Borderline: A Letter to New Therapists

At some point in clinical training, a therapist will be warned about working with a borderline patient. The warning may come from a supervisor, a colleague, or a referral note that introduces the patient as difficult, demanding, manipulative, or particularly likely to test boundaries. Usually, the warning is intended to be helpful. There may be genuine concerns about the treatment, and the experience of more seasoned clinicians deserves consideration. Yet something curious happens when a therapist begins a relationship with someone they have already been taught to anticipate. Before the patient has spoken, an image has arrived in their place. The therapist may begin listening for evidence of a person they have not yet met.

Psychiatric diagnoses are not without purpose, and there are important reasons for studying personality organization. Borderline personality disorder describes recognizable difficulties that may require particular forms of treatment, while the psychoanalytic formulation of borderline personality organization considers the organization of identity, defenses, and object relations in a somewhat different way. Nancy McWilliams develops this distinction in Psychoanalytic Diagnosis, where the clinical interest moves beyond identifying symptoms toward understanding how a person experiences themselves and others. Yet the more familiar these categories become, the easier it may be to confuse recognizing a pattern with understanding the person whose life has given that pattern its particular form. What begins as a useful clinical distinction can become an image through which nearly everything the patient says is interpreted.

Consider the progression through which someone might describe their relationship with food. At first, they say, "I struggle with disordered eating." Later, perhaps after seeking treatment, they say, "I have an eating disorder." The name may bring considerable relief, allowing an experience that once seemed confusing or shameful to become recognizable. But another movement is possible, one in which the person begins to say, "I am my eating disorder." Something has changed in the grammar of suffering. What was first experienced as a difficulty became something the person possessed, and what they possessed has become something they are. The diagnosis has begun to organize a story of identity. Shame may no longer belong only to particular experiences of eating, desire, or bodily dissatisfaction. It becomes attached to the person who imagines themselves through the diagnosis, as though their suffering has disclosed something essential about who they are.

The movement is neither inevitable nor necessarily conscious. A diagnosis can offer language, community, treatment, and relief without becoming an identity. But when it does become an identity, its consequences may reach beyond the symptoms it was intended to describe. A person may come to anticipate how others will respond to them, explain their relationships through the diagnosis, or interpret ordinary disappointments as evidence of an established defect. The imago becomes important here. It is not simply a mistaken picture that can be corrected through reassurance, but an image around which someone has learned to recognize themselves. The suffering is not imaginary, nor does calling the identification a fiction mean that it has no consequences. Rather, the fiction is the assumption that an image can finally tell the truth of the person. One may become deeply invested in an identity that also produces considerable shame, precisely because it offers a familiar place from which to experience oneself and others.

Something similar can happen when a person begins to say, "I am borderline." The words may express an attempt to understand repeated experiences of abandonment, anger, emotional intensity, or disappointment. Yet they may also carry the history of being accused of being too much, difficult to love, or impossible to satisfy. A diagnosis that once offered an explanation may become another way of telling the familiar story. It is especially interesting when this story is shared by the people surrounding the patient. Family members may describe the person as manipulative, former partners may remember them as unstable, and clinicians may recognize familiar examples of splitting or projective identification. Their accounts may contain important observations, but agreement does not necessarily make the image complete. The person who arrives in treatment may already inhabit an identity that others have spent years helping to construct.

The therapist is not entirely outside this process. Clinical training also introduces images of what a therapist ought to be: attentive, reliable, thoughtful, compassionate, and capable of maintaining the frame. These are admirable aspirations, but they may become more complicated when the therapist begins to depend upon being recognized through them. A patient who experiences a scheduling change as abandonment may challenge the therapist's understanding of themselves as reliable. A patient who becomes angry after an interpretation may trouble the therapist's image of being insightful or helpful. The therapist may feel increasingly compelled to explain their intentions, demonstrate their care, or establish that nothing inappropriate has occurred. The patient, meanwhile, may become more convinced that their suffering has once again gone unrecognized. Both may leave the encounter feeling misunderstood, though the misunderstanding has begun to accomplish something neither person intended.

