Abstract
When the holocaust survivor, psychiatrist and founder of logotherapy Victor Frankl was asked in an interview about the meaning of his life he replied: ‘The meaning of my life is help others find meaning in theirs’ [1]. Psychotherapy, of whatever variety, inevitably involves the search for meaning, ‘making sense’ as it is often put, of the difficulties, problems, hang-ups, miseries, confusions, worries, and distortions that characterize mental ill health.
But what does it mean to ‘find meaning’? From a psychotherapeutic perspective, the idea of ‘meaning’ can be approached from three distinct directions. First, in ‘sense 1’, there is the ethical/aesthetic sense of finding meaning and beauty in the world: a life worth living. Second, in ‘sense 2’, in the medical/scientific sense, meaning implies a purposeful – whether useful or pathogenic – relationship between structure and function. In physical medicine the meaning, say, of chest pain on exertion might be a narrowing of the coronary arteries (sense 2), while the angina sufferer may come to value life more deeply as a result of his brush with death (sense 1).
Similarly a psychotherapeutic formulation implies an underlying psychological structure accounting for a patient's difficulties. Thus borderline patients often find it difficult to take the other's point of view (failure of mentalization [2]). This difficulty will be understood as meaningful in the sense that (sense 2) it is the end result of problematic psychological developmental, related perhaps to parental separation, maternal depression, or childhood abuse.
Attachment theory, firmly rooted in a scientific perspective, most obviously offers sense 2 meanings, seeing distorted function in terms of underlying pathological psychological structures. Insecure attachment is understood as an attempt to maintain security in the face of suboptimal parenting. The hypo-activated, avoidant, attachment pattern is a way of staying in some sort of touch with a rejecting or mildly aggressive caregiver. The hyperactivated, ambivalent, clinging pattern is a response to unpredictable parenting [3] in which the child clings to his secure base even though this means putting his autonomous exploratory needs into abeyance.
But attachment theory also privileges meaning in sense 1 through its emphasis on language, and especially narrative style, as a mark or indicator of underlying attachment patterns. The Adult Attachment Interview (AAI) is a way of ‘reading’ attachment patterns from linguistic style [4]. Thus language cannot be reduced to its purely denotive function. There is an aesthetic dimension to the succinctness, relevance and appositeness which comprise ‘Grice's maxims’ and which form the basis for the ‘fluid/autonomous’ classification of secure attachment as revealed by the AAI.
A third sense in which psychotherapy approaches meaning can be approached via the Witgensteinian notion of ‘language games’ [5]. For Wittgenstein the meaning of a word is to be found not so much in its formal definition as its ‘use’. We learn a language in the same way that we learn to play a game, not by looking things up in dictionaries, but by participating in language behaviour with other members of our linguistic community. People suffering from borderline personality disorder (BPD) might be seen as unable or unwilling to play by the rules of a normal affective language game: feelings are enacted, ignored, and over-ridden rather than described, heard, understood, or reciprocated. Here then is a ‘sense 3’ for meaning: meaning as a participatory interpersonal ‘game’. Psychotherapy entails the evolution of a shared linguistic universe between therapist and patient, one that enables unique quasi-private interpersonal meanings – here described as ‘sense 3’ – to emerge (cf Margison [6]).
A final preliminary point concerns the relationship between meaning and the self. The faculty for understanding, and the notion of meaning, is intimately connected with the self. To state that ‘I understand what you mean’ is to posit the existence of two interacting selves, each with its own point of view and meaning structure. Conversely the collapse or restriction of meaning may be associated with a self that feels depleted or fragmented.
Moving on now from this background discussion, my main aim in this paper is to connect the evidence about a specific pattern of insecure attachment – disorganized – with the clinical problems presented by BPD patients. I shall look at the ways in which individuals whose attachment patterns are disorganized attempt to create some sort of structure, that is meaning, however degraded, simplistic, distorted, or self-defeating this may be. I shall also draw on attachment theory's capacity to discover meaning in the detailed analysis of minute segments of behaviour and to make interpersonal sense out of them.
