Loving Him Without Losing You (33 page)

• Although the exact cause of BPD is highly controversial, most theorists agree that early family life or developmental factors help cause the illness.
  

  One major theorist, Heinz Kohut, considers the illness to be caused by the child’s belief that she has been, or will be, abandoned, and the sense of alone- ness that results.
  

  According to Janice M. Cauwels, the author of
  Imbroglio: Rising to the Challenges of Borderline Personality Disorder:
  

  This fear results from parental, especially maternal, failure to provide sufficient holding and soothing, enough attention to and validation of the child’s feelings and experience. . . . Her primary feeling is a terror of utter aloneness, emptiness, hunger, coldness, and annihilation. The fear or actuality of such abandonment also produces rage.
  

  The borderline therefore uses other people to help evoke soothing images or to perform other functions she does not have built in. Unable to recall sustained love, she becomes a reassurance addict seeking a fix of affection to help maintain her self-esteem. The loss or threatened loss of a relationship leaves the borderline feeling hollow and aban- doned, bereft of self-esteem, and anxious to end these feelings through self-mutilation or suicide.
  

  In other words, women who suffer from Borderline Personality Disorder not only lose themselves in relationships with men but never developed selves worth defending.
  

  Many experts also believe that BPD, like many mental disorders, is caused by a combination of genetic influences and environmental circum-
  

  stances. According to prominent BPD psychiatrist Kenneth R. Silk, prelimi- nary research suggests that BPD behavior may be influenced by neurotrans- mitter disturbances.
  

  How to Find the Right Treatment
  

  Many of you have already sought help for your problems in the past, and some may have had years of individual psychotherapy. But you may not have received the right kind of therapy. While conventional, insight-based therapy can help with a wide range of psychological problems, it generally does not help with BPD. This is not to say that conventional therapy may not have helped you feel somewhat better about yourself and may have helped you resolve an immediate problem (such as leaving an abusive relationship), but in the long run you have probably continued to be plagued with the same problems you’ve always had—a fear of abandonment and at the same time a fear of being smothered, a fear of being alone, excessive rage, hypersensitiv- ity to rejection, etc.
  

  In fact, one of the ways to tell whether you likely suffer from BPD is by noticing whether the therapy you have received did you any good in terms of alleviating your major symptoms (assuming you had a good experience in therapy with a reputable, skilled therapist).
  

  Moreover, even those who have been in therapy may not have been diag- nosed correctly. Unless you have acting-out behavior such as self-mutilation or suicide attempts, no one but an experienced therapist can tell whether you suffer from BPD. Typically, BPD shows up primarily in relationships—how you relate to other people—so unless a person is in a relationship with you, including a therapeutic relationship, he or she will not recognize your symp- toms. Even then, many therapists are just not skilled enough to diagnose this problem correctly.
  

  In addition, many therapists resist giving this diagnosis because insurance companies are notorious for denying claims when the diagnosis is given. This is because some believe those suffering from BPD are untreatable, but most deny claims because it requires long-term care.
  

  Medication
  

  Some medications have been used successfully to help people with BPD, but they do not cure it. What they can do, in optimum situations, is reduce depres- sion, minimize emotional ups and downs, and curb excessive impulsivity. By alleviating these symptoms a patient can participate more fully in psychotherapy and gain much more from it.
  

  The Modalities of Therapy
  

  There are several modalities of therapy that are used for the treatment of BPD. These can be broken down into two general categories: exploratory (or intrapsychic) and supportive techniques.
  

• E
  XPLORATO RY
  T
  HERAPY
  

  Exploratory or intrapsychic psychotherapy is a modification of classical analysis. Recommended by experts in BPD such as Otto Kernberg and James Masterson, this form of therapy is more intensive than regular “supportive” therapy and has a more ambitious goal—to alter personality structure.
  

  Unlike supportive therapy, there is little direct guidance provided by the therapist. Instead the therapist uses confrontation to point out the destruc- tiveness of specific behaviors of the client and interprets unconscious behav- iors in the hope of eliminating them.
  

