Some treatments are usually avoided. Strict behavior modification is seldom utilized. Classical psychoanalysis on the couch with use of “free association” in an unstructured environment can be devastating for the borderline whose primitive defenses may be overwhelmed. Because hypnosis can produce an unfamiliar trance state resulting in panic or even psychosis, it is also usually avoided as a therapeutic technique.

Goals of Therapy

All treatment approaches strive for a common goal: more effective functioning in a world that is experienced as less mystifying, less harmful, and more pleasurable. The process usually involves developing insight into the unproductiveness of current behaviors. This is the easy part. More difficult is the process of reworking old reflexes and developing new ways of dealing with life’s stresses.

The most important part of any therapy is the relationship between the patient and therapist. This interaction forms the foundation for trust, object constancy, and emotional intimacy. The therapist must become a trusted figure, a mirror to reflect a developing consistent identity. Starting with this relationship, the borderline learns to extend to others appropriate expectations and trust.

The primary goal of the therapist is to work toward losing (not keeping) his patient. This is accomplished by directing the patient’s attention to certain areas for examination, not by controlling him. Though the therapist serves as the navigator, pointing out landscapes of interest and helping to re-route the itinerary around storm conditions, it is the patient who must remain firmly in the pilot’s seat. Family and loved ones are also sometimes included on this journey. A major objective is for the patient to return home and improve relationships, not to abandon them.

Some people are fearful of psychiatry and psychotherapy, perceiving the process as a form of “mind control” or behavior modification perpetrated on helpless, dependent patients who are molded into robots by bearded, Svengali-like mesmerists. The aim of psychotherapy is to help a patient individuate and achieve more freedom and personal dignity. Unfortunately, just as some people erroneously believe that you can be hypnotized against your will, so some believe you can be “therapized” against your will. Popular culture, especially cinema, frequently portrays the “shrink” as either a bumbling fool, more in need of treatment than his patients, or a nefarious, brilliant criminal. Such irrational fears may deprive people of opportunities to escape self-imposed captivity and achieve self-acceptance.

Length of Therapy

Because of the past prominence of psychoanalysis, which characteristically requires several years of intensive, frequent treatment, most people view any form of psychotherapy as being extended and drawn out, and therefore very expensive. The addition of medications and specialized treatments to the therapeutic armamentarium are responses to the need for practical and affordable treatment methods. Broken bones heal and infections clear up, but scars on the psyche may require longer treatment.

If therapy terminates quickly, one may question if it was too superficial. If it extends for many years, one may wonder if it is merely intellectual game playing that enriches psychotherapists while financially enslaving their dependent and helpless patients.

How long should therapy last? The answer depends on the specific goals. Resolution of specific, targeted symptoms—such as depression, severe anxiety, or temper outbursts—may be accomplished in relatively brief time spans, such as weeks or months. If the goal is more profound restructuring, a longer duration will be required. Over time BPD is usually “cured.” This means that the patient, by strict definition, no longer exhibits five of the nine defining DSM-IV criteria. However, some individuals may continue to suffer from disabling symptoms, which can require continued treatment.

Therapy may be interrupted. It is not unusual for borderlines to engage in several separate rounds of therapy, with different therapists and different techniques. Breaks in therapy may be useful to solidify ideas, or to try out new insights, or merely to catch up with life and allow time to grow and mature. Financial limitations, significant life changes, or just a need for a respite from the intensity of treatment may mandate a time-out. Sometimes years of therapy may be necessary to achieve substantive changes in functioning. When the changes come slowly, it can be difficult to determine whether more work should proceed, or if “this is as good as it gets.” The therapist must consider both the borderline’s propensity to run from confrontations with his unhealthy behaviors and his tendency to cling dependently to the therapist (and others).

For some borderlines, therapy may never formally end. They may derive great benefit from continuing intermittent contacts with a trusted therapist. Such arrangements would be considered “refueling stops” on the road to greater independence, provided the patient does not rely on these contacts to drive his life.

