[ Pobierz całość w formacie PDF ]
Family Therapy with Personality-Disordered
Individuals and Families: Understanding and
Treating the Borderline Family
Len Sperry
Abstract
Working with individuals with the diagnosis of a severe personality disorder can
provide a therapeutic challenge for most clinicians. This challenge is significantly
magnified when the clinician endeavors to work with the individual's family only to
find considerable psychopathology within the family. Unfortunately, conventional
individual and family therapies have little to offer these individuals and their fami-
lies. This article describes the dynamics of the "borderline family," a constellation of
severe personality pathology manifested in family members. It also provides targeted
treatment suggestions for working with these families. The indications for the use of
insight-oriented and action-oriented Adlerian psychotherapy approaches with such
individuals and families are also discussed.
A Personal Introduction
I can vividly recall my first professional encounter with a personality-
disordered family. I was starting the second year of my psychiatry residency
and had just returned from a much needed week of vacation with my wife
and kids. The first year had been 52 weeks of 70-90-hour weeks with a lot of
on-call responsibilities (every third night), no time off, and certainly no vaca-
tion time. The second year of residency at the Medical College of Wisconsin
was focused on outpatient psychiatry, which translated to half time at the
department's Psychotherapy Center and the other half at its Family Center.
Although I had gotten clearance from my residency director to take the
time off, the clinical director of the Family Center claimed that he received
no such notification from the residency office. Like the seven other physi-
cians in my residency class, he had assigned me to a beginning caseload
for new psychiatry residents on that service: two new families for evalua-
tion and treatment, treatment meaning structural-strategic family therapy.
Because I was not at the Center when my first two families were sched-
uled, neither had been evaluated. When I showed up on Monday of the
second week of the rotation at 8:00 a.m., I was hardly prepared for the re-
ception I was to receive: the director's wrath and condemnation of me as an
The Journal of Individual Psychology,
Vol. 67, No. 3, Fall 2011
©2011 by the University of Texas Press, PO Box 7819, Austin, TX 78713-7819
Editorial office located in the College of Education at Georgia State University.
Borderline Family 223
"unreliable and incompetent human specimen." I was also not prepared for
his vengefulness because I had "caused havoc in Center operations by [my]
unauthorized absence." When I tried to explain that the training director
had approved the vacation, he said he "didn't approve it and that's all that
matters." Leaving the room, he ceremoniously handed me a list of my initial
caseload of six families to start (three times more than the others received!)
with the promise that a new family would be added each week for the next
50 weeks. He also gave me the name of the family with whom I was sched-
uled to complete an intake evaluation at 10 a.m. that morning.
I went into that intake evaluation relatively confident. After all, 1 had
already seen hundreds of patients in individual therapy after completing
my PhD and certificate in psychotherapy at the Alfred Adler Institute of
Chicago. To that point, I had some professional experience with families,
but it was mostly consulting with family members of the child or adult who
I was treating in individual therapy. I had completed a graduate course on
family therapy, and I had observed Adierian family counseling demonstra-
tions on several occasions. None of these experiences seemed to matter
when 1 opened the consulting room door and encountered a single-parent
family from hell! There were six people in the room, a 35-year-old mother
with five children ages 2 to 16.
The room was typical of a family therapy room in the early 1980s: square
room with one-way mirror on one wall, a video camera perched in the cor-
ner, a black telephone (to receive feedback from the director-supervisor
behind the one-way mirror) on a coffee table, one couch, and three chairs.
I couldn't find a seat because they were all taken—by the mother in one
chair, the 16-year-old sprawled on the couch, and the other two chairs oc-
cupied on and off by the other children. The two oldest were arguing loudly
and occasionally screaming at each other while the mother was looking the
other way and combing her 7-year-old daughter's hair. The 8-year-old son
was lying on top of his 5-year-old sister, who was on the floor; he was lick-
ing her face. The 2-year-old was dragging the phone around by the receiver,
so even if the director (who I knew was watching) had wanted to call and
"rescue" me, he could not. It was utter chaos.
1 was not present when the director explained the family evaluation
protocol during the week I was on vacation, and the director gave me no
guidance or even the Center's intake form before I met this family. So I
was left to my own devices. While I was quite comfortable taking a fam-
ily constellation and eliciting early recollections with individual patients
and couples, and thought I might even use these assessment devices with
this family, it seemed to have no relevance with that family, at least dur-
ing this initial meeting. Instead, my intuition was to coach the mother to
provide some structure and a measure of control to her family. This is, in
224 Len Sperry
fact, what I did. By the end of 90 minutes (the scheduled length of a family
intake evaluation and for most therapy sessions), the children bad calmed
down and stopped fighting and engaging in unusual behaviors; the phone
receiver was back in its cradle; and all were seated with the mother holding
the 2-year-old on her lap. I had collected some rudimentary information on
why the mother and family had been referred to the Center, the identity of
the so-called "identified patient," their previous therapy and family therapy
experiences, and their expectations for this therapy experience. A follow-up
appointment was made, and the mother thanked me as she and her family
left the room. Afterwards, the director stopped harassing me, although he
never said a word about tbe session—even though I would meet with him
weekly for supervision.
Thus was my introduction to family therapy. Eortunately or unfortu-
nately, it occurred in a tertiary-care medical school clinic that accepted
referrals of families that had failed in other practice settings. It was fortunate
in that I had the opportunity to learn much from these families; however, for
most of my colleagues, this experience was an unfortunate one in that they
experienced little success and subsequently resolved not to work with these
(or any other) families again.
