What Happens if Adults with Borderline Behavior Start to Act Better?

People who have dealt with those who have been diagnosed with borderline personality disorder (BPD) often wonder why those folks persist in their often infuriating as well as self-destructive behavior when it seems so obvious that they are making themselves as well as everyone who cares about them completely miserable. 

When I first started to treat them, I know I did. These patients were not psychotic, nor were they stupid, so why did they persist in dysfunctional behaviors in the face of overwhelming evidence of their consequences. So I started asking the magic, Adlerian question: What would happen if you got better and stayed better?

As I described in that previous post, patients would often answer with the non-answers, "I'd just find some other way to screw things up" or "I cannot even imagine what that would be like." I would not accept those "answers" and pressed on.

When the answers finally started to emerge, I was totally amazed. One thing that might happen was described in my very last post. If a patient with BPD got better, their families would run for the hills. Exile them. Shun them. Abandon them. Anyone wonder why those with BPD have "abandonment issues?" Wonder no more.

But abandonment was far from the worst or the most likely outcome when patients acted beter.

I found that something family therapy pioneer Murray Bowen described was quite real - only that it was the just the first thing that would begin to happen before things got far far worse.

I found that the power of family members to invalidate anything a therapist tries to teach a patient should not be underestimated. As first pointed out by Dr. Bowen, they will literally gang up on a patient with messages that scream, roughly translated, "You're wrong! Change back!"  Previously uninvolved family members may come out of the woodwork, and previously sympathetic family members may suddenly turn on the patient and scream things like, "HOW CAN YOU TREAT YOUR MOTHER LIKE THAT!?!" 

I dubbed this phenomenon "clustering." Try to imagine what it would be like if everyone you know and loved started to come after you like that. If you don't think you would wilt, you are kidding yourself. And that would be true even if you came from a family that was relatively functional to begin with. Imagine having been invalidated like that for your whole life.

As I said earlier, however, that would only be the first thing that would happen if someone with BPD started to act better. The next thing that happens is that the parents start to act out in alarming and frightening ways. I'm talking about things like parents making suicide threats or actual attempts, increasing drug or alcohol abuse to alarming levels, worsening domestic violence, family members getting thrown out on the streets penniless, or any children left in the home starting to be abused, neglected or molested. You know, minor, inconsequential stuff.

Furthermore, as first pointed out by Lorna Smith Benjamin, in "borderline families" all these problems would be blamed on the patient, who would be subtly expected to somehow exert control over them.

Think you'd be able to turn your back on your family if all this happened to you? Very few can. Even if you could, it would only be because your family would, through their own behavior, engineer your dismissive attitude - so that you would continue to not only be their scapegoat, but so they could also label you as an uncaring son of a bitch as well. 

Americans like to think that they don't care what their families think of them. Horse manure!

In response to all of this, individuals with BPD usually start to actively undermine ("spoil") any efforts anyone might make to encourage them to continue with their "good" behavior - without telling anyone (including a therapist if they have one) about any of their family's behavior - and revert right back to the way they had always been. 

Addict Cleans Up, THEN is Shunned by Family

An interesting letter appeared in the advice column Dear Abby on 11/30/14:

DEAR ABBY: I am a former drama queen and addict now enjoying long-term sobriety, or trying to. What's missing in my life is my family. Since returning from rehab, I have been "going it alone" -- and I'm not sure why. My kids are the only grandchildren in the family. I work and go to school. I am pleasant. There have been some rough spots I have had to deal with, and when I have needed to, I have called my mom or sister, but they don't call me or visit. They have expressed no love for me through all of this. When I call, I feel like I'm intruding. Aren't I entitled to their love and caring? I feel abandoned. It's hard doing things on my own. My family lives close by, so distance isn't the issue. What am I missing? I want my kids and me to have a family, but when I try to reach out, I end up hurt by their lack of interest. Should I just get on with my life? I have been going through this for years. -- MOVING ON IN FLORIDA

DEAR MOVING ON: It's possible that the "drama" and turmoil you put your family through while in the throes of your addiction is the reason your mother and sister avoid you. They may be reluctant to take a chance again. Because they have made it plain that they aren't interested in a closer relationship with you and your children, you should absolutely get on with your life.

