Ramie Bou-Saab, AM LCSW is a licensed psychotherapist specializing in depression, anxiety, and trauma at Depth Counseling. He currently works with individual adults and couples in Ravenswood, Chicago, and brings a special interest in working with individuals on the borderline personality spectrum. He recognizes the demographic diversity in this spectrum and how this contributes to the differing needs and challenges they face when it comes to managing their emotions, responsibilities, and relationships. I recently sat down with Ramie to ask him about how he uses psychodynamic concepts to work with people with borderline personality organizations.
— Micaiah Warren, student intern
What are some of the common themes associated with individuals on the borderline personality spectrum? How does being on the borderline personality spectrum present itself?
One common theme is the feeling that emotions feel intense, overpowering and very hard to manage. This can lead to difficulty working with people on this spectrum because both therapist and client have a hard time trying to manage these feelings, especially when a client talks about wanting to commit suicide. Another part of the spectrum involves having an unstable, murky sense of identity. People in this range tend to lack self-confidence and an overall cohesion in who they see themselves as being. All these factors contribute to their difficulty maintaining stable, intimate relationships with others. Their attempts at making personal connections with other people can often feel chaotic which partially results from their inability to manage intense emotions.
Another component is that individuals on the borderline spectrum draw perceptions of their reality from whatever emotion they might be feeling in the moment, and, oftentimes, feel emotionally invalidated. For example, these individuals may view reality from a very ‘black and white’ perspective, and they often have trouble detaching from their immediate subjective reactions, which can distort the realities of their environment. The term “borderline” was originally coined to reflect the line between psychotic and neurotic, neurotic being relatively healthy individuals who have a firm sense of reality, and psychotic being those who have lost some connection with their reality. Those on the borderline spectrum are understood to have a shaky sense of reality and tend to balance between this line of having a more “accurate” perception of what they are experiencing and having a disconnect with some of the realities in their life.
It’s important to note that a majority of people in the borderline range have had early experiences with chronic sexual, emotional, or physical abuse, neglect, and, above all, emotional invalidation from caregivers. This is not to say that all the emotional chaos is related to abuse or neglect but the theme that connects their experiences is chronic invalidation and pervasive shame. One may start to feel “less than” as a result of these traumatic experiences, and that can cause intense emotional dysregulation.
Can you elaborate on what the conflict is in regard to how borderline personality is viewed and the labeling of it?
There is the psychoanalytic lens which dates all the way back to Freud about these ranges of psychological experience: psychotic, borderline, and neurotic. Then there’s the American Psychiatric Association’s DSM and “Borderline Personality Disorder,” which is very rigid. It’s like, if you meet these set of requirements so you are “Borderline,” which can almost be like branding somebody. If you put these labels on someone’s medical chart it can be inescapable, people will change their perception of you just from seeing this labeled diagnosis on someone’s chart. I made this mistake during one of my internships, where I put what I thought was an accurate label on the patient’s chart but then I got an email from the therapist and the client saying if I put this diagnosis on their chart, doctors will start to treat the client differently. They are going to treat them as a more difficult client and be more dismissive of the client’s own accounts of how they are feeling. The irony here is that even just by labeling this way, a dynamic is created for the patient where they will be put in situations where they are even more emotionally invalidated. For me, trying to force people into boxes is not realistic; the idea of a spectrum is more realistic because you are able to see the nuance and there is more of a sense of organizing ways to think about these things when therapists are interacting with these individuals. The themes present themselves a lot more clearly.
What is the “object of desire”? How is it associated with borderline personality and the relationships that they build with others?
Object in this sense means an internalized other person or experience. “Object of desire” refers to some longing for someone or something old and familiar. This desire develops over time during childhood/adolescence and it can be carried with us into adulthood. This is not something specific to borderline spectrum patients; this can be a common theme in human maturation in general. For people in the borderline range, though, the “object of desire” is the ‘outside of awareness’ gravitation into chaotic situations or chaotic relationships where the resulting overwhelming emotions make them feel connected to both the person in the present and to folks in their past, often family, where they felt similarly. So they then have found this “object.”
For example, a past client of mine had a really invalidating mother and father. Parents were never really home, and the client wasn’t taught to process difficult emotions in a healthy way. When they would get angry with their parents, their parents often seemed to have trouble responding with empathy or validation, and they frequently responded with their own overwhelming feelings of anger or anxiety. For a young child growing up with parents who respond this way to their feelings, it is common to develop a sense of instability and unpredictability around emotions. So when this child grows up, they will be more likely to seek relationships with partners who end up responding to them in a similar way that their parents did. My client was dysregulated and overwhelmed by these childhood relationships, but at the same time, in the present they are, outside of their own awareness, afraid to do something different because this feels like home, this is what they have grown accustomed to. This way of doing things has its own sense of control and safety which unfortunately serves to affirm these unhealthy relationships and conflicts. This can also be a common occurrence for people who aren’t even on the borderline spectrum.