My purpose is primarily clinical. I shall use attachment theory to consider some of the difficult states of mind that are characteristic of the BPD patient. I start by reviewing the literature on disorganized attachment, especially as it might pertain to adult psychopathology, and borderline personality disorder in particular, and go on to consider its clinical implications for treatment methods and service arrangements for such patients.
Disorganized attachment
‘D’ was first described by Main and Solomon [7] after reviewing a series of ‘Strange Situation’ tapes of a group of infants previously categorized as ‘unclassifiable’ [8]. The ‘Strange Situation’ is a standardized test devised by attachment researchers for studying the reactions of 1–2 year old infants to brief separations from their caregivers. The essence of their observations was that the children's behaviour when stressed by separation could not be understood by the observer to be based on an identifiable attachment strategy. In other words, these infant's behaviour appeared ‘meaningless’. Their responses to separation and reunion were typified by behavioural incongruity; they appeared dazed, there were sudden switches of behaviour, and/or they would freeze or exhibit bizarre stereotypies of movement.
The D category appeared to be stable over time, to be unrelated to temperamental factors, and to appear not infrequently in relation to one parent but not the other. The prevalence was relatively low in middle-class samples (14%) but Van Ijzendoorn found much higher figures in low socio-economic status groups, generally (24%), and in maltreating samples the figure reaches 60–70% [9].
Cortisol levels are higher in D infants than in controls, and they show decreased mental development compared with controls even when maternal IQ is controlled for [10]. All this suggests we are looking here at a stressed and potentially disadvantaged group of children. D classification coexists with the other three attachment categories. The largest proportion of D infants showed ambivalent attachment (46%) (see case report); only 14% are secure and 34% avoidant [8]. It is important to note that Crittenden [11] sees in D features mixed avoidant and ambivalent characteristics.
If D is a valid entity, as it appears to be, two immediate questions occur: under what circumstances does the D pattern arise, and what are the long-term implications for the child of D classification? Main's fundamental theory about D is that it represents an approach–avoidance dilemma, intrinsic to the very nature of attachment [12]. Attachment theory postulates that a threatened or frightened child will turn to an attachment figure for comfort, security, or reassurance. But if that attachment figure is itself the very source of the threat the child is presented with an insoluble problem. No consistent behavioural strategy will relieve the threat. There is no equilibrium point comparable to the situation in avoidant attachment in which the child gets close to the mildly rebuffing secure base, but not too close; or in ambivalent attachment where the child clings to an inconsistent attachment figure. It is worth noting, in passing, that there is more than a superficial similarity between Main's D hypothesis and Bateson's ‘double bind’ theory of schizophrenia [13], in which it was postulated that psychotic behaviour was the result of an individual confronted by two contradictory messages in a field from which he could not escape.
What parental characteristics might lead to this approach–avoidance bind? The adult analogue of D is the ‘unresolved’ category on the AAI. Unresolved is coded when the respondent shows ‘signs of disoriented disorganization when discussing potentially traumatic events’ together with ‘lost awareness of the discourse context’. Main's idea [12] is that the caregiver of a potentially D child is herself the subject to unresolved loss or trauma. This disrupts her capacity to focus on her caregiving role, which triggers painful memories from her own childhood. Thus the caregiver is not just frightening, but frightened. She cannot maintain affective continuity in her own inner world, and so lacks the capacity to provide buffering for her infant's affective peaks and troughs. Main emphasizes the ‘dissociative’ aspect of D in both child and caregiver. They see the child as dissociated from the immediate environment and the insoluble fright/flight dilemma itself. They also see the caregiver as triggered into a frightened state herself by the child's distress, dealing with this again by dissociation, thereby making herself all the less available to the child as a secure base.
Dissociation implies not just a distancing of the sufferer from her own psychological distress, but also a failure of a central integrative function associated with the self. The caregiver of the D child is responding with parts of herself over which she has no control. This in turn will impact on the nascent self-experience of the child: ‘If my mummy doesn't know who I am or what I might be feeling, how am I to discover those things for myself?’ Thus repeated episodes of collapse or fragmentation of the self–other representation in D attachment patterns in childhood may contribute to the problematic self-states characteristic of borderline pathology, including the construction of a ‘false self’ based on compliance or control, but dissociated from feelings of terror and helplessness.