Abby's response was predictable. There were also several comments on the website from the public about the letter, and the commenters were more or less unanimous: the letter writer had probably "burned her bridges," the family probably got sick of giving her one chance after another and were burned out, etc. etc. 

After all, as another commenter opined, "Addicts hurt a lot of people and cause a lot of problems." The family's response is due to their need for "self preservation." The writer probably used to call them "only when she needed something."

These responses were in fact so predictable that the letter writer herself undoubtedly knew what she was going to get. She was setting herself up, and making herself look bad while all the while criticizing her poor family. The criticisms of the family did not go over well at all with Abby's readers. With her criticism the writer was in fact garnering sympathy for her family, rather than making them look bad. She had to know that would happen.

The burning bridges thing probably contains an element of truth. But more likely a half truth.

How did this former drama queen/addict turn out the way she did in the first place? Wasn't she in fact raised by the very family that is now shunning her? How many chances did they give her before giving up on her? When she was actively using did they get involved with her over and over again?  Enable her? Try to "rescue" her?

Notice that she identifies herself as a former drama queen. Where did that label come from? Is that what everyone in her family would call her over and over again until it became a role she would play in order to confirm their opinion of her? 

Was she in fact the only one in the family who had been expressing feelings that everyone else was stuffing? Was she the identified patient, as  family systems therapists call such folks, who gets all the blame for a problem shared by the entire family?

And most importantly, did they abandon her only after she cleaned up?

Inquiring minds want to know the answers to these questions before passing judgment.

This is a counter intuitive way to look at this. I understand that. But when the whole story comes out from patients in therapy, the answers to my questions are often yeses. Respected interpersonal theorist Lorna Smith Benjamin describes an analogous dynamic in which she lists two of the four characteristics she has observed in families that produce offspring with borderline personality disorder (BPD) - who often share many characteristics with both drama queens and addicts:

1. Parental love and concern is elicited only by misery, sickness and debilitation

2. Family chaos - The borderline individual is subtly blamed for problems or expected to exert control over them.

(The other two characteristics:  3. Episodes of traumatic abandonment are interspersed with periods of traumatic over-involvement, and 4. Efforts by the person with borderline disorder to establish autonomy are interpreted by the family as indicated disloyalty).

What may be happening in the case of the letter writer is that her family needs a black sheep, and she was elected to play the part. Because she finally stopped playing the part, they then shun her. In this situation, they would be in effect be punishing her for not being who they need her to be. However, they would also be helping her out in a strange way - by protecting her from their own pernicious presence. As Dr. Benjamin has also said, pathological behavior can be a gift of love.

This could be the real answer to the letter writer's question.

Hatefulness as a Gift of Love, Part I

Lorna Smith Benjamin, a well-respected researcher on the relationship between interpersonal psychology and personality disorders, has a saying that “Every Psychopathology is a Gift of love.”  In other words, she believes people develop maladaptive traits because, as she explains on her website:

“… problem patterns…are the result of one or more of three copy processes started in relation to an important early caregiver…Those are (1) Be like him/her (identification); (2) act as if he/she is still around and in charge (recapitulation); ( 3) treat yourself as he/she did (introjection). Sometimes the copying is in negative image (e.g., be the opposite)…The purpose of the copying is to seek reconciliation, approval, love of the internalized representation of that original object (person). People unwittingly act accordingly to the "rules" laid down by these early relationships and even when they believe they hate the original copy person. Every psychopathology is a gift of love.”

