What could be stressed as a "division" between mental health and madness is very subtle. Indeed, it could be considered as a continuous or a borderline field that could develop toward a direction or another in human different expression of own features. By the way understanding mind could be frightening. Constitution of anatomical and psychopathological features of one's mind as own has had many investigations resulting in a complexity that is mysterious yet. It has been a focus of interesting by the past century and beyond, inspiring many theories and models. Among them developmental trauma, that is first parental-son relationship, may highlight further insight into factors threatening integrity of human consciousness and inner perception of that [1]. There is a very big consensus in clinical representation of borderline personality disorder, although aetiology of borderline functioning could not be seen as a lonely one, being involved different aspects. Among these literature data reports that trauma exposition, relational trauma and incest in particular, could have a very heavy role in borderline dynamics [2]. Otherwise Sociological basis [3], relational dysfunctional ones in particular, have been considered: Compromised interaction mother-son in an early phase of development could be considered as determining one [4], as long as separation-Individuation phases that are compromised [5].
The term "borderline", that we have just been referred to the field between mental health and mental illness, is otherwise mostly referred to a very big manifold of clinical representation. In clinical milieu it has widely regarded subjects having high risk of splitting, besides specific psychiatric category. The same term involves each "not-easy" clinical case that is more serious of a neurosis for its clinical implication, but with less psychotic permanent failure. This clinical perspective applies to borderline personality disorder as long as to borderline functioning that undergrounds different psychiatric diagnosis as bipolar disorders, addiction and conversion frames [5].
Borderline disorders range indeed from a spectrum of character pathology that could be thought between the psychosis one side and narcissistic personality spectrum on the other side. These human states, states or clinical conditions elicited reflect different degrees of disruption and many kinds of levels of personality integration. Depending on the form of pathological organization, these conditions manifest different intensity that could be seen in transference-countertransference balance. The more the mobile degree of interaction transference/countertransference, the most the corresponding modifications in therapeutic response [6].
It is at the end XIX century that some psychiatrist observe that some patients seem to live in a psychological "borderline" field between mental health and madness [7]. Then widespread ideas on personality organization in-between neurosis and psychosis. Literature speaks of "as if personality" [5] related to the first clinical cases of borderline personality disorder. Clinicians of psychoanalytical perspective speaks of character lability of certain patients, with a peculiar chaotic trend with neither hallucination nor delusional aspect. Borderline level as a feature of organization of personality found its shape with Otto Kerneberg [4,8,9] and Masterson [5, 10] and widespread in psychoanalytical world.
Diagnostic confusion sometimes exists between bipolar spectrum disorder and borderline personality disorder. Literature data report that a positive family history of bipolar disorder is not a direct useful marker to subclinical bipolar disorder in bipolar relatives. Indeed, the same relatives have the same frequency one side of excessive or inappropriate anger, and on the other side of affective instability, impulsivity or suicidal behavior, that are criteria that could come in defining borderline personality frame too [11].
Literature data report, among other, the frame of peri-and post-relation trauma condition as an origin to a mental trajectories which could culminate in only a yet mysterious overlapping clinical syndromes, which comprehend "borderline phenomena", dissociative patterns, mood disorders and complex PTSD. In these clinical situations maladaptive trauma-related formation comes into being processes more than categories where internal detachment serve to preserve the outer and symbolic aspect of the subject until a strong life event as a trauma indirectly, or a psychotherapy directly could reclaim this inner and more than rich world [1].
"neither able to fly nor to come near", Chris.
Chris is a skinny student, who is 24-years-old when she presents to me. Chris live with some university partner in an apartment she has just taken about 2000 km far from her birth home. When entering my office Chris is upbeat, energic and smiling. She also appear younger than she is. Despite her youth Chris is very successful in all studies pathways she follows, a very "good and nice girl". By the way her private life was a "inner crash" by her same words. When describing her life to me Chris no longer seem upset. She would like to be helped in overcoming her "bad" feelings of death, her feelings of emptiness, self-denial that come out through anger, irritability, dysphoria, global insomnia. She also asks for caring of her acting-out trend and frustration intolerance. Chris allow me the sensation that her outer presentation could be quickly destroyed by her description of her "inner crash": There is fear and anger in-between me and her talk.
Moreover, Chris tell me she has no friends: She says, "no one could understand my feelings, although someone try on". Moreover, she tells me she is "weary" and "stove" by her relationship with her mother, a 55-years-old woman. Image that Chris give me is of a well-outfitted woman, emotionally far from her own life, perhaps suffering and quite surely frightening Chris. I then know by Chris that her mother is a heavy drinker often loosing contact with real world, that have had more than a contact with psychiatric services, that have all fallen dawn. Chris says she needs to go away by her also minimal contact because she hates "this her" mother, so that and she choose the university location, the farer from her mother (2000 km almost). By the way the longer the time and the distance, the stronger the angst she felt. So, she goes back home leaving University and she arrive thinking to get her own life out: She has an acting out by ingestion. She signs to be released by hospital, then she arrives to me.