Thomas Ogden's work on projective identification provides an important clinical foundation for considering these experiences. His account attends to the ways unconscious feelings may be communicated and enacted within the analytic relationship, rather than remaining entirely contained within one person's psychic life. I have been interested in extending this understanding through the collision of two imagos. In this formulation, projective identification may be understood as an encounter in which each person, working within the imaginary, demands that the other embrace their imago as the true person in the room. The patient may need to be recognized as the one who is always abandoned, while the therapist may need to be recognized as the conscientious professional who has done nothing wrong. Each becomes increasingly occupied with securing recognition of an image that cannot finally represent the subject. The difficulty is not necessarily that either person is lying. Both may be painfully sincere about their experience, even while participating in a fiction that neither can easily relinquish.

A familiar disagreement illustrates something of this problem. One person insists, "You never understand me. I'm always the one who gets left." The other responds, "That's not fair. I'm the one who's always trying to help." The statements appear to describe two different experiences, yet each also proposes an identity that requires something of the other. The abandoned person requires someone who abandons, while the helpful person requires someone whose failure to appreciate help can explain their frustration. The disagreement becomes less concerned with what happened than with which image will be recognized as the truth of the relationship. Each person may genuinely resent the other's response while remaining attached to the position from which the disagreement becomes familiar. Something about the relationship has been arranged around the preservation of identities that neither person experiences as particularly satisfying.

The collision may become more difficult to recognize in treatment because the therapist possesses a professional language for describing it. A patient who protests an absence may be understood as projecting an abandoning parent onto the therapist. This interpretation may illuminate something important, but it may also allow the therapist to overlook their own wish to be seen as someone who would never abandon a patient. If the therapist becomes defensive, the patient's accusation may seem increasingly unreasonable. If the patient grows more distressed, the therapist may feel increasingly justified in their interpretation. What began as an experience of separation has become a struggle in which each person's response confirms the other's expectations. The patient encounters another person who appears unwilling to recognize their suffering, while the therapist encounters another patient who seems incapable of recognizing appropriate care.

There is no reason to assume that one person's imago is more imaginary than the other's. The therapist's professional identification may be as emotionally consequential as the patient's identification with abandonment, shame, or rejection. This does not erase the asymmetry of the therapeutic relationship or suggest that clinician and patient carry identical responsibilities. The therapist remains responsible for the treatment, the frame, and their clinical decisions. But responsibility does not require the therapist to occupy a position outside the imaginary. Indeed, the conviction that professional training has provided such a position may become one of the more difficult images to question. The clinician who believes they are interpreting the patient's projections may also be defending an image of themselves as the person who understands.

This complicates the familiar emphasis on maintaining boundaries with borderline patients. Boundaries are essential to clinical work, although they do not become important only when a patient is particularly demanding or distressed. The therapeutic frame allows a relationship to develop without requiring every wish to be satisfied or every disappointment to be avoided. Yet there may be occasions when maintaining a boundary becomes confused with demonstrating that the therapist has done nothing wrong. An explanation of the cancellation policy, for example, may be entirely appropriate while also serving as a defense against the experience of having disappointed someone. The patient may need to discover that a therapist can be absent without having abandoned them, but the therapist may also need to discover that being responsible does not prevent another person from feeling abandoned. These experiences are not identical, and neither is necessarily corrected by establishing which account is reasonable.

Melanie Klein's writing on splitting and ambivalence offers another way of considering what becomes difficult in such encounters. A person may struggle to experience someone as loving and frustrating at the same time, particularly when dependence has become associated with danger or humiliation. The therapist who was experienced as understanding may suddenly appear uncaring, while the patient who seemed grateful may become furious. The temptation is to restore the earlier relationship through reassurance or explanation. Yet the movement between idealization and disappointment may express something about the difficulty of sustaining contradictory feelings toward a person whose presence has become important. The wish to preserve a good object can become inseparable from the fear of recognizing its limitations, while anger toward the disappointing object may threaten the relationship upon which the person still depends.

The therapist's wish to become the good object introduces another difficulty. Hearing about a patient's experiences of neglect, abuse, or repeated disappointment may awaken a sincere wish to offer something different. The therapist may become unusually accommodating, particularly attentive, or invested in being the first person who truly understands. Such responses may arise from compassion, but they can also become part of the imaginary arrangement of treatment. The therapist becomes the caring person who will not disappoint, while the patient becomes the person who has finally found someone dependable. The arrangement may offer relief until an inevitable misunderstanding, absence, or failure of recognition disrupts it. The question then becomes whether something about the relationship can be thought about without requiring either person to recover the image that has been lost.

