Karen Woodall – Psychotherapist, Writer, Researcher, Trainer

6 responses to “Helping the Parentified Child to Know What They Do Not Know”

1. Ruth K.

   February 27, 2023 at 3:41 pm

   An excellent article as always. Thank you Karen.

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2. Bob Rijs

   May 15, 2023 at 1:47 am

   Psychosis, Trauma and Dissociation
   Evolving Perspectives on Severe Psychopathology
   (Second Edition) 2019

   Click to access 10.1002@9781118585948.pdf

   [367]

   The Role of Double Binds, Reality Testing, and Chronic Relational Trauma in the Genesis and Treatment of Borderline Personality Disorder
   Ruth A. Blizard

   The essence of Borderline Personality Disorder (BPD) has been something of a conundrum. It has been variously conceptualized as (i) a disorder on the border with psychosis (Stern, 1938), (ii) a level of personality organization more pathological than neurosis (Kernberg, 1975), (iii) a pattern of unstable and intense relationships (Millon, 1981) or (iv) a complex traumatic stress disorder (Chu, 2011; Courtois, 2012; Herman, 1992). The DSM‐5 diagnostic criteria (APA, 2013) emphasize the instability of relationships, self‐image, and affect; criterion 9 notes that, under extreme stress, ‘paranoid ideation or severe dissociative symptoms’ may occur, but are described as transient, lasting minutes to hours.

   These official formulations of BPD fail to recognize the prevalence of childhood trauma and the pervasiveness of dissociative processes in persons with BPD. Trauma‐based dissociative processes may underlie most of the symptoms described in the diagnostic criteria for BPD, including the apparently psychotic symptoms. More importantly, dissociation based in the double binds inherent in chronic relational trauma may account for the essential characteristic of BPD – the instability of identity, affect, behavior, and relationships. In BPD, acute, episodic impairment in reality testing is based on dissociative symptoms such as illusions, disorientation, and flashbacks. A more pervasive and essential form of impairment of reality testing seen in BPD is based on polarized, severely distorted perceptions of self and others. These distortions may be patterned on the quality of attachment relationships with dysfunctional caregivers in childhood.

   The term borderline was originally used to describe patients who appeared to be on the border between neurosis and psychosis (Stern, 1938) or borderline schizophrenic.

   This characterization was abandoned when research showed that persons with BPD rarely developed schizophrenia (Stone, 1992). However, the propensity to have brief, acute psychotic episodes is still recognized. This chapter addresses the relationship of BPD to psychosis of emotional or functional origin. Psychosis is here defined as such extensive impairment in a person’s ability to interpret reality, respond emotionally, and behave appropriately that it interferes grossly with the capacity to meet the ordinary demands of life (Stone, 1988).

   The confusion that has marked the relationship between BPD and psychosis is due in part to the lack of diagnostic specificity for both BPD (Howell & Blizard, 2009; Şar & Öztürk, 2009) and schizophrenia (Read, 2004), and to the commonality both diagnoses have with dissociative disorders. The dissociative disorders have significant conceptual overlap with schizophrenia (Kluft, 1987; Ross et al., 1990) and, in many cases, delusions and hallucinations have post‐traumatic content (Reiff, Castille, Muenzenmaier, & Link, 2012). In BPD, there is considerable co‐occurrence with dissociative disorders (Dell, 1998; Korzekwa, Dell, Links, Thabane, & Fougere, 2009; Putnam, 1997; Şar, Akyuz, & Dogan, 2007; Şar, Akyüz, Kugu, Öztürk, & Ertem‐Vehid, 2006; Şar et al., 2003).

   The dissociative nature of BPD derives in part from a history of overt trauma, childhood abuse, and neglect (Golier et al., 2003; Gunderson & Sabo, 1993; Herman, 1992; McLean & Gallop, 2003; Silk, Nigg, Westen, & Lohr, 1997; Terr, 1994; Zanarini, 1997).

   As predicted in betrayal trauma theory (Freyd, 1996), the closer the relationship to the perpetrator, the greater the dissociation of memory for trauma (Freyd, DePrince, & Zurbriggen, 2001), as well as presence of borderline traits of idealizing and devaluing (Kaehler & Freyd, 2009).

