paul, 21–22
Antiquity, maladies of the feminine and
the feminine as malady in, 10–16, Caroline, case of, 97–99
109–10 Cases: Andria, 5–6; Caroline, 97–99;
Aquinas, Thomas, 17 Charley, 102–8; Ethan, 81–96; Jane,
Aretaeus of Cappadocia, 11, 12, 14 49–63, 113; Mary, 3–4; Melanie, 65–
Aristotle, 9, 11 80; Violet, 100–102
Atwood, George E., 44–45 Charcot, Jean-Martin, 21
Charley, case of, 102–8
Bateson, Gregory, 38 Countertransference, 49, 113–14.
Bettelheim, Bruno, 31 See also Borderline personality
Binet, Alfred, 23 disorder: experientialist description
Blundell, S., 13 of being with
“Borderline”: is to psychiatry what Creation myth of women, 13, 17, 110
psychiatry is to medicine, 32–33;
origin of the term, 27, 111; Defense mechanisms, 26–27. See also
terminology, 27 Projective identification
Borderline personality disorder (BPD): Diagnostic and Statistical Manual of
DSM diagnostic criteria, 6, 29–30; Mental Disorders (DSM), 6, 29–30,
experientialist description of being 33; BPD diagnostic criteria, 6, 29–30;
with, 41–48; historical perspective BPD’s inclusion in, 27–30, 33;
on, 9–16; personified, 1–7; criticism of, 1–2, 6, 32–33; DSM-5,
prevalence and epidemiology, 4–5, 9; 6, 29–30, 32; DSM-III, 27–29
158 Index
Dialectic behavior therapy, 90 Identity disorder, 28–29. See also

Double-binds, 38, 46, 57, 59, 106 Self-image instability
Impulsivity, 6
Eating disorders. See Overeating Incest. See Sexual abuse and trauma
Egypt, ancient, 10
Elkins, David, 33 Jane, case of, 49–63, 113
Empathy, 54, 70, 71, 113 Janet, Pierre, 21
Emptiness, 40
Enlightenment, 20, 110. See also Kernberg, Otto F., viii, 27
Modernity King, A. F. A., 23
Ethan, case of, 81–96 King, H., 13
Klein, Melanie, 43–44
Feminine, the: deliteralizing, 24–27; Knight, R., 27
dynamic, developmental, and social Kohut, Heinz, viii
contextualisms, 24–27; maladies of,
10–16; as malady, 10–16. See also Laing, R. D., 29, 40
Gender Limit setting and punishment, 42
Frankl, Viktor E., 31, 47
Freud, Sigmund: borderline personality Magnetism, 20, 22
and, 31; on defenses, 26; gender and, Mary, case of, 3–4
25–26, 31; on hysteria, 21, 24–26, 31, Maté, G., 34–35, 46
111; on Oedipus complex, 25; on Melanie, case of, 65–80
secondary gain, 25; on sexual etiology Mental disorders: nature of, 1–2. See
of neurosis, 25–26; structural theory, 26 also Brain disease; Diagnostic and
Friedenberg, E., 40 Statistical Manual of Mental Disorders;
Modernity
Galen, 12, 16 Mesmer, Franz Anton, 20
Gender: BPD and, 4; Freud and, 25–26, Mesmerism, 20, 110
31; hysteria and, 10–11, 14–15, 17–26, Micro-trauma, 112
109–11. See also Feminine; Women Middle Ages (from uterus as
Greece, ancient, 10–16, 109–10 endoparasite to demonic possession),
Greek mythology, 13–14, 110 16–20, 110
Grinker, Roy R., 27, 111 Modernity, mental illness in,
Gynecological theories and practices, 20–24, 110
ancient, 10, 13, 15, 22, 23. See also
Uterus; Womb Neurobiology. See Brain disease
Hildegard of Bingen, 17 Oedipus complex, 25

Hippocrates, 10–11, 14 Orange, Donna M., 44–45
Horney, Karen, 1, 99–100 Orgasm deficiency and mental illness,
Hypnotism, 22, 23, 110 14. See also Orgasm therapy
Hysteria: early theories of, 10–11, Orgasm therapy (physician-assisted
14–24, 109–10; Freud on, 21, 24–26, paroxysm), 23–24, 110–11; and
31, 111; gender and, 10–11, the rise of the respected physician,
14–15, 17–26, 109–11; male, 25; 20–24
treatment, 15, 17 Overeating, 91, 93–95. See also Cases:
Hysteric and borderline prototypes, 9 Ethan
Index 159
Pandora, 13–14 Spitzer, Robert, vii, 29