If you're looking for a therapist, find one who knows this stuff

[Some trivia for you: Dr. Benjamin started out as a student of Timothy Leary, way back when he was a respected academic interpersonal psychologist and before he went off the deep end as a hippie guru telling everyone to “turn on, tune in, and drop out.” Don't hold it against her].

Ellllllesssssdeee

That people may mistreat themselves because of loyalty to their kin group and a sense of altruism in that context seems to me to be due to a biological imperative (see my post on kin selection), albeit one that we can consciously choose to ignore.

This idea is understandably difficult for most people to wrap their heads around.  Self destructiveness as a sort of altruism?  (I explained some patterns associated with this phenomenon in my posts of 2/6/11 and 2/11/11).  The idea that the biological forces of kin selection may lead individuals to act in hateful and/or frustrating ways to other people for altruistic purposes within the kin group (although certainly not altruistic to outsiders) is even harder to swallow.  But the idea that individuals are willing to sacrifice their own children as a gift of love to the family system is the most difficult of all.

I think that the attraction of the Biblical story of Abraham nearly obeying a command from God to kill his own beloved son, not to mention the story of God being willing to sacrifice his only Son for the good of humanity, stems from the pervasiveness of this phenomenon within our species.  Certainly, the common willingness of parents to send their children off to war illustrates how powerful this human tendency is.  

The military in this country honors the mothers of fallen soldiers as “Gold Star Mothers.”  The government gives them a folded flag and a dead son or daughter, and usually they somehow consider it quite an honor.

That parents somehow still love their children even if they are acting out a hateful, nasty, and/or abusive family role is something my patients often have a great deal of trouble accepting, and understandably so.  In order to explain their parents strange hatefulness, which I also refer to in my post of July 6, 2010 as distancing behavior, they have usually come to the conclusion that their parents are heartless, evil, insane, or stupid. 

If I were in their shoes, I am absolutely certain I would have come to the exact same conclusion. Still, as they tell their stories to me in psychotherapy, I always hear of those rare times when their parents were not hateful but actually loving.  Sometimes such parents even will unexpectedly express their love directly, although often in a way which undermines their own credibility.  However, because of the total context of the relationship, these positive acts and statements are discounted.  Again, discounting such contradictory double messages is perfectly understandable.

Why would you believe the professions of love of anyone who generally tends to treat you like sh*t?  That would really be insane. Why should you believe them when there is so much evidence to the contrary?

And who knows if they are not doing those positive things for you on purpose to set you up once again for disappointment?  Letting you start to hope that they could finally be the parents you always wished you had, only to dash those hopes to pieces.  Like waiting for your estranged father to come and pick you up as he promised, when he has broken such promises time and time again.

Still, what does one make of a mother who, for the first time, admitted to her adult daughter that she had severely verbally abused the daughter when she was very young, but then told her not to bring it up again because she would deny ever having admitted it?  

And therapists tell patients whose parents do this crap that they have “trust issues” as if somehow that indicates that there is something wrong with them.  If such patients did not have trouble trusting people, then there would be something wrong with them.

I have been corresponding with two women whose mothers are described as having many traits that are suggestive of the diagnosis of borderline personality disorder.  While they both really want to believe that beneath all the horrible distancing behavior their mothers really did and do care about them, they of course find that the idea induces a lot of cognitive dissonance.  Again, I do not blame them one bit for thinking that I am just a little bit crazy for thinking so.

In part II of this post, I will describe some of the “maternal” behavior that one of them described to me, as well as translating some of her mother’s behavior and verbalizations into what I think is really being expressed covertly.

How to Disarm a Borderline, Part III: Overall Philosophy

Before reading this post, particularly if you are going to try this at home with a real adult family member with borderline personality disorder (BPD) (which is not recommended without the help of a therapist), please read my previous posts Part I (October 6) and Part II (October 29).

In this post I will discuss the general philosophy about approaching anyone who is trying to distance you (also see my post, Distancing: Early Warning [apologies to the rock group Rush] , from July 6), particularly if that person is very good at it like an individual with BPD is. In future posts, I will begin to run down specific countermeasures to the usual strategies in the BPD bag of tricks used to distance and/or invalidate you.