  In this form of therapy there is less focus on childhood and developmental issues than in classical psychoanalysis, particularly in the early stages of treatment, when the focus is on diminishing behaviors that are self- destructive or disruptive to the treatment process (including prematurely terminating therapy), solidifying the patient’s commitment to change, and establishing a trusting, reliable relationship between patient and therapist. Later stages emphasize the processes of formulating a separate, self-accept- ing sense of identity, establishing constant and trusting relationships, and tolerating aloneness and separations (including those from the therapist).
  

  In some forms of exploratory therapy, primarily those based on the con- cept of object relations, the therapist will not ask questions or try to elicit information in any way. Instead the therapist, with his or her silence, encour- ages the client to step out on her own—to take the risk of expressing her true self instead of performing or attempting to please the therapist—and, in essence, begin to individuate. This is radically different from most therapies, particularly supportive therapy, in which the therapist often asks questions to get therapy sessions under way or to express caring or concern. Some clients, especially those who have experienced supportive therapy in the past, will feel abandoned, hurt, and angry when met with the therapist’s silence.
  

  Silence in the presence of a therapist can be very healing. In such moments of accompanied solitude, the client has the time and the space nec- essary to sense out her own impulses and to sense out things going on inside herself. The quality of this presence of the other is the critical point: It must be felt, and at the same time not be intrusive. This means that no demands be made and no expectations expressed, not even well-meaning interventions.
  

  Sessions are usually conducted two or more times a week, and the dura- tion of treatment is a minimum of four years but often lasts as long as six to ten years.
  

• S
  UPPORTIVE
  T
  HERAPY
  

  Even though this form of therapy is often referred to as “supportive,” it is not to be confused with conventional insight-based therapy, which can help alle- viate some symptoms but generally does not help to restructure the person- ality, as is needed for BPD. Supportive therapy is the most common type of therapy used for borderline personality. Instead of confrontation and inter- pretation of unconscious material, therapists offer direct advice, education, and reassurance.
  

  Meant to be less intense and to bolster more adaptive defenses, this form of therapy may reinforce suppression of emotions and discourages discussion of painful memories that cannot be resolved. As opposed to discovering the roots of defenses and then eradicating them, as in psychoanalysis, defenses may be acknowledged as useful ways of retaining a sense of mastery and control.
  

  Supportive therapy most often continues on a once-a-week basis for approximately four to five years before proceeding to an as-needed basis. Therapy gradually terminates when the patient forms other lasting relation- ships and when gratifying activities become more important in the patient’s life.
  

  Although some experts have insisted that supportive therapy is not effective in treating borderline patients since it is less likely that lasting changes will occur, others insist that significant behavioral modifications can occur.
  

• The Cognitive Behavioral Approach
  

  Not everyone has the financial means for the long-term, intensive treat- ment that is most often recommended for those suffering from BPD, espe- cially since insurance companies usually don’t pay for treatment (unless you are hospitalized for such problems as an eating disorder, a sexual addiction disorder, or for alcohol treatment). For this reason, for those with limited income I recommend the supportive therapy known as the cognitive behav- ioral approach.
  

  With a cognitive behavioral approach the therapist focuses on teaching you new behaviors versus attempting to make deeper changes that take far more time. The therapist uses your ability to think (many who suffer from BPD are highly intelligent) to help you control your behavior.
  

  Many borderlines are very enthusiastic about researcher Marsha Linehan’s cognitive-behavioral method, known as Dialectical Behavior Therapy (DBT). It has been shown in empirical research to help BPD patients experience less anger, less self-mutilation, and fewer inpatient psychiatric stays than patients who received other forms of treatment.
  

  Cost of Therapy
  

  Unfortunately, the bottom line as to what type of therapy you choose will come down to your finances. It is a sad testament to our society that the only people who can hope for significant change are those who are financially well off or those who have excellent health insurance.
  

  Generally speaking, BPD psychotherapy is practiced primarily by licensed psychologists who have had specialized training in the treatment of borderline personality disorder. Therefore, it will likely cost you far more than counseling by a social worker or a marriage counselor.
  

