Emerging from the Shadows

MY FIRST APPOINTMENT WITH MY NEW CLIENT, A REFERRAL from a college counseling center, was still several weeks away when I got a message on my answering machine asking me to call her in Minnesota, where she was visiting family. She was in anguish about leaving behind her therapist at the college counseling center and coming to see me. She wanted to know: Was she that crazy? I had never even met Vicki face to face, and yet already she had called me, wanting some kind of stability and solace. Here I was, with only the barest notion of what her life was like, not knowing anything of her history, only a wisp of a telephone call to connect the two of us, but in Vicki’s heart, I was already on the job.

And I found myself with two distinct reactions, both of which were to continue from that time on to swirl around and shape my work with her: one was a sort of withdrawing shock at how intensely important I already was to Vicki, and the other was a sturdy admiration for this intensity, for this looking to grab and hold on.

Vicki had only been in treatment for a few months at the university counseling center when she revealed to her counselor, Peg, that she often felt so hopeless and so numb that she sometimes cut her leg with scissors. Peg was a trainee, and she realized that she would be unable both because of the policies of the counseling center and the time limits of her placement there to provide the long-term relationship she felt Vicki needed. So Peg referred Vicki to me.

Vicki was crushed. Peg had forged an extraordinary connection with her, making her feel truly seen and recognized. “For the first time in my life, I felt a self,” Vicki later told me. The sense of being recognized was so new and so disturbing that sometimes, after a session, she would just sit in her car, shaking uncontrollably. And then there was a final, humiliating encounter with the consulting psychiatrist, Dr. Flint, who had been called in and pronounced Vicki too difficult for Peg to handle. In a session with the three of them, Dr. Flint fired off a series of grueling and personal questions, embarrassing Vicki and invasively asking her about her sex life, among other things all the while keeping his head ducked behind his clipboard while he wrote notes nonstop. “You need a specialist,” he kept saying, as if Vicki had some sort of puzzling growth coming out of her head.

Vicki spent her first months with me perseverating over the details of her previous treatment: her attachment to Peg, her panic at her loss, her betrayal at the hands of Dr. Flint. She circled and circled over the events, sometimes finding fresh insults, sometimes reopening old wounds. Anyone who might have overheard Vicki at this time would have thought her reactions were exaggerated, melodramatic, out of sync with the precipitating events. “Get a grip!” they might have said, “Don’t be such a victim!” At times, in the beginning of my work with Vicki, I thought as much myself.

But I had worked with enough people in distress to notice something different about the persistent quality of Vicki’s suffering. Neither comfort nor humor nor interpretation nor limit setting seemed to be what she needed, and sometimes any intervention at all just inflamed her pain. Even though she seemed profoundly embarrassed to be grinding on in this way, in full view of another human being, she still couldn’t shift gears. “Stupid” was her word for it, “I know this is stupid, but. . .” I wanted desperately to “do” something, but mostly I had to settle for just sitting with her disturbance. I often wondered in these early days about clients like Vicki: their suffering was obviously burdensome, but what on earth was its source, its meaning? Was this real suffering?

VICKI, OF COURSE, EXHIBITED benchmark behaviors of the borderline diagnosis sky-rocketing emotions that couldn’t be soothed, a history of hurting herself and clinging to would-be rescuers. Vicki was also bulimic, and heartbreakingly uncertain about who she was, including her sense of herself as a woman. She had marked shifts of mood, including dissociative states. She had chronic and debilitating feelings of emptiness and paralyzing numbness, during which she could only crawl under the covers of her bed and hide. On these days, she was sometimes driven to mutilate her thighs with scissors. Although highly accomplished as a medical student and researcher who had garnered many grants and fellowships, she would sometimes panic and shut down in the middle of a project, creating unbearable pressures on herself to finish the work. While she longed for intimacy and friendship, she was dis-ablingly shy around men.