An observation held in common by many psychotherapy treatment paradigms for BPD is that respectful treatment of the patient by therapists in the face of the patient’s chaotic behavior patterns often seems to induce the patient to behave less chaotically with the therapist, although not with anyone else. It is particularly important for a therapist to respects differing values while not changing his or her own.

To disarm someone with BPD, you should look to find something that is wise, correct, or of value in the emotions, thinking, and behavior of the BPD person. You should never assume that the BPD’s problems stem primarily from crazy thinking, faulty interpretations, distortions of reality, or maladaptive assumptions. You should assume that individuals with BPD have unhappy lives and therefore, despite all evidence and appearances to the contrary, they really want down deep to act better.

Persons with BPD often have a high level of interpersonal skills, as evidenced by their ability to manipulate others. You should try to keep their considerable strengths in mind as you interact with them.

You should aim to validate the BPD’s reality and try to make sense of their behavior within their current interpersonal environment. See my post Validating Invalidation from Sept. 23 to get a better idea of the importance of being willing to validate someone when that someone is practically inviting you to invalidate him or her.

The troublesome behaviors of the BPD must be looked at not as a problem with the BPD but as imminently reasonable and understandable responses that derive from a problem for the BPD. You should not view the BPD as psychotic, malevolent, immature, or unintelligent but as someone who is struggling with a highly dysfunctional social network.

Remember, you yourself are very likely to be an important part of that dysfunctional social network, so please do not act like you think that you are superior to the BPD in any way. If you do, you are inviting the BPD to knock you off of the pedestal that you put yourself on, and you will not know what hit you.

Never treat the BPD as if he or she is fragile or incapable of being reasonable, particularly when tension occurs in your relationship. Ultimately, no subject should be thought of as too sensitive to discuss. While you should be sensitive to such issues such as incest or family violence, you should try to talk about them when they arise calmly and reasonably even in the face of the BPD’s anxiety or acting out (This ain’t easy, and it is where a therapist for you would be useful if not indispensable).

If you do not agree with what a BPD says, calmly say you disagree without making an issue of who is right and who is wrong. If you feel that something you have said or done is being misinterpreted or being taken out of context, kindly explain what you had meant to say or do without trying to convince the BPD that they got you wrong the first time. Therapist par excellence Lorna Smith Benjamin employs what she calls the Caribbean Solution, named for the behavior of a hotel clerk confronted by an irate guest. You remain calm and friendly but continually reiterate your own opinion about a disputed interaction.

Lorna Smith Benjamin

Be scrupulously honest. If you actually have done something wrong, do not deny or minimize it, but do not go into a big mea culpa either. (The best way to come clean if you were physically or sexually abusive to the BPD when he or she was a child is another matter and will be discussed in a future post). On the other hand, I have seen individuals admit to things they had not done in order to pacify someone with BPD. Not a smart move.

You will have to be comfortable with your own limitations concerning what you can or cannot do for the BPD. Be respectful of your own needs. Never rush in to “take care” of the BPD in an infantilizing manner even when the need to do so seems to hit you across the face.

You cannot be afraid of the BPD’s anger, neediness, or anxiety; and you must be completely unwilling to attack him or her in the face of provocation. Once again, this is where a therapist for you might be necessary.

In summary, be relentlessly respectful of BPD’s suffering, abilities, and values. Be humble without disrespecting yourself or your own well being. Be honest. Communicate an expectation that the BPD will be able to behave in a reasonable and cooperative manner, and play to the BPD’s strengths. And keep it up, or ye olde variable intermittent reinforcement schedule will rear its ugly head.