   Transient, psychotic symptoms may be generated by the triggering of dissociated memories, emotions, and behaviours, leading to the disorientation, perceptual distortions, and illusions common to flashbacks (Ellenson, 1986; Howell & Blizard, 2009; Terr, 1990). In BPD, these may temporarily impair reality testing and the ability to cope with present‐day events. Even in severe hallucinations and delusions observed in schizophrenia, the content based in childhood abuse suggests these are intrusions of traumatic memories (Reiff et al., 2012). Thus, the tendency of dissociative symptoms to interfere with reality testing falls along a continuum, from occasional, brief episodes with full recovery in BPD to episodes whose frequency and severity preclude objective interpretation of reality in psychosis.

   Likewise, the general ability to accurately perceive and interpret the characteristics of self and others can range along a spectrum from normal biases that can be corrected by new information, through more stubborn, borderline tendencies to idealize or devalue, to fixed delusions of grandeur or persecution.

   Borderline personality may be best understood as a chronic relational trauma disorder, ensuing from contradictory, double‐binding, caregiving relationships (Blizard, 2003; Howell & Blizard, 2009). The essential characteristic of BPD – instability of identity, affect, behaviour, and relationships – is more characteristic of dissociative spectrum disorders than of personality disorders. The alternation between idealizing and devaluing perceptions of self and others may best be explained by shifts between dissociated self‐states with contradictory patterns of attachment (Blizard, 2001, 2003; Howell, 2002; Howell & Blizard, 2009). Moreover, polarized perceptions of self and others may underlie impalpable, generalized, delusional beliefs about the behaviour and intentions of others that pervade overall personality functioning.

   Attachment relationships with caregivers who are dissociative, psychotic, or sociopathic involve thousands upon thousands of frightening, double‐binding interactions that may impair the development of reality testing in a more pervasive and insidious manner than discrete traumatic events. Such contradictory relationships lead to disorganized attachment in infants, a condition that predicts dissociation from childhood into young adulthood (Carlson, 1998; Lyons‐Ruth, Bronfman, & Atwood, 1999; see also Chapters 7 and 8 of this book, for links between disorganized attachment, double binds, and schizophrenia). The child may need to form dissociated, i.e. split, mental representations of the good and bad aspects of the self in relationship to the caregiver (Blizard, 1997a, 2001, 2003; Liotti, 1992, 1999). These contradictory attachment patterns cannot be integrated into whole self and object representations, impairing the interpretation of people’s appearance, intentions, and behaviour. During stress‐induced, acute dissociative episodes, these distortions may be intensified and interact with traumatic memories to cause loss of contact with reality.

   A parent’s distorted or fragmented model of reality may actively discourage the use of important modes of reality testing needed to construct an integrated view of the world.

   Children need repeated interactions with adults who can articulate and empathize with the child’s experiences as well as differentiate them from their own. Otherwise, these experiences remain as disconnected, implicit knowledge, and cannot be cognitively and emotionally integrated (Lyons‐Ruth, 1999, 2001). When caregivers do not perform this reflective function, children are unable to be aware of their own experiences and begin to dissociate their sense of self (Schwartz, 2000). When the parental relationship is pervasively abusive and lacking in empathy for the child’s perceptions, the child may develop a narcissistically closed system of self‐nurturance (Howell, 2005). Afraid to look outside the self for care and protection, the child turns to an internalized representation of a caregiver.

   This prevents the child from engaging in consensual reality testing and lays the groundwork for the elaboration of distorted, idiosyncratic perceptions into full‐blown delusions.

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3. Bob Rijs

   May 15, 2023 at 1:48 am

   Psychosis, Trauma and Dissociation
   Evolving Perspectives on Severe Psychopathology
   (Second Edition) 2019

   Click to access 10.1002@9781118585948.pdf

   Caregiver Pathology, Double Binds, Disorganized Attachment, and Dissociated Self‐states

   When children are attached to dissociative, sociopathic, or psychotic caregivers, they are repeatedly placed in double binds (Blizard, 2003; Spiegel, 1986; see Chapter 8 of this book for a discussion of the double bind theory). Despite their caregivers’ empathic failures, eccentricity, bewildering behaviour, or outright abusiveness, children still have to depend on them for survival. When a young child seeking comfort encounters fear, anger, or contradictory verbal and behavioural signals from the caregiver, the child is placed in a double bind, unable to approach the parent, survive alone, or turn to others.