In psychiatric hospital settings, the term “borderline” was originally used to describe a kind of in-between state, a condition sharing features borders with both neurosis and psychosis. It is judged to be a character disorder, which is to say that it is seen as a highly ingrained set of self-defeating personal traits. But although borderline personality disorder is well described, there has never been any agreement on its etiology or even on the meaning of its infamous symptoms. Some influential thinkers have hypothesized that the borderline condition results from a lack of fit between mother and infant, either because the infant was temperamentally difficult or because the mother was somehow not able to tolerate her infant growing and separating from herself. Indeed, James Masterson, who has written many books on the condition, claims that the mother of every borderline is herself a borderline. And there is much debate about the function of borderline symptoms, a debate over what it is that the borderline personality is struggling so mightily to avoid. Some say the borderline is trying to hide a desperate rage at the mother, while others insist it is a bone-crunching depression over the loss of the mother. And others believe the borderline client’s essential energy is spent ambivalently seeking and rejecting trustworthy relationships.

In the minds of many therapists, the borderline diagnosis has come to be a code word for trouble. The diagnosis signals a kind of impossible case long, grueling work with the client often challenging the therapist’s equanimity over and over, withdrawing in a sulk or attacking in a rage, creating melodramatic scenes, threatening suicide, demanding more and more of the therapist’s love and time, while the shaken therapist feels used, abused and manipulated, thinking that he or she is often making no difference at all.

If the borderline diagnosis has come to mean trouble, it has, in particular, come to mean “female trouble.” For the borderline diagnosis has inherited the special spot that used to occupied by the label “hysterical,” hysteron being a Greek word for that quintessentially female organ, the womb. The empirical evidence is that women receive a borderline diagnosis much more frequently than men. The DSM-IV cites a 75-percent-higher rate of diagnosis for women. But psychologists Dana Becker and Sharon Lamb have reviewed the literature and find that women are diagnosed borderline twice as often as men in some studies, nine times more frequently than men in others. And so the question arises, do more women actually present with so-called borderline features or is it that therapists are more likely to label women “borderline” than men?

In researching this question, Becker asked 311 therapists, psychiatrists, psychologists and social workers to diagnose a case history she gave them. Some therapists received a case about a male client, some about a female client. All the histories were any of three basic cases, with only a change in the names and pronouns used to make the case a story about either a male or a female. Each story contained a history of sexual abuse, including symptoms that are typical results of such trauma, such as numbing or hypervigilance, and each story also described other behaviors couched in the language of the classic borderline diagnosis, such as impulsivity, self-destructiveness and intense anger. Then the therapists were presented with a variety of diagnoses from which to choose e.g., Antisocial Personality Disorder, various forms of depression, an Adjustment Disorder, Post-Traumatic Stress Disorder and, of course, the borderline diagnosis. Becker found that not only did the clinicians use the borderline diagnosis more than any other diagnosis, despite the clear history of trauma, but also that the fictional female cases were labeled “borderline” significantly more often than the fictional male cases. Even given the same set of behaviors, women are more apt to be labeled borderline than men.

The fact that the “borderline” client is most often a woman no doubt reflects the greater exposure of female children to sexual abuse, and also the hidden disgust of many therapists toward extremely emotional women. Even clinicians, it would seem, can perpetuate time-honored, cultural stereotypes, in this case the infamously overwrought, emotionally manipulative, out-of-control woman. She’s the woman that people love to hate and to dismiss. She’s every overbearing mother and nagging wife, every raving, scorned woman playing out a fatal attraction in short, everyone’s feared and hated symbol of twisted, grotesque, suffering femininity. Furthermore, the classic treatment of women with borderline features has as its hallmark intervention the setting of boundaries. Mostly, she wants too much-she wants time, she wants gratification, she wants revenge, she wants control and savvy therapists must be on red alert for all the ways that this kind of woman will “manipulate” them.

AT THE TIME I STARTED WORKING with Vicki, I was steeped in the tradition of diagnosing women with her symptoms as borderline. I focused not so much on rage or depression but on relationship, believing that clients like Vicki must experience connection and trust before they are ready to deal reliably with risk and separation. So our sessions slowly shifted from Vicki’s experience with Peg and Dr. Flint to the relationship between the two of us. Vicki was very clear and maddingly uninhibited on one particular point if I were going to be her therapist, then I must never leave her.

