I Hate You--Don't Leave Me - Jerold J. Kreisman [76]
Yet it is imperative to gain some support from the family, for without it therapy may be sabotaged. For adolescents and young adults, family therapy involves the patient and his parents, and sometimes his siblings. 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 insurance policies will not cover treatment that is labeled “marriage therapy” or family treatment.) The dynamics of borderline family interaction usually adopt one of two extremes—either very strongly entangled or very detached. In the former case, it is important to build an alliance with all family members, for without their support the patient may not be able to maintain treatment independently. When the family is estranged, the therapist must carefully assess the potential impact of family involvement: if reconciliation is possible and healthy, it may be an important goal; 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.7 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).
Debbie, a twenty-six-year-old woman, entered the hospital with a history of depression, self-mutilation, alcoholism, and bulimia. Family assessment meetings revealed an ambivalent but basically supportive relationship with her husband. The course of therapy began to focus on previously undisclosed episodes of sexual abuse by an older neighbor boy, starting when the patient was about eight years old. In addition to sexually abusing her, this boy had also forced her to share liquor with him and then would make her drink his urine from the bottle, which she would later vomit. He had also cut her when she tried to refuse his advances.
These past incidents were reenacted in her current pathology. As these memories unfolded, Debbie became more conscious of long-standing rage at her alcoholic, passive father and at her weak, disinterested mother, whom she perceived as unable to protect her. Although she had previously maintained a distant, superficial relationship with her parents, she now requested an opportunity to meet with them in family therapy to reveal her past hurts and disappointment in them.
As she predicted, her parents were very uncomfortable with these revelations. But for the first time Debbie was able to confront her father’s alcoholism and her disappointment in him and in her mother’s detachment. At the same time all confirmed their love for each other and acknowledged the difficulties in expressing it. Although she recognized there would be no significant changes in their relationship, Debbie felt she had accomplished much and was more comfortable in accepting the distance and failures in the family interactions.
Therapeutic approaches to family therapy are similar to those for individual treatment. A thorough history is important and may include the construction of a family tree. Such a diagram may stimulate exploration of how grandparents, godparents, namesakes, or other important relatives may have influenced family interactions across generations.
As in individual and group therapy, family therapy approaches may be primarily supportive-educational or exploratory-reconstructive. In the former, the therapist’s primary goals are to ally with the family; minimize conflicts, guilt, and defensiveness;