  To prescribe medication, a therapist must be a psychiatrist or refer you to one for a psychiatric evaluation. Treatment by a psychiatrist is usually extremely expensive, but many only require you to see them once a month to track the medication.
  

  In addition, because this treatment usually involves what is referred to as “intrapsychic” work, “reparenting,” or restructuring work, it will take several years of treatment, often involving twice-a-week sessions.
  

  The Cognitive Behavioral Approach can be conducted by social workers and marriage counselors as well as by psychologists and psychiatrists. Not only will you pay less per hour, but since this treatment focuses more on symptoms rather than on intrapsychic work, it tends to take less time.
  

  It is important that you become educated about your choices so you can work with what is available in your community and use the resources avail- able to you. At the end of this appendix I will provide the addresses and phone numbers of some agencies that may be able to help you.
  

  Finding the Right Therapist
  

  It is quite appropriate for you to “interview” several therapists before decid- ing which one is best for you. However, this can become quite costly and emo- tionally draining. Therefore, you may wish to begin your interviewing over the phone.
  

  1. Begin by asking whether the therapist is taking on new clients. Obviously there is no need for you to talk any further if she or he does not have room
     

     in his or her schedule to see you. Some therapists do, however, have a wait- ing list. If this is the case, the therapist is likely to be very good, so it might be worth your while to continue your phone interview to ascertain whether the therapist sounds like someone you might want to work with. If, after asking the following questions, you decide you would like to work with this person, ask how long the wait would be before you could start. If it is less than a month, it might be worth it for you to wait. On the other hand, if it has taken all your courage to make the decision to finally seek pro- fessional help and you are likely to back off soon, then by all means keep calling until you find someone who can be available immediately. If you don’t wish to wait, this therapist is probably a very good resource for you. Ask if she or he can refer you to another therapist.
     

  2. Next, ask whether the therapist has special training and experience work- ing with those who have borderline tendencies. I encourage you not to say “Borderline Personality Disorder” since you do not know for certain whether you are borderline. Only a trained professional who has the expe- rience of observing you over time will be able to make that diagnosis. What you do know, from reading this book, is that you (along with mil- lions of other people) most likely have borderline tendencies.
     

     Some critics may say that by encouraging you to discuss the issue of your borderline tendencies you will prejudice the therapist against you. There are still some therapists who are afraid to work with those with bor- derline personalities due to the bad rap borderlines have received or neg- ative experiences they’ve had with these patients in the past. But my opinion is that you wouldn’t want to work with such a therapist anyway. You need someone who has the skills and the confidence to work with your symptoms, not someone who is so inept that they get caught up in them.
     

  3. Next, ask the therapist what type of licensing and schooling she or he has, what type of therapy she or he conducts, and how many years she or he has been in practice. A good therapist should be willing to tell you all of these things without feeling resentful or defensive. There are many excellent therapists who don’t have Ph.D.’s after their name, but you do want some- one with training and experience in working with borderline personality disorder.
     

  4. It is also appropriate for you to ask how much the therapist charges and whether she or he requires two or more sessions a week. Even though you realize you need this specialized therapy, if you can’t afford a particular therapist’s fees you will have to keep searching until you find someone more affordable. Many of my clients have made therapy a priority and have
     

     sacrificed other, less important expenditures to pay for their therapy, but you don’t want to increase your stress level by adding a financial burden. Remember, this is not a short-term process but an ongoing one. Your budget needs to be able to accommodate your therapist’s fees for several years. Even if you have insurance, it is not likely to pay for all your ses- sions. Most insurance will only pay for one session a week for a limited number of sessions a year, and few pay for more than a year of treatment. Check your policy, or call your insurance company and ask for their lim- its.
     Do not, I repeat, do not say anything to your insurance company
     

     about borderline personality disorder.
     

     Do not expect a therapist to lower his or her fee or to offer to see you at a discounted rate (e.g., to charge less if you see the therapist twice a week).
     

