The following is a summary of a brief talk Dr. Reiss has given describing his model for the Phenomenology of the Borderline Condition. The diagrams referred to in the discussion, and a more detailed discussion of this topic, will be added in the near future.

The paper I'll be discussing describes a phenomenological model of the relationships formed by Borderline patients. Borderline personalities, both adolescents and adults, are surely known (and feared) for their lability and unpredictability within relationships. Having my undergraduate degree in engineering, I found myself trying to integrate the various theories of Borderline psychopathology, and my clinical experiences in working with Borderline patients, by plotting a flow sheet describing the phenomena that occur in the relationship with these patients. From that, I have constructed a model of certain aspects of the Borderline interaction which I believe can be seen to follow a rather regular and cyclical pattern over time. I find this model of the "Borderline cycle" empirically helpful in understanding what is happening within the treatment relationship, and in determining which therapeutic interventions and techniques are most likely to be productive at a given point in time.

I will first extremely briefly mention a rather simplistic, but I think helpful schematic of object-relationship development in order to give you a sense of the theory behind this model. I will then discuss an over-view of the "Borderline cycle", and how certain treatment strategies can take place at various points in the cycle. [FIGURE 1]

For this purpose, I conceptualize the development of the ability to maintain mature relationships into 6 phases, as shown here. The first stage, for which I use the term MERGER essentially represents the in-utero state - the child is contained within, and nurtured by, the mother, and there is no verbal or behavioral communication (in the usual sense). The second stage, which I'm calling SYMBIOSIS, is essentially post-natal. Here, typically the mother (or mothering person, institution, etc.), must respond to the child's rather non-specific communications of discomfort to discern and respond to the total needs of the child. If all goes well, the child develops a non-verbal understanding of patience, or the toleration of discomfort. This can best be stated as "I am uncomfortable, but soon enough I will be reasonably satisfied". In the third stage, for which I'm loosely using the term NARCISSISM, the child has developed some sense of autonomy, and the mothering person is perceived as a generally al-powerful, all-knowing, pick-emergency room-upper, who will give to the child whatever he or she wants - and clean up afterwards. At this point, the child communicates not only discomfort, but specific wants. That is, not only "I am hungry", but also "I want THAT food". If all goes well, the child develops a toleration of frustration, best stated as "I am uncomfortable and I want THAT, and soon enough, if it is really good for me, it will probably be given to me".

The fourth stage of SHARED OMNIPOTENCE is where I believe most behavioral and affective aspects the Borderline phenomena evolve. At this point, it is not only the discomfort and desired "thing" that is identified, but the child recognizes that there is a relationship to the providing person. That is, "I am hungry and I want YOU to give me THAT". The mothering person (I will use the term "mother", but I am referring to the mothering agency) is no longer seen as quite so overpoweringly omnipotent, but the fantasy is maintained that if the child and mother act in concert together, together they will form a single omnipotent entity and, in essence, "You and I together can do anything". When this perfect and powerful union is disrupted, it is not only discomfort and frustration that is experienced, but also personalized anger, rage, and attendant impulses for revenge - directed at the failed provider. However, when this occurs, the child's view of self quickly disintegrates. Instead of perceiving the self as an integral and controlling part of an omnipotent entity, the child has become a damaged, enraged, isolated, helpless, hopeless and probably doomed half-of-a-person. If all goes well in this stage, the mothering person safely contains the child's rage, comforts the child's disappointment, and teaches the child problem solving regarding both practical problems and disappointments within relationships. Through that support, the child learns to tolerate and work through the frightening feelings of disruption and disintegration, and that in fact, neither the child nor the mother are severely damaged by such disappointments within the relationship. However, I believe that the guts of the Borderline dynamics are formed when the child perceives, rightly or wrongly, that the mother or mothering person himself/herself has not mastered this stage. In such a case, disruption of the fantasized omnipotence does not result in the mother providing healthy limit setting, reality testing, and containment and comforting of fear, anger and rage. Rather, what is elicited from the mothering person is HIS or HER OWN untamed and/or inappropriately expressed affects and impulses of fear of disintegration, anger and rage - directed at the child. The child's alternatives at this time are to try to somehow re-instate within the relationship the fantasized Shared Omnipotence; accept the fate of being a hated and bad helpless, hopeless, half-of-a-person; or regress back to a more infantile form of interaction. With the environment unable to provide any other options, the development of the ability to relate stops at this point, with the elaboration of defenses that promote these pathological responses, rather than moving towards working through and mastery of the loss of omnipotence, and the formation of healthy relationships which can tolerate reasonable disappointments.