How Psychotherapy Works

As we shall see later in this and the next chapter, there are several established therapeutic approaches for the treatment of BPD. They may proceed in individual, group, or family settings. Most of these are derived from two primary orientations: psychodynamic psychotherapy and cognitive-behavioral therapy. In the former, discussion of the past and present are utilized to discover patterns that may forge a more productive future. This form of therapy is more intensive, with sessions conducted several times a week and usually continuing for a longer period. Effective therapy must employ a structured, consistent format with clear goals. Yet there must also be flexibility to adapt to changing needs. Cognitive-behavioral approaches focus on changing current thinking processes and repetitive behaviors that are disabling; this type of therapy is less concerned about the past. Treatment is more problem-focused and often time-limited. Some therapy programs combine both orientations.

Whatever the structure, the therapist tries to guide clients to examine their experience and serves as a touchstone for experimenting with new behaviors. Ultimately, the patient begins to accept his own choices in life and to change his self-image as a helpless pawn moved by forces beyond his control. Much of this process emerges from the primary relationship between therapist and patient. Often, in any therapy, both develop intense feelings, called transference and countertransference.

Transference

Transference refers to the patient’s unrealistic projections onto the therapist of feelings and attitudes previously experienced from other important persons in the patient’s life. For example, a patient may get very angry with the doctor, based not on the doctor’s communications, but on feelings that the doctor is much like his mother, who in the past elicited much anger from him. Or, a patient may feel she has fallen in love with her therapist, who represents a fantasied, all-powerful, protective father figure. By itself, transference is neither negative nor positive, but it is always a distortion, a projection of past emotions onto current objects.

Borderline transference is likely to be extremely inconsistent, just like other aspects of the patient’s life. The borderline will see the therapist as caring, capable, and honest one moment, deceitful, devious, and unfeeling the next. These distortions make the establishment of an alliance with the therapist most difficult. Yet establishing and sustaining this alliance is the most important part of any treatment.

In the beginning stages of therapy, the borderline both craves and fears closeness to the therapist. He wants to be taken care of but fears being overwhelmed and controlled. He attempts to seduce the doctor into taking care of him and rebels against his attempts to “control his life.” As the therapist remains steadfast and consistent in withstanding his tirades, object constancy develops—the borderline begins to trust that the therapist will not abandon him. From this beachhead of trust, the borderline can venture out with new relationships and establish more trusting contacts. Initially, however, such new friendships can be difficult to sustain for the borderline, who, in the past, may have perceived his formation of new alliances as a form of disloyalty. He may even fear that his mate, friend, or therapist may become jealous and enraged if he broadens his social contacts.

As the borderline progresses, he settles into a more comfortable, trusting dependency. As he prepares for termination, however, there may again be a resurgence of turmoil in the relationship. He may pine for his previous ways of functioning and resent needing to proceed onward; he may feel like a tiring swimmer who realizes he has already swum more than halfway across the lake, and now rather than return to the shore must continue on to the other side before resting.

At this point the borderline must also deal with his separate-ness and recognize that he, not the therapist, has effected change. Like Dumbo, who first attributes his flying ability to his “magic feather” but then realizes it is due to his own talents, the borderline must begin to recognize and accept his own abilities to function independently. And he must develop new coping mechanisms to replace the ones that no longer work.

As the borderline improves, the intensity of the transference diminishes. The anger, impulsive behaviors, and mood changes—often directed at, or for the benefit of, the therapist—become less severe. Panicky dependency may gradually wither and be replaced by a growing self-confidence; anger erupts less often, replaced by greater determination to be in charge of one’s own life. Impatience and caprice diminish, because the borderline begins to develop a separate sense of identity that can evolve without the need for parasitic attachment.

Countertransference

Countertransference refers to the therapist’s own emotional reactions to the patient, which are based less on realistic considerations than on the therapist’s past experiences and needs. An example is the doctor who perceives the patient as more needy and helpless than is truly the case because of the doctor’s need to be a caretaker, to perceive himself as compassionate, and to avoid confrontation.