Paré, Ambroise, 18–19 Starkey, Marion, 19
Pinel, Philippe, 20–21 Stern, Adolf, 27
Plato, 11, 12 Stolorow, Robert D., 44–45
Projective identification, 43–46 Suicidality, 9, 32, 41–42, 59, 61, 62, 95,
Prometheus, 13 103. See also Self-harm
Psychoanalytic theory, 25–27 Sydenham, Thomas, 19
Raulin, Joseph, 19–20 “Therapeutic minute,” 49, 77

Relational volatility, 6 Trauma, 34–38, 40, 45–48; BPD as
Relationships, 45–46. See also untreated, 47–48, 112; micro, 112.
specific topics See also Sexual abuse and trauma
Richer, Paul, 22–23 Trotula de Ruggiero, 16–17
Risk taking, 6
Rousseau, Jean-Jacques, 20 Uterus, 17, 19; hysteria and, 10–11, 14,
Roussel, Pierre, 20 15, 19, 20, 110; interventions related
to, 10, 12–16; personification of,
Secondary gain, 25 11–14, 109; “wandering,” 10–12, 14–16
Self-destructiveness, 6. See also
Suicidality Vesalius, Andreas, 18–19
Self-harm, 59, 95–98. See also Violet, case of, 100–102
Suicidality
Self-hate, 53–54, 79, 98 Willis, Thomas, 19
Self-image instability, 6, 34, 39. See also Witchcraft and witch hunts, 17–20, 110
Identity disorder Womb, 11–14, 24, 110; hysteria and
Self psychology. See Kohut, Heinz the, 11, 14, 15, 21, 24; interventions
Separation. See Abandonment related to, 12–16; personification of,
Sexual abuse and trauma, 22–23, 82, 11, 12, 14; “wandering,” 11, 12,
85–88. See also Orgasm therapy 14–16, 21, 24
Sexual interventions by physicians, Women: religion, mythology, and,
23–24, 110 13–14, 17, 110. See also Feminine;
Sexuality, female, 13–17, 25–26, 110– Gender; Uterus; Witchcraft and
11. See also Orgasm therapy; Uterus; witch hunts; Womb
Womb
Soranus, 11–13, 15 Zeus, 13
About the Authors
JACQUELINE SIMON GUNN, PsyD, is a clinical psychologist in private prac-

tice and a freelance writer. She is the former psychology internship training
director and clinical supervisor at the Karen Horney Clinic. Her published works
include In the Therapist’s Chair, Bare: Psychotherapy Stripped, and her short-story
series, Stranger Than Fiction. Gunn holds two master’s degrees: one from John
Jay College in forensic psychology, and the other from Duquesne University in
existential-phenomenological psychology. She holds a doctorate in psychology
from Miami Institute of Psychology.
BRENT POTTER, PhD, is a licensed psychotherapist, child mental health spe-

cialist, and ethnic minority mental health specialist (WA). Potter earned his
master’s degree in existential-phenomenological psychology from Duquesne
University. He holds a doctorate in clinical psychology with an emphasis in
depth psychology from the Pacifica Graduate Institute. He has more than
20 years of experience providing clinical services in a range of settings including
inpatient, hospital, outpatient, and private practice. He has published numerous
articles, Elements of Self-Destruction, and has three forthcoming books.
About the Series
The books in this series, Practical and Applied Psychology, address topics
immediately relevant to issues in human psychology, behavior, and emotion.
Topics have spanned a wide range, from the psychology of black boys and adoles-
cents, to the sexual enslavement of girls and women worldwide, and living in an
environmentally traumatized world.
About the Series Editor
Judy Kuriansky, PhD, is a licensed clinical psychologist, adjunct faculty in the

Department of Clinical Psychology at Columbia University Teachers College,
and also the Department of Psychiatry at Columbia University College of Physi-
cians and Surgeons. Kuriansky is a United Nations representative for the
International Association of Applied Psychology and for the World Council
for Psychotherapy. She is also a Visiting Professor at the Peking University
Health Sciences Center, a Fellow of the American Psychological Association,
Founder of the APA Media Psychology Division, and a widely known journalist
for CBS, CNBC, Lifetime, and A&E, as well as a regular weekly columnist for
the New York Daily News. She has also been a syndicated radio talk show host
for more than 20 years.