She began to wish that she could be my little girl and I could be her mother, her good mother. In particular, she could not imagine how therapy could ever work, because the whole notion of getting well contained within it the idea of getting on about one’s life and business without the therapist at hand, and the idea of finally getting something good and secure and then losing it was intolerable to her.

Not surprisingly, many of Vicki’s attempts to make a reliable connection tested the rules of therapy: Could me meet more often? What about telephone calls? If a session started even a few minutes late, we were sure to spend most of our time together that day struggling with its impact on her. I thought carefully about when to gratify and when to draw a line. Every line drawn precipitated a battle, but the fights themselves were vital and clarifying. At Vicki’s well-argued behest, we began to meet twice a week (and several years later, at my reasoned insistence, we cut back to once a week). As Vicki’s feelings were often spinning out larger than herself, we both struggled to become a team, a reliable two-person system.

And it was a struggle. Along with my larger-than-life importance to Vicki came another phenomenon that startled me with its force and suddenness. She sometimes responded to what I said or did by “disappearing” on me. It seemed that one minute we were talking about her family or her school or therapy, and the next it was as if she had all the breath sucked out of her, as if she were suddenly frozen solid, or shrunken to a tiny speck of a person. One second she was here, the next second she was gone. Maybe 1 questioned something a bit too much or maybe I just expressed a kind of sympathy that struck Vicki as hollow, or maybe I laughed in the wrong place or said something stupid. To judge by Vicki’s reactions, I kept making “mistakes” at every turn.

It took some getting used to both Vicki’s need for an exquisite kind of mirroring, a kind of symbiosis, and her real inability to defend herself if I somehow read her wrong or hummed the wrong tune. Early on in our work together, she drew a startling picture trying to show how morbidly intrusive I could be: she drew my hand literally cutting into her heart.

Once again, I was shocked by the power for both good or evil that Vicki attributed to me. In the early phase of therapy, I only begrudgingly accepted my position as the all-powerful mother, seemingly able to give life and even take it away, able to give pleasure and comfort, and then deny that, too. I had to struggle then with my own rising feelings of engulfment, feelings that I might be seized, consumed, blotted out by Vicki’s overwhelming feelings. Nonetheless, I watched her like a hawk, and seeing over and over again the fear that shut her down, I sought to maximize her comfort and trust.

And the trust came. Later Vicki reminded me of a moment of pure safety, something registering at last in her soul as the serenity she had so long desired: it was a summer day, the air-conditioning was broken and so the windows in the office were open. Vicki remembers that we were sitting together on my beige sofa, hardly speaking, just comfortably together, my arms across the back and Vicki curled in toward me. A breeze was coming in the window. That was it.

But despite these moments of pure safety and calm, once Vicki felt that I was “off”‘ with her, once she shrank to that tiny speck, it was hard to draw her back. She would become profoundly mute, sitting in silence for long anxious stretches, her eyes darting, words almost coming to her lips, then her head shaking, “no.” And although she was clearly struggling and clearly in pain, she nonetheless would start to look stubborn to me, which is to say, that I would feel manipulated by her and I would start to lose my empathy for her, and then I would feel like a bad therapist, and so the silence would feel thicker and more difficult between the two of us.

We were both challenged to tolerate this oscillating moments of deep connection and then demoralizing disconnection, back and forth, back and forth. As the therapist, I inevitably was inducted into her emotional world. Sometimes I would think: “It’s all too hard, this will never work, I can’t do it.” Then, by hanging in, staying as open and present as I could, something would shift, I would begin to feel differently, the tension between us would soften and ease up. I would think, “There’s hope, I can see a way.”

VICKI GREW UP IN A HOUSE SET OFF by itself on a lonely hill in the woods. The family was ruled by her father’s anger and alcoholic outbursts, and Vicki lived in a constant fear that one grisly day, out there in the woods with no one to hear their screams, her rageful father would murder them all.

She had been terrorized by her father plenty of times. Here Vicki describes one of those incidents when she was 14 years old:

/ remember the night I didn’t finish the dishes before I went to bed. My father had been out drinking and when he came in, he saw the frying pan soaking in the sink. My bedroom door flew open, and the doorknob cracked against the wall. He told me to “GET UP!” In a flash I went from sleep to vigilance to terror. I thought this was it, the night we would die. I stood up, and as he berated me, I began to shrink, shrink back inside of myself to protect that little bit of self I had from destruction. He told me to “GET OUT THERE!” The tone in his voice sounded as though he were talking to something so vile that disposing of it would be doing everyone a favor. I stood there frozen, waiting for him to move out of the doorway.

