I Hate You—Don't Leave Me (20 page)

Higher functioning adult borderlines who do not fully recover may still have successful careers, assume traditional family roles, and have a cadre of friends and support systems. They may live generally satisfactory lives within their own separate corner of existence, despite recurrent frustrations with themselves and others who inhabit that niche.

Lower functioning borderlines, however, have more difficulty maintaining a job and friends, and may lack family and support systems; they may inhabit lonelier and more desperate “black holes” within their own personal universe.

Common to most borderlines is an element of unpredictability and erratic behavior. It may be more obvious in the lonely, isolated individual, but those who know the contented family man well can also detect inconsistencies in his behavior that belie the superficial rationality. At work, even the borderline who is a successful businessman or professional may be known by those working closely with him to be a bit strange, even if they can't quite localize what it is that projects that aura of imbalance.

As many borderlines grow older, they may “mellow out.” Impulsivity, mood swings, and self-destructive behaviors seem to diminish in dramatic intensity. This pattern might be an objective reflection of change or a subjective evaluation of those living or working with the borderline; the borderline's friends and lovers may have adjusted to his erratic actions over time and no longer notice or respond to the outrageousness.

Maybe it is because he has settled into a more routine lifestyle that no longer requires periodic outbursts—drinking binges, suicide threats, or other dramatic gestures—to achieve his needs. Perhaps with age the borderline loses the energy or stamina to maintain the frenetic pace of borderline living. Or perhaps there is simply a natural healing process that takes place for some borderlines as they mature. In any event, most borderlines get better over time, with or without treatment. Indeed, most could be considered “cured” in the sense that they no longer fulfill five of the nine defining criteria. Long-term prognosis for this devastating disease is very hopeful (see chapter 7).

Thus, those sharing life with the borderline can expect his behaviors over time to become more tolerable. At this point the unpredictable reactions become more predictable and therefore easier to manage, and it becomes possible for the borderline to learn how to love and be loved in a healthier fashion.

Seeking Therapy

I'm gonna give him one more year, and then I'm going to Lourdes.

—From
Annie Hall
, by Woody Allen, about his psychiatrist

 

 

 

Dr. Smith, a nationally known psychiatrist, had called me about his niece. She was depressed and in need of a good psychotherapist. He was calling to say that he had recommended me.

Arranging an appointment was difficult. She could not rearrange her schedule to fit my openings, so I juggled and rearranged my schedule to fit hers. I felt pressure to be accommodating and brilliant, so that Dr. Smith's faith in me would be justified. I had just opened my practice and needed some validation of my professional skills. Yet I knew that these feelings were a bad sign: I was nervous.

Julie was strikingly attractive. Tall and blond, she easily could have been a model. A law student, she was twenty-five, bright, and articulate. She arrived ten minutes late and neither apologized for nor even acknowledged this slight on her part. When I looked closely, I could see that her eye makeup was a little too heavy, as if she were trying to conceal a sadness and exhaustion inside.

Julie was an only child, very dependent on her successful parents, who were always traveling. Because she couldn't stand being alone, she cruised through a series of affairs. When a man would break off the relationship, she'd become extremely depressed until embarking on the next affair. She was now “between relationships.” Her most recent man had left her and “there was no one to replace him.”

It wasn't long before her treatment fell into a routine. As a session would near its end, she'd always bring up something important, so our appointments would end a little late. The phone calls between sessions became more frequent and lasted longer.

Over the next six weeks we met once a week, but then mutually agreed to increase the frequency to twice a week. She talked about her loneliness and her difficulties with separations, but continued to feel hopeless and alone. She told me that she often exploded in rage against her friends, though these outbursts were hard for me to imagine because she was so demure in my office. She had problems sleeping, her appetite decreased, and she was losing weight. She began to talk about suicide. I prescribed antidepressant medications for her, but she felt even more depressed and was unable to concentrate in school. Finally, after three months of treatment, she reported increasing suicidal thoughts and began to visualize hanging herself. I recommended hospitalization, which she reluctantly accepted. Clearly, more intense work was needed to deal with this unremitting depression.

The first time I saw the anger was the day of her admission, when Julie was describing her decision to come to the hospital. Crying softly, she spoke of the fear she had experienced when explaining her hospitalization to her father.

Then suddenly her face hardened, and she said, “Do you know what that bitch did?” A moment passed before I realized that Julie was now referring to Irene, the nurse who had admitted her to the unit. Furiously, Julie described the nurse's lack of attention, her awkwardness with the blood pressure cuff, and a mix-up with a lunch tray. Her ethereal beauty mutated into a face of rage and terror. I jumped when she pounded the table.

After a few days, Julie was galvanizing the hospital unit with her demands and tirades. Some of the nurses and patients tried to calm and placate her; others bristled when she threw tantrums (and objects) and walked out of group sessions
.
“Do you know what
your
patient did this morning, Doctor?” asked one nurse as I stepped onto the floor. The emphasis was clearly on the “your,” as if I were responsible for Julie's behavior and deserved the staff's reprimands for not controlling her. “You're overprotective. She's manipulating you. She needs to be confronted.”

I immediately came to my own—and Julie's—defense. “She needs support and caring,” I replied. “She needs to be re-parented. She needs to learn trust.” How dare they question my judgment! Do I dare question it?

Throughout the first few days, Julie complained about the nurses, the other patients, the other doctors. She said I was understanding and caring and I had much greater insight and knowledge than the other therapists she had seen.