   This may cause a breakdown in cognitive and behavioural schema, leading to rapidly alternating approach and avoidance behaviour and disorganized attachment (Hesse & Main, 1999). Unable to cope with the contradictory demands of the situation, the child cannot develop integrated strategies for negotiating relationships and so alternates between opposing relational schemas. In adults this takes the form of alternating between a submissive, self‐deprecating, guilt‐ridden, victim self‐state and a dismissive, blaming, judgmental, perpetrator self‐state.

   Clinical Vignettes

   The alternation of victim and perpetrator states leads to emotional lability and contradiction between perceptions of self and others as good or bad. This was demonstrated by Paula, who switched between the role of the child desperately trying to placate the abuser and identification with the aggressor. Rejected by her mother, she had a pathologically enmeshed relationship with her father, clearly the primary attachment. He’d become enraged at her behaviour and beat her brutally. Later, he’d feel guilty, dissolve into tears, tell her he forgave her for making him angry, and then comfort himself by holding her. This double bind left Paula alternately feeling enraged, rejected, and deeply loved. She described how awful it was that he treated her this way, then, in the next breath, said that she loved him and he loved her. She would go from rage to tears within seconds. In therapy, she could feel invalidated by a minor misunderstanding. As her anger surged out of control, she’d berate the therapist for failing to manage her rage.

   Then she’d feel guilty about getting so angry and condemn herself for being so damaged. Finally, she calmed down and could take in empathic statements, perhaps mirroring the momentary closeness she felt with her father. But in the next session, she’d be depressed over her Jekyll and Hyde range of emotions. Then she’d start blaming the therapist for failing to teach her how to interact better. This emotional lability and contradiction of her own perceptions could be considered borderline psychotic, but it clearly mirrored the reality, albeit dissociated, of her relationship with her father.

   Roy had a similar relationship with his mother. She constantly rebuked him for his inadequacies, and yet she insisted she couldn’t live without him. The double bind was all the more powerful because she never held or comforted him. He was forbidden to express emotional needs, and he was beaten for crying, even when he’d broken his nose playing soccer. The combination of punishment for being vulnerable and rejection for being worthless made him desperately needy and dependent on his mother. Her fierce insistence that her life depended on him made the attachment more intense. Her behavioural message was that no other kind of love was available, and the accompanying verbal message was that no one else could ever love him. The only way Roy could function in the face of this dilemma was to develop two dissociated self‐states: one, strong and stoic, needing no‐one, and able to defend against punishment with ingenious arguments; the second, deeply devoted to his mother, maintaining the attachment even at the cost of actively cooperating in her brutal punishments.

   Soon after Roy joined the military to get away from home, his mother died of a drug overdose. He always felt deeply that her death was his fault, despite being able to reason that taking the pills was her own responsibility. He used the GI bill to go to law school, and became respected as a public defender, working tirelessly to prevent unfair sentencing of the disadvantaged. In his personal life, he married a possessive woman who criticized him relentlessly, mirroring his attachment to his mother. When his wife left him, he fell into an immobilizing depression, believing that the divorce was his fault and that no other woman would ever want him. He heard his mother’s voice telling him to kill himself. Without an understanding of dissociative processes, such command hallucinations are typically viewed as indicative of schizophrenia. However, given Roy’s history, hearing such voices could be viewed as a stress‐induced, acute dissociative episode in which an introject of his mother was simultaneously imploring him to join her in the after‐life and punishing him for leaving her. In a last‐ditch effort to replace his marital relationship, this dissociated maternal introject was re‐enacting the double‐bind attachment he had to his mother.

   The child’s ability to interpret people’s motivation and behaviour realistically can be seriously impaired by growing up with double‐bind attachment relationships. To cope with caregivers’ contradictory demands, the child is forced to develop dissociated self‐states in order to keep relational strategies for maintaining attachment separate from conflicting tactics to protect the self from frightening caregivers. In order to maintain perceptions of others that are consistent with a particular relational strategy, one aspect of the double‐binding message may be routinely denied, discounted, or dissociated.