Briefly, in the fifth stage of ACCEPTANCE, which the truly Borderline individual probably cannot be expected to reach until somewhere between the third and fifth year of treatment, the loss of omnipotence is not as much raged against, but rather it is appropriately grieved and mourned, resulting in the acceptance of being a whole but imperfect self - who ha relationships with other whole but imperfect persons. Going through the classical stages of grief, often in a subtle, but nonetheless important way, is necessary during this stage (which, if all goes well, occurs during adolescence, and contributes to the normal emotional lability that occurs at certain stages of adolescent development). In the sixth stage of MUTUALITY, what is developed is the ability to have grieved integrated the loss of fantasized omnipotence, and the learning how to establish and maintain relations of varying degrees of intimacy, as might appropriate to the situation - as one whole-but-imperfect-self to another whole-but-imperfect-self.

Following the supposition that the Borderline pathology emerges from the inability to work through Shared Omnipotence, I would like to present the following phenomenological model of the Borderline interaction. [Figure 2 ] I will describe a cyclical pattern of affect and behavior that can be seen in the Borderline patient - which is not to be confused with bi-polar cycles (although the two pathologies can co-exist). This cyclical pattern can be observed occurring in a "nested" fashion - over days, weeks or months in the patient's external life circumstances (depending upon the severity of the pathology); over hours or days in a less obvious manner; between sessions within therapy; and even multiple times, over a period of minutes, within the therapy, in a very subtle but significant manner.

The truly Borderline personality has no conception of the possibility of a satisfactory relationship with another human being other than in a state of Shared Omnipotence. The Borderline patient, adolescent or adult, is not truly interested in psychotherapy. The only real motivation to be in treatment is to form a relationship which will provide a sense of Shared Omnipotence. Such wishes are not seen as fantasies to be explored or worked through, (as would be the case in classical psychoanalytical therapy), but as the very real ultimate and absolutely necessary goals of any relationship, including the therapeutic relationship. I recall a 20 year old woman, who I had seen for just over a year. For various reasons, she had decided to spend the session raging and railing about my utter uselessness in relieving her depression or anxiety, and how, in fact, she was getting continually worse since she began treatment with me. Rather naively, I questioned why, in light of these views, she continued to faithfully attend sessions twice weekly. Suddenly looking rather perplexed, she responded, "What does THAT have to do with THIS?" In her perception, my calm response to her rage was in fact exactly what she needed, and she could see no contradiction between the content of her statements that I was useless, and her emotional sense that by not raging back at her, I was in fact being useful - and she could not conceive that I would not be quite happy to provide this useful service to her, notwithstanding her determined protests that I was of no use to her.

As the Borderline patient is constantly searching for a new source of Shared Omnipotence, as soon as a new alliance is formed the relationship usually enters the Phase of Omnipotence, noted at the top of the diagram. I will begin my discussion of the cycle at that point. Here, the patient usually presents his or her perception of "just what is expected". For example, the presentation may be of the "good" patient, the "bad" or "difficult" patient, or the a "perfectly typical" example of any of the stereotypes of a teenager which the patient has felt led to identify with. When contact and an initial alliance is made, there is often a striking pseudo-maturity and pseudo-intellectualization of this presented persona. The patient may even exhibit the ability to use observing ego, and to develop "insight". This often can elicit the most positive and hopeful counter-transference from the therapist - despite the patient having a terrible developmental history, having a record of several failed therapies, or having initially presented in a very "difficult" manner. There is often a somewhat disconcerting lack of consistent and appropriate affect with these presentations, but this can be subtle and easily over-looked or denied due to the powerful influence of the positive counter-transference. Also in the stage, there can be subtle or overt idealization of the relationship, reaching even towards idolatry. A sincere generosity and pseudo-closeness can be exhibited by the patient. The patient may be very seductive to the therapist in a sexualized or non-sexualized (e.g. intellectual) manner. There can be a sense of genuine agreement or at least mutual respect. There can be what can be confused with almost a hypomanic aspect to the patient's affective expressions at this point - but without the generalized grandiosity typical of a true manic or hypomanic state.