Studying parents of D infants with the AAI, a metaanalysis of nine studies involving 548 subjects showed high correlation/effect size between parental unresolved status and child D [8]. Lyons-Ruth et al. agree with Main that D arises in very specific circumstances and cannot merely be seen as a manifestation of caregiver insensitivity (which will give rise to insecure attachment, but not specifically D). These authors specify a range of caregiving behaviours likely to be associated with D, including role confusion (parent uses child as surrogate parent), negativity, intrusiveness, disorientation, asynchronous mother–infant exchanges (‘not being able to get on the same wavelength’), and apparently unmotivated emotional withdrawal.
The next piece of the jigsaw comes from follow-up studies of children classified as D at 1 year. Two such prospective studies by George and Solomon have shown that there is a strong link between D and controllingness of children with their mothers and peers at ages 6/7 years [14]. These children insist on a kind of role reversal with their caregivers, in which only they make executive decisions, and are unable to engage in ‘democratic’ play. Further studies with these children using picture completion methods found that the controlling children, often with helpless parents, are unable to resolve frightening scenarios: they respond with total silence, or stories illustrating passivity or catastrophe.
Much more research needs to be done in this area, but we can begin to build up a picture of links between D and adult psychopathology which starts with:
1 parental unresolved/traumatized states of mind; 2 moves to the D infant caught in an approach– avoidance bind, with no secure base refuge when threatened either from without, or within by his or her own unmodulated feelings; 3 then shifts to the controlling 6 year old who has eventually found a security strategy based on role reversal and providing a pseudo-secure base and a ‘false self’ for herself; 4 includes repressed terror and inability to repair interpersonal discontinuities and loss as revealed by picture completion studies; 5 finally shifts to adolescence and early adulthood in which the individual is controlling, aggressive, unable to self-soothe when faced with emotional turmoil and loss, liable to dissociation, and cannot extricate herself from pain-producing relationships; in other words, has become a potential candidate for a diagnosis of BPD.
It comes as no surprise therefore that Hobson and colleagues found that a group of patients suffering from BPD (as opposed to major depressive disorder) were almost entirely classified as unresolved/preoccupied on the AAI [15].
There are many issues still to be resolved and researched. To mention two: what about resilience, what kinds of positive experiences will mitigate against the long-term consequences of D; and what is the differential role of physical, sexual and emotional abuse in setting up the approach–avoidance dilemma of the D child? I shall leave these as yet unanswered questions, moving now to the clinical implications of this research.
I start with an extract from an assessment interview with a BPD sufferer.
Clinical material
Case-history A
Deidre is a twice divorced woman in her mid-40s. She has lived with her third main partner, Geoff, for the past 11 years. She has four children; the eldest, a daughter from her first marriage, with whom she has no contact; a boy and a girl in their late teens from her second; and a 9 years old daughter by Geoff. She has been employed in the past as a care assistant, but is currently unable to work because of depression and anxiety. She was referred to our personality disorder clinic by her community care worker because of worrying outbursts of rage and violence, and in particular an episode in which she attacked her husband with a brass candle stick, causing quite extensive scalp injuries.
She arrives at the clinic with Geoff, and clearly found it hard to separate herself from him in the waiting area when invited to come to the consulting room. He is a large, reassuring man, obviously younger than his partner. I perceive her as petite, slightly overweight, with dyed black hair. She asks immediately for a glass of water before she is able to start the session. With some encouragement, she then tells her story: a dismal childhood, her (according to her mother) violent and useless father having disappeared when she was 2 years old, leaving her with a mother who quickly remarried, and had two further children. Deidre felt de trop from the start, and more so when her stepfather began to abuse her, physically in public, and sexually in private. She left home as soon as she could, married the first man who would have her, who promptly got her pregnant and left her. She then met her second husband which led to 10 years of beatings and rape before she found the courage to leave him.
