Psychotherapy With Borderline Patients

An Integrated Approach

David M. Allen

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781351552844
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Patients with borderline personality disorder (BPD) or borderline traits are among the most difficult for mental health practitioners to treat. They present an incredible range of symptoms, dysfunctional interpersonal interactions, provocative behavior in therapy, and comorbid psychiatric disturbances. So broad is this array that indeed the disorder constitutes a virtual model for the study of all forms of self-destructive and self-defeating behavior patterns. Psychotherapy With Borderline Patients: An Integrated Approach fills the need for a problem-focused, clinically oriented, and operationalized treatment manual that addresses major ongoing family factors that trigger and reinforce the patient's self-destructive or self-defeating behavior. In it, David Allen draws on the theoretical ideas and techniques of biological, family systems, psychodynamic, and cognitive-behavioral therapists to describe an integrated approach to adults with BPD or borderline traits in individual therapy. Innovative, practical, and specific, the book * helps therapists teach their patients, through the use of various role-playing techniques, strategies to alter the dysfunctional patterns of interaction with their families of origin that reinforce self-destructive behavior or chronic affective symptoms; * explains the nature and origins of the characteristic oscillation of hostile over- and underinvolvement between adults with BPD and those who served as their primary parental figures during childhood; * elucidates the nature and causes of the dysfunctional communication patterns in patients' families that lead to misunderstanding; and * provides concrete, clearly spelled out advice for therapists about how to deal with provocative patient behavior, how to minimize distorted descriptions by patients of significant others, how to avoid patients' misuse of medications, and how to respond to managed care restrictions on patients' insurance coverage. Psychotherapy With Borderline Patients: An Integrated Approach will be welcomed by all clinicians who work with these patients, whatever their training or theoretical orientation.

I
The Relationship Between Family of Origin and Individual Dynamics of Adults With Borderline Personality Disorder

1
The Borderline Family

The relationship between ongoing interpersonal interactions within the family of origin of adult patients with borderline personality disorder (BPD) and the patient's symptoms and behavior patterns is a critical one. An understanding of this relationship opens up new strategies for successful psychotherapy with these patients. The aim of this book is to explicate this relationship and to describe in detail a method of psychotherapy based on this understanding. We look at the nature and interpersonal causes of behavior patterns of patients with BPD, as well as treatment techniques for changing them, from a perspective that integrates family systems, psychodynamic, and cognitive-behavioral ideas.

Almost all theoretical concepts of BPD acknowledge the effects of experiences within the family of origin on the genesis of certain aspects of the disorder (Allen & Farmer, 1996). Even biogenetic hypotheses presuppose an interaction between a vulnerable central nervous system and environmental traumata (Paris, 1993; Van Reekum, 1993). Some authors have compared BPD to posttraumatic stress disorder, postulating a relationship between the disorder and physical or sexual abuse within the family (Gunderson & Sabo, 1993). Such abuse is reported to be present in the past history of a significant proportion of patients with BPD (Herman, Perry, & van der Kolk, 1989; Ogata et al., 1990; Zanarini, Gunderson, Marino, Schwartz, & Frankenburg, 1989). Linehan's (1993) highly regarded theory of dialectical behavior therapy postulates that one of the major causative factors of BPD is an "invalidating environment," defined as one in which communication of private experiences is met by erratic, inappropriate, or extreme responses. That environment is almost invariably the family environment.

Because the therapists who first described BPD were primarily psychoanalysts, and because of the analytic view that early childhood experiences are the primary source of adult psychopathology, very little has been written about the family interactions of adult patients with the disorder. The clinical and theoretical literature about family of origin interactions of adult patients with BPD consists mostly of retrospective reports about those interactions that occurred during their early childhood or, to a lesser extent, their adolescence. In the extensive clinical experience of the author, these troublesome interactions and their importance in the pathogenesis of BPD behavior and symptomatology do not cease after a child grows up or leaves home. They continue well into the patient's adult life.

One of the basic premises on which the treatment method described in this book is based is as follows: Certain ongoing, presentday, transactional patterns among such individuals and members of their family of origin influence, trigger, and maintain the troublesome affects, cognitions, and behavior that make the patient suffering with the disorder so miserable and so difficult to treat. Before discussing in detail how and why this process plays out, I first briefly review some of the current literature about the family experiences of patients with the disorder.