Borderline personalities in this phase generally elicit from other people quick and superficial acceptance, a pre-mature pseudo-closeness and pseudo-intimacy, over indulgence, and a sense of mutual entitlement (i.e. a rekindling in the other person of their own resolved or unresolved wishes for omnipotence) - and the rush towards Shared Omnipotence is off and running. As an example of this, I had received a call from a woman who was referred to me for treatment by another therapist. She immediately explained, "I'm very Borderline, and I know that no one likes Borderlines. Only the very best doctors will work with me. I really want therapy. Can I make an appointment?" The stage was being set.

What is required of the therapist at this time is the immediate discussion of clear and firm limits, boundaries and expectations for the relationship. This must be presented naturally, in a calm and confident manner, and with a level of simplicity or sophistication consistent with the patient's cognitive development. It must be made clear that therapy without safety is useless and counterproductive, and dangerous or destructive behaviors will not be tolerated. Any dangerous actions or threats will result in the institution of appropriate measures of behavioral containment with all due haste. It must be explained that there are limits to the availability of the therapist, and there is an expectation that these limits will be scrupulously respected. The therapist must explain that the therapy will attempt to help the patient to experience relief, but that the therapist can neither control what the patient feels, nor be responsible for the patient experiencing painful feelings that will inevitably surface during the course of the treatment. Neither is the therapist responsible for the patient's behaviors, regardless of what feelings may be present. The therapist also is not an agent of the patient's family unit, and must hold out no promise, to the patient or the family, that patient will eventually return to the parent's good graces. The therapist also must communicate that he or she cannot be counted on to intervene to ameliorate the "natural" consequences of the patient's behaviors. In short, the therapist must openly be fully invested in taking complete responsibility for being the best therapist he or she can be - but not bearing responsibility for the outcome of the treatment, which may or may not succeed regardless of the efforts of the therapist. This is an important transference/counter-transference issue, because as soon as the therapist takes responsibility for the success of the therapy, the patient assumes, consciously or unconsciously, that the patient is given total control over the therapist's self-esteem - because the patient always has the power to make any specific intervention or therapy fail. Even though the Borderline patient may present earnestly seeking help, and promising collaboration, it must be expected that when an inevitable rift in the relationship occurs, the sadistic and masochistic expressions of rage will at lead to an attempt to deflate the therapist by sabotaging the therapy - in essence, re-enacting the situation described above, wherein the self-esteem and identity of both the child and the parent deteriorates into a terrified, ragefull state of disintegration. The therapist must set the stage for diffusing this reaction by not disintegrating, and not letting his or her self-esteem be dependent upon the behaviors of the patient. Thus, there must be the clear message that the rules, limits and boundaries will not be broken for any reason (including either "good" or "bad" behavior).

The therapist must also present with a model of honesty - in both content and affective expression - and provide reasonably warm human contact - but without pre-mature, inappropriate, unrealistic, or false intimacy. The therapist must show that he or she is capable of calmly, firmly, and definitively confronting and refusing attempts to transgress the stated boundaries - while also showing that he or she can tolerate the requests and manipulations of the patient without responding with the fear, rage, and disruption of self that the patient has come to expect in the other person when a state of Shared Omnipotence is disrupted. One 15 year old boy I began working with would respond to frustration and disappointment by saying something to the effect of "If you don't do what I want, I'll get ANGRY". He had come to expect, and usually received, an angry admonition in response. He was initially stunned, but later became delighted and formed a reasonable alliance, when I responded to his prediction anger by saying, "Well, feeling angry would be reasonable. But tell me what you usually do when you get angry, and what gets you into trouble." A simple intervention, but very novel - and barely if at all understandable - to the Borderline patient.