I shall focus on two key moments in the assessment interview. The first comes after about half an hour. Diedre is describing the fact that she finds it hard to go out of the house. Asked why, she lets slip (or so it seems): ‘I keep catching glimpses of myself in shop windows – I hate mirrors’. At this point her bottom lip begins to quiver. ‘What is it you find so difficult about that?’ I ask. Silence. The silence hangs for a few moments. She looks terrified, glances at the door, and imploringly at me. She wants to be let off the hook, released from some nameless horror. I try to keep her on track. ‘When you look in the mirror you see something frightening, something difficult to put into words,’ I suggest. ‘I… don't… recognize… myself… who … am… I?’ the words come falteringly.
We had established earlier in the interview that she looks like her father; when she asked her mother what her father was like, the only reply she could extract was ‘look in the mirror – you're his spitting image’. ‘So what you see reflected is a terrifying part of you that in your mind is like your father,’ I suggest. She nods, with what looks like a mixture of relief and despair.
The conversation then moves into less threatening territory and after a few minutes I suggest we bring in her husband, whom I then go to collect, leaving Deidre with my colleague who is the supervisor and observer in the interview. The moment I return with Geoff she leaps to her feet, and buries herself in his arms, sobbing furiously. They leave the room for a few minutes to hug and cuddle until she is calm enough to resume.
How can we understand, make meaning out of, this story? Some of it is relatively straightforward. Bowlby [16] maintained that the need for a secure base was not something we outgrow; he saw development in terms of a move from immature to mature dependence. At times of extreme stress we turn to our secure base whatever our age. Geoff is Deidre's secure base. The stress of the interview activates attachment behaviour in them and, like a child in the ‘Strange Situation’, she needs physical comfort and reassurance from him before she is able to face the threat posed by the PD team. She has in fact already signalled, via her request for a drink of water before the interview can begin, her vulnerability and bid for nurturance.
How would we characterize Deidre's attachment style? Her need for physical proximity to Geoff and difficulty in calming suggest an ambivalent pattern, and this is consistent with her narrative style in the interview which is rambling, discursive and overwhelmingly affect-laden. How then would we understand the story of the mirror and her difficulty in talking about it. I suggest we are seeing here the coexistence of disorganized/ incoherent pattern with ambivalent insecurity. Her thoughts are confused. She finds it difficult to stay on track. She is in a state of extreme terror out of proportion to the context, and she describes quasi-psychotic and dissociated feelings. When faced with threat, she has no stable self-representation: she doesn't recognize who she is and wonders if she is seeing her father rather than herself in the shop windows.
We can speculate that ‘behind’ this incoherent (in the technical sense) speech pattern there may lie unprocessed trauma (her mother's aggression, her father and second husband's abuse) which my insistence on keeping her on track (which in my counter-transference felt quite abusive and bullying) may have activated. In order to avoid the eruption of this potentially disorganizing constellation of thoughts and feelings, she narrows her behavioural repertoire and seeks the physical proximity of Geoff to provide the external secure base which she lacks internally. She resorts to a restricted, helpless self, and remains dissociated from any competence or functioning ego which she may exhibit under less threatening circumstances.
How then do we understand the outbursts of uncontrollable rage towards Geoff which are what have brought her for help? There are perhaps three aspects to this. First, like Harry Harlow's Feli [17], the goose that was deliberately reared without attachments and who also showed inexplicable episodes of aggressive behaviour when faced with fellow-geese, they represent ‘displacement activity’ in someone who lacks a consistent behavioural strategy for dealing with problematic intimacy. She wants to be close to Geoff, but she is terrified of being so, and attack is a way of escaping from that dilemma. Second, in a more straightforward way she is punishing him for not being with her at all times, a standard attachment-influenced interpretation of interpersonal aggression, similar to our understanding of deliberate self-harm when faced with an ‘attachment crisis’. Aggression here is essentially a negative reinforcement schedule designed to re-establish a compromised attachment bond.
