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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.

Handling Impulsivity

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,