Inevitably, the patient's sense of Shared Omnipotence that has been elicited by the preliminary alliance with the therapist is damaged by some real, perceived, or imagined disappointment. The Phase of Disappointment is entered. Immediately, feared affects and impulses related to the disruption of Shared Omnipotence begin to unconsciously and consciously emerge. Terror, humiliation, rage, revenge, and guilt are lurking very nearby. The patient suddenly changes dramatically. Observing ego and insight disappear. There may be withdrawal, irritability, and affective fragility. Various defenses intended to avoid the feared affects start to be called into play. This will typically elicit from others, (and the therapist should expect to experience within the counter-transference), surprise, worry, and concern, possibly leading to guilt, anger, fear and masochistic over-indulgence or sadistic acting out. Counter-transference feelings must be accepted and worked through, and not acted out. The therapist's interaction with the patient must clearly and consistently maintain the limits and boundaries as previously set forth. The therapist cannot erase the feelings of disappointment, but can provide for the patient honest clarifications of the reality of what has transpired in the interaction, as well as here-and-now interpretation that there has been a significant change in the therapeutic relationship, which seems to be connected to a significant change in the patient's affective and cognitive state. When disappointment is being experienced but before the Borderline defenses have begun to be acted out, there can be a "therapeutic window". At such time, the therapist can somewhat didactically provide the patient with appropriate alternative ways of expressing available affect, and repairing the relationship. Most importantly, the message must be given that disappointment is an inevitable and tolerable experience in relationships, and truly not an ominous and/or terminal event, although it is understood that the patient experiences it as such. This leads to the eventual exploration of the issue of the difference between normal, unavoidable, disappointment in personal relationships - as opposed to inappropriate neglect and/or abuse. That in turn can lead to a useful exploration of the effects upon the a child or adolescent of growing up in a continual or continually fluctuating Post-Traumatic state - an important aspect of treatment for the Borderline, which due to time constraints, I will not discuss at this point.

If therapeutic interventions during this "window" are successful, there can be a swift and at times dramatic return to pseudo-maturity on the part of the patient. More often, there is the entering of a phase of Defensive Retreat, as the patient attempts to use various, often mal-adaptive mechanisms, to return to a state of Shared Omnipotence. I will briefly name a few defenses, without much elaboration. There can be withdrawal and flight - leaving the relationship, and seeking Shared Omnipotence somewhere else. There can be a striking, often grandiose, and at times quasi-psychotic, denial of any or all of the events surrounding the disappointment, in attempt to return to the previous positive state of being. In the extreme, this can be represented metaphorically by the Anorexic position of, "I'm not disappointed because you aren't feeding me enough, in fact, I'm not hungry, I'm actually fat, I don't need to eat at all". The patient may deny that any disappoint occurred - while still exhibiting starkly angry, bitter emotions in an overtly "pleasantly" passive-aggressive manner. Affects of rage, guilt and revenge can thus be dramatically acted out rather than felt. Of course, drugs, licit or illicit, are frequently used by the patient to avoid the feared affective states related to disruption of the relationship. Frequently, a sense of Shared Omnipotence is maintained through projection of all of the negative affects and disappointment onto another, and "protecting" the "good" person, i.e., splitting. Manipulative interactions and seemingly dangerous but truly empty threats may be used to avoid the emerging sense of helplessness and hopelessness by "forcing" the therapist to take a protective stance, i.e. proving that indeed there is the magical protection of Shared Omnipotence available. However, even threats that the patient initially has no intention of carrying out, may be acted upon as a power struggle ensues and escalates, if the situation is not skillfully dealt with by the therapist, or if environment allows or supports those actions, regardless of the interventions of the therapist.

These defenses against disappoint usually elicit shock, frustration, anger and guilt from others, who may then respond with withdrawal, rejection, sadistic retribution, or masochistic over-indulgence. The therapeutic response must be to continue to maintain all previously stated boundaries and limits. Threatening and dangerous behaviors must be immediately confronted and behaviorally contained as necessary. True symptoms of affective or cognitive disruption require psychopharmacological intervention. The therapist must express empathy for what the patient is experiencing, but at the same time maintain a strong, firm, and calm position in support of the reality of the situation. To the extent that the patient is maintaining some degree of observing ego, interpretive interventions as in the Disappointment Phase can be used. However, when it is recognized that the patient has entered into a more dense defensiveness and is not cognitively or affectively available, (whether this is the result of ego fragmentation, dissociation, or drug use) interpretive interventions are not only useless, but are perceived by the patient as confusing, useless, and non?empathic. At this time, the function of the therapist is purely to maintain safety, honesty, and calm support of appropriate boundaries.

