question for the psychodynamically oriented

[DrGachet]

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I'm thinking Kernberg mostly. I was reading an article on "regression" and how someone with neurotic personality organization can regress to a borderline state. Is this the exact same organization as someone with a borderline personality organization? We can help those who regress, returning them to the neurotic personality organization...presumably. Why then is it so difficult to help someone with BPD or NPD (classically defined) to see the world and themselves as neurotics do? Are neurotics more resourceful, psychologically? Does the neurotic organization, unlike the borderline organization, contain a scaffold that remains in place despite the regression?

 

[billypilgrim37]

Don't get caught up too much on the labels. The organizations refer to what defenses are being used most actively. Under a stress, healthier, even neurotic defenses go away, and borderline ones show up.

Take a professional baseball pitcher who usually throws a 90mph fastball, who suddenly develops some bad habits, and for some reason he can only hit 84 on the radar gun. He works a little while with the pitching coach, and within a few weeks he's hitting 90 again, and maybe his curve breaks a little sharper than it did before too.

Then take a minor league pitcher who, for whatever reason, can only hit 84 on a good day, maybe hit 86 once while juicing, but his testicles shrunk, so he stopped. Your job as pitching coach is now to get him to throw 90.

Pitching coaches (therapists) have an entirely different job in front of them when faced with somebody throwing 90 who has developed some bad habits (w/ neurotic organization) and somebody who has only ever been able to throw 84 (w/ borderline organization), even though the radar gun shows the same.

Yeah, I know, I'm Captain Lousy Analogy.

 

[OldPsychDoc]

Don't get caught up too much on the labels. The organizations refer to what defenses are being used most actively. Under a stress, healthier, even neurotic defenses go away, and borderline ones show up.

Take a professional baseball pitcher who usually throws a 90mph fastball, who suddenly develops some bad habits, and for some reason he can only hit 84 on the radar gun. He works a little while with the pitching coach, and within a few weeks he's hitting 90 again, and maybe his curve breaks a little sharper than it did before too.

Then take a minor league pitcher who, for whatever reason, can only hit 84 on a good day, maybe hit 86 once while juicing, but his testicles shrunk, so he stopped. Your job as pitching coach is now to get him to throw 90.

Pitching coaches (therapists) have an entirely different job in front of them when faced with somebody throwing 90 who has developed some bad habits (w/ neurotic organization) and somebody who has only ever been able to throw 84 (w/ borderline organization), even though the radar gun shows the same.

Yeah, I know, I'm Captain Lousy Analogy.

I'll give you a B- for effort. 😀

 

[loveoforganic]

At least it didn't reference a crappy old movie 😀 small steps

 

[slope]

In the psychoanalytic literature, some authors use borderline state and borderline personality organization interchangeably.

"Why then is it so difficult to help someone with BPD or NPD (classically defined)"...classically defined...I assume you meant defined as per DSM?!

"Why then is it so difficult to help someone with BPD or NPD (classically defined) to see the world and themselves as neurotics do?" BPD, NPD, and similar labels don't help much in the psychotherapy setting for reasons more than one. When we talk about someone's personality organization, we take into account a number of variables, but for simplicity's sake, I will focus on the reality testing which is different for the different levels of personality organization (i.e., neurotic, borderline, psychotic). Borderline and narcissistic people come in all colors, and the level their personality is organized on will play a significant role in how they will do in therapy. In the orthodox Freudian view, borderline and narcissistic personalities were regarded as not suitable for therapy, and there were a number of papers talking about why this was the case. That view has changed a lot over the following decades. Your question raises, in fact, another question. Is the therapist supposed to provide the patient with a specific Weltanschauung, to help him see the world in a specific way (i.e., the way neurotics do)?

"Are neurotics more resourceful, psychologically?" Yes

"Does the neurotic organization, unlike the borderline organization, contain a scaffold that remains in place despite the regression?" I'm afraid that you will need to elaborate a little on the regression part before I answer this one.

 

[DrGachet]

In the psychoanalytic literature, some authors use borderline state and borderline personality organization interchangeably.

Okay, that must be it. That's why I got confused. I have to find a book that explains the difference well.

classically defined...I assume you meant defined as per DSM?!

No, I guess my wording was unclear, but I meant pathological narcissism and borderline organization, as opposed to NPD and BPD as defined in the DSM. So when I mentioned BPD--classically defined--I was actually talking about histrionic traits with a borderline personality organization, which is different from how DSM defines BPD. Same with pathological narcissism which, unlike NPD, is necessarily associated with a borderline personality organization.