How to Disarm a Borderline, Part I

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If you are an adult in a relationship with another adult, either through blood or through a romantic liaison, who fits the description of a patient diagnosed with borderline personality disorder (BPD), then you already know that you have your hands full.  A New York Times blog post about BPD drew 470 rather contentious comments (http://well.blogs.nytimes.com/2009/06/16/understanding-borderline-personality-disorder/?apage=1#comments) from people who were dealing with BPD relatives and other people who themselves have the disorder.  Although I am in neither category (hopefully), I wrote a few posts myself. 

I wrote about some of the ideas that I describe below.  A couple of people who said they were dealing with BPD parents did not like what I wrote, but showed that they had adopted some of the very behavior they were complaining about in their parents, as evidenced by their responses to me (more on why this might happen shortly).  I was being nice, so I didn't point that out to them.

Some people say that the only way that you will surely survive a relationship with someone with BPD is by cutting all contact with the "toxic" individual.  Some therapists even say this.

If you are in a romantic relationship with a person with BPD, that might indeed be the best course.  Has the relationship already been going on for quite a while?  You won't like hearing this, but this means you: you need to ask yourself why you are attracted to such a difficult person in the first place.  Please don't give me the usual crap like, "I didn't know what (he or she) was like that at first, but now I'm involved and I can't get out.  (He or she) was so charming at the beginning of the relationship!" 

Puh -leeeze!  You are like the wife who insists her husband is not having an affair while she looks for the stain remover to get the lipstick off her husband's shirt collar. Sorry, but most people run at the first sign of BPD behavior.  It is not subtle, and one does not often have to wait very long before one first sees it.

Well, you might object, the person threatens suicide if I tell them I'm going to leave them!  So, let me get this straight.  You're planning to sacrifice your whole life because someone might stab themselves in the heart in front of you and then quickly hand the knife to you before they die so your fingerprints are all over it?  If you feel so responsible for other people that you respond to this kind of threat by caving in to it, please, get some therapy.

When it comes to parents with BPD, however, the strategy of divorcing one's family, while better than remaining in a toxic relationship with them, creates other problems.  First of all, it's kind of lonely to have no family.  You will be faced with a cavernous hole in your life. 

Second, you came from them.  If they are monsters, what does that make you?  You undoubtedly share at least some of their toxic behaviors whether you like to admit to it or not, because one can not grow up in a toxic household without adapting to it in ways that are both problematic themselves and very hard to stop later on in other social contexts. 

Especially with your own children.  Attachment studies clearly show that the best predictor of one's relationship with one's children is......one's relationship with one's parents or other primary caretakers.  Some people from abusive households wisely decide not to have children for fear that they, too, might become abusive.  But is that what you really want to do?

Besides, you cannot completely divorce yourself from your family, because you carry them around with you in your head. Literally. We in the biz call these mental representations schemas.

Your choices are not just limited to these two:
1) To either to continue to be mistreated, or
2) to cut off all contact with your family.

A third choice is to change the nature of your relationship with your parents so that you are not being mistreated but are still in contact with them.  Impossible, you say?  I disagree.  While you do not have the power to "fix" your parents, you do have the power to fix your relationship with them.  If you change your approach to them in a consistent manner, that will force them to change their approach to you. 

However, there is a big problem that you will face in doing this: since you have been in a relationship with them your whole life, they have developed a whole repertoire of behaviors, include recruiting other family members, to give you the powerful message, "You're wrong.  Go back to responding the way you used to."  If one strategy does not work, no worry.  There are plenty more where that came from. Scary to be sure, but not insurmountable if  you can enlist a therapist who knows something about the family dynamics in people with BPD.

Therapists like myself who work primarily with patients with BPD, regardless of their "school" of psychotherapy or their theoretical ideas about the causes and cures for the condition, all have independently developed some ways of getting BPD patients to be more cooperative with them.  (That is, cooperative just with the the therapist. Unfortunately, not with anyone else). We seem to have all come up with these little tricks of the trade independently, yet they are all very similar, as I described in a paper called, "Techniques for Reducing Therapy-Interfering Behavior in Patients with Borderline Personality Disorders: Similarities in Four Diverse Treatment Paradigms" (Journal of Psychotherapy Practice and Research 1997; 6:25-35). 

