The average somatic practitioner has one of two reactions to the word “borderline.” The look in his/ her eyes is either a blank stare that indicates ignorance, or abject terror that indicates a strong negative bias, probably unexamined. I think both are mistakes. This article is about what we can learn from “borderlines,” and more broadly how we can work with some of the boundary issues in our practices. Bear with me: I promise that by the end of this article the application to practice will be apparent.
DEFINITIONS: BORDERLINE WHAT?
A reasonable place to start would be a definition of “borderline,” which would be wonderful if only it were that simple. There is the nosological, or categorizing, approach, which basically states that if certain behavioral criteria are met then a diagnosis is assigned (for example, Borderline Personality Disorder – BPD – in the DSM-IV, the current diagnostic manual for psychology and psychiatry). This hangs a label on someone, which can be helpful so long as we remember that “the map is not the territory.” However, labeling does little or nothing to help understand the chaotic mess that the relationship between practitioner and client becomes if a “borderline” has come “unglued.”1
Another approach is dimensional, which comes closer to helping us understand. Basically, this says that there are personality traits that are “borderline-like,” and that everyone falls somewhere on a continuum of this dimension. Some people have few or no borderline traits, and others have so many that they meet the diagnostic criteria of the nosological approach. According to this way of thinking, most people fall somewhere in between, depending in part on innate temperament, in part on life experiences, and in part on the level of current stress. This approach, by the way, can be applied to any personality trait (narcissism, masochism, etc.) and at least some other psychological manifestations (e.g., dissociation).
A third approach to personality disorders in general, and BPD in particular, addresses the formative role of chronic trauma such as childhood physical and/or sexual abuse. Many people who work with this population argue that the diagnosis of BPD should not be made at all; instead, they believe that the proper diagnosis is Chronic (or Complex) Post-Traumatic Stress Disorder. I think this approach has value, in that it removes the onerous implications and immediately negative reactions that people have to the word “Borderline.” Obviously, if we see someone as having suffered repeated trauma we are much more likely to make an attempt at understanding and less likely to think of the person as simply obnoxious. But in order to understand this last sentence, we need to address the manifestations of BPD as they are likely to effect somatic practices.
DOES IT TAKE ONE TO KNOW 0NE?
So how does one recognize “borderline,” and why would we bother? One bothers because if you see it coming you’re a lot more likely to either pass on the work or to know what to do; if you don’t you are likely to have at least the most unpleasant experience of your career and perhaps an ethics complaint or a lawsuit. Worse, it’s possible that you will do genuine harm to the client, retraumatizing or driving him/her into a psychotic decompensation. The reason for this is that the central features of BPD2 are chronic and intense problems with personal boundaries, coupled with an uncanny ability to get practitioners to ignore even normally very clear boundaries.
The obvious indicators of BPD are extremely intense and chaotic relationships, extreme and rapid mood swings, and thinking that is intensely and rigidly black-and-white. As stated above, the central feature is an almost stunning lack of boundaries. It is common for a therapist faced with a BPD client to feel overwhelmed, “sucked in,” and “trapped.” This sense of feeling trapped, particularly if the therapist feels compelled to make an exception to his or her normal way of working (extending sessions, working on Sunday when this is not the routine, working later hours than usual, etc.), is in fact the first of the main warning signs that trouble in the therapeutic relationship is at hand. In borderline dynamics there is frequently another feeling that parallels the sense of entrapment, and that is the sense of conviction that there is something “special” about this relationship. This sense of “special-ness” is the second warning sign of trouble. Actually, it can happen in either of two ways: (a) the therapist treats the client as if the client is special, and makes exceptions to the normal “rules” (the things we feel “trapped” into, or perhaps that “just for this client” we’ll go out to lunch while processing the session); or (b) the therapist feels special, thinking that s/he is the one person who can help this client where all the other therapists have failed. If it happens that the sense of entrapment and one or both feelings of “specialness” occur together, particularly if coupled with a vague feeling of confusion, it is virtually a guarantee that borderline dynamics are afoot.
In terms of the therapist’s experience, perhaps the most characteristic thing about borderline dynamics is a sudden vacillation between extremes. Quite commonly, the client moves from idealizing the other to despising the other. If the “other” is you and you happen to be in the middle of feeling inflated by the client’s idealized image of you, it will come as a great and bitter shock when you inevitably say the “wrong thing” and suddenly find yourself in the pits of despair because you are now inexplicably the worst practitioner in the world. That last sentence is complicated, but worth reading again, because it contains all the warning signs of the misery that can come of playing out borderline dynamics with a client. As you will see however, it also contains the requirements for turning a destructive contact into a potentially healing relationship.
WHAT IS IT LIKE TO LIVE “ON THE BORDER?”
