I Hate You—Don't Leave Me (23 page)

Elaine, a twenty-nine-year-old woman, was referred for group therapy after two years of individual psychotherapy. The oldest of four daughters, Elaine was sexually abused by her father, starting around age five and continuing for over ten years. She perceived her mother as weak and ineffectual and her father as demanding and unable to be pleased. In adolescence, she became the caretaker for the whole family. As her sisters married and had children, Elaine remained single, entering college and then graduate school. She had few girlfriends and dated infrequently. Her only romantic relationships involved two married, much older supervisors. Most of her off-work time was devoted to organizing family functions, caring for ill family members, and generally taking care of family problems.

Isolated and depressed, Elaine sought individual therapy. Recognizing the limitations in her social functioning, she later requested a referral for group therapy. There, she quickly established a position as the helper for the others, denying any problems of her own. She often became angry with the therapist, whom she perceived as not helpful enough to the group members.

The group members encouraged Elaine to examine issues she had previously been unable to confront—her constant scowling and intimidating facial expressions and her subtly angry verbal exchanges. Although this process took many frustrating months, she was eventually able to acknowledge her disdain for women, which became obvious in the group setting. Elaine realized that her anger at the male therapist was actually transferred anger from her father and recognized her compulsive attempts to repeat this father-daughter relationship with other men. Elaine began to experiment in the group with new ways of interacting with men and women. Simultaneously, she was able to pull back from the suffocating immersion in her family's problems.

Most standardized therapies (see chapter 8) combine group with individual treatment. Some approaches (such as Mentalization-Based Therapy [MBT]) are psychodynamic and exploratory with less direction from the therapist. Others (such as Dialectical Behavioral Therapy [DBT] and Systems Training for Emotional Predictability and Problem Solving [STEPPS]) are more supportive, behavioral, and educational, emphasizing lectures, “homework” assignments, and advice, as opposed to nondirective interactions.

Family therapy is a logical approach for the treatment of some borderline patients, who often emerge from disturbed relationships with parents engaged in persistent conflicts that may eventually entangle the borderline's own spouse and children.

Though family therapy is sometimes implemented with outpatients, it is often initiated at a time of crisis, or during hospitalization. At such a point the family's resistance to participating in treatment may be more easily overcome.

The families of borderlines often balk at treatment for several reasons. They may feel guilt over the patient's problems and fear being blamed for them. Also the bonds in borderline family systems are often very rigid; family members are often suspicious of outsiders and fearful of change. Though family members may be colluding in the perpetuation of the patient's behaviors (consciously or unconsciously), the attitude of the family is often “Make him better, but don't blame us, don't involve us, and most of all, don't change us.”

Yet it is imperative to gain some support from the family, for without it therapy may be sabotaged. For adolescents and young adults, family therapy involves the patient and his parents, and sometimes his siblings. For the adult borderline who is married or involved seriously in a romantic relationship, family therapy will often include the spouse or lover and sometimes the couple's children. (Unfortunately, many insurance policies will not cover treatment that is labeled “marriage therapy” or family treatment.) The dynamics of borderline family interaction usually adopt one of two extremes—either very strongly entangled or very detached. In the former case, it is important to build an alliance with all family members, for without their support the patient may not be able to maintain treatment independently. When the family is estranged, the therapist must carefully assess the potential impact of family involvement: if reconciliation is possible and healthy, it may be an important goal; if, however, it appears that reconciliation may be detrimental or hopelessly unrealistic, the patient may need to relinquish fantasies of reunion. In fact, mourning the loss of an idealized family interrelationship may become a major milestone in therapy.
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Family members who resist an exploratory psychotherapy may nevertheless be willing to engage in a psycho-educational format, such as presented in the STEPPS therapy program (see chapter 8).

Debbie, a twenty-six-year-old woman, entered the hospital with a history of depression, self-mutilation, alcoholism, and bulimia. Family assessment meetings revealed an ambivalent but basically supportive relationship with her husband. The course of therapy began to focus on previously undisclosed episodes of sexual abuse by an older neighbor boy, starting when the patient was about eight years old. In addition to sexually abusing her, this boy had also forced her to share liquor with him and then would make her drink his urine from the bottle, which she would later vomit. He had also cut her when she tried to refuse his advances.

These past incidents were reenacted in her current pathology. As these memories unfolded, Debbie became more conscious of long-standing rage at her alcoholic, passive father and at her weak, disinterested mother, whom she perceived as unable to protect her. Although she had previously maintained a distant, superficial relationship with her parents, she now requested an opportunity to meet with them in family therapy to reveal her past hurts and disappointment in them.

As she predicted, her parents were very uncomfortable with these revelations. But for the first time Debbie was able to confront her father's alcoholism and her disappointment in him and in her mother's detachment. At the same time all confirmed their love for each other and acknowledged the difficulties in expressing it. Although she recognized there would be no significant changes in their relationship, Debbie felt she had accomplished much and was more comfortable in accepting the distance and failures in the family interactions.

Therapeutic approaches to family therapy are similar to those for individual treatment. A thorough history is important and may include the construction of a family tree. Such a diagram may stimulate exploration of how grandparents, godparents, namesakes, or other important relatives may have influenced family interactions across generations.

As in individual and group therapy, family therapy approaches may be primarily supportive-educational or exploratory-reconstructive. In the former, the therapist's primary goals are to ally with the family; minimize conflicts, guilt, and defensiveness; and unite them in working toward mutually supportive objectives. Exploratory-reconstructive family therapy is more ambitious, directed more toward recognizing the members' complementary roles within the family system and attempting actively to change these roles.