Marsha Linehan of DBT fame, Otto Kernberg of psychoanalysis fame, Lorna Smith Benjamin of interpersonal therapy fame, and myself (with my not-at-all famous treatment paradigm called Unified Therapy) all do pretty much the same things at the beginning of treatment.  (We then start to diverge considerably).  These strategies are survival skills for us.  Therapists used to come up to me all the time and ask me how I could stand to work with several patients with BPD at the same time, but it really is not a big problem if you know the "tricks."  I had to devise them a long time ago because I built up a private practice by taking referrals of these patients whom no one else wanted to treat.

As I mentioned, it is much harder for someone who is already enmeshed with a relative with BPD than it is for a therapist who has just met a patient with BPD.  One reason is the aforementioned repertoire of behaviors they have designed over many year specifically with you (the enmeshee) in mind.  They know all of your weaknesses and exactly how to take advantage of them.   Second, as a therapist, I do not have to deal directly with a bunch of interfering relatives like the enmeshee does.

The third reason has to do with something behaviorists call a variable intermittent reinforcement schedule.  This schedule is why slot machines in casinos are so successful.  You never know when the damn thing is going to pay off, and it pays off just often enough, so you keep pulling the lever until you lose your shirt.

I should mention that, as John Rosemond is fond of saying, people are not lab rats that blindly respond to rewards and punishments. However, if a person has a goal, and their behavior helps them to reach it, reinforcement schedules kick into play. It is not the person being "rewarded," but the behavior. It is not rewarding to have people hate you.

The goals of the worst of the behavior exhibited by people with BPD, for reasons I will not discuss here, is to cause in their targets one of three reactions.  The first two of these invariably lead to the third.  The three reactions they shoot for in their targets are a sense of anxious helplessness, a sense of anxious guilt, and overt hostility. 

The great big secret, however, is that folks with BPD are often highly ambivalent about getting these reactions.  They will try like hell to get them - and believe me, they are real professionals at it - but they secretly wish to fail. (How do I know this?  Experience.  But I can not prove it - because there is literally no way to set up an "empirical" experiment that would fill the bill - so readers can call this highly speculative if they wish).

If the persons with BPD succeeds at getting one of three reactions, they will continue to draw for it.  Pull out all the stops in order to get them, in fact.  If they fail at getting the reactions, however, they will suddenly become more conciliatory.  However, because of the variable reinforcement schedule, if they only occasionally succeed in getting one of the reactions with a person with whom they have already been interacting for a long time, they will keep trying much longer. 

Therefore, if you already have a history with them, and they have a track record of making you react in any or all of the three ways, their behavior will get much worse before it gets better.  If you can not keep your cool and occasionally react the wrong way, it becomes even harder to get the BPD's to change their behavior toward you than if you react the wrong way all the time!

In later posts, I will share with readers the therapist's tricks for avoiding "rewarding" the bad behavior of persons with BPD, but most people who are already enmeshed with a BPD family member will find it nearly impossible to employ them successfully without the help of a therapist who understands the family dynamics of those who suffer with the BPD traits, and who can prepare them for your "adversary's" formidable defenses.  I will start in an upcoming post with what not to do.

Childhood Sexual Abuse Taken out of Context

Albert Einstein was said to have had a sign over his office at Princeton that said, “Everything that counts cannot be counted and everything that can be counted does not count.” When it comes to studying the long-term psychiatric effects of child sexual abuse (CSA), it is wise to keep this in mind.

CSA, particularly within an individual’s family of origin, has been implicated as a risk factor for a wide variety of adult psychiatric diagnoses and behavioral problems, including borderline personality disorder (BPD), dissociative identity disorder, depressive disorders, anxiety disorders, alcoholism, eating disorders, somatization disorder, sexual dysfunction, and suicide attempts.