After three days, Julie insisted on discharge. The nurses were skeptical; they didn't know her well enough. She hadn't talked much about herself either to them or in group therapy. She was talking only to her doctor, but she insisted her suicidal thoughts had dissipated and she needed “to get back to my life.” In the end I authorized the discharge.

The next day she wobbled into the emergency room drunk with cuts on her wrist. I had no choice but to re-admit her to the ward. Though the nurses never actually said, “I told you so,” their haughty looks were unmistakable and insufferable. I began to avoid them even more than I had until that point. I resumed Julie's therapy on an individual basis and dropped her from group sessions.

Two days later she demanded discharge. When I turned down the request, she exploded. “I thought you trusted me,” she said. “I thought you understood me. All you care about is power. You just love to control people!”

Maybe she's right, I thought. Perhaps I am too controlling, too insecure. Or was she just attacking my vulnerability, my need to be perceived as caring and trusting? Was she just stoking my guilt and masochism? Was she the victim here, or was I?

“I thought you were different,” she said. “I thought you were special. I thought you really cared.” The problem was, I thought so too.

By the end of the week the insurance company was calling me daily, questioning her continued stay. Nursing notes recorded her insistence that she was no longer self-destructive, and she continued to lobby for discharge. We agreed to dismiss her from the hospital, but have her continue in the day hospital program, in which she could attend the hospital scheduled groups during the day and go home in the afternoon. On her second day in the outpatient program she arrived late, disheveled, and hungover. She tearfully related the previous night's sleazy encounter with a stranger in a bar. The situation was becoming clearer to me. She was begging for limits and controls and structure but couldn't acknowledge this dependency. So she acted outrageously to make controls necessary, and then got angry and denied her desire for them.

I could see this, but she couldn't. Gradually I stopped looking forward to seeing her. At each session, I was reminded of my failure, and I found myself wishing that she would either get well or disappear. When she told me that maybe her old roommate's doctor would be better for her, I interpreted this as a wish to run away from herself and the real issues she faced. A change at this point would be counterproductive for her I knew, but silently I hoped that she would change doctors for
my
sake. She still talked of killing herself, and I guiltily fantasized that it would be almost a relief for me if she did. Her changes had changed me—from a masochist to a sadist.

During her third week in the day hospital, another patient hanged himself while home over the weekend. Frightened, Julie flew into a rage: “Why didn't you and these nurses know he was going to kill himself?” she screamed. “How could you let him do it? Why didn't you protect him?”

Julie was devastated. Who was going to protect
her
? Who would make the pain go away? I finally realized that it would have to be Julie. No one else lived inside her skin. No one else could totally understand and protect her. It was starting to make some sense, to me and, after a while, to Julie.

She could see that no matter how hard she tried to run away from her feelings, she could not escape being herself. Even though she wanted to run away from the bad person she thought she was, she had to learn to accept herself, flaws and all. Ultimately she would see that just being Julie was okay.

Julie's anger at the staff gradually migrated toward the suicide patient, who “didn't give himself a chance.” When she saw his responsibility, she began to see hers. She discovered that people who really cared about her did not let her do whatever she wanted, as her parents had done. Sometimes caring meant setting limits. Sometimes it meant telling her what she didn't want to hear. And sometimes it meant reminding her of her accountability to herself.

It wasn't much longer before all of us—Julie, the staff, and I—began working together. I stopped trying so hard to be likeable, wise, and unerring; it was more important to be consistent and reliable—to
be there.

After several weeks, Julie left the hospital outpatient program and returned to our office therapy. She was still lonely and afraid, but she didn't need to hurt herself anymore. Even more important, she was accepting the fact that she could survive loneliness and fear but could still care about herself.

After a while, Julie found a new man who really seemed to care about her. As for me, I learned some of the same things Julie did—that distasteful emotions determine who I am to a great extent and that accepting these unpleasant parts of myself helps me to better understand my patients.

Therapists who treat borderline personality often find that the rigors of treatment place a great strain on their professional abilities, as well as on their patience. Treatment sessions may be stormy, frustrating, and unpredictable. The treatment period proceeds at a snail-like pace and may require years to achieve true change. Many borderline patients drop out of therapy in the first few months.

Treatment is so difficult because the borderline responds to it in much the same way as to other personal relationships. The borderline will see the therapist as caring and gentle one moment, deceitful and intimidating the next.

In therapy, the borderline can be extremely demanding, dependent, and manipulative. It is not uncommon for a borderline patient to telephone incessantly between sessions and then appear unexpectedly in the therapist's office, threatening bodily harm to himself unless the therapist meets with him immediately. Angry tirades against the therapist and the process of therapy are common. Often, the borderline can be very perceptive about the sensitivity of the therapist and eventually goad him into anger, frustration, self-doubt, and hopelessness.

Given the wide range of possible contributing causes of BPD, and the extremes of behavior involved, there is a predictably wide range of treatment methods. According to the American Psychiatric Association's “Practice Guideline for the Treatment of Patients with Borderline Personality Disorder,” “The primary treatment for borderline personality disorder is psychotherapy, complemented by symptom-targeted pharmacotherapy.”
¹
Psychotherapy can take place in individual, group, or family therapy settings. It can proceed in or out of a hospital setting. Therapy approaches can be combined, such as individual and group. Some therapy approaches are more “psychodynamic,” that is, emphasize the connection between past experiences and unconscious feelings with current behaviors. Other approaches are more cognitive and directive, focused more on changing current behaviors than necessarily exploring unconscious motivations. Some therapies are time-limited, but most are open-ended.

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.