Synopsis of Treatment of Borderline States in Substance Users

Half of drug-dependent women report CAAN; such trauma predisposes to personality problems. About 30% of current alcoholics and almost 50% of current drug users are personality disordered. Multiple types of abuse yield more severe personality disturbances. Axis II co-morbidity interferes with the working alliance with drug and alcohol counselors and robustly predicts relapse after treatment. The combination of Axis I and II disorders is the best predictor of relapse one year post-treatment. In one study, only 6% of patients with more than one personality disorder (PD) were sober in a year, compared to 44% in those with no PD. Up to 30% of substance users in treatment are borderline.

A study of Australian heroin addicts aged 18–24 found high rates of psychiatric comorbidity. Table 1 depicts its findings. Clearly, personality disorders, particularly Borderline Personality Disorder (BPD) and Antisocial Personality Disorder (ASPD), are very common among substance users.

	Males	Females
Major Depressive Disorder	17%	32%
Lifetime history of suicide attempt	26%	40%
Attempted suicide in last 12 months	12%	25%
Antisocial Personality Disorder	80%	68%
Borderline Personality Disorder	46%	59%
Posttraumatic Stress Disorder	30%	47%

Table 1. Psychiatric comorbidity among heroin users. Adapted from Mills, et al.

In summary, up to 30% of substance users in treatment are borderline, if criteria shared by both diagnoses are included. Conversely, in a study of persons seeking treatment for personality issues, half had a lifetime SUD, and 15% were actively using. Among the users in this group, those using heroin, cocaine, or amphetamines were 12 times more likely to have a cluster B disorder. Among borderlines in treatment, those with SUDs who persist in substance use fail to resolve their borderline issues.

Diagnostic criteria for Borderline Personality Disorder

A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five or more of the following:

• frantic efforts to avoid real or imagined abandonment
• a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation
• identity disturbance: markedly and persistently unstable self-image or sense of self
• impulsivity in at least two areas that are potentially self-damaging, e.g. spending, sex, substance abuse, reckless driving, binge eating
• recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
• affective instability due to a marked reactivity of mood, e.g. intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days
• chronic feelings of emptiness
• inappropriate, intense anger or difficulty controlling anger, e.g. frequent displays of temper, constant anger, recurrent physical fights
• transient, stress-related paranoid ideation or severe dissociative symptoms

With 9 criteria of BPD, and 5 needed for the diagnosis, there are a great number of possible combinations. Using the formula n!/r!(n-r)!, where ‘n’ equals the total number of criteria, and ‘r’ equals the number required for diagnosis, there are 126 possible combinations. BPD can present with 126 different clinical pictures! Bateman and Fonagy write that it is possible for two persons who receive the diagnosis to share only one of the nine criteria. They go on to note that having only three of the criteria can impact the course and outcome of treatment of a depressed person (or a substance abuser — italics mine). Severity of symptoms can further complicate the clinical picture; borderline persons can be high or low functioning, thus at least doubling the possible number of presentations.

Etiology

In summary, genetic factors, trauma and neglect history, and disorders of attachment are implicated in the etiology of BPD. A study comparing MZ and DZ twins for BPD found a 35 versus 7% concordance rate if 5 or more criteria for BPD were met, and more if 3 or more criteria were met. A study of BPD inpatients found that more than 90% had suffered abuse or neglect, and more than 80% biparental abuse or neglect. The latter increased the risk of sexual abuse by someone other than the parents. Studies point to disruptions in attachment as contributing to etiology. Conflicts over approach and avoidance present a dilemma for borderlines.

James Masterson’s approach differs in his emphasis on certain features of the borderline experience, but his psychotherapeutic interventions are intensely mentalizing in their effects. Acknowledging maternal libidinal unavailability, he focuses on the propensity for many mothers and fathers of future borderline persons to cling to their offspring, punishing any efforts at separation and individuation by further withdrawal of affection, support, or attention. This abandonment leads to a depression in the child, resulting in impairments in such self-functions as self-activation, self-assertion, and self-esteem. The child then defends against the depression by various forms of acting out, including clinging (exercising the wish to be taken care of), compliance, pleasing behaviors, demanding behaviors, and in adolescence and adulthood promiscuity, distancing, and substance use. Masterson is unique in positing the central importance of the abandonment depression and the frantic and persistent efforts patients take to avoid it. His primary psychotherapeutic gambit is the confrontation of actions that are contrary to the best interests of the self, such as the forms of acting out listed above.