   This can lead to a failure to perceive entire aspects of relational interchanges, such as body language, facial expression, or tone of voice, as well as the inability to interpret their significance. This tendency to see only half the picture, to perceive only the signs indicating that a person is either dangerous or entirely trustworthy, has traditionally been called ‘splitting’. The alternation between idealizing and devaluing relationships in BPD is fundamentally the same as the switching between idealizing child states and angry perpetrator states in dissociative identity disorder (DID).

   Treatment of alternating, contradictory perceptions of reality depends on the therapist’s understanding of the respective needs of dissociated self‐states to maintain these distorted views. Dissociated self‐states with contradictory attachment models develop early in life, are based on thousands of interactions with caregivers, and regulate the child’s management of relationships necessary for survival. Thus, they are very resistant to change. Beyond the processing of traumatic events, there must be the opportunity to process the nature of attachment relationships within a continuing therapeutic relationship. The therapist must relate empathically with both self‐states, and, over time, act as a relational bridge, bringing the attachment models and world views of these states together to integrate them into a whole (Blizard, 1997b, 2001, 2003; Howell & Blizard, 2009). It is only possible to overcome resistance by working with what was, in childhood, the adaptive need to maintain separate perceptions of self and other in order to preserve attachment and protect the self.

   When a parent is unable to be empathic with a child, the parent can neither acknowledge the child’s perspective nor validate the child’s experience. Even when an impaired parent is able to be caring some of the time, the erratic nature of this relatedness forces the child to be closely attuned to the parent’s mental state and internal world, precluding awareness of the child’s own experience and needs. In order to maintain attachment to incomprehensible, frightening, or abusive parents, the child becomes exquisitely attuned to the caregivers’ thoughts, feelings, and perceptions, and incorporates their behaviour and relational patterns (Blizard, 1997a, 2001; Howell, 2002). Such parents may project their own thoughts, feelings, and intentions onto the child, interfering with the child’s ability to differentiate his own experience from that of the parent. This may lead to difficulty distinguishing internal from external and imagination from reality.

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4. Bob Rijs

   May 15, 2023 at 1:49 am

   Psychosis, Trauma and Dissociation
   Evolving Perspectives on Severe Psychopathology
   (Second Edition) 2019

   Click to access 10.1002@9781118585948.pdf

   Treating the Effects of Dissociative, Psychotic, or Sociopathic Caregivers on Reality Testing

   When caregivers are contradictory or unpredictable, the connections between cause and effect will seem tenuous to the child. There may be little opportunity to articulate incomprehensible events, engage in consensual validation, or learn some form of hypothesis testing. Whether the child is attached to dissociative, sociopathic, or psychotic caregivers, there will be exposure to fragmented or highly distorted views of others and poor modelling of consensual reality testing. Further, when parents suffer from dissociative, sociopathic, or psychotic pathology, their external presentation is often not representative of their internal state. Caregivers with DID have dissociated self‐states that appear without warning, may be diametrically opposed to what the previous state presented to the child, and present the multiple realities of their multiple self‐states. Psychotic parents are responding to internal stimuli that are not available to the child and present a reality that is not experienced by others. Sociopathic parents deliberately deceive the child, and are often very practiced at presenting a false version of reality. In all of these cases, the child’s experience is that people are not who they appear to be, that people live in more than one reality, and that no one’s perception of reality is necessarily to be trusted.

   Clinical Vignettes

   Theresa exhibited the classic borderline alternation between idealizing and devaluing in all of her relationships to an extreme degree. It was almost as if each person with whom she was in relationship were actually two separate persons. For example, Theresa described her mother as if she were two different people, suggesting that her mother was exhibiting DID. Theresa associated separate and distinct realities with these ‘different mothers’. The mother who read Shakespeare to her inhabited a world of proper comportment and trips to the library, while the one who sexually abused her picked up men in seamy bars and was addicted to Valium. It was extremely difficult for Theresa to integrate her concept of these two sides of her mother. As a consequence, Theresa anticipated that all people could suddenly transmute into radically different personalities. In her work as an assistant librarian, she lived in one reality, while she avoided relationships and social activities in fear and contempt of people in the other reality.