The nature and effects of interpersonal relationship patterns, such as those that transpire in the families of CSA victims, are so complex and unique that it is almost impossible to quantify them for an “empirical” study or “proof” of the causation of a specific psychiatric problem.

Biological and genetic factors almost certainly play a significant factor in predisposing a victim to one or another psychiatric problem. However, that is not the complete answer to two questions: why do certain individuals develop one disorder while seemingly similar individuals develop a different one, and why do some individuals who appear to have suffered severe abuse develop no psychiatric problems at all, while others who seem to have had relatively minor abuse develop several disorders?

Studies that examine psychological and social variables in CSA tend to focus on factors such as who the perpetrator was, what type of abuse was suffered (penetration vs. fondling, for example), the severity and frequency of the abuse, and whether the social welfare or criminal justice system became involved. Rarely, the response of non-abusive relatives to CSA victims, usually the mother, is examined. Most results of such studies have been disappointing regarding finding links between specific psychiatric disorders and these variables.

Often the backgrounds of CSA victims are also characterized by several other types of adverse childhood experiences or generally chaotic family relationships. Not only is that fact often ignored by those who study CSA, but these investigators usually ignore the entire environmental context in which CSA takes place.

Clearly, most of the victim’s interactions with perpetrators and bystanders alike occur at times when abuse is not occurring, and these other parts of such relationships may also have profound effects on the victim’s later relationships and self image. Again, due to their staggering complexity and intermittent nature, they are difficult to study using statistical techniques.

Contextual factors include the entire history of the relationship between the victim and the perpetrator: what is said during, before, and after the abuse; what the relationship between victim and perpetrators is like when the abuse is not taking place; what other people in the family are doing at the time of the abuse and at other times; how each family member relates to the victim; who if anybody knows what is going on and whether or not they intervene; and a whole host of other characteristics of the interpersonal environment of the victim.

The context of the abuse is made even more complex due to the effect of chaos, the theory of which predicts that even small differences in environmental conditions can have large future effects. The so called butterfly effect would occur when small differences in the interpersonal environment of a child lead to a cascade of events which will be somewhat unique to each individual and greatly impact the exact nature of any psychiatric responses to the CSA.

Even during abuse, a victim’s interactions with a perpetrator is not limited to the sex act alone. Words may be spoken; other activities may occur right before, right after, and even simultaneously. For example, personality theorist Lorna Smith Benjamin discussed how the nature of verbal interactions with the perpetrator at the time of the abuse may influence the production of later BPD symptoms. The tendency of some BPD patients to have unstable and intense interpersonal relationships characterized by alternating extremes of idealization and devaluation, for example, might result from a case in which a father “directly instructed her [the incest victim] in how to shift from idealization to devaluation.

“Early in a night visit, the father may say, ‘You are the light of my life; I live for these times together…’ Then, after the incestual attack, he might say, “It’s your fault. You bitch. You whore. You’re filthy. Go take a shower’” (Interpersonal Diagnosis and Treatment of Personality Disorders, 1st edition, p.119).

In helping to create another BPD symptom, at times (other than those times in which CSA takes place), the BPD patient’s autonomy may be attacked by either or both parents, with an accusation of disloyalty if the victim tries to assert her or his independence. This may lead to the type of self-sabotage often seen in BPD patients.

Other and different types of dysfunctional interactions may lead to the development of still other BPD symptoms, leading not only to the unique clinical picture of each individual CSA victim, but to the different combinations of DSM criteria seen in different patients with BPD.

In getting a full description of patients of the entire family context in which CSA takes place, and also tracing back the family context in which the parents grew up (genograms), it becomes possible to make an educated guess about exactly why a given patient developed particular coping skills. The particulars will be different with every patient and every family, but certain themes do come up again and again in patients who develop certain disorders like BPD.