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Sexual Enslavement of Girls and Women Worldwide

The Global Muslim Community at a Crossroads: Understanding Religious

Living in an Environmentally Traumatized World: Healing Ourselves and Our

The Psychology of Black Boys and Adolescents

Lucid Dreaming: New Perspectives on Consciousness in Sleep

The Myth of Black Anti-Intellectualism: A True Psychology of African

Jacqueline Simon Gunn and Brent Potter

Practical and Applied Psychology

Series Foreword by Judy Kuriansky vii

1 Introduction: The Borderline Personality Personified 1

Passive-Aggressive type whose anger shows up in backhanded compliments that

constructed by committees of professionals, most with financial ties to the

THE SCARLET LABEL

ANTIQUITY: MALADIES OF THE FEMININE AND THE FEMININE

acknowledge that the uterus appeared to be responsive to cooling and loosening

elaboration of why scent treatment worked implied that it was possible to

The Greek physician differentiates hysteria, which he clearly distinguishes

MIDDLE AGES: FROM UTERUS AS ENDOPARASITE TO DEMONIC

as Sanatrix Salernitana, Trotula was an expert in women’s diseases and illnesses.

responsibility to “punish, imprison and correct” heretics (Kramer & Sprenger,

the foundation of modern medical science. Additionally, the Cartesian philo-

which he described hysteria as an affection vaporeuse (vaporous condition).

MODERNITY: FROM BEDEVILMENT TO BRAIN DISEASE: ORGASM

and gullibility inherent in women. Significantly, he broke with traditional

hysterical delirium of which she denied to herself in waking consciousness

DELITERALIZING THE FEMININE: DYNAMIC, DEVELOPMENTAL,

CONTEXTUALISM ABANDONED AND BPD’s FORMAL ENTRY

safety/efficacy of medication interventions. The summary blow dealt to these

“BORDERLINE” IS TO PSYCHIATRY AS PSYCHIATRY IS TO MEDICINE

childhood experiences (ACE), are common. Almost two-thirds of the partici-

• Alcoholism and alcohol abuse

Of note, ACAs encapsulate this confused and confusing communication net-

AN EXPERIENTIALIST DESCRIPTION OF BEING WITH “BORDERLINE

Most clinicians have experienced or have had a colleague experience some-

We have come to regard the doctrine of projective identification—the objectified

“borderline personality disorder” is basically untreated trauma. It is possible to

attractive woman by traditional standards, but I noticed that sometimes I had a

My inner dialogue was complicating the situation. My wheels were spinning

my experience of Patty revealed a worried, loving family member. Jane came to

ambivalence about entering treatment, combined with her unexpressed deep

Melanie and I spent months in twice-weekly sessions exploring her relation-

Melanie called and cancelled our next session, leaving a cavalier—“Sorry,

Melanie arrived to our session looking uncharacteristically disheveled; she

As a result of his childhood experiences of abuse, Ethan was disconnected

I decided to implement a few new techniques in an effort to help Ethan gain

Although Horney never directly addresses character pathology—she uses the

This placed me in a double-bind. If I responded to his sickness with added

One pronounced example of this happens when one experiences losses.

Alexander, F. G., & Selesnick, S. T. (1975). History of psychiatry. Rome: Newton

Stolorow, R. (2011). World, affectivity, trauma: Heidegger and post-Cartesian

We are pleased to offer this resource guide. Of course, it is impossible to provide

RECOVERY AND WELLNESS ORGANIZATIONS

are challenges to expand their possibilities in a safe, nurturing environment.

National Empowerment Center

Recovery Opportunity Center

The Icarus Project

Ann Blake Tracy

– National Association for Rights Protection and Advocacy (http://www.narpa.org)

FACEBOOK ONLINE SUPPORT PAGES/SUPPORT GROUPS

MINDFREEDOM INTERNATIONAL DIRECTORY OF ALTERNATIVES1

Service Rates: $85–$145/session. In exceptional cases, I will consider lower-

Services Provided: Individual Psychotherapy, Couples Psychotherapy, Fam-