In the first part of this series, I discussed Allan Schore's video about early neurological damage resulting from failures in the attachment relationship between mother and baby. In the second part, I used Schore's research to help explain why our defense mechanisms are so tenacious, and why authentic change is difficult and rare. I'd now like to conclude with my personal, somewhat idiosyncratic view on how real change occurs, how that early damage can to some degree be healed, and what conditions are necessary to do so. I don't have the science to back it up; all I can offer is my experience, both as a client on the couch for 14 years, and in working with my own clients for the last three decades.

My thesis is simple: if failures in early attachment damage the brain as it develops, the way to repair that damage (to the extent possible) is through another "attachment" relationship that somewhat resembles but also differs in major ways from that early bond: the psychotherapy relationship. I suppose I mean that in therapy, something like a "corrective emotional experience" occurs, as long as we don't idealize that experience and we understand that therapy doesn't fully correct for all those early emotional failures. The corrective emotional experience in therapy is not a replacement for a mother who truly loved and cared for you. It's the closest to such an experience that many people ever get but it's a distant "second best."

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Attachment Theory and the Tenacity of Defense Mechanisms

As you can see from the comments to my last post about attachment theory and the origins of shame, many people are struggling with the idea of lasting neurological damage as the result of failures in early attachment. This is a difficult truth to accept, but we're talking about scientifically verifiable changes in the brain that result from different experiences during the first two years of life. I have no problem with people hoping that science will eventually figure out how to repair that damage; I can't argue with religious faith when people believe that their God will do the same. But while we are waiting, full of hope and faith, we must try to make the best use of what we know. Contrary to what one of the comments suggested, facing the truth does not lead to a sense of hopelessness and despair about changing. Rather, it allows us to be realistic in our expectations and to work for attainable change, rather than hoping for salvation from science or God. I would suggest it is the hope for a "complete cure" (instead of facing the truth) than undermines the hard work of psychotherapy.

In an earlier post about the tenacity of defenses, I discussed how our defense mechanisms are mental habits of coping etched in our neural pathways. I'm not a neurologist and my ability to describe the science is limited, but based upon the work of Allan Schore and others, I think we can now expand on this idea. When there are early failures of attachment and the infant doesn't learn to manage its own emotional experience, it instead makes use of psychological defenses to ward it off; such defenses are built into the structure of the brain as it develops. When an adult comes into my office -- a person who relies heavily on denial, his neuro-anatomy has developed in a way -- an abnormal way -- that reflects the use of that defense. If someone else resorts to splitting and projection, her neuro-anatomy will have developed differently. These defensive strategies are inherent in the very structure of the brain as it developed.

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Attachment Theory and the Origins of Shame

Joseph Burgoin

Self-Esteem and Self-Sabotage

Shame/Narcissism

December 10, 2011December 15, 2011

The following video was brought to my attention by one of my long-term clients who also happens to be an excellent therapist and works extensively with concepts of shame in her own practice. This week, I'll be discussing the video in several posts. I recommend that you watch the entire video. It's fascinating, informative and provides a neurological basis for an understanding of shame. The primary lecturer, Allan Schore, and the other researchers don't discuss shame, in particular -- they approach this topic from the perspective of attachment theory; but as you'll see, their explanation of neurological development in the infant help us understand how an early and deep-seated shame takes root. I'm very grateful to my client for sending me a link to this valuable resource:

You're no doubt familiar with the nature vs nurture debate concerning the relative importance of heredity and the environment. Nowadays, the prevailing view seems to be that it's neither one nor the other but an interaction between the two that defines us. Even so, most people assume that you are born into the world with your complete genetic makeup and that you then interact with your environment. The primary lecturer in this video -- Allan Schore, a member of the clinical faculty of the Department of Psychiatry and Behavioral Sciences at UCLA -- challenges this view: "One of the great fallacies that many scientists have is that everything that is before birth is genetic and that everything that is after birth is learned. This is not the case." He goes on to explain that there is much more genetic material in the brain at ten months than at birth. Only the brain stem or "primitive brain" is "well advanced" at birth; the rest of brain continues to unfold and develop for the next two years as neurons become myelinated and interconnect. This development does not occur in an automatic and predetermined way in all people; it is powerfully affected by the environment, in particular by interactions and relationships with the primary caretakers.