Family Experiences of BPD Patients: Current Perspectives

The prevalent psychoanalytic view regarding the genesis of BPD behavior is that the family environment has a toxic effect on the development of the young child, which then leads to a developmental arrest (Masterson, 1981). However, several authors suggest that, although experiences at each developmental stage are important in personality formation, longer-term continuous experiences are also relevant to the genesis of adult personality disorders (Links & Munroe-Blum, 1990; Paris, 1993). According to this view, problematic family patterns expose vulnerable children to chronic rather than episodic stress and abuse, which results in continuous development of problematic behavior patterns. These patterns are then acted out in later life.

Zanarini and Frankenburg (1994) hypothesized that borderline psychopathology develops "in response to serious, chronic maladaptive behaviors on the part of immature and emotionally incompetent, but not necessarily deliberately malevolent, caregivers" (p. 26). Consistent with this view, Millon (1987) observed that "the significance of early troubled relationships may inhere less in their singularity or the depth of their impact than in the fact that they are precursors of what is likely to become a recurrent pattern of subsequent parental encounters" (p. 360). He added, "Early learnings fail to change, therefore, not because they have jelled permanently but because the same slender band of experiences which helped form them initially continue and persist as influences for years" (p. 361).

Links and Monroe-Blum (1990) reviewed 10 studies on the childhood environments of patients with BPD (Akiskal et al., 1985; Bradley, 1979; Frank & Paris, 1981; Goldberg, Mann, Wise, & Segall, 1985; Gunderson, Kerr, & Englund, 1980; Herman, Perry, & van der Kolk, 1989; Links, Steiner, & Offord, 1988; Snyder, Pitts, Goodpaster, & Gustin, 1984; Soloff & Millward, 1983; Zanarini et al., 1989). As the studies are all based on potentially biased retrospective patient reports, the results must be interpreted with some caution. Nonetheless, the fact that several themes recur time and time again lends some credence to their validity. Additionally, these conclusions have been replicated several times in later studies. These themes include family histories of neglect, abuse, loss, overprotection, overinvolvement, and biparental failure. Biparental failure is defined as a significant impairment in both parents that leads to a failure to carry out parental functions.

Although superficially somewhat dissimilar, these themes can be conceptualized in an integrated way. All of them relate to the polarized manner in which these parents are involved with their children. The themes reflect either the parents' persistent overinvolvement or persistent underinvolvement with their child. Incest, for example, may be thought of as extreme, inappropriate overinvolvement of, say, a father with his own daughter.

Walsh (1977) first suggested the idea that a combination of both parental overinvolvement and underinvolvement might be present in these families, rather than just one or the other. Melges and Swartz (1989) described oscillations in attachment behavior in patients with borderline personality between the two extremes. They postulate that these oscillations stem from patients' fears that they will be abandoned if they grow up and become independent of their families, but dominated and controlled if they remain close. These authors believe that, consistent with attachment theory, this pattern emerges from ambivalent reactions to children by their caretakers. A prospective study of family interactions and the emergence of BPD (Bezirganian, Cohen, & Brook, 1993) is consistent with these formulations. They find that neither maternal overinvolvement nor maternal inconsistency alone predicts emergence of BPD, but the coexistence of the two factors together does.

The paradigm of Melges and Schwartz (1989) described earlier receives further empirical support from the work of Shapiro (1978, 1982, 1992) and Shapiro and Freedman (1987). The latter authors base their findings on extensive observations of the families of adolescents diagnosed with BPD. They find that, in the families of patients with BPD, both parents seemed to experience major conflicts regarding the issue of their child's autonomy. The conflicts seem to prevent them from responding to their adolescent's growing independence in appropriate ways. A common pattern is that the parents experience their child as clinging and demanding, and become angry about it. This results in the parents' defensive withdrawal from their teen. However, even while neglecting the developing needs of the adolescent, the parents continue to focus much of their attention on the child.