The borderline is often very perceptive about others, including the therapist. This sensitivity often provokes the therapist’s own unresolved feelings. The doctor’s needs for appreciation, affection, and control can sometimes prompt him into inappropriate behavior. He may be overly protective of the patient and encourage dependency. He may be overly controlling, demanding that the patient carry out his recommendations. He may complain of his own problems and induce the patient to take care of him. He may extract information from the patient for financial gain or mere titillation. He may even enter into a sexual relationship with the patient “to teach intimacy.” The therapist may rationalize all these as necessary for a “very sick” patient, but in reality they are satisfying his own needs. It is these countertransference feelings that result in most examples of unethical behavior between a trusted doctor or therapist and patient.

The borderline can provoke feelings of anger, frustration, self-doubt, and hopelessness in the therapist that mirror his own. Goaded into emotions that challenge his professional self-worth, the therapist may experience genuine countertransference hate for the patient and view him as untreatable. Treatment of the borderline personality can be so infuriating that the term “borderline” has been inaccurately used sometimes by professionals as a derogatory label for any patient who is extremely irritating or who does not respond well to therapy. In these cases “borderline” more accurately reflects the countertransference frustration of a therapist than a scientific diagnosis of his patient.

The Patient-Therapist “Fit”

All of the treatments described in this book can be productive approaches to the borderline patient, though no therapeutic techniques have been shown to be uniformly curative in all cases. The only factor that seems to correlate consistently with improvement is a positive, mutually respectful relationship between patient and therapist.

Even when a doctor is successful in treating one or many borderline patients, this does not guarantee automatic success in treating others. The primary determining factor of success is usually a positive, optimistic feeling shared between the participants—a kind of patient-therapist “fit.”

A good fit is difficult to define precisely, but refers to the abilities of both the patient and therapist to tolerate the predictable turbulence of therapy, while maintaining a sturdy alliance as therapy proceeds.

The Therapist’s Role

Because treatment of BPD may entail a combination of several therapies—individual, group, and family psychotherapies, medications, and hospitalization—the therapist’s role in treatment may be as varied as the different therapies available. The doctor may be confrontational or nondirective; he may either spontaneously exhort and suggest or initiate fewer exchanges and expect the patient to assume a heavier burden for the therapy process. More important than the particular doctor or treatment method is the feeling of comfort and trust experienced by both patient and therapist. Both must perceive commitment, reliability, and true partnership from the other.

To achieve this feeling of mutual comfort, both patient and doctor must understand and share common objectives. They should agree upon methods and have compatible styles. Most important, the therapist must recognize when he is treating a borderline patient.

The therapist should suspect that he is dealing with BPD when he takes on a patient whose past psychiatric history includes contradictory diagnoses, multiple past hospitalizations, or trials of many medications. The patient may report being “kicked out” of previous therapies and becoming persona non grata in the local emergency room, having frequented the ER enough times to have earned a nickname (such as “Overdose Eddie”) from the medical staff.

The experienced doctor will also be able to trust his countertransference reactions to the patient. Borderlines usually elicit very strong emotional reactions from others, including therapists. If early on in the evaluation, the therapist experiences strong feelings of wanting to protect or rescue the patient, of responsibility for the patient, or of extreme anger toward the patient, he should recognize that his intense responses may signify reactions to a borderline personality.

Choosing a Therapist

Therapists with differing styles may perform equally well with borderlines. Conversely, doctors who possess special expertise or interest in BPD and who generally do well with borderline patients cannot guarantee success with every patient.

A patient can choose from a variety of mental health professionals. Though psychiatrists, following their medical training, have years of exposure to psychotherapy techniques (and, as physicians, are the only professionals capable of dealing with concurrent medical illnesses, prescribing medications, and arranging hospitalization), other skilled professionals—psychologists, social workers, counselors, psychiatric nurse-clinicians—may also attain expertise in psychotherapy with borderline patients.