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Rage and Entitlement in Borderline Personality Disorder

Joseph Burgoin

Love and Hatred

The Psychotherapy Relationship

December 2, 2011

A site visitor who signed with the name "Jay" recently left an interesting comment to my earlier post on borderline personality disorder. As this bears on the issue of rage and the sense of entitlement, I'll quote his remarks at length. He's a young mental health professional, working at an in-patient facility:

"I have one BPD patient. Just one and the stress is starting to get to me. It is becoming a nightmare. She cuts, threatens suicide, hits her peers, urinates on the floor and yells at the top of her lungs when she does not get her way. She pulled the fire alarm during her tour of the building because she wanted to be let in the music room. That room was under construction. I explained to her why she could not go in there, her answer was "how do you know?" I pointed to the "under construction keep out" sign. She replied "well you still donâ€™t know that.â€ She then proceeded to yell at me for not taking her side.

Another example, she ordered cereal for breakfast the night before. She woke up and asked for oatmeal and bananas. We did not have any oatmeal. We offered cereal and bananas. She flipped a few chairs, threw her tray at the kitchen staff, threatened to kill herself and burn the place down. That lasted 3 hours. There was no talking with her, no pacifying her. Finally she was placed in restraints and medicated. She sleeps 10 hours.

Empathy does not work, group therapy, one on one, drawing, meditating, bribery, nothing . Yes, I bribed her with snacks, tried a few reward systems. Sheâ€™s in her early 20s, as I am. I can not reach that girl. She hates me one day and can not live without me the next. My colleagues are all sick of her. Being the youngest of the staff, sheâ€™s is mine until she leaves. I am seriously considering switching to hospice care. She has no boundaries and does not respect mine. For example, I stated that I am uncomfortable with kissing on the cheeks, hugging, holding hands and such. However I do shake hands. She will try to hug me every time I see her, or touch my clothes, hair, to touch my papers. Iâ€™d say "please donâ€™t", she'd say "but I want to see what it is" or "they are just papersâ€. Yes papers that are on my lap . That make my blood boil."

In this comment, Jay dramatically illustrates the emotional challenge of working with someone who suffers from borderline personality disorder. His reactions are not unusual; I have felt very similar ways during sessions with my own clients. His account also reminds me of other such stories I've heard, about the way bpd patients affect their ward staff. They are highly provocative and evocative; they inspire feelings of hostility and resentment. They make you want to quit the profession.

In order to help someone like this young woman, you first have to get clear on the difference between empathy vs sympathy. Jay states that "empathy does not work," but I doubt he or anyone else on the staff is truly empathizing with her ... at least they're not aware that they are. She fills them (via projection) with all her own unbearable emotions of rage and anger; the way she treats her caretakers evokes the same feelings within them that she is struggling with. Jay says her behaviors make his "blood boil" -- that's where the empathy comes in. The problem is that, for the most part, we mental health professionals believe it's inappropriate to have such feelings, and when we're forced to admit that we do have them, we want to blame the patient.

What I recommend instead is to use those feelings to connect with her. In my response to Jay, I suggested that he say something to his patient like this: "When you can't force me do what you want, it makes you so furious you hate my fucking guts and want to kill me." It's clear from what Jay writes that she's struggling with murderous rage and it's important to name it for her, to articulate the emotions and impulses she's feeling. It's easy to assume that she knows what she's feeling; the truth is, her mind is continually blown apart by the violence of her feelings; she doesn't really know what they are in any way you or I would recognize. It's the job of the therapist to help her bear with those feelings and learn to understand them -- very difficult work.

This young woman also finds any kind of frustration unbearable; she's goes into a rage whenever she feels it. In part, this reflects the sense of entitlement you so often find with borderlines; it also betrays the limits of her capacity to bear any kind of pain. She demands to be treated as if she were an infant, really -- ministered to by a perfect mother who would tend to her every need and never let frustration become an issue. It would be important to address this with the patient: "I think you find any kind of frustration unbearably painful; when you feel it, you just want to kill somebody." With my own clients, I've also said things like: "You expect me to understand and gratify your every need without you having to say a single word."

Neither can she bear the experience of separateness; those boundary-crossing behaviors that understandably annoy Jay represent her attempt to take possession of him, to own him, and to deny the separation between them. When the experience of need, separateness and frustration is unbearable, fantasies of merger often come to the rescue. If she "owns" Jay by merging with him, then on some level, she believes she won't have to feel frustration, or become enraged when he doesn't instantly do what she wants him to do. When she feels "at one" with Jay, she "loves" him (it's not really love, of course); when she experiences him as separate and frustrating, she wants to kill him. To me, these are familiar borderline dynamics.