At one point in therapy, Elaine focused on her relationship with her parents. After confronting them with the revelation of her father's sexual abuse, she continued to feel frustrated with them. Both parents refused further discussion about the abuse and discouraged her from continuing in therapy. Elaine was puzzled by their behavior—sometimes they were very dependent and clinging; other times she felt infantilized, especially when they continually referred to her by her childhood nickname. Elaine requested family meetings, to which they reluctantly agreed.

During these meetings Elaine's father gradually admitted that her accusations were true, though he continued to deny any direct recollection of his assaults. Her mother realized that in many ways she had been emotionally unavailable to her husband and children and recognized her own indirect responsibility for the abuse. Elaine learned for the first time that her father had also been sexually abused during his childhood. The therapy succeeded in releasing skeletons from the family closet and establishing better communication within the family. Elaine and her parents began for the first time speaking to each other as adults.

Individual, group, and family therapies require patients to express their thoughts and feelings with words, but the borderline patient is often somewhat handicapped in this area, more likely to exhibit inner concerns through actions rather than verbalization. Expressive therapies utilize art, music, literature, physical movement, and drama to encourage communication in nontraditional ways.

In art therapy, patients are encouraged to create drawings, paintings, collages, self-portraits, clay sculpture, dolls, and so on that express inner feelings. Patients may be presented with a book of blank pages, in which they are invited to draw representations of a variety of experiences, such as inner secrets, closeness, or hidden fears. Music therapy uses melodies and lyrics to stimulate feelings that may otherwise be inaccessible. Music often unlocks emotions and promotes meditation in a calm environment. Body movement and dance use physical exertion to express emotions. In another type of expressive therapy called psychodrama, patients and the “therapist-director” act out a patient's specific problems. Bibliotherapy is another therapy technique in which patients read and discuss literature, short stories, plays, poetry, movies, and videos. Edward Albee's
Who's Afraid of Virginia Woolf?
is a popular play to read, and especially perform, because its emotional scenes provide a catharsis as patients recite lines of rage and disappointment that reflect problems in their own lives.

Irene's chronic depression was related to sexual abuses that she had endured at an early age from her older brother and that she had only recently begun to remember. At twenty-five and living alone, she was flooded with recollections of these early encounters and eventually required hospitalization as her depression worsened. Because she felt overwhelmed by guilt and self-blame, she was unable to verbalize her memories to others or allow herself to experience the underlying anger.

During an expressive-therapy program that combined art and music, the therapists worked with Irene to help her become more aware of the fury that she was avoiding. She was encouraged to draw what her anger felt like while loud, pulsating rock music played in the background. Astonishing herself, she drew penises, to which she then added mutilated disfigurements. Initially fearful and embarrassed about these drawings, they soon made her aware and more accepting of her rage and obvious wish for retaliation.

As she discussed her emotional reactions to the drawings, she began to describe her past abuse and the accompanying feelings. Eventually, she began to talk more openly, individually with doctors, and in groups, which afforded her the opportunity to develop mastery over these frightening experiences and to place them in proper perspective.

Borderline patients constitute as much as 20 percent of all hospitalized psychiatric patients, and BPD is far and away the most common personality disorder encountered in the hospital setting.
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The borderline's propensities for impulsivity, self-destructive behaviors (suicide, drug overdoses), and brief psychotic episodes are the usual acute precipitants of hospitalization.

The hospital provides a structured milieu to help contain and organize the borderline's chaotic world. The support and involvement of other patients and staff present the borderline with important feedback that challenges some of his perceptions and validates others.

The hospital minimizes the borderline's conflicts in the external world and provides greater opportunity for intensive self-examination. It also allows a respite from the intense relationships between the borderline and the outside world (including with his therapist), and permits diffusion of this intensity onto other staff members within the hospital setting. In this more neutral milieu the patient can reevaluate his personal goals and program of therapy.

At first, the inpatient borderline typically protests admission but by the time of discharge may be fully ensconced in the hospital setting, often fearful of discharge. He has an urgent need to be cared for, yet at the same time may become a leader of the ward trying to control and “help” other patients. At times he appears overwhelmed by his catastrophic problems; on other occasions he displays great creativity and initiative.

Characteristically, the hospitalized borderline creates a fascinating pas de deux of splitting and projective identification (see chapter 2 and Appendix B) with staff members. Some staff perceive the borderline as a pathetic but appealing gamin; others see him as a calculating, sadistic manipulator. These disparate views emerge when the patient splits staff members into all-good (supportive, understanding) and all-bad (confrontive, demanding) projections, much like he does with other people in his life. When staff members accept the assigned projections—both “good” (“You're the only one who understands me”) and “bad” (“You don't really care; you're only in it for the paycheck”)—the projective identification circle is completed: conflict erupts between the “good” staff and the “bad” staff.

Amid this struggle the hospitalized borderline recapitulates his external world interpersonal patterns: a seductive wish for protection, which ultimately leads to disappointment, then to feelings of abandonment, finally to self-destructive behaviors and emotional retreat.

Since the 1990s, increasing costs of hospital care and greater insurance restrictions have restructured hospital-based treatment programs. Most hospital admissions today are precipitated by acute, potentially dangerous crises, including suicide attempts, violent outbursts, psychotic breaks, or self-destructive episodes (drug abuse, uncontrolled anorexia/bulimia, etc.).