He did not move. He seemed to experience excitement as I submitted to his power, committing the most powerless act walking into the hands of one’s executor. All of the life drained from me. My body shook uncontrollably. I felt empty, numb. I walked toward the door. When I got close enough, he knocked me to the ground but told me to get up. I got up. He knocked me down. I can’t remember how long this went on. I remember crawling. He would stand on my nightgown while I was trying to get up. Again he would knock me down, beating, punching. I can’t remember getting into the kitchen: everything seemed surreal, somehow I managed.

While I stood at the sink scrubbing the pan, he pressed his chest up against my shoulder and breathed into my face. Out of the comer of my eye I could see his nostrils flare with rage, as if to let me know that he was deciding if I would live or die. I remember watching my hand make circles in the pan. 1 was frozen, mesmerized. I couldn’t stop, the risk was too great. To this day I don’t know how the pan got in the dishrack. When I was finished, he would not move out of my way, as if he were thrilled at my terror as I chanced getting away. Back in my bed, I moaned deep, hollow sounds, my body throbbing. 1 finally rocked myself to sleep, softly calling, “Mommy, Mommy.” She never came. The next morning as I left for school, she said, “I told you not to leave any dishes.”

As a little girl, Vicki treasured her mother the most beautiful woman in the world and always took her side in the high-strung maneuvers between her parents. But by the time she was 7 years old, she saw her mother’s spirit break: her mother attempted suicide with an overdose of pills. From then on, Vicki said, “I knew we were doomed.” As she grew up, her mother seemed more and more hopeless, a thin, clinging woman, sly around her husband, asking advice from Vicki. When Vicki would turn desperately to her mother after her father had lashed out at her, her mother would say lamely, “But you know how he is.”

When Vicki was 8 years old, she was, on several occasions, sexually fondled by her maternal grandfather. It took some time before she found the courage to say that she did not want to have to take naps with her grandfather when he came to visit, but no one bothered to find out what she was trying to tell them. Often in those days, Vicki tried to get people to look at her, get them to care for her. She remembers, for example, deliberately cutting her finger and feeling thrilled when the school nurse saw how bad it was. But none of the adults around her really saw what was going on. At 8 years old, she was already desperately alone.

SINCE MY GRADUATE TRAINING IN the 1970s, indeed since Vicki first called me from Minnesota 10 years ago, there has been a slow revolution in our thinking about people like Vicki. In fact, I did not realize myself what a full turn our profession might be taking until I began to research this article. In addition to a wealth of anecdotal evidence, what I found was that more and more research studies document histories of childhood trauma in people diagnosed borderline. In one study of 1,040 people admitted to the psychiatric unit of a military hospital, George Brown and Bradley Anderson found that 60 percent of the people diagnosed borderline had a history of abuse and, furthermore, that of the 853 people with no acknowledged history of abuse, only 3 percent were diagnosed borderline. In another study, 71 percent of the people diagnosed borderline had a history of sexual abuse, in contrast to 22 percent of the people who had been diagnosed with depression. Psychiatrist Judith Herman found an incidence of severe trauma in 81 percent of the cases she investigated that had been diagnosed borderline. Conversely, I found many writers who pointed out that the behavior and symptoms of people with histories of abuse easily fit the diagnostic criteria for borderline disorder (see annotated bibliography). It seems the pathways between the borderline diagnosis and a history of trauma, mostly sexual abuse, are sighted over and over.

What is added to our treatment of so-called borderline functioning when we locate its roots in a history of trauma? It is a profound shift in focus from character to context, like uneasily observing a person on the crowded street who seems to be gesturing and talking to himself, and then, thankfully, spotting the person across the street with whom he is in conversation.

