In Freud’s time, the patients coming to him with problems were frequently hysterics, so his theories tended towards solving the mental phenomena he encountered on his couch. Thus repression, the Oedipus complex, infantile sexuality etc. were all attempts to figure out the meanings behind the baffling symptoms of paralysis, mutism, tics and phobias his patients presented with. Freud’s ideas were a crucial first step in unraveling the complexities of narcissism and ‘borderline’ states of mind because he posited that psychological problems stemmed from an internal conflict between different aspects of the self and this has remained central to psychodynamic thinking ever since.
However, Freud thought if a patient couldn’t develop a transference, then they were not treatable. This meant he never attempted to analyze psychotic patients. Then along comes Melanie Klein in the late 1940s and 50s and as part of her drive to establish her claim to being Freud’s true daughter in terms of taking psychoanalysis forward, her followers (analysts such as Hanna Segal, Herbert Rosenfeld and Wilfred Bion) started taking psychotic patients into analysis using the strict application of the Freudian method – sessions five times a week, the patient lying on the couch – in addition to Klein’s new theories of the paranoid schizoid and depressive positions with particular reference to the defence mechanisms she explored of splitting and projection. These analysts and others like them in America, such as Harold Searles, Otto Kernberg and Thomas Ogden, discovered that Klein’s concept of projective identification, whereby patients project into the analyst the emotional states they cannot name or contain, was very helpful when it came to understanding counter-transference in psychotic and personality disordered patients.
One hundred years on after Freud published The Interpretation of Dreams in 1900, perhaps because sexually repressive attitudes in society have waned, analysts have increasingly found themselves trying to help patients they broadly call ‘narcissistic’ rather than the hysterics who lay on Freud’s Viennese couch. Now, obviously, this is a very broad term and its colloquial use designed to describe someone who looks in the mirror a lot does not match the diagnostic categories of patients Herbert Rosenfeld called ‘thick-skinned’ and ‘thin-skinned’ narcissists, nor the psychiatric diagnostic category of narcissistic personality disorder. But Klein’s ideas have proved useful in thinking about narcissism, especially as they have been developed by Wilfred Bion, because they offer new ways to articulate how a Self develops; especially the critical business of understanding where the Self ends and the Other begins. Due to early developmental difficulties, psychoanalysts argue that patients with poorly established boundaries of the Self are prone to acting in ways which they term ‘narcissistic’. Key analysts involved in exploring this psychological terrain in Britain have included Ron Britton, John Steiner, Mary Target and Peter Fonagy and I will go on to elaborate some of their helpful ideas in this presentation.
But First Some Definitions…
Narcissism: google it and you get three definitions
- Noun – excessive interest in or admiration of oneself and one’s physical appearance.
- Psychology – extreme selfishness, with a grandiose view of one’s own talents and a craving for admiration, as characterizing a personality type.
- Psychoanalysis – self-centredness arising from failure to distinguish the self from external objects, either in very young babies or as a feature of mental disorder.
Borderline Personality Disorder
BPD is a psychiatric diagnosis used to describe people who suffer at least 5 of the following: (definitions taken from Mind’s website)
- You feel very worried about people abandoning you, and would do anything to stop that happening.
- You have very intense emotions that last from a few hours to a few days and can change quickly
- You don’t have a strong sense of who you are, and it can change depending on who you’re with.
- You find it very hard to make and keep stable relationships.
- You act impulsively and do things that could harm you (such as binge eating, using drugs or driving dangerously).
- You have suicidal thoughts or self-harming behaviour.
- You feel empty and lonely a lot of the time.
- You get very angry, and struggle to control your anger.
- When very stressed, sometimes you might: feel paranoid, have psychotic experiences or feel numb and ‘check out’ (dissociate).
Called ‘borderline’ because when it was first developed as a diagnostic category, it was felt people operated on the border between psychosis and neurosis, BPD is also referred to as EUPD or Emotionally Unstable Personality Disorder.