We begin a weekly psychodynamic psychotherapy. In addition, I start Chris on lithium, to which I add ariprazole 15 mg a day, because her delusional idea content of death that do not remit fully on lithium alone at full dosage. By that time, she is no longer dysphoric, and her suicidal thought is in full remission despite ongoing urge to leave many often and get away. By the way, in a not far setting therapy session, Chris bring me a drawing. In the same moment she gives me the drawing she says me: "this is what I want tell you now". In this picture there was a white cloth, on which a pink and a green shape could be seen. These shapes seemed no clear but seeing with more attention they looked like a butterfly (the pink one) and a plant with many needles (the green one). But neither birds, nor sky, sun or clouds could be seen behind butterfly and no colorful ground is under the green plant. The butterfly is positioned just above the plant and she is paralyzed linked with a very thin wire to the plant: "neither able to fly nor to come near", as she only says describing the position of the pink shape. We are then silent for almost half than an hour. Then she says me it is a carnivorous plant and that butterfly is failing her escape, frightened in her only little flight. Then she says me she wants to go away she ask me a new data for a session, out of weekly established day. I say she could come the day after at the same hour.
The clarity of expression through the picture of a butterfly near to a carnivorous plant could say much more than two natural shapes. In other-than-words, via a symbolic way, Chris seem to be in confusion, numbness, distress and shame, bring her picture to me.
In the drawing the little but colorful butterfly is near the plant and it has just tried to fly away, as a flight that could be seen as a denial. Leaving sounds as the last chance to give up its lifelong threatening "relational grounding", that is its plant, lived as a carnivorous. By the way the butterfly stay caught to the plant being perhaps feared to leave it. By picture and Chris poor verbal description loneliness and neglect of the butterfly in the white background of the picture are in front of the carnivorous plant, just ready to be "eaten". In this direction freudian Hilflosigkeith could be considered a possible way Chris live her inner world to the outer one: A frightened Hilflosigkeith brings right to the "predestined/necessary" fate to be incorporate and eaten. The same Hilflosigkeith is also this one that deny itself and its relational needs and difficulties by flying very far away-as butterfly could make being otherwise "not able to", staying just then caught by the plant, but as Chris make choosing a very far location for her studies, making her "symptoms" speak of her inner distress. The same powerlessness destroys her own possibility to feel free by accepting her being safe if far enough by its "threatening object", the threatening plant, the threatening mother, that is perhaps not recognized as dangerous one yet.
In a so perspective the butterfly is "paralyzed" in-between threatening object and empty and no-colorful background, that could represent one side the paralyzing Hilflosigkeit and its related fusion wish, but also a new possibility in which someone other, the therapist, "feel with" her-own destroying feelings, she needs to see and inclose to give up [12].
What just said could be thought as born by confusion of tongues [13], leading to freudian hilflosigkeit but also making a link matching Otto Kernberg and Sandor Ferenczi.
Misunderstanding is what confusion of tongues speak about: Tenderness language is denied, and passion language speak instead. In an interpersonal dimension of adult toward child, love and its attachment needs diverge: They calls for a lack of representation, of an "inner place" to be set in. Then defense mechanisms of child and adult get each other involved representing complex relational dynamic of a traumatic situation in-between child and its reference figure [13].
"…many times, it is that trauma is claimed by child unconscious, so that, calling for Freud, child, having a possible pathology yet, could charm adult through its Hilflosigkeit…" [12].
Unconscious wish and fulfillment desire of this Hilflosigkeit come on together with distressing guilt and denied feelings that are splitted. Then, a day something happens and resemble primary trauma awakening all these symbols and feelings that have been removed. Then symptom show up.
In a so perspective essential defensive aspect of borderline functioning individuals in Kernberg theory is otherwise exactly a bulky splitting, that allows cohabitation in inner world of two different relational modality that rule each other out, being idealizing and devaluing toward the same object that is in a different "hic et nunc" moment invested of libidic energy. That mean that, besides a "different" event lived as meaningful (as the therapist in transference), borderline individuals keep an only object as reference, affectively relating to two different ones, that are splitted in an object that is absolutely good and another one that is absolutely bad. In a so milieu therapist's recognition of and capacity to deal with countertransference issues become crucial to the treatment progression [6].
Otherwise patient is ferried toward assumption of responsibility for himself: Contradictions between actual behavior patterns and life goals, between personality potentials and present functioning, in a constellations of regressive narcissistic features [14].
That are being together in the same perhaps "hic et nunc paralysis" position of the butterfly, that is necessary to ground a "different" meaningful relationship that could exist in parallel existence of the primary and frightening one.
So, a meaningful moment to be paralyzed with intensive emotional reaction could be necessary to give a new mean to a different reference object, otherwise always potentially destroyed when lived.
"When dealing with borderline or severely regressed patients (...) the therapist tends to experience rather soon in the treatment intensive emotional reactions having more to do with the patient's premature, intense and chaotic transference and with the therapist's capacity to withstand (...)" [4].
In this direction the balance of transference/countertranference could take care of what empty ground could mean for the butterfly of the drawning-speaking for Chris in other than word-that need to think itself dangerously linked to the plant that could eat it-talking about how Chris could have lived her primary object reference. This "position of need", well represented by paralyzed butterfly, is full of intense feelings, being now seen with someone else, the therapist in a perspective that is Kernberg's one [4]: just for a moment the therapist "paralyze with" the patient, there is a stop toward feeling that are dangerous for the butterfly as only one in the world, but that gives many intensive emotional spurt for a therapist that could feel a reaction with regressed patients.