A Double Bind: Communication in Patients With Borderline Personality Disorder

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Borderline personality disorder (BPD) is a severe mental disorder characterized, in part, by paradoxical and self-defeating behavior, particularly in the realm of interpersonal relationships. I have described BPD as fundamentally a disorder of self-contradiction¹; via the process of cyclical psychodynamics, first described by Paul Wachtel, PhD,² the patient with BPD inadvertently elicits precisely what they most fear.

An underappreciated aspect of BPD is the patient’s characteristic methods of communication. Although several classic theorists, such as Eric Berne, MD,³ and Thomas Szasz, MD,⁴ have attempted to apply game-theoretical concepts to the understanding of psychopathology, relatively little attention has been paid specifically to the communicative patterns of patients with BPD.

Because the symptoms of BPD manifest most noticeably in the context of human relationship, and because the disorder is most effectively treated via the human relationship known as psychotherapy, an understanding of these patterns is of importance.

The anthropologist Gregory Bateson, PhD,⁵ and colleagues introduced the concept of double bind communications to psychiatry in a 1956 paper titled “Toward a Theory of Schizophrenia.” Although we now know that the etiology of schizophrenia is far more complex, the notion of the double bind has continued relevance, particularly in the area of personality disorder.

What is a double bind? It is, in essence, a dilemma in communication in which 2 or more messages are relayed simultaneously, or in close proximity, and 1 message contradicts the other(s). In a classic example, Bateson describes an interaction between mother and child. The child hugs his mother. The mother, dissatisfied with being hugged, backs away from the child, and the child removes his arms. In response, the mother looks at the child and says, “What’s the matter? Don’t you love me anymore?”

Double binds leave the recipient of such communications in a proverbial lose-lose situation. Regardless of whether the person chooses A or B, they still “lose.” This results in confusion, frustration, and ultimately, a sense that one is “losing their mind.” It is as if the recipient is trapped in a room with 100 doors. Behind each door is a negative outcome. If they choose not to open a door, ie, if they choose not to “play the game,” they still lose.

I submit that double bind communication reflects a hallmark feature of BPD, ie, that it represents a characteristic pattern of communication utilized by patients with BPD.

Examining double binds more closely, the psychologist Paul Watzlawick, PhD,⁶ described 4 variations on the theme. The first and probably most common is what Watzlawick called the “Be Spontaneous” paradox. This occurs when 1 person requests or demands something from another that can only be given spontaneously.

For instance, a woman who expects her partner to surprise her with flowers places the partner in this dilemma. She wants him to do something that by its nature must be spontaneous; if he fails to meet her expectations, he is criticized. However, if he does get her flowers, the response will be, “You only got them for me because I told you to.” Either way, he loses.

Other examples of the Be Spontaneous paradox include the following:

• “Tell me you love me.”
• “Why won’t you initiate sex more often?”
• “If you really cared about me, you would hold the umbrella for me.”

A related dilemma has been termed the covert contract.⁷ In this scenario, person A makes a contract within their own mind between them and person B. Person A expects person B to do something for them without actually telling them about it. When person B does not do what person A expects them to do, person A turns around and says, “See, you do not care about me.” Because no one is a mind reader, person A has entered person B into a game person B does not know they are playing.

Clinical experience teaches us that patients with BPD often engage in this manner. Owing to their intense fear of abandonment, the patient tests their partner in various ways, a phenomenon that Otto Kernberg, MD,⁸ has noted in his seminal work on borderline personalities. When the BPD patient engages in this type of communication, the conscious intent is to gauge the other person’s interest, love, or concern. But what the patient fails to realize is that they set the other person up for failure and, in the process, they set themselves up for disappointment.

Such patterns in communication are representative of broader pathological patterns in BPD, notably, the patient’s routine engagement in behavior that serves only to elicit the reaction they so desperately seek to avoid. In the case of double bind communications, that is, the playing of games that by design others cannot win, a common and quite predictable result is that the other person decides to opt out of any future games. In other words, the partner leaves. The patient’s greatest fear—abandonment—has come to fruition.

That is not to say that the patient with BPD does any of this consciously. We must remember that the patient does not intend for any of this to happen; they are legitimately looking only for safety, security, and love. But their dual anxieties of abandonment and engulfment fuel this confusing, paradoxical pattern. Left unexamined, it plays out indefinitely, in different circumstances and with different individuals over a number of years.

What is the relevance of this observation to psychotherapy? Because patients with BPD often play out relational themes from their outside life with the therapist, such patterns will undoubtedly occur within the psychotherapy itself. Indeed, these situations are ripe for analysis and may represent the most important area of therapeutic intervention.

For instance, a patient with BPD may expect the therapist to schedule an extra appointment for them one week. Because the therapist’s schedule is full, or because extra sessions are not a part of the therapeutic contract, the therapist does not accommodate the patient. The patient takes this as proof that the therapist does not actually care about them.

Similarly, a patient may communicate to their psychiatrist that they are interested in a medication to help with their unstable emotions. When, at the next appointment, the psychiatrist offers a mood stabilizer, the patient responds, “You must think I am crazy!”

Although these are mere preliminary observations regarding the nature of double bind communication in borderline syndromes, it seems plausible that a more thorough understanding of these patterns might lead to important advances in the treatment of these patients. Given the paradoxical nature of BPD, double bind communication appears to be a common method of engagement that ultimately serves only self-defeating purposes.

Dr Ruffalo is an assistant professor of psychiatry at the University of Central Florida College of Medicine in Orlando, Florida, and adjunct instructor of psychiatry at Tufts University School of Medicine in Boston, Massachusetts. He is a psychoanalytic psychotherapist in private practice.

References

1. Ruffalo ML. The great paradox of borderline personality disorder. Psychology Today. Updated February 9, 2024. Accessed March 18, 2024. https://www.psychologytoday.com/us/blog/from-freud-to-fluoxetine/202402/the-great-paradox-of-borderline-personality-disorder

2. Wachtel P. Psychoanalysis and Behavior Therapy. Basic Books; 1977.

3. Berne E. Games People Play: The Psychology of Human Relationships. Grove Press; 1964.

4. Szasz T. The Ethics of Psychoanalysis: The Theory and Method of Autonomous Psychotherapy. Basic Books; 1965.

5. Bateson G, Jackson DD, Haley J, Weakland J. Toward a theory of schizophrenia. Behav Sci. 1956;1(10):251-264.

6. Watzlawick P. A review of the double bind theory. Fam Process. 1966;2:132-153.

7. Glover R. No More Mr. Nice Guy. Running Press Adult; 2000.

8. Kernberg OF. Borderline Conditions and Pathological Narcissism. Aronson; 1975.