Patrick Casement's Learning from the Patient is particularly valuable in this respect. His writing considers how the therapist's understanding can become an obstacle to discovering what is happening within treatment. Learning from a patient involves more than remaining receptive to new information. It may require recognizing that the therapist's preferred explanation has become part of the difficulty, or that an interpretation offered in the service of understanding has foreclosed something the patient was attempting to communicate. A therapist who has become invested in being helpful may find this especially uncomfortable. The patient's dissatisfaction is no longer simply an obstacle to treatment, but an occasion to consider what the clinician has been unable to hear.

Shame may be especially important at these moments. The patient who has organized their identity around being difficult, abandoned, or unlovable may experience disagreement as another confirmation of who they are. Yet shame may also emerge when this familiar identity begins to lose its certainty. If the person is no longer required to be the one who is always abandoned, something remains to be discovered about what they desire and how they might relate to someone who does not occupy the expected position. The familiar suffering may be difficult to surrender, not because the person secretly wishes to remain unwell, but because the identity through which it has been understood has provided a recognizable place in the world. Even a painful imago may offer a kind of continuity when something less familiar begins to emerge.

Clinical consultation can become especially important when these arrangements are difficult to think about. A therapist may feel unusually frustrated, anxious, protective, or convinced that the treatment has become impossible. Consultation offers the possibility of considering these experiences without requiring the clinician to manage them alone. Yet it also has the potential to reproduce the same imaginary struggle. A group of clinicians may find considerable relief in agreeing that a patient is difficult, manipulative, or incapable of sustaining treatment. Their agreement may contain valuable clinical observations, but it may also protect a shared image of professional competence. The patient becomes the person who prevents good treatment from occurring, while the clinicians become the people who understand why the treatment has failed. There may be something more useful in consultation that remains interested in the points where professional certainty becomes unusually satisfying.

None of this diminishes the need for careful assessment, appropriate boundaries, or attention to clinical risk. Suicidality, self-injury, violence, severe dissociation, and other safety concerns may require additional support, structured interventions, or a different level of care. Psychoanalytic interpretation does not replace these responsibilities. Nor should every disagreement or failed treatment be understood as an imaginary collision. Sometimes a clinician has made a mistake. Sometimes a patient has encountered an actual rejection or a harmful relationship. Sometimes a clinical approach is insufficient for the person's needs. The difficulty lies in allowing these possibilities to remain available without assuming that the language of diagnosis has already settled the question.

As therapists acquire experience, they become more capable of recognizing familiar patterns, defenses, and forms of personality organization. This development can make treatment more thoughtful and less frightening. Yet expertise may also introduce the temptation to know a person too quickly. The patient becomes an instance of a familiar clinical category, and the therapist begins hearing what they have learned to expect. The identification may then be reinforced from both directions. The patient has come to understand themselves through a diagnosis, and the clinician has come to understand the patient through the same diagnosis. Each may experience the encounter as confirming something already known, even as the particularity of the person becomes increasingly difficult to hear.

The movement from "I struggle with disordered eating" to "I have an eating disorder" to "I am my eating disorder" illustrates more than the possible appropriation of diagnostic language. It reveals how suffering can become organized around a recognizable image of the self, and how shame may bind a person to the very identity through which they experience themselves as deficient. In the treatment of someone understood as borderline, this becomes especially interesting when the therapist is also invested in an image of who they are supposed to be. The encounter between two imagos may generate considerable conflict, but it may also reveal something about the limits of recognition itself. Neither person can finally establish their identity by compelling the other to confirm it.

There is something uncertain, and possibly liberating, in allowing the clinical relationship to remain open at this point. The diagnosis may continue to be useful, the therapeutic frame may remain necessary, and the patient may still experience familiar fears and disappointments. Yet the person need not be exhausted by the image through which these experiences have become recognizable. The therapist, too, may discover that being a thoughtful clinician does not require securing the patient's recognition of that identity. Something different may begin when the necessity of these images becomes available for interpretation, leaving room for the person who has been speaking all along without being entirely known.