Similar patterns have been observed in the case material described by interpersonal theorists and researchers. Benjamin (1993) described an interpersonal theory of borderline behavior patterns. She viewed the behavior of the patient with BPD as a response to other people, primarily those within the patient's family of origin and spousal relationships. She observed that the family backgrounds of individuals with borderline traits show four major characteristics:

1. Family chaos in which the individual with BPD is subtly blamed for family problems and is expected to exert control over family misbehavior.
2. Episodes of traumatic abandonment (such as being locked in a closet) interspersed with periods of traumatic overinvolvement (such as an incestual assault).
3. Efforts by the individual with BPD to establish autonomy that are interpreted by the family as disloyal,
4. Parental love and concern that are elicited only when the patient presents with misery, sickness, and debilitation.

Patterns like these are likely to be ingrained characteristics of the dysfunctional interactions within these families. As such, it would seem unlikely that they would dissipate as the children in the family mature into adult life. In the next section, I present some examples of ongoing family patterns that I believe to be major factors in the genesis and maintenance of BPD symptoms and behavior patterns.

Family Interactions of Adults with Borderline Personality Disorder

I initially became interested in the family dynamics of adult patients with BPD after a particularly dramatic incident during my treatment of a hospitalized young woman. This rather rude introduction took place during my first year in private psychiatric practice. Having had very little family therapy training during my psychiatric residency training, and being young and green in more ways than one, I was completely unprepared for what was to come.

A 21-year-old woman (Case I-A) was referred to me for psychiatric hospitalization because of ongoing violent episodes that took place in her mother's home, wherein the patient resided. To my knowledge, all of this violence had been directed toward inanimate objects. I was told that she had, at several different times during temper outbursts, destroyed pieces of furniture and other objects. When we first met, the girl, who was quite strong, was taking exception to being admitted into a psychiatric inpatient ward. She was thrashing about so aggressively that it took three large male psychiatric technicians to restrain her.

After she had calmed down, and despite my having little family training, I decided to meet with both the patient and her mother. Much later on, I had the opportunity to see the patient's mother and a sibling alone in individual psychotherapy. Additionally, I had conjoint sessions with her and her father. These sessions gave me a good opportunity to get a pretty good picture of one "borderline" family.

The mother, it later turned out, had the disorder herself, as did several other family members. It is believed that many of the parents of borderlines also suffer from the disorder; it may be true, in fact, that there are first-generation borderlines and second-generation borderlines who are somewhat different. I have observed that it is in the nature of borderline psychodynamics to reproduce themselves.

During my first session with the patient and her mother, both of them complained bitterly about one another. Mom complained that the daughter continuously dropped classes at college on various pretexts, and picked fights with school officials. She complained about the patient's occasional drug use, and opined that perhaps the patient had become brain damaged. She wondered aloud why the patient's anger always seemed to focus on her and never on the patient's father. After all, her ex-husband had spent little time with her and had never paid nor even offered child support. Oddly, the mother then volunteered that she had never pursued the patient's father for back child support. In fact, she had run up huge charge bills and then sat around and waited for the ex-husband to pay them. Of course, he never did.

The patient countercomplained that the mother did not have any money to help her buy books and pay college fees. Furthermore, although her mother had given her the "gift" of a car to get to college, the car did not run. She stated that her mother would complain about her not having applied for financial aid, but would not fill out the forms the patient had given her for that very purpose.

The conjoint session quickly began to deteriorate at an alarming rate. The mother suggested to the patient that she go to school full time—or maybe she should drop out altogether in order to get her head straight. At that point, the subject suddenly seemed to change completely. The patient started to complain that the two of them lived like pigs, because the mother would come home from work, do nothing but sit around watching television and eating, and leave a huge mess. The mother responded that her habits were none of the daughter's business. The daughter replied that maybe she should just leave, and insisted that the she could go out and support herself, without any help from the mother. Mother then said, "But you'll support yourself by selling drugs!" Mother then added, "I found your drugs and flushed them down the toilet."

Suddenly and without warning, the patient went into a rage. In response, the mother, instead of moving back prudently, put her nose in the patient's face and began berating her daughter. Before I had the slightest chance to try to intervene, the patient slammed her closed fist into the mother's face with as much force as she could muster. The technicians quickly came and dragged her away.