In general, a therapist who works well with BPD possesses certain qualities that a prospective patient can usually recognize. He should be experienced in the treatment of BPD and remain tolerant and accepting in order to help the patient develop object constancy (see chapter 2). He should be flexible and innovative, in order to adapt to the contortions through which therapy with a borderline may twist him. He should possess a sense of humor, or at least a clear sense of proportion, to present an appropriate model for the patient and to protect himself from the relentless intensity that such therapy requires.

Just as the doctor evaluates the patient during the initial assessment interviews, so should the patient evaluate the doctor to determine if they can work together effectively.

First, the patient should consider whether he is comfortable with the therapist’s personality and style. Will he be able to talk with him openly and candidly? Is he too intimidating, too pushy, too wimpy, too seductive?

Secondly, do the therapist’s assessment and goals coincide with the patient’s? Treatment should be a collaboration in which both parties share the same view and use the same language. What should therapy hope to achieve? How will you know when you get there? About how long should it take?

Finally, are the recommended methods acceptable to the patient? There should be agreement on the type of psychotherapy advocated and the suggested frequency of meetings. Will the doctor and patient meet individually or together with others? Will there be a combination of approaches, which might include, say, individual therapy on a weekly basis, along with intermittent conjoint meetings with the spouse? Will therapy be more exploratory or more supportive? Will medications or hospitalization likely be employed? What kinds of medicines and which hospitals?

This initial assessment period usually requires at least one interview, often more. Both the patient and the doctor should be evaluating their ability and willingness to work with the other. Such an evaluation should be recognized as a kind of “no-fault” interchange: it is irrelevant and probably impossible to blame the therapist or the patient for the inability to establish rapport. It is necessary only to determine whether a therapeutic alliance is possible. However, if a patient continues to find every psychotherapist he interviews unacceptable, his commitment to treatment should be questioned. Perhaps he is searching for the “perfect” doctor who will take care of him or whom he can manipulate. Or he should consider the possibility that he is merely avoiding therapy and should perhaps choose an admittedly imperfect doctor and get on with the task of getting better.

Obtaining a Second Opinion

Once therapy is under way, it is not unusual for treatment to stop and start, or for the form of therapy to change over time. Adjustments may be necessary because the borderline may require changes in his treatment as he progresses.

Sometimes, however, it is difficult to distinguish when therapy is stuck from when it is working through painful issues; it is sometimes difficult to separate dependency and fear of moving on from the agonizing realization of unfinished business. At such times there will arise a question of whether to proceed along the same lines or to take a step back and regroup. Should treatment begin to involve family members? Should group therapy be considered? Should therapist and patient reevaluate medications? At this point a consultation with another doctor may be indicated. Often the treating therapist will suggest this, but sometimes the patient must consider this option on his own.

Although the patient may fear that a doctor is offended by a request for a second opinion, a competent and confident therapist would not object to, or be defensive about, such a request. It is, however, an area for exploration in the therapy itself, in order to assess whether the patient’s wish for a second evaluation might constitute a running away from difficult issues or represent an unconscious angry rebuke. A second opinion may be helpful for both the patient and the doctor in providing a fresh outlook on the progress of treatment.

Getting the Most from Therapy

Appreciating treatment as a collaborative alliance is the most important step in maximizing therapy. The borderline frequently loses sight of this primary principle. Instead, she sometimes approaches treatment as if the purpose were to please the doctor or to fight with him, to be taken care of or to pretend to have no problems. Some patients look at therapy as the opportunity to get away, get even, or get an ally. But the real goal of treatment should be to get better.

The borderline may need to be frequently reminded of the parameters of therapy. He should understand the ground rules, including the doctor’s availability and limitations, the time and resource constraints, and the agreed-upon mutual goals.

The patient must not lose sight of the fact that he is bravely committing himself, his time, and his resources to the frightening task of trying to understand himself better and to effect alterations in his life pattern. Honesty in therapy is therefore of paramount importance for the patient’s sake. He must not conceal painful areas or play games with the therapist to whom he has entrusted his care. He should abandon his need to control, or wish to be liked by, the therapist. In the borderline’s quest to satisfy a presumed role, he may lose sight of the fact that it is not his obligation to please the therapist but to work with him as a partner.