  5. If the therapist sounds like someone you could work with, make an appointment. If not, ask for a referral.
     

  Face-to-Face Interviews
  

  If you are fairly certain you suffer from BPD, you may wish to divulge this to the therapist during your face-to-face interview and then ask the therapist more questions concerning her or his knowledge of the subject. This is com- pletely optional but it can be important, since there are so many therapists who are not adequately trained to work with BPD, because some still do not believe BPD patients can get better, and because many still bring negative expectations and attitudes about borderlines into treatment. Here are some suggestions for further questions:
  

How do you define BPD? If the therapist doesn’t seem to know that much about the disorder, or insists it is rare, you may wish to keep looking.

What do you believe causes BPD? If the therapist believes that all BPD is caused by sexual abuse or does not mention possible biological causes, she or he may not be up to date on the latest research.

Ask what the therapist’s treatment plan is for clients with BPD. Although treatment is modified for each individual, a good therapist should be able to give you a general overview of the treatment she or he provides.

You may also wish to ask if the therapist has special training in and experience with those who have associated problems such as substance abuse, eating disorders, or self-injury, whichever apply to you.

Ask if the therapist believes borderlines can get better. While no one can give you a guarantee (if they do, continue to look for a therapist), you don’t want to work with someone who is overly pessimistic.

Ask about her or his views on medication. If the therapist is not a psychi- atrist, ask if she or he will consider referring you to one for medication if needed.

Forming a Therapeutic Alliance

The most important factor determining whether you will be able to stick it out long enough to get better is if you and your therapist establish what profes- sionals call a “therapeutic alliance.” To form this alliance there must be a pos- itive relationship of mutual respect between you and the therapist. In addition, there must be what is commonly referred to as a patient-therapist “fit.” You should feel comfortable with the therapist’s personality and style and be able to talk with her or him openly and candidly. In addition, your personal goals should coincide with the therapist’s goals for therapy. (The main goal of therapy is to help you to individuate and achieve more freedom and personal dignity.)

For both you and the therapist to properly evaluate your ability and will- ingness to work together you will need to meet together for at least one ses- sion, possibly more. If it is determined that there isn’t the proper “fit,” do not blame yourself or the therapist. Instead, consider it a “no fault” exchange, since your inability to establish rapport is no one’s fault.

However, if you continue to determine that each psychotherapist you meet with is unacceptable, question your commitment, and consider the strong possibility that you are merely avoiding therapy. If this is the case, choose a therapist you feel is competent, and go forward with the task of get- ting better.

In general, a therapist who works well with BPD possesses certain qual- ities that a prospective client usually can recognize. In addition to being experienced in the treatment of BPD, the therapist obviously needs to have the following qualities. She or he:

• is tolerant and accepting, as opposed to being impatient and critical;
  

• maintains appropriate limits and boundaries;
  

• is able to maintain a certain level of objectivity—that is, does not take the actions of her or his clients personally.
  

  What to Expect from Therapy
  

  If you suffer from BPD, therapy isn’t going to make you feel better right away. In fact, it’s probably going to be quite painful. This may sound odd to you— after all, isn’t the purpose of therapy to make us
  feel
  better? The answer is no, especially for the treatment of BPD, which will probably make you feel much worse before you feel better. BPD therapy will, however, make you feel bet- ter in the long run if you make a commitment to stick with it through the pain. If you are receiving treatment from someone who has had special train-
  

  ing and experience in working with Borderline Personality Disorder, you will likely be expected to follow certain rules:
  

In an attempt to provide you needed structure and consistency, your thera- pist will be very particular about starting on time and ending on time. This may seem overly rigid to you, and you may interpret this as a sign that your therapist doesn’t really care about you or that she or he is just interested in money, but try to remember that there is a good reason for the therapist’s behavior.

You will be expected to commit to therapy, meaning that you make therapy a priority by attending each therapy session. This commitment is so impor- tant that some therapists require you to pay for any therapy sessions you miss,
no matter what the reason.
This may seem unreasonable to you, but this rule is in place to encourage you to continue to view therapy as a pri- ority and to discourage you from canceling appointments when you are feeling afraid.