If the patient does not get "stuck" in a particular defensive posture (e.g. chemically dependent, sociopathic, or avoidant of therapy), the therapeutic interventions taken do offer a measure of comfort and support, the terror and fury of the disruption lessens with time - and the Shared Omnipotent stage is usually re?entered. However, other times, the reality of the situation, combined with the ineffectiveness or unavailability of higher order defenses, do not allow sufficient containment of the feared affects. When this defensive retreat is ineffective, the patient enters the phase of Disruption, experiencing himself or herself as truly a bad, helpless, hopeless, probably doomed, half-of-a-person. Intense terror and helplessness emerges - not in a theatrical, defensive or manipulative manner, but in a devastating, overwhelming and dangerous manner. Desperation ensues. Demands escalate. Rage becomes more self?righteous and more poorly controlled, as the person is no longer using rage to try to manipulate, but is actually in the throes of uncontrollable rage. Affect becomes unstable, with frighteningly deep depression. Ego functions begin fragmenting severely, and cognitive abilities deteriorate with primitive, at times psychotic processes coming to the surface. This can elicit from others strong fear, rage, guilt, or withdrawal, with concomitant impulses towards retribution and or infantalization. The very frightening severity of the desperation can be denied in the counter-transference, and perceived as "manipulative", when it is truly not. At such times, the therapist must, foremost, recognize and respect the patient's personal limitations in ability to contain the emerging affective storm and cognitive deterioration. This is most often a time to provide immediate, firm, supportive interventions for affective and behavioral containment. The therapist can provide reinforcement for the use of whatever higher level defenses available to the patient to avoid affective overload. Various ancillary therapies can be used to diffuse the inner distress. Changes in the external environment can be suggested to the patient and family. Inappropriate behaviors must be firmly and clearly confronted, and options for appropriate containment must be provided. Use of psychotropic medications is usually essential at this time. Yet all of this must occur without changing the previously set expectations, boundaries and limitations of the therapeutic relationship. Clear differentiations must be made between the patient's statements which describe his or her affective state - these can be accepted, and if possible, explored and interpreted - as opposed to statements of threat or dangerous intent, which must be taken at face value and responded to behaviorally. The patient must get the clear message that REGARDLESS of the severity of inner pain, and REGARDLESS of the patient's inherent "innocence" and the "unfairness" of the patient's predicament, the patient is still held responsible for their actions. Continuing only verbal therapy in the face of overt threats or dangerous behaviors is counter-productive and dangerous - and actually models a situation in which the therapist is implicitly omnipotently responsible for the patient's safety and behavior, and the patient perceives him or herself as "entitled" to act out when sufficiently distressed. Unlike during the "therapeutic windows", this is NOT a time to encourage unstructured "sharing of feelings". The feelings emerging are primitive, unintegrated, disorganizing, and potentially dangerous. To encourage expression of affect without proper containment is perceived by the patient not as empathic or helpful, but as dangerous, cruel, and hostile. This re-enacts the patient's perception of the enraged and threatening parent, and the therapist is seen as dangerous and useless "like all the rest". Many therapeutic relationships have been irreparably damaged in this manner. In short, you don't pour the soup until you have a bowl.

At the most severe point of disruption, there is a severely Masochistic Regression. With the patient perceiving the relationship of Shared Omnipotence as irreparably damaged, the only options perceived as possible are a life of futile and terrified hopelessness, or regression to an infantile state. This perception results in depression, regression, dependency, somatization, self-destructive impulses which are severe and "real" (not theatrical or manipulative), and severely regressed, primitive and psychotic cognition. The extent to which regression can drastically compromise cognitive processes - even in patients who previously seem quite intact, was poignantly described to me by a young woman who had a history, as an adolescent, of "taking all the Valium I can find to try to kill myself, and crawling into bed, under the covers." Several years into therapy, when we were able to discuss this behavior, I questioned the importance to her of getting under the covers to die. Still showing no sense of contradiction, despite the fact that she no longer saw the behavior as appropriate, she explained, "Being under the covers, it felt so much SAFER!" The patient still had a complete cognitive dissociation between the suicidal intent of the action, and the secret wish to be rescued and safe. The therapist must recognize the very real dangers of such cognitive pathology, and must act to provide adequate containment and provision of safety, but again, without transgressing previously stated boundaries. Focus must be on reality testing. The therapist can calmly and honestly express his or her own realistic fears and concerns for the patient's well being which lead to the requirement of the provision of additional behavioral containment in order for treatment to continue - while still NOT accepting any responsibility for the patient's behaviors. Use of psychopharmacological agents are essential to help modulate the affective and cognitive disruption that is occurring, and without the availability of a therapeutic containing environment (i.e. use of psychotropic medications and/or hospitalization), a patient who reaches this point cannot effectively treated.