A third aspect concerns the characteristics of spouses of people suffering from BPD. Many or most BPD sufferers manage to drive partners away, and instability of relationships is typical of this diagnostic group. Those whose relationships do survive often are married to people who are phlegmatic in the extreme, and usually highly emotionally avoidant. The attack on Geoff was both a desperate attempt to elicit an emotional response, and at the same time an attempt to reassure herself that however, outrageous her behaviour he would stand by her.
A final point I want to draw from this example returns to Deidre's emotional ‘collapse’ when talking about the shop windows. Her tears and quivering lip here were quite different from what happens for instance when someone is talking about a bereavement or loss in their life in which the painful feelings remain within the ‘envelope’ of the narrative and the patient's felt self. In Deidre's case there was an incongruity and suddenness with which the overwhelming feelings erupted, disrupting her sense of self, thus increasing her vulnerability to exploitation or attack.
Compare the sudden change of mood that might be seen in a 2 year old, happily playing ‘alone in the presence of the mother’ [18], when the caregiver goes out of the room without warning, to attend to a chore for instance. The child may suddenly dissolve into tears and the narrative envelope of her play collapses no less instantly than it might for the audience if a fire-alarm went off in the middle of a theatrical performance. In Diedre's case and that of the small child there is no sustaining internal caregiving presence that can soothe and smooth affective fluctuations. Under favourable developmental conditions, the child will gradually internalize these functions from the external caregiver. For the less fortunate, these un-buffered emotional states or failures of self-soothing will form part of the core diagnostic profile of borderline conditions.
Psychotherapeutic implications
Psychotherapeutic work with patients suffering from BPD is notoriously difficult [19]. Over and above ‘nonspecific factors’, the therapeutic effectiveness of dynamic psychotherapy is based on two main clinical tools. First is the therapist's counter-transferential capacity to use her own emotional reactions in the service of the sufferer. Second is the ability to put those feelings into words, in the terms of this discussion, to create a language-game of shared meaning with the patient. In the light of the above we can begin to understand how both of these can be compromised when working with borderline patients.
The eliciting of powerful counter-transference is in itself almost diagnostic of borderline states. People who work with such patients will recognize feelings of rage, anger, exasperation, murderousness, intense pity, desire to rescue, erotic arousal, wish to extricate themselves from the relationship and many other intense emotional reactions in themselves. These feelings are usually understood in terms of projective identification, and in the Klein-Bion model represent the projection of the patient's primitive un-modulated feelings into the caregiver. Using Bion's digestive metaphor, if these feelings remain ‘un-metabolised’ they cannot subsequently (this implies temporal sequence, although in reality the process all takes place in the blink of an eye) be reintrojected by the dependent child or patient in treatment in a transmuted form.
Adding an attachment framework to this, we can postulate that an interpersonal situation akin to infancy is recreated in the consulting room in which the supposed caregiver (the therapist) is potentially distracted from her secure base function by powerful, preoccupying and potentially terrifying emotions. At this point the trauma of non-mirroring caregiver is reproduced as the therapist is in the thrall of strong feelings and so unable to reflect accurately the patient's state of mind, despite the fact that those feelings were evoked precisely by the patient. The pressure on the therapist to ‘act out’ – to enact or give vent to her controlling, angry, loving, rejecting or all-embracing feelings in some way – is insistent. Like the D caregiver, we (i.e. psychiatrists, psychologists, therapists) become frightened by our own fear and seek to evacuate it through action. We become subject to role-reversal pressures and try to use the patient as a receptacle for our own unbearable feelings. We try to impose a pseudo-organization on a chaotic situation, thereby deepening the split in the patient's inner world between control and pseudo-order on the one hand and the un-modulated terror which lies beneath. Like the D caregiver we operate with a restricted or constricted self, losing sight sometimes of who we are or what our role might be.