You may also be expected to follow other rules, such as not calling your therapist unless it is an emergency. If you call too often, your therapist may limit the number of times you can call her or his office.

You are likely to respond to your therapist in much the same way you do in other personal relationships. Sometimes you will perceive your therapist as being capable, honest, and caring, while at other times you will see her or him as inadequate, deceitful, and uncaring. This is due to your tendency to both idealize and devalue others as well as your lack of what is called “object con- stancy”—the ability to understand others as complex human beings who nonetheless can relate in consistent ways.

It is not your obligation to please your therapist but to work with her or him as an equal. Therefore it is important to be as honest as possible and to feel as if you are actively collaborating with your therapist. Avoid either the extreme of assuming a totally passive role or of becoming a competitive, con- tentious rival who is unwilling to listen to feedback.

What’s the Prognosis?

In the past, many clinicians and researchers were pessimistic about whether those suffering from BPD could recover. But today there is ample research proving that borderlines can get better. For example:

The McGlashan Chestnut Lodge study (1986) showed that 53 percent of patients with BPD were considered “recovered” and that patients seemed to do better once they reached their forties.

A 1990 New York State Psychiatric Institute study showed that two-thirds of patients in their thirties and forties were rated as either “good” or “recov- ered” on the global assessment scale, a standard tool used by clinicians to measure functioning.

While the prognosis can be good for recovery from BPD, it is also impor- tant to understand that it is common for many suffering from this disorder to consciously or unconsciously sabotage their treatment in any or all of the fol- lowing ways. They might:

• discontinue therapy when faced with issues that make them feel uncomfortable;
  

• continually test their therapist and/or push against their limits until the clinician discontinues treatment;
  

• put up a false front and hide information from the therapist so that she or he continues to operate under the false assumption that the client is far healthier than the client is;
  

• accuse the therapist of being incompetent and refuse to go forward with treatment.
  

  For three years Paul T. Mason and Randi Kreger, the authors of
  Stop Walk- ing on Eggshells: Taking Your Life Back When Someone You Care About Has Borderline Personality Disorder,
  interviewed borderlines who greatly improved. They noticed several commonalities:
  

  1. First and foremost, those who greatly improved accepted responsibility for their behavior and for their recovery.
     

  2. They were willing to work through their inner pain instead of deflecting it onto other people or dealing with it through other means (drugs, self- mutilation, etc.). Even though they sometimes lapsed back into old pat- terns, they got back on track.
     

  3. They had faith in themselves and believed that other people (or a Supreme Being) had faith in their inner worthiness—the “real them” behind the borderline symptoms.
     

  4. They had access to continued therapy with a competent clinician who did not take their actions personally, believed that recovery was possible, gen- uinely cared about them, was willing to stick with them in the long term, and observed appropriate limits.
     

  5. They received the appropriate medication.
     

  If you are interested in learning more about the cognitive-behavioral model known as Dialectical Behavior Therapy (DBT) I recommend you order the book
  Skills Training Manual for Treating Borderline Personality Disorder
  by Marsha Linehan (The Guilford Press, 1-800-365-7006).
  

  Although this is a workbook for clinicians using Linehan’s method of cognitive-behavioral therapy, the handouts and homework sheets are extremely useful and practical, and the book teaches four valuable skills: mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance.
  

  To locate a clinician who specializes in Dialectical Behavior Therapy, contact the following for referrals:
  

  Behavioral Technology Transfer Group (206) 675-8558
  

  For cognitive-behavioral therapy in California: Mary Nowicki, LCSW
  

  2628 El Camino Avenue, Suite C-1 Sacramento, CA 95821
  

  (916) 482-1255
  

  For exploratory or intrapsychic psychotherapy nationwide: The Masterson Institute for Psychoanalytic Psychotherapy 60 Sutton Place South
  

  New York, NY 10022
  

  (212) 935-1414
  

  Among Internet and e-mail resources, there are several BPD-related Internet support groups, called “mailing lists,” where you can share stories, ask for help, and offer help to others: