I Hate You--Don't Leave Me: Third Edition: Understanding the Borderline Personality

by Jerold J. Kreisman

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

Walking the borderline individual through the likely results of behavior can sometimes mitigate it. When his fifteen-year-old daughter angrily threatened to run away again with her forbidden boyfriend, Terry responded in a matter-of-fact manner: “Oh, dear. I

really wish you wouldn’t. Because you know then we’ll have to call the police, who will find you and Jordan, and he will get arrested again. And then you’ll have to go to the hospital again, which I know you hate. And they’ll probably want to keep you longer this time. I would really rather talk some more with you than go through all of that.”

Focus on the anger and self-hatred. Pleading with the borderline loved one not to go out on another drinking binge is probably fruitless. But asking why he is so angry and why he must deal with it in such a self-defeating way may have more impact. Getting him to talk rather than act out is great progress.

Individuals with BPD are very sensitive to people and things around them. Affective changes are usually reactive to environmental circumstances and can whipsaw from one emotion to another. Negative responses, in particular, can be intense.

She may be demanding and impatient and insist on a response right now, even though the response may soon be countermanded, disavowed, or denigrated. In some situations, it may be useful to stall rather than to commit to a demand during a time of high emotionality. Useful possible rejoinders are: “I know you’re concerned about this, but let me check my schedule first.” “I understand you want to do this soon, but I need to see if I can rearrange some things.” “I’m caught up in some things now; let me get back to you.”

Encourage new interests. Hobbies, music, or reading provide intellectual stimulation that can fill in some of the emptiness. Encourage social engagement. Joining community groups, church groups, volunteer organizations, or social clubs or enrolling in classes can mitigate the isolation.

Let the dust settle. Wait for the tirade to finish before jumping in with responses. Then wait a beat, to let the flash of silence contrast with the loudness of the outburst.

De-escalate. As she becomes louder, try to lower the volume of your voice. As she becomes more physically animated, try to control your own physical expressions.

Refocus. Ignoring the source of anger will further inflame the situation, but diverting the confrontation to a related area can help settle things down.

Stay safe. If you feel there is risk of physical violence, leave the scene. Arrange safety for minors and separation for others not involved. Borderline rage often cannot be reasoned with, so discussion and debate are unnecessary and may only inflame the situation.

Maintain a safe, comfortable environment. Preserve calm, familiar surroundings with known, trusted others. Move away from potential weapons and choose a position in the room where you have ready access to an exit if you feel threatened.

Talk the other person down. Keep interactions nonthreatening by using a low, reassuring voice. Since episodes are usually precipitated in relation to stressful events, be consoling.

Avoid direct challenges. Don’t argue or try to talk him out of his experience. You don’t have to confirm his delusion, but you can acknowledge y...

Get help. Even if you are able to calm things down, arrange for pr...

Avoid derogatory phrases. After a casual remark like, “Don’t be silly!” or “That’s crazy,” the BPD individual may focus on the critical word and erupt with a response like “So now you think I’m crazy!”

Avoid demeaning or directly contradictory expressions. Challenging his perception may merely inflame the situation. “That’s not how it happened” or “You’re overreacting” are phrases that undermine Empathy expressions and invite more conflict.

Don’t deny your responsibility. Attempts to redirect your meaning (“You’re misinterpreting what I said!” “I was only kidding!” “Can’t you take a joke?”) will sound like you’re shifting the blame on to him and will stim...

Don’t lie. Be gentle with Truth, but don’t lie. Inconsistencies and lies are frequent aspects of borderline experiences. An uncovered falsehood undermines the nec...

Eventually let it go. Don’t keep plowing the same...

why . . . ?”), the borderline individual may persistently argue a point. If you find yourself repeating the same words, try to move on: “I know you’re still not satisfied, but we’ve been over and over this. Let’...

Be careful with humor. It is usually best to avoid humor. Borderline sensitivity may interpret lighthearted kidding as trivializing or humiliating ridicule. Only in a long-standing relationship in which playful whimsy has been established can levity be helpful....

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.

On her second day in the outpatient program, she arrived late, disheveled, and hung over. 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.

Therapists who treat borderline personality disorder 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 difficult because the borderline patient responds to it in much the same way as to other personal relationships. She will see the therapist as caring and gentle one moment, deceitful and intimidating the next.

In therapy, the patient with BPD can be extremely demanding, dependent, and manipulative. It is not uncommon for her to phone or text incessantly between sessions and then appear unexpectedly at the therapist’s office, threatening bodily harm to herself unless the therapist meets with her immediately. Angry tirades against the therapist and the process of therapy are common. Often she can...

