I Hate You—Don't Leave Me (18 page)

Friends and jobs became an indistinguishable blur of unsatisfying encounters. Whenever a new acquaintance or occupation disappointed in any way, Ray quit. His parents wrung their hands; Denise basically ignored him. Ray continued spinning out of control with no one to restrain him, including himself.

On the surface a borderline personality can be very difficult to identify, despite the underlying volcanic turbulence. Unlike many people afflicted with other mental disorders—such as schizophrenia, bipolar (manic-depressive) disease, alcoholism, or eating disorders—the borderline can usually function extremely well in work and social situations without appearing overtly pathological. Indeed, some of the hallmarks of borderline behavior are the sudden, unpredictable eruptions of anger, extreme suspiciousness, or suicidal depression from someone who has appeared so “normal.”

The borderline's sudden outbursts are usually very frightening and mystifying—both to the borderline himself and to those closest to him. Because of the sudden and extreme nature of certain prominent symptoms, the concerned party can be easily misled and not recognize that it is a common manifestation of
BPD
rather than a separate primary illness. For example, a person who attempts to kill himself by overdosing or cutting his wrists may be diagnosed with depression and prescribed antidepressant medications and brief, supportive psychotherapy. If the patient is suffering from a chemical depression, this regimen should improve his condition and he should recover relatively quickly and completely. If, however, the destructive behaviors have been triggered by BPD, his self-harming will continue, unabated by the treatment. Even if he is both depressed and borderline (a common combination), this approach will only partially treat the illness and further problems will ensue. If the borderline features are not recognized, the continuation of suicidal or other destructive behaviors, despite treatment, becomes puzzling and frustrating for the patient, the doctor, and everyone concerned.

Abby, a twenty-three-year-old fashion model, was treated in a chemical dependency unit for alcoholism. She responded very well to this program, but as she continued to abstain from alcohol, she became increasingly, compulsively bulimic. She then entered an eating-disorders unit where she was again successfully treated.

A few weeks later, she began experiencing severe panic attacks in stores, offices, even while driving in her car, and eventually became afraid to leave her house. In addition to these phobias, she was becoming more depressed. As she considered entering a phobia clinic, a psychiatric consultant recognized all of her symptoms to be representative of BPD and recommended instead that she enter a psychiatric unit specializing in borderline conditions. Where her previous treatments had focused exclusively on alcoholism or bulimia, this hospitalization took a more holistic view of her life and treatment.

Eventually, Abby was able to connect her problems to her continued ambivalent relationship with her parents, who had interfered with her attempts to separate, mature, and be more independent. She realized that her various illnesses were really means to escape her parents' demands without guilt. Her bulimia, drinking, and anxieties occupied all her energy, distracting her from addressing the conflicts with her parents. What's more, her “sick” role excused her from even feeling obligated to work on this relationship. Ironically, the illnesses also kept her
attached
to her parents: Because they had serious marital problems (her mother was an alcoholic and her father was chronically depressed), she could stay close to them by replicating their pathological roles.

After a brief hospitalization she continued individual outpatient psychotherapy. Her mood improved and her anxieties and phobias dissolved. She also continued to abstain from alcohol and purging.

Abby's case illustrates how a consuming, prominent behavior may actually represent and camouflage underlying BPD, in which one or more of its features—unstable relationships, impulsivity, mood shifts, intense anger, suicidal threats, identity disturbances, feelings of emptiness, or frantic efforts to avoid abandonment—result in psychiatric symptoms that might mistakenly lead to incomplete diagnosis or even misdiagnosis.

It is important to remember that BPD is an illness, not a willful attempt to get attention. The borderline lacks the boots, much less the bootstraps, with which to pull himself up. It is useless to get angry or to cajole and plead with the borderline to change; without help and motivation he cannot easily modify his behavior.

However, this does not imply that the borderline is helpless and should not be held responsible for his conduct. Actually, the opposite is true. He must accept, without being excused or protected, the real consequences of his actions, even though initially he may be powerless to alter them. In this way, BPD is no different from any other handicap. The individual confined to a wheelchair will elicit sympathy, but he is still responsible for finding wheelchair accessibility to the places he wishes to go, and for keeping his vehicle in good enough condition to take him there.

The borderline's extremes of behavior typically lead to either a hard-nosed “You lazy good-for-nothing SOB, pull yourself together and fly right” response, or a cajoling “You poor baby, you can't do it; I'll take care of you” pat on the head. All must be aware of how their interactions may encourage or inhibit borderline behaviors. Those who interact with a borderline must attempt to walk a very thin line between, on the one hand, providing reassurance of the borderline's worthiness and, on the other, confirming the necessary expectations. They must try to respond supportively, but without overreacting. Affection and physical touching, such as hugging and holding a hand, can communicate to the borderline that he is a valued person, but if it is exploitative, it will hinder trust. If caring results in overprotectiveness, the borderline stops feeling responsible for his behavior.

In most settings, concentrating on the
Truth
segments of SET-UP principles (see chapter 5) can allow for reasonable guidelines. But when suicide is threatened, it is usually time to contact a mental health professional or suicide-prevention facility. Suicide threats should not be allowed to become “emotional blackmail,” whereby the friend or relation is manipulated to behave as the borderline demands. Threats should be taken seriously and met with prompt, predictable, realistic reactions, such as demanding that the borderline obtain professional help (a
Truth
response).

Jack, a forty-one-year-old single man, worked part-time while attempting to return to school. His widowed mother continued to support him financially, and whenever he failed at work, school, or with a relationship, she would reinforce his helplessness, by insisting he could not succeed in achieving his goals and suggesting he return “home” to live with her. Therapy involved not only helping Jack understand his wish to remain helpless and reap the inherent benefits of helplessness but also confronted his mother's need to maintain control, and her role in perpetuating his dependency.