What impressed me the most about all this, other than the fact that at that time I had not a clue as to the nuances of the argument they were having, was not the violent behavior of daughter. The mother's behavior was far more fascinating. I had barely met the patient and I had already been informed that the daughter was violent. Obviously, Mom knew this better than anyone. She was not stupid; she'd witnessed the rage first-hand. Granted, the patient had supposedly not hit anyone before, but why on earth would the mother stick her nose in the patient's face in the middle of the rage? A lay person might say, only half in jest, that mom was "asking for it."

Since this episode, I have continued to notice similar peculiar behavior in the parents of adults with BPD. I am not alone in this observation; many other writers from all therapy schools have commented about this as well. For example, the analytically oriented writers Brandchaft, Stolorow, and Atwood (1992) described the example of a 23-year-old man (Case I-B) who was having trouble concentrating at school. His father was assuming financial responsibility for his son's schooling and his therapy. Father resented the financial burden, and thought of his son as weak and as a source of shame for himself. At home, the patient had to wait for his father to finish a variety of activities before he could speak to the father, and then only talk about subjects the father was interested in. His mother told him when, what, and how to eat, whether he should sit or stand, and what music he liked. Whenever he attempted to assert himself, he was told that he was selfish, inconsiderate, and that his father would not come home at all if he continued to behave that way.

In the latter example, the question might arise whether or not these parents wanted their son to "grow up." Instead, did they need to have him around in order to control and criticize him? Patients with BPD are often accused of splitting, which is defined as an inability to integrate good and bad images of other people. It is not surprising to me, however, that this patient would have trouble putting his parents' good and bad behavior together. It was bizarre and contradictory. In fact, most therapists are hard pressed to explain this sort of behavior, and often themselves have a tendency to think in terms of the polarities of all good or all bad. Perhaps our patients who seem to "split" are thinking the way almost anyone might given a need to comprehend such an utterly confusing picture.

When I first described my own model for the genesis of BPD behavior patterns (1988), I focused on my observation that the parents of offspring with the disorder seemed to be overinvolved and often overprotective of their progeny to an exceptional and overblown degree. This overinvolvement by the parents was oddly mixed with a large degree of hostility. This pattern started when the children were born and continued into their adulthood. The combination of simultaneous overinvolvement and hostility led to the hypothesis that the parents of those with the condition are highly ambivalent about their role as parents. They seem to feel that being a parent is their full-time mission in life, yet they also feel it to be burdensome and an impediment to their own satisfaction.

My initial focus on parental overinvolvement did not incorporate the underinvolvement/neglect polarity, and therefore turned out to be only part of the picture. In order to better understand the family and individual dynamics present in the families of BPD patients, let us return to the limited empirical data about the families of patients with BPD. Unfortunately, as mentioned, there are few published empirical studies of the families of adult borderlines in the present. In the following discussions, the term child refers to the biological relationship of the patients to their family of origin, not to their chronological age. Later I return to the example of Case I-A and her mother and translate their argument into more understandable terms.

To reiterate, studies of the families support several seemingly dissimilar themes: neglect, abuse, parental overinvolvement, parental overprotection, and biparental failure. These themes can be conceptualized as representing a combination of or oscillation between both parental overinvolvement and underinvolvement. Overprotection, the theme that seems to show up the least, may be one subset of parental overinvolvement. The two cases that I just described are consistent with the overinvolvement dynamic, as are many case reports from a variety of sources. Some forms of abuse, such as incest, can be thought of as yet a different form of overinvolvement, to say the least. Biparental failure could also very easily lead to neglect in a variety of ways.

On first glance at many case studies, parents may seem to be either overinvolved or underinvolved, and there seems to be little or no oscillation between the two. However, I have found, along with other observers (Everett, Halperin, Volgy, & Wissler, 1989), that although the overinvolvement or underinvolvement dynamic may predominate in any given family, if one waits long enough, one eventually will see the opposite polarity. It is helpful to think of these, not as two separate patterns, but merely two sides of the same coin. The behavior of the parents of BPD is polarized at one or the other extreme, but then switches to the opposite ext...