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Projective identification has been a particular topic of interest in the treatment of borderline patients because this process can often persuade therapists, even experienced therapists, to become enmeshed in distressing anxiety, guilt, and anger, and even to feel overwhelmed by feelings of passionate attachment to patients. An exceptional degree of personal intelligence appears to be involved because at times such patients accurately perceive subtle or hidden feelings of the therapist and then facilitate intensification of these feelings until the therapist behaves in a specific fashion that can even be irrational, all usually occurring without the therapist (or the patient) aware of the coercive dynamics.
There are various theories to explain projective identification. One holds that it reflects an inborn mechanism or a faculty to promote attachment, in line with theories of Bowlby (1988) and Kohut (1971). For instance, the infant cries not just from distress or to simply generate a response, but, at a much more powerful level, to directly coerce caring feelings and behaviors from caregivers that the latter experience as originating from within themselves. Some of the literature suggests that the coercive projective identification of borderline patients reflects an inherent pathology of such a characteristic. This view would require careful research to evaluate inborn defects versus caregiver effects (Dunn & Plomin, 1990).
It seems unlikely that an infant has an inborn capacity for more than rudimentary projective identification. For example, the "distress cry" can have an impact without the detection of specific emotions in a given individual by the infant (MacLean, 1985; Morgan, 1995; van der Kolk, 1987a). Projective identification as manifested by borderline patients appears to reflect a remarkable, albeit pathological, skill that must have been learned through a great deal of interactive experience with caretakers exhibiting certain characteristics and behaviors, as we discuss later.
An important issue to study is the occurrence of defective personal intelligence in the care of offspring. Did personal intelligence and the intrusive power of language develop primarily through social interactions of adults and, if so, what does this say about childrearing? There is not good evidence that personal intelligence involves a particular knack for knowing how to understand and care for infants. Miller (1983) discussed poisonous pedagogy, the history of severely harmful childrearing practices that encouraged stamping out a child's individuality and sense of self. Traditional religions have tended to promote adult power and control over children. Books on how to raise children are purchased in great numbers by insecure parents who will believe the popular fad of the day, from very strict schedules to almost complete abdication of structure. None of this suggests that personal intelligence involves special inborn directedness for knowing how to be or what to do.
There has been a general assumption that humans have a basic instinct, characteristic of all primates, for the care of offspring that existed long before the development of personal intelligence. Welldon (1988) found that parenting was not studied with appropriate objectivity because of a deep bias to believe in this maternal instinct and to idealize motherhood (Hrdy, 1995). This bias has inhibited the consideration that instincts can be attenuated in primates as well as become perverted in expression (Bard, 1995; Harlow, 1964). Drawing on extensive clinical experience, Welldon argued that perverted parenting is the product of defective and abusive experiences in the childhood of the parent. These experiences fashion a perverted parental personal intelligence that may suppress or misdirect any primal parenting instinct to serve private purposes damaging to the child (Fonagy et al., 1995). Miller (1981) also wrote about perverted parenting, including parents who try to make their children care for them as their own parents did not, a complete reversal of the appropriate parental role. In addition, some parents try so hard to be different from their own self-centered parents that they are hopelessly unable to set any limits, thereby fostering self-centered children (Sherman, 1994). As we discuss later, the very capacities we have for observing and perceiving our peers and for infiltrating psychological boundaries by gesture and speech, can be used with enormous destructiveness to the minds of children.
Finally, some ethological theories emphasize the negative manifestations of human social intelligence in deeply rooted patterns of aggression, manipulation and deception. One view is that these behaviors reflect instinct-based, essential characteristics of human nature (Alexander, 1989; Byrne, 1991; Davies, 1981; Lorenz, 1966; Storr, 1972). The more prevalent view is that these behaviors, are not usually the result of instincts specifically for such behaviors but reflect the enormous developmental plasticity of humans, who are "polymorphously educable" (Montagu, 1978), and whose follow-the-leader and us-versus-them mental programs can be bent or perverted to align with cultural belief systems and the goals of charismatic leaders (Benedict, 1934; Gould, 1988; Leakey & Lewin, 1992). Dramatic illustrations of submission to a charismatic leader are the mass murders and suicides of fanatical religious groups and Nazi Germany. Examples of extreme culturally enforced patterns include: (a) children who participate in robbery and brutal murder of strangers without the slightest distress and yet seem otherwise perfectly normal psychologically (Bruce, 1968); (b) brutal warriors who can be cultured, sensitive, and artistic (Forgey, 1988); (c) grotesquely deformed feet as highly ere tic objects (Levy, 1992); (d) marriage as a very hostile struggle for dominance (Undholm & Lindholm, 1979); and (e) culturally designated group homosexuality in adolescence to be followed by heterosexuality in adulthood (Herdt, 1981).