This article describes the dynamics of severe personality pathology
manifested in individuals and families, including the lifestyle convictions
of the borderline personality disorder as well as systemic dynamics of what
could be called the "borderline family." Then, it describes some treatment
suggestions, including the types of Adierian therapies, botb individual and
family, that can be effective with such families.
The Personality-Disordered Individual versus the
Personality-Disordered Family
The reality is that there is no shortage of "difficult-to-treat" families.
Difficult to treat
has become a code phrase for personality-disordered in-
dividuals or families. While working with severe personality-disordered
individuals is a challenge for most clinicians, working with the families of
these individuals can be incredibly more taxing. The clinician may find that
one or more family members also carry Axis I or Axis II diagnoses (American
Psychiatric Association, 2000), but if they do not, they may well be symp-
tomatic or impaired in one or more functional areas. Occasionally, one
or two family members may at first appear to be reasonably functioning
because tbey may work or attend school. In time, however, the clinician
discovers that although the individual shows up at the job or school, their
performance is rated as minimal to average at best, just as it is with other
Borderline Family 225
activities in the home. For the most part, even though one member is desig-
nated as the "identified patient," because of an Axis II diagnosis, the whole
family shares a common pathology. It is extremely rare for one family mem-
ber to be personality-disordered and quite impaired while all other family
members are highly functioning, assuming the impaired individual has
been actively involved with his or her family. Accordingly, the "personality-
disordered family" is a better designation.
Severe Personality Disorders and the Borderline Personality Disorder
Personality disorders are commonly defined as enduring patterns of per-
ceiving, relating, and thinking which are inflexible and maladaptive and
which lead to clinically significant distress or impairment (Sperry, 2003).
Many clinicians and researchers distinguish personality disorder by level
of severity. For example. Millón (1999) considers the borderline personality
disorder, the paranoid personality disorder, and the schizotypal personality
disorder as the severe personality disorders, less amenable to change and
with longer treatment anticipated. In the remainder of this article, 1 empha-
size the borderline personality disorder and the borderline family.
Features of the borderline personality. DSM-IV-TR
(American Psy-
chiatric Association, 2000) describes the essential feature of borderline
personality disorder as a pervasive pattern of instability in relationships,
emotions, and self-esteem. Also essential is a marked level of impulsivity
that began in early adulthood or even earlier and is manifest in most areas
of the individual's life. While the
DSM
criteria have limited clinical value
in planning treatment, the Global Assessment of Functioning (GAF) scale,
which is Axis V, can be useful. GAF ratings range from 1-100, specified in
10-point ranges. For example, the range 41-50 reflects serious symptoms
and/or serious impairment in all or most of the life tasks, while the range
51-60 reflects a moderate level of symptoms and/or a moderate degree of
impairment in all or most of the life tasks. Clinically, individuals who meet
criteria for borderline personality disorder and are rated in the 51-60 range
are more likely to be receptive to therapy that is reasonably structured and
focused, while patients with GAF ratings in the 41-50 range or below are
less likely to be receptive to individual therapy.
While this profile is elaborated with several diagnostic criteria, this
description and these criteria characterize individual behavior and not
systemic or family behavior. At this point in time,
DSM
does not provide
descriptions and criteria for family pathology. It does, however, recognize
the context in which individuals function and provides a means of rating
family functioning.
226 Len Sperry
The Global Assessment of Relational Functioning (GARF) scale is used
to rate a family's level of functioning. It is analogous to the GAF scale, for
rating an individual's level of functioning. GARF permits clinicians to rate
the degree to which a family meets the affective or instrumental needs of
family members with regard to three areas: problem solving, organization
or structure, and emotional climate. GARF can be rated from 1-100 and
identifies five ranges (20 points) of functioning from the lowest (1-20) to the
highest (81-100).
Many, if not most, personality-disordered families would likely be rated
in the range of 21-40 on the GARF scale. This range describes a family
that is obviously and seriously dysfunctional. Their relationships with each
other would seldom be experienced as satisfactory. In terms of the areas of
problem solving, organization and structure, and emotional climate, GARF
provides these characterizations of family functioning.
• Family/couple routines do not meet the needs of members; they are
grimly adhered to or blithely ignored. Life cycle changes, such as de-
partures or entries into the relational unit, generate painful conflict
and obviously frustrating failures of problem solving.
• Decision making is tyrannical or quite ineffective. The unique char-
acteristics of individuals are unappreciated or ignored by either rigid
or confusingly fluid conditions.
• There are infrequent periods of enjoyment of life together; frequent
distancing or open hostility reflect significant conflicts that remain un-
resolved and quite painful. Sexual dysfunction among adult members
is commonplace. (American Psychiatric Association, 2000, p. 815)
Clinical conceptualization ofthe borderline personality.
The following
integrative case conceptualization may be helpful in understanding how the
borderline personality pattern is likely to have developed and been main-
tained. It is a biopsychosocial conceptualization in which the biological,
psychological, and social dynamics of this disorder can be described.
Biologically and psychologically, individuals with borderline personality
disorder can be understood in terms of the three main subtypes: borderline-
dependent, borderline-histrionic, and borderline-passive aggressive. The
temperamental style of the borderline-dependent type is that of the passive
infantile pattern (Millón, 1999). Millón hypothesized that low autonomie
nervous system reactivity plus an overprotective parenting style facilitates
restrictive interpersonal skills and a clinging relational style. On the other
hand, the histrionic subtype was more likely to have a hyperresponsive
infantile pattern. Thus, because of high autonomie nervous system reactiv-
ity and increased parental stimulation and expectations for performance.
[ Pobierz całość w formacie PDF ]