Viewing borderline traits as the fallout of real suffering ineluctably shifts therapy from a mission impossible with irredeemable clients to a mutually constructed, more empathically demanding task of naming and sizing the effects of trauma. So, what were Vicki and I to make of those times when she felt especially victimized? What was I to do as a therapist when she became mute and would shrink to a tiny speck of impotent confusion, hurt and rage?

In Vicki’s account of her terror at the hands of her father, she wrote that she was “frozen,” all the life was drained from her, she felt empty, everything seemed surreal. She couldn’t move, she could only moan. And then, later, she used some of this language when she described our therapy sessions together: “I remember in the first years of therapy when you would say something that we would later label as ‘off.’ Almost like an animal, I would dart for cover. I would disappear behind layers of defense frozen. I couldn’t speak or move.”

Traditional discussions of borderline pathology rarely recognize the real historical trauma underlying dissociative behaviors. In those discussions, it is not fully appreciated how dissociation is a form of constriction, a kind of blinding, so that not so much is taken in. Dissociative processes are a way to reduce painful and overwhelming stimulation, the method par excellence for surviving life’s horrors. This past year I came across an Emily Dickinson poem that stopped me in my tracks; it’s plainly an experience with dissociation:

There is a pain so utter
It swallows Being up,
Then covers the abyss with trance
So memory can step
Around, across, upon it
As one within a swoon
Goes steady, when an open eye
Would drop him bone by bone.

Dissociative processes protect the self from dropping “bone by bone.”

Recognizing the impact of her early trauma in her family also helped both Vicki and me better understand the particular triangle created by Vicki, Peg and Dr. Flint, how they replicated her attacking father and her nonprotective mother. It became clearer why this blow in particular was difficult for Vicki to shake off, why she circled it over and over. We began to understand not only the damage of the original traumas, but also how the threatening power of the perpetrator silences others, so that the parent who might comfort or protect is instead weakened. What is ultimately unbearable about this kind of trauma, it seems, is not only the suffering of the violations, but the breaking of the protective bonds in the family.

So beyond her speaking of the violent excesses of her father, grandfather, and even the callous Dr. Flint, Vicki needed to trace the thread of nonprotection and betrayal that ran through her life, betrayal by her mother, by Peg, by me as well-not intentionally, but nevertheless all of us helping to reenact the abandonment she had felt all her life. Certainly, if I had nervously set limits on Vicki’s early perseverative anguish about Dr. Flint, if I had irritatedly felt “manipulated,” I would have looked as dismissive as her mother: “Oh, you know how he is.” In the beginning phases of therapy, as long as the abuses against her spirit remained unnamed, mysterious, private, Vicki could not distinguish between limitations and being dismissed. It was 18 years, from childhood to several years into therapy, before she finally found a voice to tell someone, “There was no place in the world for me. It’s as if it all happened in a vacuum, as if it didn’t happen at all, like that tree that falls in the forest.” A persistent sense of unreality and terror were constant background static, until she sat in those first therapy sessions with Peg.

When Vicki shared her fantasies of being my little girl, these longings were not just a kind of immature clinging, not just a symptom of “dependent personality,” or “intolerance of being alone” as DSM-IV would call it. Rather, this longing represented a powerful, healthy energy often distorted, often engulfing me, embodying her lifelong attempt to locate a protective spirit. Indeed, Vicki once wrote, “I remember daydreaming my way through elementary school. If I liked my teacher, I would dream about having a happy family, and my teacher was usually my mother. I would imagine a house, and I would always create a scene where I was being appreciated for being such a good girl. These fantasies kept my spirit alive.” Vicki had a poignant capacity to imagine what would protect her spirit and to keep that alive within herself. Living with her stalker-father, her demoralized mother, subjected to her corrupting grandfather, she nonetheless was imagining a life in which it was possible she might be part of a loving community.

THERE IS A FUNDAMENTAL difference between thinking of oneself as treating a traumatized person and treating a “borderline.” Therapists are advised not to become inducted into the emotional dramas of the borderline client, but the induction of the therapist treating traumatized clients is recognized as an integral, if exhausting, part of the healing. Still it is never an easy task to experience this kind of induction without becoming sunk in confusion and swept along in a shadowy and hopeless melodrama.