A patient with BPD can provoke feelings of anger, frustration, self-doubt, and hopelessness in the therapist that mirror his own.

Treatment of borderline personality disorder can become so frustrating and infuriating that some professionals invoke the term borderline inaccurately as a derogatory label for any patient who is extremely irritating or who does not respond

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.

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

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

The families of borderline individuals 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 ...

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 health insurance policies will not cover treatment that is labeled marriage therapy or family treatment.)

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.8 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).

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.11 Borderline propensities for impulsivity, self-destructive behaviors (suicide, drug overdoses), and brief psychotic episodes are the usual acute precipitants of hospitalization.

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 patient with BPD recapitulates the interpersonal patterns of his external world: a seductive wish for protection, which ultimately leads to disappointment, then to feelings of abandonment, and finally to self-destructive behaviors and emotional retreat. In the hospital setting he has the opportunity to work through these conflicts.

The goals of longer hospitalization extend those of short-term care—not only to identify dysfunctional areas but also to

The greatest potential hazard of long-term hospitalization is regression. If staff do not actively confront and motivate the patient, the borderline individual can become mired in an even more helpless position, in

which he is even more dependent on others to direct his life.

The dialectic of the treatment refers to the goal of resolving the inherent “opposites” faced by BPD patients—that is, the need to negotiate the patient’s contradictory feeling states, such as loving, then hating the same person or situation. A more

DBT posits that borderline patients possess a genetic/biological vulnerability to emotional overreactivity. This view hypothesizes that the limbic system, the part of the brain most closely associated with emotional responses, is hyperactive in BPD. The second contributing factor, according to DBT practitioners, is an invalidating environment: that is, others dismiss, contradict, or reject the developing individual’s emotions.

Schema-Focused Therapy (SFT) SFT combines elements of cognitive, Gestalt, and psychodynamic theories. Developed by Jeffrey Young, PhD, a student of Aaron Beck’s, SFT conceptualizes maladaptive behavior arising from schemas. In this model, a schema is defined as a world view developed over time in a biologically vulnerable child who encounters instability, overindulgence, neglect, or abuse. Schemas are the child’s attempts to cope with these failures in parenting.

SFT attempts to challenge these distorted responses and teaches new ways of coping through a process denoted as re-parenting.9 Multiple schemas can be grouped into five primary schema modes, with which borderline patients identify and which correlate with borderline symptoms: Abandoned and Abused Child (abandonment fears) Angry Child (rage, impulsivity, mood instability, unstable relationships) Punitive Parent (self-harm, impulsivity) Detached Protector (dissociation, lack of identity, feelings of emptiness)

Neurological Dysfunction Disturbances in brain function have been frequently associated with BPD. A significant subset of borderline patients has experienced a history of head trauma, encephalitis, epilepsy, learning disability, EEG (electroencephalogram, or brain wave) abnormalities, sleep pattern dysfunction, and abnormal subtle neurologic “soft signs.”7,8

However, it is now generally accepted that personality traits can change over time, and that these changes can emerge at any point in the lifespan.19 Longer-term evaluations of individuals with BPD have demonstrated significant improvement over time.20,21,22 In these studies, tracking borderline patients over a ten-year period, up to two-thirds of the patients no longer exhibited five of the nine defining criteria for BPD and therefore could be considered “cured,” since they no longer

Change for someone with borderline personality disorder involves more of a progressive fine-tuning than a total reconstruction. In rational weight-loss diet plans, which almost always resist the urge to lose large amounts of weight very quickly, the best results come slowly and gradually over time, with the weight loss more likely to persist. Likewise, change in BPD is best initiated gradually, with only slight alterations at first, and as in a successful diet program, with acceptance and encouragement, despite the inevitable regressive fluctuations.

Change begins with self-assessment: before plotting a new course, the BPD sufferer must first recognize his current position and understand in which direction modification must progress. Imagine personality as a series of intersecting lines, each representing a specific character trait (see Figure 10-1). The extremes of each trait are located at the ends of the line, with the middle ground in the center. For example, on the “conscientiousness at work” line, one end might indicate obsessive over-concern or workaholism and the other end irresponsibility or apathy; the middle would be an attitude somewhere between these two extremes, such as calm professionalism.

Change occurs when one acquires the awareness to objectively place oneself on the spectrum and then compensate by adjusting behavior in a direction toward the middle.