Successful Intervention with a Family Impacted by Treatment-Resistant BPD

Successful Intervention with a Family Impacted by Treatment-Resistant BPD

by Daniel Lobel
Work more effectively with teens with Borderline Personality Disorder by being consistent, setting boundaries, and allying with parents.
In This Article…

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Borderline Personality Disorder (BPD) is one of the most difficult psychiatric disorders to treat, the main reason being that it affects the entire family
Borderline Personality Disorder (BPD) is one of the most difficult psychiatric disorders to treat, the main reason being that it affects the entire family. Thus, effective treatment requires working with as much of the family as possible in a coordinated effort. Multiple professionals are also often involved, which adds to the need for coordination of resources. Further adding to the complexity of intervening with families impacted by this disorder is the fact that there is usually significant resistance to the treatment by one or more parties.

Treating families impacted by BPD also requires specialized therapeutic skills. I have found that many techniques that are effective with other diagnostic groups are not only ineffective with BPD, but may actually make the disorder worse. This is why most of the families who present themselves to me have already been exposed to numerous therapists and treatment modalities by the time we meet, leaving them exhausted and disappointed. In many cases, large amounts of money and other resources have already been spent, also leaving them jaded and skeptical. These families are very often on the brink of their breaking point.

Am I expected to produce a Hail Mary, or am I just another soon-to-be-discarded and/or disappointing clinician in their minds? This is a very high-pressure situation for a clinician, and for this reason I suggest that colleagues only take on such situations if they have specialized skill in treating this disorder or other debilitating personality disorders. A full illustration of all of the specialized skills needed to work with these families is beyond the scope of this paper. For expediency, I will focus first on four tools that I have crafted and found to be highly useful in treating families impacted by this disorder. These tools are described below and will be illustrated in a case study that follows.

Useful Tools

Manage Expectations

This applies to the patient, the family, the other professionals, and yourself. Healing and growth are processes and not singular, disconnected events. All participants in the intervention should be told overtly that this process will take months, if not years, to reach an optimal outcome. I generally tell patients and their families, “Things will most likely get worse before they get better.” This prepares everyone for the inevitable resistance while creating a future milestone measured by increased cooperation.

Protect, Protect, Protect

The therapist must provide some basic level of safety to the process and all who are involved
You must protect the patient, the family, the process, and yourself. A key, and possibly the most disruptive, feature of BPD is the client’s lashing out at others when frustrated. Many families allow this behavior to provoke them into participating in disruptive behavior by shouting back or threatening. The therapist must provide some basic level of safety to the process and all who are involved in order to avoid disruption of the therapeutic work, often manifested by one or more parties’ walking out.

As a therapist in this situation, you are at very high risk for being triangulated into the family dysfunction, in which case this lashing out may be directed at you. Your chair should be the closest to the door, and you need to prepare to split up the group if you cannot deescalate conflicts with all present.

Modeling

You have to teach the family how to cope with disruptive behaviors such as lashing out, triangulation, codependency, and self-mutilation that are common with BPD and rare in other disorders. This is where the specialized skills come in. Each of these disruptive behaviors requires its own set of coping mechanisms. This is where conventional methods can backfire. For example, healthier families can share diverse opinions without the divisive effects of triangulation. In families with BPD, encouraging sharing of diverse opinions is likely to lead to further polarization and increased conflict, thereby worsening rather than improving the situation.

Starve, Do Not Feed, the Monster

The monster is the disorder, the BPD, not the sufferer
The monster is the disorder, the BPD, not the sufferer. The family must bond together with the sufferer and the professional team to fight it. While traditional therapeutic methods encourage compromise and flexibility as solutions to conflict, these methods may feed the monster or make the disruptive and disturbing nature of the disorder worse in families with BPD. The emotional dysregulation caused by the BPD often escalates into rapid, impulsive acting out towards self and others. Introducing compromise, flexibility, or, worse, compliance, reinforces that lashing out will get at least some of what you want. This will increase the frequency and intensity of the lashing out. Conversely, withholding all possibility of acquiescence because of the lashing out starves the monster and sets the stage for the introduction of more socialized, and hence more successful, strategies. This is consistent with basic behavioral principles.

Case Study

The following is based on a real case, but with many details changed in order to protect identity.

Mary Zohn called me about her 19-year-old daughter, Rosa. She had been referred to me by her therapist because although her daughter was in treatment with a therapist, things were getting much worse at home and the family was in crisis. I agreed to meet with her and her husband Charlie for an intake.