Furthermore, when adult persons attempt to curtail acting out by such acts of separation-individuation as getting sober, mentalizing, saying ‘no’ to abuse by a mate, self-assertion, or limiting sexual acting out, the mother image in their heads, or perhaps actual mother, says ‘no, no, no’, triggering their childhood depression of abandonment, which they attempt to avoid by relapsing in some form. Separation-individuation (self-activation, self-assertion) → depression → defense (acting out in some form). Masterson calls this the “personality disorders of the self triad.”

Treatment of the borderline personality disordered user

Figure 4. Development of Borderline Personality Disorder, from faulty parenting to the Disorders of the Self Triad.

The diagram above emphasizes the personal and interpersonal in the creation and maintenance of BPD. Treatment starts with a thoughtful intake, covering the points in the intake history advocated in the Brief Initial Visit Questionnaire. Axis I disorders must be diagnosed and addressed, but detecting the presence of BPD alerts the clinician that this condition immensely complicates Axis I disorder treatment. Bateman and Fonagy point out that the primary task of therapy of BPD is to foster mentalization. Taking a history includes constantly being neutral, always inquisitive, and always questioning to clarify various points. I particularly like Bateman and Fonagy’s urbane question, posed after a formulation has been proposed: “As we start this treatment, what things can go wrong, what do we need to be on the lookout for?” Recalling that we are dealing with chronic relapsers, I advocate informing patients of the diagnosis of BPD, and then letting them know that substance use will undermine any hope of recovery from BPD.

On the diagram, the point of “abandonment depression” is a kind of watershed. Various approaches to enhancing mentalization, working with core attachment and child abuse and neglect issues, and dealing with the IWM through working with the transference, reduce abandonment depression pressures from upstream. It is the preferred treatment for severe borderlines; confrontation of maladaptive behaviors in such persons often draws a blank.

It is important to keep in mind, when working with any level of borderline patient, that their deficits in mentalization will manifest in a variety of ways. First, they are rigid people who have a poor understanding of the mental states and motivations of others; Bateman and Fonagy point out that they believe, implicitly or explicitly, that only one interpretation of another’s mindset or motivation is possible. As they learn to mentalize, their thinking processes become supple. Second, their lifestyles are chaotic; hence, they miss appointments, show up on the wrong day, may be several hours late, disregard advice, change their minds about the importance of therapy, suddenly change their opinions about their therapists, plunge headlong into love in a day, and equally quickly have a relationship come crashing to a close. The authors advise therapists to therefore remain flexible by constantly holding a mentalizing stance, attempting to understand the mind of the patient at any given moment and conveying that understanding to the patient, all the while keeping countertransference in mind.

For the poorly functioning substance user, the first goals are the attainment of sobriety and finding adequate housing. Then, psychotherapeutic work with severely afflicted persons can proceed by (1) enhancing mentalization, (2) working with the Agentive Self, (3) denoting mental states and affects, (4) focusing on relationships, and (5) for those that can tolerate and respond to confrontation, confronting maladaptive behaviors and beliefs, the optimal procedure for higher functioning patients. A mentalizing stance is at the heart of each of these aspects of therapy.