   While Theresa manifested DID with high co‐consciousness, her frequent alternation between a helpless, submissive, idealizing child state and a self‐sufficient, dismissing, aggressive state, with accompanying fear of abandonment, affect dysregulation, and destructive behaviour, warranted a concurrent diagnosis of BPD.

   An important element of Theresa’s treatment was validating that her mother did do some good things, while helping her to keep in mind her own reports of her mother’s cruelty. Eventually, Theresa was able to see how her mother could make several personality switches during a single phone call. She became aware of her own alternation from idealizing child to self‐sufficient adult personalities in concert with her mother’s shifts. This allowed her to adapt to her mother’s changing demands and avoid provoking her anger. Group therapy with other borderline and dissociative patients was extremely helpful. They could validate her experiences with similar stories of their own parents’ abrupt fluctuations. They also helped Theresa maintain awareness of the contradictory messages of her mother’s alternating states, and avoid denial of the unpleasant ones.

   A psychotic parent responds to his own delusions or hallucinations. Perceptions of people in the external world are likely to be coloured by internal stimuli. The child may incorporate these distorted views. The discovery that others, at best, are confounded by these strange perceptions and, at worst, ridicule them, may make the child afraid to test her perceptions against those of others. As the child feels increasingly alienated, she may retreat further into a closed system of thinking and be able to trust only those who resonate with it.

   Molly was an emotional caretaker for her psychotic mother, an archaeologist who was reclusive and suspicious of everyone. To manage her mother’s mental state, she had to be exquisitely attuned to her mother’s often bizarre view of people and society. Her mother could provide little reflection or emotional validation of Molly’s experience, and even less differentiation of their separate perspectives. Molly lost touch with her own feelings and perceptions and learned to relate to others in a dichotomous way. Either she became totally absorbed in their experiences, identifying with them without questioning, or she rejected them as suspect and part of the larger conspiracy her mother saw everywhere. This mode of relating became an extreme form of idealizing and devaluing. Molly was unable to engage in consensual reality testing. She fell briefly under the thrall of a charismatic religious guru, and later believed that many of the people she knew belonged to a secret society connected with an alternate universe.

   Otherwise, she excelled as a sociology professor. Early in treatment it was important to avoid challenging Molly’s distorted perceptions of her relationship with her mother. As the therapeutic alliance developed, it was possible, gradually, for the therapist to present progressive differences between Molly’s point of view and her own. Molly became better able to tolerate the therapist acknowledging her own shortcomings. This allowed Molly to experience reflection of her own emotions, differentiation of personal boundaries, the ability to maintain a relationship despite disagreements, and eventually a means of engaging in consensual reality testing.

   A sociopathic parent distrusts others implicitly. He categorically rejects their perspectives and so cannot engage in consensual reality testing. He treats the child as an object, and thus deprives the child of any validation that her own perceptions, emotions, and thoughts exist. He lies and deceives, and so cannot be trusted by the child as a source of valid information. Ironically, the child has little option but to incorporate the parent’s skewed perspective and assume that everyone is deceptive and manipulative. The child may need to develop a closed system of self‐care in order to survive, especially if the parent is sadistically abusive, as in the case of Jeremiah (Blizard, 2003).

   Jeremiah was a brilliant research physicist who grew up in a family devoid of affection and with only minimal interaction, ‘Like strangers in a rooming house’. His father could be considered a psychopathic sadist. While he enforced extreme standards of academic excellence, far more frightening was the planned sexual torture he organized. Jeremiah perceived his mother as putting on a charade of excessive maternal concern while being largely absent and absorbed with her own needs. He may have experienced some comfort in serving as her narcissistic object, perhaps soothing her by listening attentively.

   However, her failure to protect him from his father made Jeremiah suspect that she gained some sadistic pleasure from appearing to watch helplessly.