To further understand the dynamics of BPD and how it impacts on a somatic practice, it’s important to consider the internal experience of the client. One of the best non technical books on BPD, which I recommend highly to patients and practitioners alike, is I Hate You, Don’t Leave Me. If ever there was a one line description of the internal experience of having BPD, this is it. Here is a terribly important question: if you as a practitioner are experiencing this person from the outside as chaotic, confusing, and unmanageable, what must it be like to be on the inside of the cyclone? What must it be like to want more than anything in the world to be held, supported, and loved, and yet to compulsively drive away the very people who are trying to help? What must it be like to be perceived as a pariah, when all you want is to be understood? And then consider for a moment how it might be that someone comes to have such poor boundaries that these experiences keep happening again and again, apparently out of one’s own control.
Originally, the term “borderline” referred to the boundary between the psychotic and the neurotic. Essentially and in much oversimplified form, early psychodynamic theory held that ego was the “reality” function, the psychological mechanism that helped us make sense of the world and to get along in it.’ The ego was thought to go through predictable stages of development, paralleled by the development of ego defenses. At birth, the ego was nonexistent or virtually so, and the infant lived in an unreal state of pure drive and instinct, merged with the primary caregiver (usually the mother). The ego defenses at this stage are very primitive: for example, if the budding ego is threatened, it will simply “de-realize” the offending other by making it mentally “disappear.” If development is disrupted at these stages, the resulting pathology would be psychotic; that is, reality contact is lost.’ Assuming reasonably healthy development and what one of the psychodynamic theorists called “good enough” mothering, eventually the ego attains a measure of stability, with relatively sophisticated ego defenses such as humor and altruism.
In between, the child must pass successfully through a critical juncture, which is the experience of separation from the caregiver. The child learns to say “I don’t like this” and to stamp his/her foot in defiance. The child wanders off to explore, and returns from time to time to make sure the nurturer is still there. Eventually, a sense of safety is gained, and the psyche can develop into a mature form. In the common vernacular, we call this transition the “terrible two’s” (although it often happens in the “three’s”). The child tests the limits constantly in a Herculean effort to define the boundary between self and other.
If, however, development is disrupted at this stage, the result is one of the “borderline” conditions (vacillating between the neurotic and the psychotic). The ego is frozen in this terrifying stage of being half merged/half-separate, never knowing exactly what to expect, alternating between feeling engulfed by an intrusive other and feeling abandoned and bereft of all contact. It is thought, and different theorists hold different opinions on this, that the disruption can happen because of poor dynamics between parent and child, or because of trauma, or any number of severe problems in development. Regardless of the actual nature of the process, if you can imagine what it must be like to be stuck in this psychological space, I believe you’ll have a good idea of the internal experience of these intensely difficult clients.’ It is helpful to remember that the client who lives in borderline dynamics isn’t trying to be wrong. S/he is usually, I believe, suffering the consequences of tragic abuse and/or neglect, and there is trauma embedded throughout the structure of both body and mind.
PSYCHE MEETS SOMA: BODYWORK AND THE BORDERLINE CONDITIONS
Hopefully, by this point the reader has at least a beginner’s sense of how to recognize borderline dynamics in the chaotic vacillations and odd pulls to “fudge” boundaries. Perhaps you also have some sense of what it’s like to be stuck inside these dynamics, and how disturbing it must be to be perceived as a pariah when doing the only thing you know (and this last applies to both therapist and client). We come then to the final points of this article, and focus on working with a client who displays borderline dynamics within the context of a somatic practice.
I indicated earlier a sentence that contained all the warning signs of disaster and all the seeds of potential healing. Here it is again:
If the “other” is you and you happen to be in the middle of feeling inflated by the client’s idealized image of you, it will come as a great and bitter shock When you inevitably say the ?wrong thing? and suddenly find yourself in the pits of despair because you are now inexplicably the worst practitioner in the world.
In that sentence, the first warning sign is being inflated by the client’s idealization of you; the antidote is to avoid being inflated and to maintain a reasonable perspective on your abilities and the work you’re doing. Don’t underestimate how powerfully seductive this idealization can be; we are all capable of falling into it. But I believe that it’s critical to bear in mind that the client’s opinion of you (and this applies to all clients, not just the ones with BPD) is always the product of an image of you, not the “real” you. The second thing to note is that, in a relationship where these dynamics are being played out, it is inevitable that you will say the “wrong” thing. No one is “special enough” to avoid it, in part because the reenactment of the idealizing/ devaluing cycle, when coupled with a corrective experience, is the path to healing; and in part because the person with BPD has an uncanny ability to hone in on the things that will most get under our skin. If you miss these two things, you will find yourself faced with the third and fourth, which are that you will be bitterly shocked at the sudden turn of emotional events, and that the whole thing will seem inexplicable to you and you will be tempted to retire. Be assured that this is not an exaggeration.