PERSONAL INTELLIGENCE IN BORDERLINE PERSONALITY DISORDER
Our interest in personal intelligence developed in the course of work with patients diagnosed with BPD (Park, Imboden, Park, Hulse, & Unger, 1992). Subsequent consideration of personal intelligence in patients diagnosed with narcissistic personality disorder occurred secondarily as a result of findings from our BPD research. Accordingly, the remaining sections of this chapter focus mainly on BPD and on our study of personal intelligence in borderline patients.
In this section, we discuss the clinical picture of BPD, the evolution of concepts about this syndrome, and our rationale for examining personal intelligence in these patients. BPD has been of considerable research interest in recent decades because of the frequency of the condition in clinical populations, its severity, its etiologic mystery, and the power of the patients to elicit emotional involvement of therapists and hospital staffs. With regard to severity, approximately 10% of patients commit suicide, usually relatively early in the illness (Stone, 1990b). Until recently it was thought the condition was essentially incurable, but several long-term studies demonstrated that by 15 years after initial clinical contact, two thirds of surviving patients are no longer borderline and are functioning normally or with only minimal symptoms (Frances, 1990; Stone, 1990b).
An epidemiological study found that BPD occurred in approximately 2% of a sample of the general population, with 73% being women (Schwartz, Blazer, George,& Winfield, 1990). Fifty percent of borderline respondents had used some form of outpatient mental health service in the prior 6 months and 19.5% had an inpatient hospitalization in the prior year. Furthermore, BPD is reported to occur in over 10% of psychiatric outpatients, in about 20% of inpatients, and in more than 60% of inpatients in settings with a predominance of personality disorders (Kass, Skodol, Charles, Spitzer, & Williams, 1985; Widiger & Frances, 1989; Zanarini, Frankenberg, Chauncey, & Gunderson, 1987).
It is probable that the enormous suffering of these patients drives such a high percentage to seek professional help. The great majority of BPD patients are chronically depressed and one third experience posttraumatic stress disorder (Gunderson & Sabo, 1993). Other frequent comorbid diagnoses are anxiety, phobic, substance abuse, and eating and panic disorders. Severe symptomatology can pervade multiple areas of functioning, including relationships, sense of self, mood, and behavior. Patients can live in almost constant psychic pain, burdened by self-hate, intense and painful
relationships, potentially damaging impulsiveness, and chronic dysphoria that can progress quickly to severe and suicidal depression. Their severely damaged sense of self can be manifested in burdensome confusion about who they are, what they value, what they want in life, and sometimes even about their sexual orientation. At times they experience dissociative states (Shearer, 1994; Spiegel, 1994). They tend to long desperately for intimacy with others and yet experience great interpersonal distrust. They often make commitments to emotionally unreliable people (Celani, 1994). When interpersonally stressed, they easily become confused and enraged, thereby distancing others while simultaneously experiencing extreme feelings of emptiness and abandonment.
Many borderline patients appear to have a heightened perceptivity of the feelings and motives of others. This ability is frequently manifested in the manipulative induction of feelings like those the patients themselves experience, that is, projective identification. For clinicians who treat these patients psychotherapeutically, the most striking personality feature is this flavor of the therapist-patient relationship. The ability of these patients to access and then strongly influence private emotions engenders the classical, perhaps pathognomonic, countertransference problems and special treatment relationships (Zanarini, Gunderson, Frankenburg, & Chauncey, 1990).