   The horror of his father’s deliberate sadistic abuse, his mother’s failure to protect him, and the absence of any other benign attachment made Jeremiah so afraid of veryone that he retreated into a fantasy life. He allowed a shell of himself to behave with perfect comportment and excel in his research work. He had two dissociated self‐states that operated mainly in fantasy. One was helpless, preoccupied with attachment, and despairing over his inability to have any relationship. He soothed this despair by fantasizing a perfect woman who was totally devoted to him, understanding his every feeling. To protect him from his fears of abandonment and abuse, a perpetrator state disowned his neediness by resorting to sadistic fantasies of torturing her slowly and horribly for rejecting him. His identification with the aggressor was also played out in contrasting fantasies approaching delusions of grandeur, on one hand expecting himself to win the Nobel Prize, and on the other, plotting the perfect mass murder. Being around men induced intrusive images of sexual abuse, leading to fears that all men wanted to torment him sexually. From his sense that his mother covertly enjoyed his suffering, he assumed that all women, including the therapist, gained some sadistic satisfaction from hearing about his misery. Without knowledge of their traumatic antecedents, these exaggerated fears could have been interpreted as delusions of persecution.

   Therapy with Jeremiah required two to three sessions a week for many years to assuage his need for attachment and keep him from the ‘abyss’ of solitude. He often described himself and his experience of the world with bizarre, psychotic images, such as a disembodied head in a vacuum jar on a barren planet. For years he managed his personal safety in sessions by talking nonstop, objecting to any therapeutic comments as intrusive. Gradually, he became able to tolerate reflections of his dilemma: feeling safe in intolerable isolation vs. fearing abuse in a relationship. After many years of treatment, he was able to allow an angry dissociated self‐state to emerge partially. Because both the memories of his father’s sadistic abuse and his own rageful impulses were so terrifying, he could not allow this part of himself to communicate directly. He found he could express his rage, horror, and despair without explicitly owning them by graphically describing violent movies that portrayed these feelings. Only in this indirect format could he express his terror of humiliating abuse and his fantasies of sadistic revenge.

   The therapist built a relational bridge between his dissociated self‐states by listening attentively, at first reflecting the needs for attachment, revenge, and understanding portrayed by the actors, and, much later, relating these to Jeremiah’s own experiences. After many years of intensive treatment, both his grandiose and his sadistic fantasies receded, and he no longer used bizarre images to describe himself. In a move toward whole object relations, his perceptions of others were transformed from a dichotomy of absolute perfection vs. annihilating contempt to being able to accept that someone with an annoying trait could be basically a good person.

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5. Bob Rijs

   May 15, 2023 at 1:49 am

   Psychosis, Trauma and Dissociation
   Evolving Perspectives on Severe Psychopathology
   (Second Edition) 2019

   Click to access 10.1002@9781118585948.pdf

   Conclusion: Borderline Psychotic Traits Stemming from Relational Trauma Require Relational Treatment

   All of the cases in this chapter portray psychotic symptoms in persons who otherwise had sufficient reality‐testing abilities to allow them to function in society and sometimes excel professionally. They provide a picture of how psychotic features may form an integral part of borderline personality along a broad spectrum of severity, from episodic disorientation and disjunctions in sense of self to acute psychotic episodes, fully dissociated self‐states, and persisting delusions of persecution and grandeur. Some of these psychotic symptoms could be traced to discrete traumatic events, including chronic child abuse. However, the psychotic quality of their relational worlds was based in traumatic attachment relationships that incorporated emotional invalidation and bizarre or fragmented reality testing. This produced patterns of pervasively distorted perceptions of self in relation to others that could be strangely fractionated or frankly delusional. Thus, our understanding of BPD has come full circle: a disorder occurring on a continuum, with the extreme bordering on psychosis.

   The implications for treatment derive from an understanding of the double binds inherent in traumatic attachment relationships. When children depend for survival on caregivers who are frightening, contradictory, or abusive, they cannot manage the attachment and still perceive the parent as a whole person. Dissociated attachment models, containing segregated representations of self in relation to others, become the template for perceiving all persons in distorted and fragmented ways. Whether these distortions and alternations between dissociated self‐states result in emotional lability, self‐defeating behaviour, or psychotic delusions, treatment depends on understanding their origins in the double binds of chronically traumatic relationships. Only by relating to both sides of the dilemma and creating a bridge between them can the therapist create a template for perceiving the self and others as whole persons. This forms the basis for comprehensive, functional reality testing.

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6. Helping the Parentified Child to Know What They Do Not Know – Het Verloren Kind

   August 18, 2023 at 10:40 am

   […] Date: 27 Feb 2023Author: karenwoodall5 Comments […]

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