Freud: On Narcissism
In On Narcissism, Freud’s paper from 1914, he argues that when a person’s libido does not flow out to the external world as it should, but is directed back into the ego, it gives rise to an attitude he calls narcissism. Now why might this be? In normal development, if all goes well a baby does develop love and concern for its mother in the external world (I am using the word ‘mother’ here but I mean the baby’s primary caregiver, whoever that is in reality and referring to the baby as ‘she’ but obviously it could equally well be ‘he’). By ‘if all goes well’, I mean the baby experiences a mother who can contingently and reliably show the baby that she resonates with her baby’s emotional reality. When this happens, it is safe for the baby to acknowledge that her mother is separate because the mother is a ‘good enough’ parent, in Winnicott’s sense. To put it another way, if you can predictably and reliably believe that mother comes if you need her, that she does understand what you are feeling, then the fact that she isn’t actually you, or you are not her, is not a tragedy.
However, a baby cannot afford to accept the mother is actually separate when they meet with the psychic pain of abandonment too often. What my clinical work has shown me is that it needn’t be physical abandonment by the mother, in fact a mother can do a good enough job of seeing to the physical needs of her baby, but can utterly fail to attend to their emotional needs – to notice ‘where they are at’, i.e. how they are feeling and how they, in particular, are feeling it. If this happens habitually, the baby experiences colossal amounts of psychic pain and the consequence is that they cannot afford to really know in psychic reality that the people on whom they depend are actually separate from them.
To protect themself, therefore, from any more of this agony, the developing baby hits upon a solution: to withdraw their libido (which I am defining as loving instincts) back into their psyche. Freud gives the analogy of an amoeba drawing back into itself its pseudopodia it originally sent out in search of sustenance. This is a mental state he characterizes by quoting Wilhelm Busch’s observation of the poet suffering toothache: ‘Concentrated is his soul in his molar’s narrow hole!’
Freud goes on to say in this paper, ‘A strong egoism is a protection against falling ill, but in the last resort we must begin to love in order not to fall ill, and we are bound to fall ill if, in consequence of frustration, we are unable to love.’ He continues, ‘We must recognize that self-regard has a specially intimate dependence on narcissistic libido […….] a person who loves has, so to speak, forfeited a part of his narcissism, and it can only be replaced by his being loved’. This ‘intimate dependence’ on another is what the clinically narcissistic patient or BPD sufferer has, as a consequence of early aberrant development, unconsciously decided never to do. This is because at far too early an age their trust in the Other was undermined by a lack of empathic handling by their primary caregiver. This has profound consequences both for their personality and of course for the kind of relationships they can make and maintain. One such consequence is that the baby may make the assumption that the reason they are contingently responded to by the mother is not because she is deficient, addicted or depressed, but because they, the baby, is loathsome and unlovable. Once this gets established it becomes very difficult for the developing child or adult to believe they are lovable and so they will often break off relationships prematurely to avoid being left by the Other down the line – which to them is an inevitability due to their loathsomeness.
Now, if you have already come across my Brain Lecture online, you will remember the part where I talk about how being with people we love and trust is addictive, in that it promotes the release of endogenous opoids (ie. opoids secreted by the brain) which make us feel safe, content, OK. You may recall me saying there that when we feel GRIEF it is because we have lost our secure base, ie. our mum if we are a toddler lost in the supermarket, or our partner who dies on us after 30 years of marriage. GRIEF feels identical to a heroin addict suffering withdrawal symptoms – we cry, we can’t sleep, we feel ‘dreadful’ and this is because the Other who guaranteed the endogenous opoid release in our brain – our attachment object – has been lost. I said in that lecture that we should not be surprised to find that people who become addicted to drugs or alcohol have often had very difficult childhoods – which is a shorthand for saying they have trouble trusting other people to really ‘see’ them, to expect that the Other will empathise with what they are feeling and not abandon them as soon as the going gets tough. If we were going to think about this in an attachment model framework, we could say that without a secure base internalized inside them, such individuals are highly likely to struggle to make stable and strong intimate relationships in adulthood.