We are particularly interested in elucidating the nature of this perceptive talent, which has not been the subject of indepth investigation. The psychological powers and intuitive perceptions of borderline patients are briefly explained in the literature as manifestations of pathology, a skill that is peculiar in some way, or a learned response to certain kinds of childhood stress.
We reviewed the clinical literature for examples of intuitive capabilities and interpersonal powers of these patients, including a review of the countertransference literature for evidence of therapist reactions to patients who detect private or hidden emotions. Adier (1985) and Gunderson (1989) discussed the frequency with which hospitalized borderline patients evoke seriously disruptive staff conflicts in which one or more staff members passionately protect the patient as a "helpless waif" requiring nurturance, and who are quite hostile to other staff members who feel helplessly enraged at the same patient as an "angry manipulator" requiring severe limits (Gunderson, 1989, p. 2757). The capabilities of borderline patients in catalyzing such psychological firestorms is remarkable considering they are in institutions managed by experienced professionals who know and make the rules.
Masterson (1976) describes borderline patients as "exquisitely sensitive to the daily emotional state of the therapist, to his tone of voice and nonverbal messages conveyed by gestures and body posture" (p. 104). Carter and Rinsley (1977), KBahn<1974), and Shapiro (1978) describe borderline patients as having a peculiar perceptiveness for subtle and unconscious feelings, impulses, and thoughts of other people. Krohn (1974) gave an example of a borderline patient who had the "uncanny capacity to recognize some very private impulses and judgments within other people" (p. 145). "He would regularly put into words private associations of the therapist just as the therapist was having them" (p. 146). Another patient manifested an "uncanny responsiveness to the most subtle, unconscious content in others" (p. 154). "The therapist of the borderline is often suddenly surprised to hear the patient voice what the therapist comes to recognize as very private conflicts. It is as if the therapist has suddenly been dealt a very deep, confronting interpretation by the patient" (p. 161). Krohn referred to this intuitive capacity as borderline empathy. Stone (1985) found that borderline patients can have the ability to sense and to respond empathically to hidden feeling of individuals for whom they care.
Discussing countertransference, Kemberg, Selzer, Koenigsberg, Carr, and Applebaum (1989) stated: "Uncannily, borderline patients seem to sense the therapist's vulnerability and may choose the exact moment when the therapist wishes the patient dead to announce a suicide plan" (p. 75). Gabbard and Wilkinson (1994) stated that borderline patients "possess an uncanny ability to tune into the therapist's vulnerabilities and to exploit them" (p. 5) to produce guilt. The problem of boundary violations in the treatment of BPD, particularly patient-therapist sexual contact, was addressed by Gutheil (1989): "What may be less universally acknowledged is that patients with borderline personality disorder possess the ability, as it were, to seduce, provoke, or invite therapists into boundary violations of their own in the countertransference" (p. 600). Averill et al. (1989) proposed that borderline patients vulnerable to such abuse may have particular "projective or sending power" (p. 391) which transmits unconscious fantasies and neediness with special impact.
Two published controlled studies found evidence of perceptiveness in borderline patients. In the first, Ladisich and Fell (1988) assessed empathy in 20 borderline patients, 20 neurotic patients, and 19 patients who had a history of schizophrenia. These were inpatients in 11 therapy groups of 4 months duration, each group having six members and a therapist. Empathy was defined as an accurate sensing or perceiving of other peoples' feelings or qualities, and was measured using the 139-item Lazare-Klerman Trait Scale (LKTS; Lazare, Klerman, & Armor, 1966), the 40 item Giessen Test (GT; Beckmann & Richter, 1972), and a 21 item Unpleasant Person Hierarchy Test (UPHT) based on the Empathy Test by Kerr (1965). Patients rated themselves and other group members both at the beginning and termination of the group therapy program. The group therapists also rated the patients. Empathy was assessed by calculating how accurately a person could rate others' ratings of themselves. The borderline patients scored significantly higher than did the neurotic and schizophrenic groups and were as good as the therapists, who presumably had more knowledge of the patients. These results apparently were unexpected, and the authors proposed a possible relationship of high empathy in BPD to vulnerability for psychosis.