Enhancing mentalization

Bateman and Fonagy write, “The mentalizing stance is an ability on the therapist’s part to question continually what internal mental states both within his patient and within himself can explain what is happening now…. Why is the patient saying this now? Why is the patient behaving like this? Why am I feeling as I do now? What has happened recently in the therapy or in our relationship that may justify the current state? The understanding of aspects of these questions will allow the therapist to link external events, however small, to powerful internal states which are otherwise experienced by the patient as inexplicable, uncontrollable, and meaningless.” The therapist translates this mentalizing stance into an open-ended curiosity about patients’ affects, behaviors, or reactions in the session. The authors continue, “The therapist must not only help the patient understand and label emotional states but also enable him to place them within a present context with a linking narrative to the recent and remote past. The gap between inner experience and its representation engenders impulsivity.” Consider the following case:

A 43 year-old alcoholic woman victim of severe CAAN lived with her parents, would go on binges, get beaten by her parents, and end up in psychiatric hospitals. She fulfilled the criteria for BPD. After a hospitalization, she enrolled in an outpatient drug and alcohol program, where I started seeing her. After 3 months of sobriety and active in our program and AA, she got a job. At about 6 months, the following interaction took place:

At this point I gave in and accepted her reassurances. Three days later she went on a binge and lost her job, but returned to the clinic in a week, after limiting her binge. In retrospect, I could have said the following and perhaps brought about a different outcome:

That outcome would certainly open things up! This example emphasizes that the absence of mentalization in an adult might be due to a deficit, or it might be due to active inhibition, the decision to not mentalize.

Working with the Agentive Self

The agentive self, the “I”, the thinker of thoughts and doer of actions, is created out of attachment bonds and in turn represents attachment relationships to form the IWM. According to the model depicted in the diagram above, disordered attachment, negative images of the IWM, CAAN, and lack of support for separation-individuation negatively influence the functioning of the Agentive self. Each of these domains presents opportunities for psychotherapeutic intervention. Working with CAAN means addressing its fallout: resentment and the wish for revenge, the lack of resilience, and difficulties with self-assertion. Psychotherapy implicitly or explicitly supports the drive for separation-individuation. It remains for us to discuss a method for approaching the essence of a disordered attachment through working directly with the images of the IWM.

The IWM consists of internalized representations of important attachment figures and the self. These internal representations are in fact images. Products of imagination such as metaphor, fantasy, and works of art point to the underlying presence of images. But images are most directly visible and palpable in dreams. In a disordered attachment, the emotionally unavailable or hostile caregiver, colored by aspects of the alien self and its negative affects, is represented by nightmarish images. The reality of these images, common in the nightmares of borderline substance abusers, is suggested by the literal impact they exert on the body during dreams, e.g. increased heart rate, increased and labored respiratory rate, and such affects as anxiety and dread. We can access the effects of disordered attachments of borderlines directly by working with the images of their dreams and nightmares.

Ultimately, it is the Agentive self that makes choices in life. Decision making is the bottom line action of the Agentive self. Ultimately, separation-individuation is making good choices. Masterson calls the therapist’s support of the patient’s good decisions “communicative matching.” It is important that therapists quietly ratify the patient’s efforts to make good choices.

Denoting mental states and affects

Bateman and Fonagy note the parallel between a mother’s mirroring of her child and the therapist’s task of accurately grasping the mental states and accompanying feelings of the patient. Failures are inevitable, however, impelling therapist and patient to re-examine and re-articulate their views, until a consensus is reached. Such focus is on present states of mind, however; the authors note that there is little to gain from continually focusing on the past. Catharsis of feelings stemming from past trauma is necessary and helpful, but work with the current chronic states of mind stemming from childhood trauma, e.g. resentment, pessimism, fear, PTSD, and psychosomatic states, will constitute the major work.

So, how do you figure out what states of mind currently occupy the patient? What can alert you that an important state needing attention is present? The fact is that the mental-emotional states of borderline patients cry out for recognition; it is what they missed out on in their childhood years. Now, in adulthood, they have difficulty knowing what they feel. They are unable to adequately consciously represent and communicate these states to themselves and others. Yet they are unconsciously continually signaling their mental states and associated affects. They are doing so via the use of anecdotes of past or present interactions with others.