All that said, the antidote to the process is to be a steady, and insofar as possible, unshakable model of simultaneous compassion and solidity. Since we are talking about dealing with someone who has poor, or no, boundaries, it is the practitioner who must provide them. We must essentially lend the client our ego, because theirs is not yet fully formed. We are the container and if we do not hold clear and definitive boundaries it is not only dangerous to us, but also dangerous for them. Here are some practical suggestions:
Consider carefully whether you want to work with this client. If you sense these dynamics at work and you also can’t find it in you to like this person, or you have the feeling that you want to run from the room, do not take him/her as a client. The dynamics will cause you to violate your boundaries in any number of ways in an attempt to make up for your lack of genuine caring. Without fail the client will feel your distance and experience it as a terrible rejection, and they are used to rejection in a way that you will never be used to their response to it.6
If you decide to take the client, consider carefully the type of work you will do. Most direct forms of somatic work are designed to “loosen” hyper-toned tissue. On a psychological level, this is well suited to the individual who has rigid boundaries and who is overly repressed, where emotions are expressed only with difficulty. But in the borderline conditions, the dynamics involve boundaries that are too loose and emotions that are under repressed and expressed too freely’ Most commonly, this will occur in the context of hypo-toned soft tissue and a collapsed structure being held together by a few rigid features. Therefore it is probably totally inappropriate to further “loosen” the client by directly attacking the defenses manifest in muscular tension. It is also important to consider that bodywork may not be appropriate at all for the client, especially early in their therapy and especially if the trauma of repeated abuse is a predominant feature of their childhood. “First, do no harm” can be translated to “First, don’t make them decompensate.”8
If you decide to continue, and you’ve considered the kind of work you’ll do, make sure that the client has someone other than you with whom to process their experience of the work (ideally a psychotherapist). Also, make sure that you have someone with whom to process your thoughts and feelings as you work. You’ll need it. I strongly recommend either individual or group supervision/consultation for all somatic practitioners who are even slightly interested in the emotional experience of their clients (not just for working with BPD). Ideally the supervisor is an experienced practitioner who has psychological training and an understanding of, if not experience in, somatic work. Finally, make sure that you get permission to talk with the client’s other therapists. This is the only chance to help forestall splitting between the therapists, as these clients are masters of turning one of you into the “good therapist” and the other into the “bad therapist.”9 The trouble is that you’ll never know which you are this week until it’s too late.
In this article I have briefly presented a definition of borderline conditions, outlined the major features of borderline dynamics in order to help the practitioner recognize them, described what it might be like to be someone who lives inside these dynamics, and briefly reviewed a few of the considerations relevant to bodywork applications. It should by now be clear that working with the client who presents with borderline dynamics is not for the faint at heart; it can be excruciatingly painful for the practitioner who is ill-prepared or who lacks the ego strength to hold steady in the midst of chaos. What may not yet be clear is that, for the practitioner who is prepared and who foes have the requisite ego strength 😮 avoid being trapped by either idealization or contempt, working ,with a BPD client can be extremely rewarding. Under the right circumstances there is the possibility of playing some part in the healing of terribly painful trauma. Just one ping: if you wish to stay off the slippery slope to muddy boundaries and a miserable experience, remember that none of us is special enough 😮 be invulnerable, none of us are the only one who can help, and none of as can do this work alone.
1. I use quotation marks here because I am deliberately using pejorative terms that are frequent in conversation about people with Borderline Personality Disorder or those with strong Borderline traits. I hope it will become apparent by the end of this article that I don’t subscribe to these terms or the ways of thinking they imply, but also that I understand why the use of these terms is so tempting
2. From this point on, I will use both the terms “BPD” and “borderline dynamics” to refer to the spectrum of borderline traits. I also assume at least some role of chronic trauma. Where BPD refers specifically to the DSM-IV diagnostic category, the context will make this clear
3. Please note that I am presenting an idea that I have found useful in understanding the dynamics involved in BPD. It is not necessarily the case that I believe early analysts got the details right (and I am leaving most of the details out), any more than I necessarily believe that Dr. Rolf got right all the details of the mechanisms by which structural integration works. There is the baby, and there is the bathwater, and it is beyond the scope of this article to sort them out
4. The best and easiest way to picture the difference between psychotic and neurotic functioning is something I heard passed down through a friend: the neurotic “builds castles in the air,” while the psychotic “moves in.
5. Please note that the “borderline condition” is characterized by a person acting in some ways “as if” s/he were stuck at the age of two; not that s/he is actually two. Treating such a person like a two year old will get you just what might be expected: a 2 year-old’s temper tantrum in a grownup’s body
6. This is just one of the reasons that I strongly recommend initial interviews during which no physical work takes place. The interview is the practitioner’s last, best chance to determine if working with this client is a good idea. It’s important to check out the client’s emotional and relationship history, and it is important to have some sense of how the client responds to the practitioner’s comments
7. In psychodynamic theory, repression is actually a relatively high-level ego defense, but that is another article altogether.
8. This paper is focused on the psychological dynamics of working with borderline conditions. The issue of what kind of somatic work is appropriate for such individuals is only briefly described here, and is a topic for a separate paper.
9. In psychodynamic terms, “splitting” is a primitive psychological defense that is characteristic of borderline conditions, and is the basis of black and white thinking. Both self and other are experienced as either “all good” or “all bad”; there is no ambivalence and no capacity to hold both good and bad images of the same person