For example, one day I became so frustrated with Vicki that I threw a pillow at her. I was strung out at the remote edge of patience with her, not a happy place to be for either of us. Although Vicki and I had resolved plenty of frustrating times with each other, throwing a pillow was something new, a complicated message not only about how exasperating she was being but also about the depths of the rapport between us.

That day Vicki had come in so angry that she couldn’t talk, but her eyes were glowering and I could almost see smoke coming out of her ears. Finally she managed to spit out a bare statement, “My life is hopeless,” and somehow she implicated me in this hopelessness. We both sat there, weighed down by some of the most powerful, despairing feelings of hopelessness I have ever had to witness. I started to offer her words of empathy, expressions of understanding. She spit them back at me. Finally, after 30 minutes of this tension, I felt my own rage begin to mount in the face of her contempt. It was this rage, no longer contained, that fired the pillow at Vicki.

The pillow was small and soft my mother’s beautiful bargello needlepoint with down feathers inside but Vicki was shocked for an instant. Taken aback, she stared at me with an open mouth. Then she couldn’t help herself, and she broke into a mischievous grin that she quickly tried to suppress. But it was no use. We laughed together. After that, we battled with the pillow from time to time, or gestured with it. Indeed, Vicki was as likely to pick it up as I was, as the pillow became, for both of us, a safe but powerful way to signal feelings of intense anger. But before the laughter and the comfort, I had had to join her where she was, even if the connection was through anger.

The rage that I consequently felt in me gave me an electric sense not only for how rageful her father had been toward Vicki, but also how much of that rage she herself had had to contain, both how angry in turn she had felt and how silent she had had to be. Throwing a pillow at Vicki, who was glaring at me with such contempt, I found myself understanding from the inside-out the abuse she had suffered. For a moment there, I felt myself abused by Vicki and, for a moment, I could feel myself becoming the abuser and turning on Vicki.

This moment with the pillow captures well enough what distinguishes my work from more traditional work with clients diagnosed borderline the central role of reenactment. What’s been secret and closeted in the client, all those fractured scenes, those dimly felt shards of relationships, gets infamously acted out, felt out in the therapeutic relationship. Here the therapist cannot help but be a player. But when a strange emotion suddenly shifts the direction of the session, neither client nor therapist may yet understand what is going on. The point is not just to stop there, in silence and shame. In therapy, we can go back over our dilemma together, we can explore its impact, we can figure things out together, we can comfort and apologize, and we might even make reparation each to the other.

It is essential to have a map to locate oneself in the face of the powerful emotional moments that spring to life in work with traumatized people. Psychologists Jill Harkaway and Dusty Miller have described how people who have been abused will internalize an abusive triad, taking in and projecting out the roles of not only the victim and the abuser, but the nonprotecting bystander as well. In fighting with Vicki, I was refusing the role of the nonprotecting bystander. I was fighting for something, fighting to keep her from being consumed by her father’s rage. Her mischievous smile when I threw the pillow announced her relief that I had not stayed helpless in the face of her stunning anger, that I had not only protected myself, but also that I had “claimed” her.

IT’S EASY WHEN THERAPISTS GET together to joke about our own depressions or compulsions or enmeshed families, but no one ever pipes up about their own borderline rage. There’s a firm line drawn: I’m just a long-suffering therapist; she’s an impossible borderline. No one questions the fact that our own perseverative, unsoothed frustrations about working with so-called borderline clients are experienced so righteously. Somehow, we have allowed the borderline diagnosis to gather the force of a nasty moral judgment. In Purity and Danger, anthropologist Mary Douglas writes: “I believe that ideas about separation, purifying, demarcating and punishing transgressions have as their main function to impose system on an inherently untidy experience. It is only by exaggerating the difference between within and without, above and below, males and female, with and against, that a semblance of order is created.”

Why would we need to exaggerate the difference between ourselves and our so-called borderline clients? What “untidy experience” does the therapist seek to control here? More than any other client, the so-called borderline is credited with a vampire’s strength to induce and overpower the hapless therapist. We’re taught to raise our crosses and cry, “Back! Back!” What evil power do we believe has been let loose here?