The work of Robert Langs is very useful in grasping the mental states of others. Langs demonstrates that in a therapy hour a patient’s several narratives, in combination with body language and voice inflection, add up to a prepotent mental state within the patient. However, a caveat: this salient state may have to do with you, the therapist! As we therapists listen to the patient’s various anecdotes, we must ask if they pertain to us. If a man I am seeing describes an early memory of an uncle who failed to show up when promised, then intersperses a comment about an offspring who gave an undesirable gift, then an aside about being disappointed in a meal at a restaurant, I must ask if this person is feeling unmirrored, and more specifically unmirrored by me. I would then proceed to discuss my hunches with the patient, and then listen for feedback. I can thus retain mental closeness with the patient.

Focusing on relationships

A primary early goal in a brief psychotherapy with any kind of patient is to establish an attachment relationship with you, the therapist. For a therapy to be effective, the patient must trust the efficacy of the therapist and the safety of the relationship. In this context, patients and therapists can examine the patient’s relationships. More specifically, they can attempt to figure out, with the assistance of the therapist, how important others think, how they themselves think as they relate to those important others, and how interactions take place as they do.

I think we as therapists have crucial information that can make explicable the mind of a mate, co-worker, or parent. Repeatedly, I have worked with patients who were chronically bewildered and unable to cope with a significant other who was dominating and intimidating them. By their descriptions, I can easily see that their antagonist is a psychopath or narcissistic personality. Armed with this information, the patient can begin to say, “I see it was him, not me.” For the patient who persists in a relationship with such a destructive character, I can ask why they continue in something that is not in their best interest, e.g. I ask them to mentalize about themselves.

It is equally important that the therapist assist the patient understand the processes of interactions with others. An “I said-she said” analysis can be quite revealing. Inevitably in many therapies, the patient will attend a family reunion or family visit, the prospects of which the patient dreads. Analyzing the projected interaction can suggest changes in the patient’s responses, which can change the whole dynamic of the relationship. For example, a Canadian woman moved to Southern California to escape her parents, particularly her mother. The parents announced a visit, which panicked the patient. It turned out that the patient could not bear a stereotyped interaction with her mother, consisting of mother complaining to her daughter, starting at about age 8, that the father routinely demanded fellatio, something the mother could not stand. The patient, at a loss to cope with this, had moved far away. Realizing this was an example of triangling, a pathological family interaction that guarantees that the family system stays stuck (‘a’ talks to ‘b’ about ‘c’), I rehearsed with her the following simple response: when mother began her anticipated complaint, she was to quietly and persistently say, “Mom, I think you should talk to Dad about this, not me.” In doing so, she took herself out of the triangle. The mother responded, after a day of frustration, with a flood of tears about how unhappy and depressed she had been for years, something she had never divulged to anyone. The patient felt much closer to her mother, and the two began a more symmetrical relationship.

Confronting pathological defenses

Klein, describing Masterson’s technique of confrontation, writes that it is the questioning of motivation for maladaptive thoughts, feelings, or behaviors. It is the pointing out of a contradiction between one’s actions and some aspect of one’s self-interest. “Why?” questions bring to a person’s attention a discrepancy between one’s self image and destructive actions. In recovery circles, an “intervention” is a good example of a confrontation. In an intervention, an assembly of family members gives dad personal descriptions of instances when they saw him become violent when drunk, when they saw him in a blackout, or when they saw him staggering with slurred speech. Police have been known to videotape intoxicated persons; when shown in court, this is a confrontation. When I worked as a jail psychiatrist, I saw men psychotic on methamphetamine require restraint in a padded cell, where they screamed, pounded, and smeared their feces, only to come out of the psychosis with no memory of their actions. After release, they’d soon be back again, in the same state. We should have videotaped it; these men lacked essential information about themselves. As clinicians, we usually can give no first-hand account of a person’s appearance when intoxicated, so we are not in a position to confront. A family doctor must, however, confront the patient with news of elevated liver enzymes.

The persistently promiscuous man described at the beginning of the chapter needs to be confronted: “I’m at a loss to understand why, after you have lost your health to HIV, you keep going out there?” Then, I would note carefully his response. Maybe he would look further into his thought that there “is something broken in me.” Then again, his denial might mean that he is protecting his meth habit. Another example of confrontation is my persistent inquiry into Joan’s discrepancy between her body language and her verbal insistence on her well-being.