The Zohns showed up at my office with two thick files that documented difficulties with Rosa since the beginning of high school. Since that time, Rosa had experienced steady deterioration
The Zohns showed up at my office with two thick files that documented difficulties with Rosa since the beginning of high school. Since that time, Rosa had experienced steady deterioration despite multiple treatments with several different professionals. They explained that although she was intelligent, she had ongoing difficulty functioning in a school environment. She often missed classes and rarely completed assignments on time, if at all.

In her frustration with school, Rosa began engaging in other less productive and more self-damaging activities such as sexual promiscuity, substance abuse, and excessive computer video gaming. She began staying out late, and then overnight. Her room was dirty and her hygiene was regressing.

The Zohns began confronting her about her poor school performance and unhealthy habits. They tried to set limits. This was associated with screaming conflicts that ended up with her sometimes leaving for days at a time, and often included self-destructive behavior such as cutting and going days without food and water in protest. Her parents were becoming increasingly concerned about her health.

They were also becoming increasingly concerned about her influence on her younger sister. Rosa was the middle child of three girls. Her older sister, Wilma, did very well in school and had a good job. She was self-supporting and lived in her own apartment about an hour away from the family residence. The younger sister, Bertha, was in middle school and struggling with a learning disability and social issues at school. The Zohns were very concerned about how Rosa’s behavior would affect Bertha’s struggles.

Initial Interview

What precipitated their reaching out to me was that Rosa had been arrested with her boyfriend
What precipitated their reaching out to me was that Rosa had been arrested with her boyfriend for possession and distribution of narcotics. Following are some excerpts from my initial interview with the Zohn’s:

Dr. Lobel: What is Rosa’s current legal status?

Mary: She is out on bail.

Dr. Lobel: What is she doing with her days?

Charlie: Supposedly she is in school.

Mary: She is enrolled in college but we think that she does not attend classes.

Charlie: She leaves every night pretending to go to school but she goes to see her boyfriend instead.

Dr. Lobel: How do you know that?

Charlie: Because she is getting incompletes in all of her classes and she doesn’t come home until 4 AM.

Dr. Lobel: How does she get to school?

Mary: She drives herself.

Dr. Lobel: She has a car?

Charlie: We got her a car so that she can go to school.

Dr. Lobel: But she is not going to school, right?

Mary: We don’t know for sure.

Charlie: Yes, we do. This is the 3rd semester I am paying for, and she hasn’t even earned two credits.

Dr. Lobel: So, you pay her tuition and buy her a car to go to school. She doesn’t go to school and you continue to pay her bills?

Mary: Are you suggesting that we should cut her off?

Charlie: I can’t do that to my daughter.

Dr. Lobel: You mean stop enabling her?

Charlie: What do you mean?

Dr. Lobel: Under the guise of paying for school you are enabling her to engage in unhealthy and illegal activities with her boyfriend.

Mary: We have discussed this before, but her therapist has recommended that we try not to stress her out; that we should give in to the small stuff so that she does not get dysregulated.

Dr. Lobel: How is that working for you?

Charlie: Not good.

The Zohns left the initial consultation a bit shaken by my recommendations. Up until this point, therapists had recommended walking on eggshells around their daughter by reasoning with her, trying to be flexible and forgiving, and overlooking Rosa’s outbursts and acting out.

Second Consultation

Three months later, the Zohns contacted me again. Rosa had been arrested. This time she had been driving while intoxicated and crashed. The car was totaled, and she was charged with driving under the influence (DUI). Fortunately, she was not significantly injured.

Up until this point, therapists had recommended walking on eggshells around their daughter
They came in for another consultation. They explained that they had come to realize that they were indeed enabling her, feeding her monster, and that they needed guidance. They didn’t know how to say no to her and follow through consistently. We agreed that we would meet with her together in order to help them to set up some healthier boundaries. Most notably, this included the plan that resources such as money and transportation would only be available for the pursuit of healthy activities.

I asked the Zohns whether they were on the same page regarding what was right for Rosa. They shared that they often argued about whether or not to be “strict” with her and how strict to be. I told them that they must be united in the setting and reinforcement of boundaries and that I would help them with this. They agreed. I suggested that I see Rosa individually before we again met as a family so that she would not feel ganged up on. They agreed, but she did not.

First Family Meeting

They are constantly on my case. I don’t do anything right
When the three arrived for our first session together, I asked Rosa to come in by herself for a few minutes, and she agreed. Here is an excerpt of our meeting.

Dr. Lobel: Do you know why your parents asked you to meet with me?

Rosa: They just want to control me. They irritate me constantly.

Dr. Lobel: How do they do this?

Rosa: They are constantly on my case. I don’t do anything right. They want me to be like Wilma. They have always favored her. I can’t be Wilma so I am a disappointment to them.

Dr. Lobel: In what way do they want you to be like Wilma?

Rosa: Smart, beautiful, and successful. That is not me.

Dr. Lobel: What do you think prevents you from being successful?

Rosa: Them. They nag me all the time and then I can’t concentrate on my studies.

Dr. Lobel: That’s why you don’t go to class?

Rosa: Yes. I get so upset I just want to get high. I would rather be with my boyfriend.

Dr. Lobel: What does your therapist suggest?

Rosa: She has tried to get them to back off, but they can’t stop themselves.

Dr. Lobel: What would you do if they were not bothering you?

Rosa: I would get a job.

Dr. Lobel: Have you ever had a job?

Rosa: Yes. Several.

Dr. Lobel: How did that go?

Rosa: I usually work for a while and then they start hassling me.

Dr. Lobel: At work?

Rosa: Yes.

Dr. Lobel: Out of the blue.

Rosa: They get all upset if I am late once or twice or if I call in sick.

Dr. Lobel: And then you get fired.

Rosa: Yes. But the reason I am late or sick is because of my parents!!

Her parents agreed to support healthy behaviors rather than unhealthy ones
We brought the parents in. We all agreed that Rosa needed to take a leave from college while she resolved her legal issues and living situation and began to more directly address her mental health challenges. We then introduced the idea that Rosa’s access to resources, such as a car and money, would be contingent on her manifesting healthy behaviors. Her parents agreed to support healthy behaviors rather than unhealthy ones. Rosa began yelling at her parents and at me, stating that this was little more than additional control and would make things worse. She stormed out of the meeting. As she came in the car with her parents, we were confident that she would not be able to go far, so we finished the hour by offering suggestions as to how to respond to her agitation. We reviewed the “form before content” tool. This basically required that Rosa speak in civil tones, or the conversation would stop.

Dealing with Resistance from Rosa’s Therapist

The following Monday morning, I received a call from Rosa’s therapist, Ms. Hartman, who wanted to know what was going on in our meetings that was so upsetting to her patient. She expressed that Rosa was “triggered” by the meeting and it was making her sicker. I was expecting this call. Here is an excerpt of our conversation:

Dr. Lobel: What about our meeting did Rosa find triggering?

Ms. Hartman: She felt ganged up on.

Dr. Lobel: Which part made her feel ganged up on.

Ms. Hartman: You and her parents trying to control her.

Dr. Lobel: Did she give you any specifics?

Ms. Hartman: No. She just said that she was so triggered she had to leave.

Dr. Lobel: She appeared to get agitated as soon as I said that her parents would support healthy activities and not support unhealthy ones. Does this contradict what she told you?

Ms. Hartman: No.

Dr. Lobel: I imagine you must be working with Rosa on increasing her tolerance for frustration and difficult situations.

Ms. Hartman: Yes. I specialize in Dialectical Behavior Therapy (DBT). I think she also takes medication.

Dr. Lobel: We are trying to help Rosa take responsibility for her choices and behaviors and she is having difficulty tolerating it. Can you help her accept that she has to accept responsibility for herself while giving her the confidence that she can do so in a healthy way and grow from the experience?

Therapy Begins

Several meetings with the Zohns followed, in which we created a contract through which Rosa could benefit from all of the resources her parents had to offer if she used them for healthy pursuits. She got a job and prepared to resume her studies. She agreed to maintain sobriety. The sticking point was the parents not wanting her to be alone with her boyfriend, as they felt his influence corrupted her. We agreed that he could visit her at the family residence but that the Zohns refused to have their vehicle or their financial support to be used to spend time with him. She very reluctantly agreed.

I thought that the stimulant alone was adding to her emotional dysregulation
I also inquired as to the status of her pharmacotherapy. She apparently had a psychiatrist who prescribed a combination of medications that included psychostimulants for attentional difficulties, a mood stabilizer, and an antidepressant. She refused to take the mood stabilizer and antidepressant but wanted to continue with the psychostimulants. The psychiatrist refused to treat her under these circumstances, so she was getting Vyvanse prescriptions from her pediatrician. I suggested that she consult with another psychiatrist, as I thought that the stimulant alone was adding to her emotional dysregulation. She saw a psychiatrist and agreed to work with her on a more therapeutic regimen.