The horror of trauma left uncomforted is that it sets in motion, like waves making wider and wider circles, a process of contamination and pollution. What was the terrible hurt that drove Vicki’s father to beat her, so that that terror came to rest in Vicki, and then years and years later was there for me to feel as well? It seems to me that it is the fear of this contamination, this contagion, that drives our clinical thinking. When we begin to feel the contaminating power, the “shadow of the perpetrator,” as Judith Herman puts it, in our own bones, we turn away in fear. To protect ourselves, we use one of the most powerful weapons that we have as clinicians, our power to label another person.

In our culture’s debate about victimization, the charge is raised against therapists that clients are being encouraged to think of themselves as damaged goods, encouraged to wallow in their own sad stories. That’s a point that undoubtedly needs to be made, but I wonder whether some of the energy in this charge comes also from a fear of contagion, all that wallowing in muddy, unending sadness. We shouldn’t be so surprised or disgusted when some people get stuck there, including therapists; trauma is first and foremost an experience of being flooded with helplessness. We would all like to quickly make our way through these dark woods.

LAST YEAR VICKI ATTENDED A CASE conference about a sick kid with a young mother who had been diagnosed as borderline. After listening to the consulting psychiatrist’s patronizing discussion about this woman, Vicki thought, “That’s me. Somebody could have said all this about me.” Afterward, she wrote a brief piece for a pediatric journal about the need for good history-taking with such patients. While she was researching the article, we shared papers, along with our mutual indignation.

But at one point Vicki called me in tears. The effort to write had stirred up both her anger and her helplessness, and she felt unable to keep going. As she first brushed aside my reassurances, I became dismayed myself. Hadn’t we gotten past this kind of unstoppable panic? Then Vicki came through in a way that has become more and more characteristic of her emerging power and flexibility.

“Look,” she said, “I know I’m being hard to comfort. But it’s a temporary thing; just hang in here.”

“Oh!” I said. “Of course,” enjoying how we had traded our places, how I could forget for a minute and she could remember. It was one of those clear moments when we both realized that we were nearing the end of our work together.

And I also thought what a revolutionary act she was committing by joining the discussions on this topic of the borderline diagnosis. It’s as if all those long-ago women, the hysterical patients of Janet and Charcot and Freud, the borderline patients of Masterson and Kernberg, so dramatically displayed to us in the lecture halls of mental asylums and in the accounts of learned journals, had risen up to shout, “No, no, you’re missing the point. You haven’t seen us yet.”

Illustration by Jem Sullivan

ANNOTATED BIBLIOGRAPHY

D. Becker & S. Lamb (1994). Sex Bias in the Diagnosis of Borderline Personality Disorder and Post-Traumatic Stress Disorder. Professional Psychology: Research and Practice, v. 25, no. 1.

G. Brown & B. Anderson (1991). Psychiatric Morbidity in Adult Inpatients with Childhood Histories of Sexual and Physical Abuse. Am.J. Psychiatry, v. 148.

J. Davies & M.G. Frawley. (Basic Books, 1994). Treating the Adult Survivor of Childhood Sexual Abuse: A psychoanalytic perspective. The best clinical thinking I’ve found, rigorous and vivid, a good companion to Herman’s now-classic Trauma and Recovery 3.

J. Herman & B. van der Kolk. (Am. Psychiatric Press, 1987). Traumatic Antecedents of Borderline Personality Disorder in Psychological Trauma. Argues that until recently the role of actual abuse in the history of borderline patients had not been considered.

D. Miller. (Basic Books, 1994). Women Who Hurt Themselves. Discusses borderline personality disorder as a misdiagnosis of what Miller calls “trauma reenactment syndrome.”

S. Ogata, K. Silk, S. Goodrick, N. Lohr, D. Weston & E. Will (1990). Childhood Sexual and Physical Abuse in Adult Patients with Borderline Personality Disorder. Am.J. Psychiatry, v. 147.

E. Saunders & F. Arnold. (Stone Center, 1991). Borderline Personality Disorder and Childhood Abuse: Revision in Clinical Thinking and Treatment Approach. Work in Progress, no. 51. Well-reasoned translation of the borderline diagnostic criteria into the day-to-day phenomenology of trauma.