Given this shaky foundation, it isn’t hard to see why drugs and alcohol can so readily take the place of reliable loved ones as ways to manage difficult feelings and thoughts. It should not therefore surprise us that people diagnosed with BPD often present co-morbidly with substance misuse issues since in substance abuse they can find ways of coping with their perennial feelings of loneliness, anger and fear of abandonment by reliance on drugs, drink or even food. It stands to reason that if you have unconsciously decided not to engage in that ‘intimate dependence’ that Freud talked about, you will suffer terrible feelings of loneliness or abandonment. Either you will be unable to make and maintain close relationships, in which case you will feel horribly lonely and that leads to mental and physical ill-health down the line; or you will be able to make relationships, but you will be so anxious about losing them that you may be destructively jealous – perceiving betrayal at every turn and therefore likely to have stormy, tempestuous relationships – and/or behave in a controlling manner. You will be hyper-vigilant to abandonment by your partner/friend resulting in behavior likely to generate the dreaded abandonment, ie. being really clingy and over-demanding, and/or cold and rejecting by turn. What underlies all such ways of carrying on relationships is the unconscious expectation, shaped by the emotional world inhabited in childhood, that expects the other person notto be sensitive to how they feel and therefore the base assumption is that they are not to be trusted.
The Kleinian British analyst, Ron Britton, devotes Part III of his seminal 2003 book, Sex, Death and the Superego to understanding Narcissism in somewhat different terminology to the attachment/neuroscientific model I have elaborated above. He opens his Narcissism section by arguing that in his view, a narcissistic state is not simply withdrawal from external objects to an internal object, but that it is,
‘A particular kind of internal object relationships in which the separate existence and particular qualities of the internal object are denied and an internal narcissistic relationship is created by projective identification. This sounds like a description of an ideal relationship between ego and superego: twin internal souls, united by a narcissistic love that might make redundant the ego’s need for that love from the superego that Freud thought a necessary condition for loving. Is a narcissistic state an evasion of the superego? Are narcissistic object relations an alternative to seeking love from the superego? If this were so, might it be prompted by fear of a hostile superego or by envy of a powerful, unimpeachable superego?’
He goes on to argue that this is exactly what he thinks is going on in people afflicted by enduring narcissistic mental states. He also takes up the distinction Herbert Rosenfeld made between those suffering predominantly from libidinal narcissism and those suffering from destructive narcissism. In libidinal narcissism, the formation of a narcissistic object relationship is motivated by the wish to preserve the capacity for love by making the love-object seem like the self (phantasies of twinship with others often predominates in such cases). But in destructive narcissism, the aim is to annihilate the object as the representative of otherness. In both types of narcissism, however, the internal object relations aim is the same: the production, by projective identification, of a narcissistic object relationship with an ego-ideal in order to evade a relationship with a destructive, parental superego.
Ron Britton’s attempts to understand narcissistic states in terms of Kleinian object relations theory is a perspective also shared by British psychoanalyst, John Steiner, whose work on pathological organisations has proved influential. In his 1993 book, Psychic Retreats: Pathological Organisations in Psychotic, Neurotic and Borderline Patients, Steiner argues these internal constellations result in patients living in ‘psychic retreats’ where specific kinds of mental pain are evaded by subordinating oneself to pathological organisations. In this way, persecutory and depressive anxieties are avoided, resulting in a severe impoverishment of individuals’ development, and stasis both in their personal lives and often in their analysis. Steiner shows that these forms of defensive structures are not restricted to very disturbed patients, but are aspects of all of us, to varying degrees.
I will use the next section to illustrate how I think early experiences work to shape the personality of someone who might go on to develop BPD and suffer from clinical narcissism, then I will turn to Mary Target and Peter Fonagy’s work on Epistemic Trust to show how all these situations have the same enduring and pervasive emotional difficulties at their destination.