Eventually, some form of protection (whether adaptive or maladaptive) is afforded to the patient. A sense of hope is revived, and re?organization begins. There is a Phase of Reparation with a re?emergence of pseudo-maturity and improved cognition. The patient begins returning towards their previous "omnipotent" state. He or she may again become a "good patient". In fact, there may be a complete dissociation and denial of the severity of the decompensation that had just occurred. There may be sincere relief and thankfulness for having survived the regressive ordeal, with even a tense playfulness and attempt at closeness. With this relief, there can be a counter-transference tendency to relax limits and boundaries, "reward" the return of some semblance of sanity, and even entertain grandiose and unrealistic fantasies that such upheavals have finally been mastered by some new treatment modality that was used during this decompensation, but not previous. However, in fact, the therapist at this time must provide honest and appropriate expressions of feeling relieved, along with honest acceptance of appropriate expressions of gratefulness, but without any relaxation or change of the previously stated therapeutic limits and boundaries. The patients strongly inflated statements of gratefulness generally should be met not with interpretations - which are perceived by the patient as rejecting or patronizing, but rather with reasonable appreciation for the realistic components of the compliment, and suggestions that since there is still much work to be done in therapy, perhaps the patient should reserve final judgment of the therapist until treatment is completed. I recall an adult patient who, having recovered from a quite severe, depressive regression, spent the session expounding my virtues. Secretly wanting to agree with her, but beginning to feel guilty about my counter-transference, I unfortunately acted out the counter?transference by attempting to directly modulate and interpret her praise, telling her that I did not deserve such worship. She initially appeared hurt, but then quickly regained her aura of well being and Shared Omnipotence and upped the stakes by gently shaking her head and declaring, "Not only wonderful, but so modest!" A more appropriate response on my part might have been empathizing that it must be a great relief to feel that the therapy is "working", but at the same time asking, "What can we do now, to prepare for the next period of disruption?" During the reparation stage, before such intense grandiosity has returned, there may be another "therapeutic window", during which cognitive and interpretive work can be done to review the reality of what has transpired affectively and behaviorally, and prepare for the next disruption. The therapist must internally realize that the cycle will continue, and the therapist can aid the patient by overtly and directly planning, with the patient, how they may better prepare for an inevitable recurrence of disappointment, and plan for dealing with the inevitable resurfacing of negative emotions with modulation of affect, more appropriate expression of emotions, and safer containment of the impulses that will inevitably again arise.

After 1-3 years of working in therapy in the fashion described here, which I call "riding the cycle", the patient hopefully will be able to begin to observe the entire cycle as an ego-dystonic symptom that may be identified, explored, and interpreted in therapy, with the aim of developing a better way of relating and being. At that point, the TRUE therapeutic relationship has formed, and more traditional psychotherapy may BEGIN.

Topics I will discuss later will include:
"Comparing and contrasting" borderline, narcissistic, bi-polar, and sociopathic pathologies; teaching the borderline patient to grieve, rather than to decompensate, in the face of real or perceived loss; dealing with the effects of chronic Post-Traumatic symptomatology, which is common to most Borderline patients; addressing therapeutically the causes of chronic Post-Traumatic symptomatology, without engendering a decompensation; dealing with the dissociation of affect, cognition, and behavior which occurs in these patients; the disruptions in perception of identity, relationships, logic, and even the perception of time that occurs in most of these patients; specific psychotherapeutic interventions, specific psychopharmacological interventions, and auxiliary psycho-social interventions which I have found useful at different points in the cycle; addressing the existential and spiritual questions that arise within the recovering Borderline patient.