Most important, the patient should always feel that he is actively collaborating in his treatment. He should avoid either the extreme of assuming a totally passive role, deferring completely to the doctor, or that of becoming a competitive, contentious rival, unwilling to listen to contributions from the therapist. Molding a viable relationship with the therapist becomes the borderline’s first and, initially, most important task in embarking on a journey toward mental health.

Therapeutic Approaches

Many clinicians divide therapy orientations into exploratory and supportive treatments. Though both styles overlap, they are distinguished by the intensity of therapy and the techniques utilized. As we will see in the next chapter, a number of therapy strategies are used for the treatment of BPD. Some employ one style or the other; some combine elements of both.

Exploratory Therapy

Exploratory psychotherapy is a modification of classical psychoanalysis. Sessions are usually conducted two or more times per week. This form of therapy is more intensive than supportive therapy (see page 161), and has a more ambitious goal—to alter personality structure. The therapist provides little direct guidance to the patient, utilizing confrontation instead to point out the destructiveness of specific behaviors and to interpret unconscious precedents in the hopes of eradicating them.

As in less intensive forms of therapy, a primary focus is on here-and-now issues. Genetic reconstruction, with its concentration on childhood and developmental issues, is important, but emphasized less than in classical psychoanalysis. The major goals in the early, overlapping stages of treatment are to diminish behaviors that are self-destructive and disruptive to the treatment process (including prematurely terminating therapy), to solidify the patient’s commitment to change, and to establish a trusting, reliable relationship between patient and doctor. Later stages emphasize the processes of formulating a separate, self-accepting sense of identity, establishing constant and trusting relationships, and tolerating aloneness and separations (including those from the therapist) adaptively.² ^,³

Transference in exploratory therapy is more intense and prominent than in supportive therapy. Dependency on the therapist, together with idealization and devaluation, are experienced more passionately, as in classical psychoanalysis.

Supportive Therapy

Supportive psychotherapy is usually conducted on a once-weekly basis. Direct advice, education, and reassurance replace the confrontation and interpretation of unconscious material typically used in exploratory therapy.

This approach is meant to be less intense and to bolster more adaptive defenses than exploratory therapy. In supportive psychotherapy the doctor may reinforce suppression, discouraging discussion of painful memories that cannot be resolved. Rather than question the roots of minor obsessive concerns, the therapist may encourage them as “hobbies” or minor eccentricities. For example, a patient’s need to keep his apartment spotless may not be dissected as to causes, but be acknowledged as a useful means to retain a sense of mastery and control when feeling overwhelmed. This contrasts with psychoanalysis, in which the aim is to analyze defenses and then eradicate them.

Focusing on current, more practical issues, supportive therapy tries to quash suicidal and other self-destructive behaviors rather than to explore them fully. Impulsive actions and chaotic interpersonal relationships are identified and confronted, without necessarily acquiring insight into the underlying factors that caused them.

Supportive therapy may continue on a regular basis for some time before dwindling to an as-needed frequency. Intermittent contacts may continue indefinitely, and the therapist’s continued availability may be very important. Therapy gradually terminates when other lasting relationships form and gratifying activities become more important in the patient’s life.

In supportive therapy the patient tends to be less dependent on the therapist and to form a less intense transference. Though some clinicians argue that this form of therapy is less likely to institute lasting change in borderline patients, others have induced significant behavioral modifications in borderline patients with this kind of treatment.