Is the therapist supposed to provide the patient with a specific Weltanschauung, to help him see the world in a specific way (i.e., the way neurotics do)?

That's a good question, I agree. Well, psychiatry these days is all about what's functional and what's not, so perhaps that answers your question to some extent. Then again the entertainment industry, for instance, has a place for all kinds of people, and that pay is not bad either. So as long as you're not a danger to yourself or others, and can find a "market" for your...talents, then why take Risperidone, I ask?

Does the neurotic organization, unlike the borderline organization, contain a scaffold that remains in place despite the regression?" I'm afraid that you will need to elaborate a little on the regression part before I answer this one.

Perhaps this comes from my confusion of borderline personality organization/state. I was thinking that a person with neurotic organization can regress to a borderline organization but as you implied earlier, we're talking "state" here.

 

[cleareyedguy]

question for the psychodynamically oriented

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I'm thinking Kernberg mostly.
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I don't think Otto comes online very often, so I'll try to expand on what people have said.

Regression can induce some primitive defenses in otherwise normal people, but I think what we most often see is regression in people who have a fragile BPO. On good days, they can seem fine, but under stress, they manifest splitting, projection, denial, etc, and we see them after they've cut or od'ed. We're then surprised that they heal up rather nicely, often within hours, and what they then need is often a good d/c plan rather than an admission. Neurotic/normal people may regress into splitting or projection, but it feels uncharacteristic to them and tends to be evanescent and often the response to someone who truly has a BPO--it's a fundamental aspect of becoming a psychiatrist, by the way, becoming adept at recognizing your own reactions to these difficult people.

The scaffold is a good analogy. The neurotic (ie, the rest of us) have a scaffold that affords a certain basic level of trust and an ability to step aside from emotion and look at the world through disinterested eyes. Someone with BPO has a scaffold that is intrinsically flawed in that the world is essentially seen from the primitive vantage point. They can scoop healthy stuff on top, but under stress, the scaffold re-emerges. And that leads to the central Kernberg/Kohut dilemma in that Kernberg would assert that therapy must actively confront the borderline scaffold else the alliance is built on an unhealthy framework, and Kohut would say the problem is not the scaffolding but the lack of a scaffolding, a deficit, that needs relentless addressing via an empathic treatment (ie, mirroring before interpretation).

Some of the theorizing can get a little muddled, but it's a bit like talking to an astronomer about black holes. They can present it in a sentence or paragraph quite clearly, but the reality of the situation is complicated enough that anything more detailed is inevitably going to sound confusing to non-experts. But as with black holes, there is a reality to BPO even if it's not fully delineated or understood.

 

[DrGachet]

I don't think Otto comes online very often, so I'll try to expand on what people have said.

Regression can induce some primitive defenses in otherwise normal people, but I think what we most often see is regression in people who have a fragile BPO. On good days, they can seem fine, but under stress, they manifest splitting, projection, denial, etc, and we see them after they've cut or od'ed. We're then surprised that they heal up rather nicely, often within hours, and what they then need is often a good d/c plan rather than an admission. Neurotic/normal people may regress into splitting or projection, but it feels uncharacteristic to them and tends to be evanescent and often the response to someone who truly has a BPO--it's a fundamental aspect of becoming a psychiatrist, by the way, becoming adept at recognizing your own reactions to these difficult people.

The scaffold is a good analogy. The neurotic (ie, the rest of us) have a scaffold that affords a certain basic level of trust and an ability to step aside from emotion and look at the world through disinterested eyes. Someone with BPO has a scaffold that is intrinsically flawed in that the world is essentially seen from the primitive vantage point. They can scoop healthy stuff on top, but under stress, the scaffold re-emerges. And that leads to the central Kernberg/Kohut dilemma in that Kernberg would assert that therapy must actively confront the borderline scaffold else the alliance is built on an unhealthy framework, and Kohut would say the problem is not the scaffolding but the lack of a scaffolding, a deficit, that needs relentless addressing via an empathic treatment (ie, mirroring before interpretation).

Some of the theorizing can get a little muddled, but it's a bit like talking to an astronomer about black holes. They can present it in a sentence or paragraph quite clearly, but the reality of the situation is complicated enough that anything more detailed is inevitably going to sound confusing to non-experts. But as with black holes, there is a reality to BPO even if it's not fully delineated or understood.

Thank you for this very lucid and helpful reply. Would you mind suggesting a book or two, or articles perhaps, for additional reading?