A similar dilemma confronts with the use of words in working with BPD patients. Clearly words are fundamental to organization and resolution of painful feelings. The human voice in itself can be soothing, a bedtime story sends us to sleep safely until morning, telling the history of a life provides objectification and verification, imposing meaning on seemingly inchoate events and feelings. But for the BPD patient words are also a threat, arousing painful memories, counteracting defensive strategies, and threatening to lay bare naked fear and panic. This can be understood in terms of the BPD patient's operating within ‘equivalence’ as opposed to ‘pretend’ mode [2]. According to this theory, in equivalence mode a word directly evokes an experience rather than being a representation of it, and therefore is associated with overwhelming affect, rather helping to process and master feelings. Words and their meanings disrupt rather than bolster the self, which fragments into a number of incomprehending parts.
Case History B
A further vignette serves to illustrate this point. The patient was a middle-aged woman referred for psychotherapy after she had a series of fits for which no neurological basis could be found. She told me that the fits were very worrying to her because she believed she was having some sort of stroke, and that the right side of her body was becoming weaker and weaker, and that she would be unable to carry out her role as carer for her disabled husband. She then told me about his progressive rheumatological condition, and about their son who had a very bad motor bike accident recently, and her daughter who was involved with an unsuitable man. She made it clear that she and her husband never rowed and that it was important to her to have a placid family life since her childhood had been so dominated by conflict.
An apparently innocuous question about her family, and especially her parents, evoked in a rather disturbing way the typical change in breathing patterns and eyeglazing of the unresolved patient. She suddenly blurted out the story of how her father had murdered her mother, had been in jail for 10 years, that she had been ostracised by her siblings because she refused to believe that he had done so. Later, after his release from jail, she described how he had threatened her on one occasion, and, in her fear, had decided, like her siblings, to have nothing further to do with him.
At this point I tried to summarize the situation by saying that I thought she had suffered a huge amount of trauma and loss in her life and that it was entirely possible that this was what underlay her ‘turns’, since ‘the body has strange ways of making its feelings known’. No sooner had I delivered this salvo (as I think she experienced it) than she began to ‘fit’. Her eyes became glazed, she started to shake, especially on the right side of her body, her lip curled upwards, and she appeared inaccessible. The episode lasted for about a minute, after which she seemed drowsy and slow in her movements.
While it is not impossible that this may have had a neurological basis, in view of normal investigations and a number of other features it is more than likely that this represented a ‘pseudo-fit’. From the perspective of our discussion it had some of the features of disorganization described by Main and others in D children in the ‘Strange Situation’ – bizarre posturing, stereotypical behaviour, incongruent affective response. The point however, is that this bizarre response emerged immediately after a comment from me trying to link together disparate and inexplicable events, an attempt to move from incoherence towards organization and meaning. I suggest however, that this put the patient in an approach–avoidance dilemma. The move towards meaning has the potential to increase her sense of security and continuity, but at the same time the words themselves arouse terrifying memories of trauma. The self can be ‘shattered’ (a word often used) when confronted with meanings which threaten a patient's stable but restricted self-state, putting them potentially in touch with experience lying outside the perimeter of the self.
Therapeutic solutions: are there any?
What then is to be done? How can we prevent ‘D dilemmas’ reproducing themselves in therapy? Can we avoid re-enactment rather than transcendence of trauma, often with the consequence that the patient either regresses and gets worse (ambivalent pattern), or drops out (avoidance pattern)? From an attachment perspective, the answer lies in what Main calls ‘meta-cognitive monitoring’ [12]. Meta-cognitive monitoring refers to the process of ‘thinking about thinking’, which entails a clear distinction between ‘pretend’ or symbolic mode on the one hand and ‘equivalence’ mode on the other. First, the therapist, usually with the help of supervision, has to be able to ‘contain’ her overwhelming countertransference feelings, to recognize them for what they are without suppressing, dismissing or acting on them. Second, she has to learn the sense in the aphorism ‘don't just do something, sit there’. She has to be able to put her aroused feelings to good use in the session by seeing them and the actions they threaten to stimulate not as ‘real’, but as symbolizing a need or inner state that had its origins within the patient. Finally she needs to be able to translate all this into words.