It takes only one actor in the drama to initiate change. Jack's mother can respond to his dependency with SET-UP responses that express her caring (
Support
), understanding (
Empathy
), and acknowledgment of reality (
Truth
)—the need for Jack to take responsibility for his own actions. If his mother is unwilling to alter her behavior, Jack must recognize her role in his problems and distance himself from her.

After a while, for someone close to a borderline, unpredictable behaviors may become commonplace and therefore “predictably unpredictable.” One of the most common, the angry outburst, usually comes with no warning and appears way out of proportion.

The close friend, relation, or coworker should resist the temptation to “fight fire with fire.” The louder and angrier the borderline gets, the quieter and more composed the other person should become, thereby refusing to collaborate in aggravating the emotional atmosphere, and spotlighting the comparative outlandish intensity of the borderline's rage. If the concerned individual senses the potential for physical violence, he should leave the scene immediately. Borderline rage often cannot be reasoned with, so discussion and debate are unnecessary and may only inflame the situation. Instead, one should try to cool off the conflict by acknowledging the difference in opinion and agreeing to disagree. Further discussion can come later when the atmosphere is more settled.

Rapid mood changes can be equally perplexing to the borderline and to those around him. From an early age, Meredith had always been aware of her moodiness. Without reason she could soar to great heights of excitement and joy, only to plummet, without warning, to the lower reaches of despair. Her parents indulged her moodiness by tiptoeing softly around her, never challenging her irritability. In school, friends would come and go, put off by her unpredictability. Some called her “the manic-depressive” and tried to kid her out of her surliness.

Her husband, Ben, said he was attracted to her “kindness” and “sense of fun.” But Meredith could change dramatically, from playful to suicidal. Similarly, her interactions with Ben would change from joyful sharing to gloomy isolation. Her moods were totally unpredictable, and Ben was never sure how he would find her upon his return at the end of the day. At times he felt that he should enter their home by putting his hat on a stick and poking it into the doorway to see if it would be embraced, ignored, or shot at.

Ben was locked into a typical borderline “damned if you do and damned if you don't” scenario. Confronting her depression would prompt more withdrawal and anger, but ignoring it might show lack of concern. Relying on SET-UP principles, however, would address his dilemma by insisting on Meredith's input into how he (and others) should react to her moods.

For Meredith, these shifts in mood, unresponsive to a variety of medications, were equally distressing. Her task was to recognize such swings, take responsibility for having them, and learn to adapt by compensating for their presence. When in a state of depression, she could subsequently identify it and learn to explain to others around her that she was in a down phase and would try to function as well as she could. If she was with people to whom she could not comfortably explain her situation, Meredith could maintain a low profile and actively try to avoid dealing with some of the demands on her. A major goal would involve establishing constancy—consistent, reliable attitudes and behaviors—toward herself and others.

Impulsive acts can be extremely frustrating for the borderline's friends and relations, particularly if the acts are self-destructive. Impulsivity is especially unnerving when it emerges (as it often does) at a relatively stable point in the borderline's life. Indeed, impulsive behaviors may emanate precisely because life is settling and the borderline feels uncomfortable in a crisis-free state.

Larry, for example, was in a marriage that was comfortably boring. Married for over twenty years, he and Phyllis rarely interacted. She reared their sons while Larry toiled for a large company. His life was a self-imposed prison of daily routine and compulsive behaviors. He took hours to dress, in order to arrange his clothing just so. At night before bed, he engaged in rituals to maintain a sense of control—the closet doors had to be opened in a special way, the bathroom sink had to be carefully cleaned, and the soap and toilet articles arranged in a certain pattern.

But within this tightly regimented routine, Larry would impulsively get drunk, pick fights, or abruptly leave town for an entire day without warning. On two occasions he impulsively overdosed on his heart medicine “to see what it felt like.” Usually he would absorb Phyllis's anger by turning somber and quiet, but every so often he would strike out at her, frequently over trivial matters.

He would remain dry for several months and then, just as he was receiving praise for abstaining, he would get abusively and loudly drunk. His wife, friends, and counselors pleaded and threatened, but to no avail.

SET-UP techniques might help Phyllis deal with Larry's impulsivity. Rather than beg and threaten, she might emphasize her caring for Larry (
Support
) and her growing realization that he is becoming more and more dissatisfied with his life (
Empathy
).
Truth
statements would communicate her own unhappiness with their current situation and the crucial need to do something about it, such as enter therapy.

It is also often helpful to be able to predict impulsive behaviors from past experiences. For example, after a period of sobriety, Phyllis might remind Larry, in a neutral, matter-of-fact way, that in the past, when things have gone well, he has built up pressures that have exploded into drinking binges. By pointing out previous patterns, one can help the borderline become more aware of feelings that preview the onset of impulsivity. This should be accompanied by
Support
statements, so it is not interpreted as defeating, “there you go again” criticism. In such a way, the borderline learns that behaviors that he has perceived as chaotic and unpredictable can actually be anticipated, understood, and thereby controlled. However, even if the borderline does feel criticized, predicting can stimulate a contrariness that motivates her to not repeat destructive patterns, “just to show you!”

Finally, in therapy, Larry began to see that his seemingly unpredictable behaviors represented anger at himself and others. He realized how he would become abusive to his wife or begin drinking when frustrated with himself. This impulsive behavior would result in guilt and self-chastisement, which, in turn, served to expiate his sins. As Larry began to value himself more highly and respect his own ideals and beliefs, his destructive activities diminished.