How do you bring attention to unhealthy behaviors exhibited by individuals on the spectrum in a way that is healthy and safe?
There is obviously a lot of stigma associated with that, between the diagnosis itself and telling someone that they are fueling their own emotional chaos and acting self-destructively. It involves a lot of tact. I had a client who liked the diagnosis CPTSD (complex post-traumatic stress disorder) better. There is a whole debate about how to describe this phenomenon in an effort to destigmatize and instead to affirm and reassure. I generally try not to label the phenomenon for my clients, but instead think in my own mind how this phenomenon presents itself for my clients individually. What I try to do is stay empathic, consistent, and reliable so that I can build a healthier relationship with my clients. Inevitably, as I build relationships with my clients, their past experiences will start to come up and affect the way they view me. They may try to seek the “object of desire” from our relationship by trying to pull me into their emotional chaos, do things that might provoke certain intense feelings from me, or view who I am or what I’m saying from a ‘black and white’ perspective. So I need to label and interpret what’s going on here to help them talk about their feelings more effectively as opposed to continuing to allow them to spiral into more chaos. The process of even just talking about the feelings that they have associated with our client-therapist relationship is more powerful than trying to psychologically stamp what their “diagnosis” or “problems” are.
Another useful tactic is setting boundaries. I work with all kinds of patients and a lot of them are lovable people, so it can be hard to say no sometimes when they are feeling in a crisis and feeling that they need more from me. Needing to end sessions on time, saying ‘no’ to additional sessions when I don’t have the time, and making sure that they pay me are all issues that come up where I need to draw the line. Saying “no” in these situations helps them become more integrated into reality, and helps them take responsibility for their own feelings and decisions as opposed to making it someone else’s responsibility. This might sound callous but a lot of the time people in this range are addicted to seeking out the “object of desire” and so they aren’t taking care of themselves, they aren’t being honest about what they are feeling, and they are burning out the people around them. This only fuels the emotional chaos. But you need the firmness of boundaries coupled with stability and empathy of the relationship to assure them that feelings are not going to kill them, and whatever they are going through, much more often than not, they can survive it.
Based on your own personal experience doing this work, what are some things that you believe are important for people to know about borderline personality?
It is very rewarding to work with these people even though it’s difficult and takes time. It is important to recognize that this work is hard and that people dealing with this phenomenon are dealing with cyclical trauma. They are ambivalent about seeking out familiar relationship dynamics or experiences that bring about chaotic feelings. Again, this is a spectrum so not everybody’s trauma is going to look the same. The trauma can be a predisposition to feeling really dysregulated when one is emotionally invalidated, this is an example of little “t” trauma. Big “T” trauma is more like physical abuse or chronic sexual abuse. And big “T” trauma can make things more severe for people on the borderline spectrum. It can reproduce dynamics of domination and humiliation which is almost always a result of previous physical, emotional, and/or sexual abuse.
With that, a certain style of attachment called “attackment” can present itself when those on the more severe end of the spectrum build intimate relationships with others. This produces an emotionally chaotic relationship where there’s a dynamic of domination going on. The person on the spectrum is trying to dominate or they are seeking partners who will dominate them. This is repeating history; the history of being chronically humiliated, shamed, and invalidated. Thinking of a specific client, most memories that they had of their parent was one of humiliation. So feeling humiliated by other people became something they were vigilant about, but it also caused them to unconsciously seek relationships or experiences with others where there was consistent humiliation. They interacted with other people in a way where it kept them experiencing this, but also feeling paranoid of and perceiving others’ words and actions as only out to humiliate them, despite much evidence to the contrary. This is what is so hard for these individuals to deal with: caught between the shame and humiliation that they feel about themselves and the constant fear of it happening, but also afraid to give the other person the benefit of the doubt and not view things only from this distrusting lens.
What advice would you have for people who have relations with individuals who are on the borderline personality spectrum? Is it possible to have a certain level of intimacy with these individuals without the “object of desire” being sought out?
I think being the “object of desire,” having that projected onto you or being pulled into that relationship dynamic is inevitable. It’s inevitable because folks in the spectrum are stuck between trying to find safety and also looking for the familiar. So they are going to be projecting to account for safety which they feel they are lacking. To navigate that as someone who isn’t in that range with someone who is in that range, having real firm boundaries helps enormously. For example, “If you start throwing things or hitting me, I am going to leave,” “If you start yelling at me, I am going to leave”, “If we continue to be in a relationship, I am not going to be the only who will emotionally support you,” “If you say you want to kill yourself or hurt yourself, I am calling 911.” A lot of times it has to do with not telling them what they shouldn’t do but what you are going to do if they do something else, so that it isn’t a threat. This not only protects the person on the receiving end of this, but it helps to create healthy separation, and models boundary setting and a sense of responsibility for the person on the spectrum around what is healthy behavior that respects the dignity of both parties.