Group Therapies

Treating the borderline in a group makes perfect sense. A group allows the borderline patient to dilute the intensity of feelings directed toward one individual (such as the therapist) by recognizing emotions stimulated by others. In a group the borderline can more easily control the constant struggle between emotional closeness and distance; unlike individual therapy, in which the spotlight is always on him, the borderline can attract or avoid attention in a group. Confrontations by other group members may sometimes be more readily accepted than those from the idealized or devalued therapist, because a peer may be perceived as someone “who really understands what I’m going through.” The borderline’s demanding nature, egocentrism, isolating withdrawal, abrasiveness, and social deviance can all be more effectively challenged by group peers. In addition, the borderline may accept more readily the group’s expressions of hope, caring, and altruism.⁴^,⁵^,⁶

The progress of other group members can serve as a model for growth. When a group patient attains a goal, he serves as an inspiration to others in the group, who have observed his growth and have vicariously shared his successes. The rivalry and competition so characteristic of borderline relationships are vividly demonstrated within the group setting and can be identified and addressed in ways that would be inaccessible in individual therapy. In a mixed group (that is, one containing lower and higher functioning borderlines or non-borderlines), all participants may benefit. Healthier patients can serve as models for more adaptive ways of functioning. And, for those who have difficulty expressing emotion, the borderline can reciprocate by demonstrating greater access to emotion. Finally, a group provides a living, breathing experimental laboratory in which the borderline can attempt different patterns of behavior with other people, without the risk of penalties from the “outside world.”

However, the features that make group therapy a potentially attractive treatment for borderlines are the very reasons many such patients resist group settings. The demand for individual attention, the envy and distrust of others, the contradictory wish for, and fear of, intense closeness all contribute to the reluctance of many borderline patients to enter group treatment. Higher functioning borderlines can tolerate these frustrations of group therapy and use the “in vivo” experiences to address defects in interrelating. Lower functioning borderlines, however, often will not join and, if they do, will not stay.

The borderline patient may experience significant obstacles in psychodynamic group therapy. His self-absorption and lack of empathy often prevent involvement with others’ problems. If the borderline’s concerns are too deviant or the material too intense, he may feel isolated and disconnected. For example, a patient who discusses childhood incest, or deviant sexual practices, or severe chemical abuse may fear that he may shock the other group members. And, indeed, some members may have difficulty relating to upsetting material. Some borderlines may share the feeling that their needs are not being met by the therapist. In such situations they may attempt to take care of each other in the ways that they fantasized they could be cared for. This may lead to contacts between patients outside of the group setting and perpetuation of dependency needs as they try to “treat” each other. Romances or business dealings between group members usually end disastrously, because these patients will not be able to use the group objectively to explore the relationship, which is often a continuation of unproductive searches to be cared for.

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 Therapies

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.⁷ 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.

Artistic and Expressive Therapies

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.

Hospitalization

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.⁸ 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.

Acute Hospitalization

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.).

Short-term hospitalization usually lasts for several days. A complete physical and neurological assessment is performed. The hospital milieu focuses on structure and limit-setting. Support and positive rapport are emphasized. Treatment concentrates on practical, adaptive responses to turmoil. Vocational and daily living skills are evaluated. Conjoint meetings with family, when appropriate, are initiated. A formalized contract between patient and staff may help solidify mutual expectations and limits. Such a contract may outline the daily therapy program, which the patient is obligated to attend, and the patient’s specific goals for the hospitalization, which the staff agrees to address with him.

The primary goals of short-term hospitalization include resolving the precipitating crises and terminating destructive behaviors. For example, the spouse of a patient who has thoughts of shooting himself will be asked to remove guns from the house. Personal and environmental strengths are identified and bolstered. Important treatment issues are uncovered or reevaluated, and modifications of psychotherapy approaches and medications may be recommended. Deeper exploration of these issues is limited on a short-term, inpatient unit, and is more thoroughly pursued on an outpatient basis or in a less intensive program, such as partial hospitalization (see page 174). Since the overriding concern is to return the patient to the outside world as quickly as possible and avoid regression or dependence on the hospital, plans for discharge and aftercare commence immediately upon admission.