Let us think of an example here to bring this idea to life. Imagine an 8-month old baby lying in her cot. She has woken up from her sleep but isn’t crying, instead her eyes are following the shape of her mobile turning in the air above her head. The father stands in the doorway taking the time to watch his child but not drawing attention to his presence. Eventually the baby turns her head and sees her father in the doorway. He sees her wriggle her arms and feet, she smiles at him and makes a coo-ing noise which he knows are her ways of signaling a greeting. So the father goes over and moves the mobile shapes for the baby saying, ‘Were you watching the shapes? Aren’t they pretty? This one is a cow, it goes ‘moo’.’ The baby kicks her legs and waves her arms to show her delight at the exchange and for a few moments they watch the shapes together. Then the father leans down, smiling at her and kisses her forehead before saying, ‘Are you hungry? Shall we go and get you some lunch?’ The baby puts her arms up to signal she wants to be picked up. He picks her up and takes her out of the room.
This tiny fragment of a baby’s experience is replete with moments of contingent mirroring. This infant is having an experience we can call ‘looking at her mobile’. She is then joined by the father in sharing this object of interest at a pace which suits her – he waits until she sees him in the doorway. When he approaches, he then further elaborates his infant’s experience in three different dimensions; first: physically, because he moves the mobile; second: emotionally, because he smiles at the infant to show he is also enamoured by the object which has caught the infant’s attention; and thirdly: aurally, because he describes the object as a cow and says what noise it makes.
This quotidian example of relating to a baby about an object in the world is no doubt repeated literally hundreds of times a day by a good-enough parent and in that sense it might not sound like a big deal. But now imagine if you can the following, different scenario:
An 8-month old baby is lying in her cot looking at their mobile. The mother comes in, sees the baby is awake, walks over to the baby and picks her up. She plants a kiss on her head and carries her out of the room downstairs to have lunch. She doesn’t say anything except maybe a ‘hello’ and doesn’t seem to notice what the baby was up to before she arrived. Crucially she does not treat the baby as someone with a mind of their own, upon which the world is acting in different ways to her own mind.
There is nothing cruel in this behavior, nothing in fact to even suggest any aberrant parenting. But repeated hundreds of times a day, such an infant would not be having their mind treated as a place where anything is going on; would not have their own experiences of the world noticed, attended to or elaborated in anything like the richness of the infant in the first example. Even if they are fed, clothed, bathed and changed with devotion – if their physical needs are perfectly well met – without the joining up work done by the parent’s mind to link up with the mind of their infant, the infant may seriously struggle to develop their own psychic reality at all. Much later on, an adult might call this, ‘I don’t know who I am, what I want, what I feel about anything. I feel dead’.
I think this sort of pervasive and enduring type of relating is a pernicious and often ‘invisible’ form of emotional neglect and is one route into people suffering BPD and narcissistic states. Having not had their own minds ‘met’ and elaborated by their early caregiver, they cannot meet other minds in turn. They do not feel they actually have a self which has any agency in the world at all, so they live apeing what others do and say, mimicking perfectly the behavior of ‘normal people’ but never feeling from their own insides who they are or what they are like. Such patients may be brilliant at knowing what other people are feeling or what they should say to make others feel at home, but having learnt from very early on that their own powerful emotional states are not ‘got’ by their caregiver, they struggle to know what they themselves feel at all and find security not by being curious about other minds, but instead by merging or fusing with the Other. When that Other leaves, they cannot process the loss in any meaningful way. I think for such patients, anger is a particularly difficult emotion to know about since it threatens their status quo which is to stay merged. Since the object is never acknowledged at an unconscious level to be separate from them, anger cannot be felt as an emotion coming out of them and towards the object; it is instead caught by their unconscious and turned back on themselves to produce pervasive and enduring states of suicidality and despair – just as Freud described in Mourning and Melancholia (1915) when he argued that anger towards an external object who has died is gobbled up and then turned against the self to torment it forever. The Other is therefore neither properly mourned nor ever given up producing pathological mourning – ie. melancholia.