Let us say a therapist is working with a patient who has been severely sexually abused, and that the patient is able to describe the ‘facts’ of what has happened, but without attendant feelings, and that the therapist finds herself experiencing disgust and rage and being on the point of offering to accompany the patient to confront her abuser. To do so would, I suggest, simply evoke the typical D response in the patient: panic, embarrassment, disempoweredness and a wish to regain control. Instead, the sensitive therapist might say something like: ‘It sounds like these are feelings that it is very difficult for you to face on your own, but that to do so with another person brings up huge feelings of shame, so you are damned if you do, and damned if you don't’. The therapist takes her own responses as reflecting, representing, or symbolizing the emotional state of the patient. By introducing a conversation about conversation the therapist is initiating the BPD sufferer to the possibility of ‘sense 3’ meaning – the possibility of a shared language of intimacy.
Thus the patient needs to be offered not just words or meanings, but words about words, and meanings of meanings. Rather than in an ex-cathedra way suggesting that the patient's fits represented her unresolved trauma (or that the weak right side of her represented the dead mother killed by her powerful and out-of-control fatherlike left side) it might have been better to have said something along the lines of: ‘We could talk about the pain and trauma you have been through, and this might help reduce the frequency of your fits, but it also might increase them because we would be approaching such painful topics which you have effectively buried for a long time’.
Such interventions can be called ‘interpretations in the alternative’. They can provide the patient with a picture of the balance of forces that threaten to disrupt the self, offered in a containing way (tone of voice, setting, consistency, etc.) that can hold them together, and has the potential for fostering psychological integration and a more coherent self.
To summarize then, the BPD patient, who may well be a D child grown up, has used various kinds of controlling strategies to maintain a modicum of security and stability. Some of the more extreme and bizarre features of borderline behaviour can be seen in this light, that is, self-injury, bingeing and vomiting, and substance abuse, all of which produce temporary physiological features associated with secure base experience. I have called these ‘pathological secure base phenomena’ [3]. Working with such patients produces similar unresolvable dilemmas to those encountered by the D child in the ‘Strange situation’. Staying with these paradoxes, while using various ‘meta-cognitive’ manoeuvres in order to transcend them, are an integral part of therapy with borderlines.
Any organized service for such patients needs also to take these issues into account. There needs to be an emphasis throughout the team on the notion of ‘holding in mind’. Fonagy and Target suggests that a crucial feature of PD is lack of ‘mentalizing capacity’, or ‘mindmindedness’ [20]. Personality disorder patients find it difficult to sustain a stable sense of a self and its other possessed of beliefs, desires, and intentions. This puts them at grave disadvantage in interpersonal relationships, and may influence their problematic relationships with caregiving institutions. It has been suggested that such people as children lacked a caregiver who could validate their internal world and see them as autonomous and sentient. One of the functions of therapy with people suffering from BPD is to offer a ‘thinking mind’ which can plan, intervene, and take a perspective on them as persons, in which metacognitive monitoring is a central component. We hope that this ‘holding in mind’ function may eventually be internalized by the PD sufferer as self-reflexive capacity which in turn will enhance their interpersonal life.
In the clinic we aim to provide just such a ‘thinking mind’, held collectively by the members of the team, through the assessment and supervisory functions which they offer to the clients, their carers and their therapists. Essentially what is being offered to these patients is continuity of care in its deepest sense. The nature of BPD is such that it tends to vitiate attempts to create such continuity, and the emphasis on engagement, consistency and long-term commitment is an attempt to mitigate the disruptive features that are so characteristic of the condition.
Conclusion
A final thought on meaning. Although science seeks meaning in the sense of the causal connections between things, many scientists also celebrate the intrinsic beauty and meaning in the pattern and form in nature which the search for causality reveals. Similarly, when patients struggle to connect and lessen the disorder in their lives, both in the wider sense, and at the microlevel of emotional regulation and interpersonal relationships, their appreciation of the value of life and its meaningfulness in the aesthetic/religious sense also seems to deepen. By putting us often painfully in touch with chaos and disorder, borderline patients help us to value connectedness and continuity, and to redouble our efforts to maintain them in face of forces of disintegration and destruction.