Long-Term Hospitalization

Today, extensive hospitalization has become quite rare and is reserved for the very wealthy or for those with exceptional insurance coverage for psychiatric illness. In many cases where continued, longer-term care is indicated, but confinement in a twenty-four-hour residence is not necessary, therapy can continue in a less restrictive milieu, such as partial hospitalization. Proponents of long-term hospitalization recognize the dangers of regression to a more helpless role, but argue that true personality change requires extensive and intensive treatment in a controlled environment. Indications for long-term confinement include chronically low motivation, inadequate or harmful social supports (such as enmeshment in a pathological family system), severe impairments in functioning that preclude holding a job or being self-sufficient, and repeated failures at outpatient therapy and short hospitalizations. Such features make early return to the outside environment unlikely.

During longer hospitalizations, the milieu may be less highly structured. The patient is encouraged to assume more shared responsibility for treatment. In addition to current, practical concerns, the staff and patient explore past, archetypal patterns of behavior and transference issues. The hospital can function like a laboratory, in which the borderline identifies specific problems and experiments with solutions in his interactions with staff and other patients.

Eventually, Jennifer (see chapter 1) entered a long-term hospital. She spent the first few months in the closet—literally and figuratively. She would often sit in her bedroom closet, hiding from the staff. After a while she became more involved with her therapist, getting angry at him and attempting to provoke his rage. She alternately demanded and begged to leave. As the staff held firm, she talked more about her father, how he was like her husband, how he was like all men. Jennifer began to share her feelings with the female staff, something that had always been difficult because of her distrust of and disrespect for women. Later during the hospitalization, she decided to divorce her husband and give up custody of her son. Although these actions hurt her, she considered them “unselfish selfishness”—trying to take care of herself was the most self-sacrificing and caring thing she could do for those she loved. She eventually returned to school and obtained a professional degree.

The goals of longer hospitalization extend those of short-term care—not only to identify dysfunctional areas but also to modify these characteristics. Increased control of impulses, fewer mood swings, greater ability to trust and relate to others, a more defined sense of identity, and better tolerance of frustration are the clearest signs of a successful hospital treatment. Educational and vocational objectives may be achieved during an extensive hospitalization. Many patients are able to begin a work or school commitment while transitioning from the hospital. Changes in unhealthy living arrangements—moving out of the home, divorce, etc.—may be completed.

The greatest potential hazard of long-term hospitalization is regression. If staff do not actively confront and motivate the patient, the borderline can become mired in an even more helpless position, in which he is even more dependent on others to direct his life.

Partial Hospitalization

Partial (or day) hospital care is a treatment approach in which the patient attends hospital activities during part or most of the day and then returns home in the evening. Partial hospital programs may also be held in the evening, following work or school, and may allow sleeping accommodations when alternatives are not available.

This approach allows the borderline to continue involvement in the hospital program, benefitting from the intensity and structure of hospital care, while maintaining an independent living situation. Hospital dependency occurs less frequently than in long-term hospitalization. Because partial hospitalization is usually much less expensive than traditional inpatient care, it is usually preferred for cost considerations.

Borderlines who require more intensive care, but not twenty-four-hour supervision, who are in danger of severe regression if hospitalized, who are making a transition out of the hospital to the outside world, who must maintain vocational or academic pursuits while requiring hospital care, or who experience severe financial limitations on care may all benefit from this approach. The hospital milieu and therapy objectives are similar to those of the associated inpatient program.

The Rewards of Treatment

As we shall see in the next two chapters, treatment of BPD usually combines standardized psychotherapeutic approaches and medications targeting specific symptoms. While at one time BPD was thought to be a diagnosis of hopelessness and irritation, we now know that the prognosis is generally much better than previously thought. And we know that most of these patients leave the chaos of their past and go on to productive lives.

The process of treatment may be arduous. But the end of the journey opens up new vistas.

“You always spoke of unconditional acceptance,” said one borderline patient to her therapist, “and somewhere in the recent past I finally began to feel it. It’s wonderful. . . . You gave me a safe place to unravel—to unfold. I was lost somewhere inside my mind. You gave me enough acceptance and freedom to finally let my true self out.”