Then there is another, perhaps more common, route into developing the symptoms of BPD and narcissistic states and this involves abusive caregiving patterns. Imagine that baby again watching the mobile in their cot. This time when the mother comes in, she has a sour expression on her face. She doesn’t notice what her baby is looking at, but fairly roughly and without any verbalization, she picks up the baby without making eye contact with them and goes out of the room. This baby will feel the mother’s unconscious hostility coming off her in waves – think here of Ron Britton’s earlier description of the development of narcissistic object relations as deriving from a wish to evade a relationship with a destructive, parental superego. This kind of maternal care – or lack of it – repeated ad infinitum would surely create an infant who grows up believing they are the source of mother’s unhappiness and distress. Such a mother would probably also enact her hate by actively hurting that infant, or enlisting another (perhaps a partner) to do the actual physical ‘punishment’. A child who grows up being hit will always believe they deserved it, since the original omnipotence of the infantile mind never thinks, ‘Mum was mean to me because she is upset about Daddy having an affair/having no money/her mother dying. The baby will always conclude they are badly treated because they are bad. This infant will grow up to be someone highly likely to have behavioral problems at home, potentially at school and out in the wider world. Being punished for their ‘badness’ will be a relief in fact and it seems likely that many of the 30,000 personality disordered prisoners in our jails out of a population of 86,000 (data from HM Prison and Probation, 2017) were babies who had this kind of experience. It is a relief to make their inside which they unconsciously know to be bad match their outside – be that jail, detention or homelessness.
I would like to turn now to Peter Fonagy and Mary Target’s work on BPD. In publications emanating from the UCL department of Clinical, Educational and Health Psychology over the last two decades, they have argued that the journey from attachment to communication involves mentalising which is an imaginative mental activity and one which is, at root, an experience of feeling contingently responded to. Being mentalised (as the father does for the infant by joining with her in having an experience of her mobile over the cot) is the QUINTESSENTIAL OSTENSIVE CUE that tells us it is safe to learn things, and this in turn enables a rapid and efficient transfer of knowledge.
Homo sapiens is the only species to be able to imagine an alternative reality from the one we are in and we use this to enable social collaboration. Our sense of self and our capacity for self-regulation are all acquired through interpersonal interaction. Fonagy argues Descartes is wrong: it is not ‘I think therefore I am’, but ‘Someone else thinks about me and therefore I am’.
The job of socialization is: ‘How can I ensure my child knows how to trust and to make relationships healthily with others?’ When a child is exposed to multiple caregivers, it fosters trust in the availability of an entire network rather than to a single caregiver in a dyadic relationship per se (eg. in the Developing World).
However it happens – in a nuclear family set-up or in a larger social grouping – Fonagy has shifted from thinking that what we need is the instinct to attach to believing that what we need fostered is the instinct to communicate. This is because safely trusting what someone says is the key to enabling us to LEARN. In the late Pleistocene, we developed a new form of evolution – CULTURAL evolution – which sees the development of tools of cultural transmission to enable the survival of the best way of doing things…
Thus you could argue human beings are learning and teaching machines; the challenge of successful development into a child-bearing adult is to figure out whom to learn from and in turn, what to teach our offspring. We have to be vigilant about the trustworthiness of our objects and this crucial facility of the human mind Fonagy and his co-workers have defined as EPISTEMIC TRUST!
How do we figure out who to trust? Those people who treat us contingently will be people we epistemically trust. Mimicry also generates epistemic trust, eg. we are more likely to trust someone who smiles back at us. Generally-speaking, any communication marked by a recognition of the listener of us, the speaker, as an intentional agent, will increase our epistemic trust and will also increase the likelihood of communication with that listener being coded by our brain as relevant, generalizable and then retained in the memory.
In a huge meta-analysis of teaching, a teacher is most effective when they can demonstrate they can see the situation through the eyes of the pupil…
Wampold et al. 2016 studied the variance in psychotherapy outcomes and showed the therapist was the greatest source of variance and the most effective ones were the most inexperienced therapists who spent more of their time seeing the patient as a one-off rather than ‘oh you are one of those’ and putting them in a box which more experienced therapists might be tempted to do!
Abusive and neglectful care-giving environments (as in the examples of the baby above) are ones where the child is not mentalised and the ostensive cues are not there or are undermined; hyper-vigilance develops and the child cannot use the parent’s mind as a source of knowledge; especially if the adult is expressing hatred and sadism because then it is safer not to think about the adult’s mind at all.
