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By Root 414 0

self-absorption and lack of empathy often prevent involvement with others’ problems. If the borderline’s concerns are too deviant or the material too intense, he may feel isolated and disconnected. For example, a patient who discusses childhood incest, or deviant sexual practices, or severe chemical abuse may fear that he may shock the other group members. And, indeed, some members may have difficulty relating to upsetting material. Some borderlines may share the feeling that their needs are not being met by the therapist. In such situations they may attempt to take care of each other in the ways that they fantasized they could be cared for. This may lead to contacts between patients outside of the group setting and perpetuation of dependency needs as they try to “treat” each other. Romances or business dealings between group members usually end disastrously, because these patients will not be able to use the group objectively to explore the relationship, which is often a continuation of unproductive searches to be cared for.

Elaine, a twenty-nine-year-old woman, was referred for group therapy after two years of individual psychotherapy. The oldest of four daughters, Elaine was sexually abused by her father, starting around age five and continuing for over ten years. She perceived her mother as weak and ineffectual and her father as demanding and unable to be pleased. In adolescence, she became the caretaker for the whole family. As her sisters married and had children, Elaine remained single, entering college and then graduate school. She had few girlfriends and dated infrequently. Her only romantic relationships involved two married, much older supervisors. Most of her off-work time was devoted to organizing family functions, caring for ill family members, and generally taking care of family problems.

Isolated and depressed, 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. She often became angry with the therapist, whom she perceived as not helpful enough to the group members.

The group members encouraged Elaine to examine issues she had previously been unable to confront—her constant scowling and intimidating facial expressions and her subtly angry verbal exchanges. Although this process took many frustrating months, she was eventually able to acknowledge her disdain for women, which became obvious in the group setting. Elaine realized that her anger at the male therapist was actually transferred anger from her father and recognized her compulsive attempts to repeat this father-daughter relationship with other men. Elaine began to experiment in the group with new ways of interacting with men and women. Simultaneously, she was able to pull back from the suffocating immersion in her family’s problems.

Most standardized therapies (see chapter 8) combine group with individual treatment. Some approaches (such as Mentalization-Based Therapy [MBT]) are psychodynamic and exploratory with less direction from the therapist. Others (such as Dialectical Behavioral Therapy [DBT] and Systems Training for Emotional Predictability and Problem Solving [STEPPS]) are more supportive, behavioral, and educational, emphasizing lectures, “homework” assignments, and advice, as opposed to nondirective interactions.

Family Therapies

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

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

The families of borderlines often balk at treatment for several reasons. They may feel guilt over the patient’s problems and fear being blamed