I feel for Jay. His comment is overflowing with all the unbearable emotion she inspires in him. Using those feelings as a guide to the patient's emotional experience (countertransference in the broad sense) is the only way to make the work bearable for the therapist, and the only way you can truly help someone this troubled. In my experience, it also helps you feel more compassionate toward their suffering. It is painful and often terrifying to feel murderous rage. If Jay, with his healthier mind and greater mental capacities, finds it so difficult, imagine how hard it must be for his patient to bear with her experience. By using your reactions as a guide to understanding your client (instead of feeling quietly guilty because you hate her), you'll truly empathize with her experience, and probably feel a lot more sympathy as well.

Will Power, Self Control and Self Discipline

Joseph Burgoin

The Medicalization of Mental Health

November 27, 2011April 10, 2013

An interesting study reported in Sunday's New York Times disputes a widely-accepted belief: that will power depends largely on chemical events in the body, especially in connection with glucose, and that it's more or less beyond our conscious control, a question of biology rather than self-discipline. This new study found that people who believe willpower actually is limited perform significantly worse on assigned tasks than people who believe it is not limited. In other words, will power and self-control are limited only if you believe they are. It's an interesting piece, and not very long -- you might want to read the whole thing.

As I was reading this article, it resonated with my familiar objections to the diagnostic labels contained in the DSM-IV, as well as to the theory holding that mental illness is the result of a chemical imbalance in the brain. The use and abuse of psychological diagnosis, to begin with, makes people believe they have a recognizable disorder, akin to a medical syndrome, and that it's beyond their control to do anything about it. If you are told and believe you suffer from borderline personality disorder, that it's a lifelong malady you can do little to modify, then you have no reason to struggle with it and try to gain insight. If you are told and believe you suffer from Asperger's Syndrome, you won't try to understand the particular nature of your defense mechanisms and to confront what lies beyond them. In my experience, providing a psychological diagnosis to people essentially deprives their suffering of its meaning, discourages them from self-exploration and encourages a sort of passivity. "I have Asperger's Syndrome -- what can I do?" I don't mean this as a criticism. When the medical establishment, the media and just about everything in our culture supports this view, why should anyone believe otherwise?

The chemical imbalance theory is even worse. Because people are told and believe that their symptoms of depression, their panic attacks or their bipolar disorder symptoms all result from chemical irregularities in their brain chemistry, they have no reason to dig in and do the hard work of self-exploration. It's a chemical imbalance; I was born that way and I need to take a pill to rectify it, like my doctor said. One of the beneficial side-effects of the medicalization of mental health is removing much of the stigma from mental illness, especially as celebrities such as Catherine Zeta-Jones have publicly acknowledged their struggles with bipolar disorder and other issues. But in the face of the relentless public relations push for psychiatric medication as the answer to all forms of mental illness, few people have the will power and self-control to struggle with their inner conflicts. They have been told that will power and self-control are irrelevant -- it's all about your biology -- and so they believe they can do nothing to help themselves get better.

There are some bright spots in the mental health profession. Cognitive Behavioral Therapy provides depressed clients with some useful techniques for coping with their negative self-talk and self-defeating behaviors -- in other words, it assumes that you can make a difference in your state of mind by exerting effort. Will power and self discipline are necessary parts of the work. Dialectical Behavioral Therapy appears to be effective in reducing suicidality, substance abuse and hospitalizations with borderline personality disorder, using a highly structured program to help clients develop a degree of self-control where impulsive behavior is concerned. Neither treatment modality explores the meaning of the client's symptoms, however, or helps them access their unconscious dynamics. Both reduce people to a recognizable syndrome that can be treated with a uniform approach, in the process accepting severe limitations on what is possible to achieve through psychotherapy.

Assumptions by the therapist as to what is possible for any given client will naturally have a profound impact on the treatment. If therapists believe they can do little to help a borderline client, they will communicate such a conviction to that client, who will then come to believe it as well. If a therapist believes that his or her client's depression is the result of a chemical imbalance, both therapist and client will come to share limited expectations for what their work together can accomplish. Everywhere I look within my profession, I see evidence of this acceptance of limitations, a kind of widespread learned helplessness in the face of mental illness, a rejection of the long hard work involved in psychodynamic psychotherapy. I'm not advocating a return to the era when we blamed people for their difficulties, when our culture viewed mental illness as a weakness, a lack of will power, the failure of self-discipline; but the pendulum has swung too far in the opposite direction, so that we no longer expect anyone to take responsibility for their struggles.

It's a medically-recognized syndrome, a chemical imbalance -- you can't help it. When you accept such a belief, you're like the subject in that study from the NYT article, who did significantly worse on assigned tasks when they believed their own will power and self control were limited.