A mind exposed to neglect or abuse becomes partially closed to processing new information and fresh information cannot be internalized as personally relevant or meaningful. Such minds are stuck in isolation with diminished capacities to learn and therefore have highly reduced responsiveness to psychotherapeutic intervention. Such patients HEAR YOU BUT THEY ARE NOT LISTENING so they cannot change. Their absence of epistemic trust thus produces individuals who struggle to learn effectively about either themselves or the world.
So in my view, BPD is not a disorder of personality so much as someone who is inaccessible to cultural communication relevant to themselves from the social context. Partner, therapist, teacher cannot reach them. They feel perennially lonely, fear abandonment and cannot cope at all if they are abandoned, since their worst fears have been realized, thus confirming they should never get close to anyone and the cycle begins again with no chance for a different outcome. Darwin argues, ‘It is not the strongest or the most intelligent who will survive, but those most able to change’.
The most common BPD (borderline personality disorder) trait is acute sensitivity to social rejection and an acute sense of loneliness. So this also means that BPD patients feel significantly more often ostracized – THE WORLD IS SEEN AS REJECTING EVEN WHEN IT IS NOT BECAUSE THEY LACK EPISTEMIC TRUST.
When you put healthy controls in the scanner and show them a computer game in which they have to assess whether or not they are being left out of a game, the left insula (which is a key part of the cerebral cortex responsible for linking up physiological sense data with social emotions) responds appropriately, but in BPD patients it does not!
So, as a therapist what are you to do? It seems that if you spend your time seeing the world from the patient’s point of view – and contingently respond to their loneliness and the mental pain they are in – they will feel you can be epistemically trusted – EVENTUALLY! Patients like this don’t tell you when good things happen, because they do not find it easy to deal with things going well, since feeling wanted and responded to contingently and reliably, simply creates a prediction error their brains don’t know how to deal with. This is why these cases are often called ‘complex’ and the NHS tends to refer them to psychoanalytic practitioners! At root, their problems date back to their earliest years and therefore take the longest times of treatment to fix.
The process of acquiring the sense you are an agent in your own world is the key mechanism of change. It may start in the therapeutic room but needs to be extended and practiced in their social world too.
Perhaps it would be helpful to end this brief introduction to narcissistic and borderline states with a conversation I had with my patient, Ms. B., who suffers many of the symptoms of BPD and has been in therapy with me for six years now. She has started her own painting and decorating business and some weeks back, she told me the following:
‘I had a thought this week about how I could give up smoking and in one month I would have saved £90 and I could buy a combi-drill. The next thing I am aware of is that I am talking to Jess [she doesn’t mean she is actually talking to Jess but that she is having the conversation with her old university friend in her mind] and I am telling her about how I have given up smoking to do this. She says to me, ‘Oh who else have you told about this?’ No sooner has she said this [in the imagined conversation] but I immediately know there is no-one particular to tell because I am alone and will never find anyone to care about me in that way. This thought is accompanied by a terrible grief-y feeling and the tears are there, just behind my eyes. This is the feeling that makes me ill [and indeed has left her spending days in floods of tears and feeling suicidal]. Just look at that – I went from thinking something healthy and growth-promoting – the thought about giving up smoking and being able to afford a combi-drill which I want and need – to being ill in 10 nanoseconds and that is happening hundreds of times a day. Is it any wonder I am not doing so well?’
This tiny excerpt from our conversation reveals something very useful about this kind of mental health problem – which is that the problem derives from a disorder of thinking and beliefs. And solving the problem involves the slow and patient work of combing over the aberrant and unhelpful beliefs that B. has about herself and how she perceives and understands, or more often misunderstands, how her attachments to the significant people in her life are functioning. It is slow work because it takes a long time for a patient’s unconscious beliefs to become capable of being observed by the patient (a process which gets going with the insights offered by the therapist) and once observed, to undergo the gradual change from an outlook characterized by a lack of epistemic trust to one powered by it. The scale of the challenge is well described for me by a story told by author, David Foster Wallace, in his Commencement Speech to Kenyon College in 2005. He recounts how two young fish are swimming along. An older fish passes them by and says, ‘How’s the water boys?’ They nod politely and swim on. After a period, one of the younger fish turns to the other and says, ‘What’s water?’