Rosa seemed to stabilize for a few months and was moving forward on our plan, until, that is, when the testing began. Her parents noticed that she was not always at work when she said that she was at work. They suspected that she was seeing her boyfriend. They also found evidence in her bedroom that she was vaping marijuana again.

Mary and Charlie met with me to discuss their fear, apprehension, and guilt at holding to their boundaries. They feared confronting Rosa, which they knew they needed to do, and they feared for Rosa as well. They did confront Rosa, who denied everything. Then Rosa disappeared.

She went to work one day and did not return. The Zohns contacted her employer the next day, who confirmed that she had not shown up for work. They tried to contact her via cell phone, but she “ghosted” them (refused to answer). They were pretty sure that she was with her boyfriend, most likely using drugs and engaging in other unhealthy and risky behaviors.

I met with the parents a few times over the next few days. They were very frightened and questioned our plan. They contemplated texting her and allowing her to do whatever she wanted if she just returned home. I discouraged this and explained that this would be a major setback. I told them that she and her boyfriend did not have the resources to survive on their own and that she would have to return home eventually. She had nowhere else to go.

We began preparing for her return with the understanding that the Zohns’ home was not viable as a therapeutic environment for Rosa and that she was in need of inpatient treatment. I encouraged the Zohns to research options and prepare to have her admitted promptly when she returned.

It took about a month. Rosa missed one of her court appearances and was again arrested. She called from the police station. The Zohn were prepared and let her know her options. She had no choice but to agree.

She was admitted to an inpatient facility that specialized in BPD and substance abuse. She stayed for three months and then transitioned to a sober living residence near her parents. She stayed there for six months, during which time she got a job, resolved her legal issues and embraced sobriety with the help of a Twelve-Step Program and a good sponsor. She went from sober living to the university.

Conclusions

In this case, BPD had not only metastasized throughout the family, but also infected the professionals involved. Approaching Rosa’s treatment from an individual perspective was not successful, because her disorder caused her to manipulate her environment into a codependent mess that enabled her to stay sick and get sicker. The only way for her to recover was to assemble a team that included her entire family and all providers working together and consistently.

The only way for her to recover was to assemble a team
Intervening in a system impacted by BPD, as in this case, required specialized skills and the willingness to confront all aspects of the patient’s treatment, including enabling providers. This was often like stirring up a bee’s nest. Great care had to be taken to protect these providers by not making them feel negligent or naïve while at the same time engaging them in a consistent therapeutic process. It was critical to anticipate resistance, even by the professionals who attacked me for challenging them. I didn’t take it personally and haven’t, which has proven to be an effective tactic. I explained to them my process and expectations in non-accusatory terms and showed them their value in the coordinated healing process.

In looking back over the case, I knew I was going to be seen as a snake-oil salesman, met with skepticism and doubt. I had to effect a paradigm shift. I also expected things to get worse before they get better. And they did. I reminded myself that as a clinician. I had to stick with what I knew: with the treatment plan, with the best techniques at my disposal.

I also knew that if this approach failed, there would probably not be another chance. Rosa would lose her only lifeline, and the family would all suffer. I reached the point of no return. I was fully committed and I had to see this case through, no matter what. I have treated families like this countless times over the years, but each case is different and each path its own.

If you are going to venture into this challenging treatment domain, conviction is critical, and still there will be no guarantees.


© 2021 Psychotherapy.net, LLC
Bios
Daniel Lobel Daniel S. Lobel, Ph.D. is an author and a clinical psychologist in private practice in Katonah, NY. He is the author of When Your Daughter has BPD: Essential Skills to Help Families Manage Borderline Personality Disorder, When Your Mother has Borderline Personality Disorder: A Guide for Adult Children and a coauthor on Stop Walking on Eggshells for Parents: How to Help Your Child (of Any Age) With Borderline Personality Disorder Without Losing Yourself, all of which can found on Amazon.com and BarnesandNoble.com. He is also working on his new book, When Your Loved One Has Borderline Personality Disorder: A Guide to Building a Healthier, More Supportive Relationship, which will be released in 2022. Dr. Lobel also has a regular blog site on Psychology Today called My Side of the Couch. Dr. Lobel can be contacted at Katonahshrink@gmail.com or 914-232-8434.