Initial Phase
Susan signed informed consent to participate in our pilot study of IPT for BPD. She was evaluated for study entry by a highly trained independent evaluator using the DIPD-IV to diagnose BPD and the SCID to diagnosis Axis I disorders.
In the initial sessions (Sessions 1-4) of acute treatment, I [KLB] obtained Susan’s psychiatric history, set the treatment framework, and began to build a therapeutic alliance. In the first session, I explained that IPT is a time-limited, diagnosis-targeted therapy that focuses on how recent life events affect mood, and how mood symptoms make it difficult to handle current life events, and especially interpersonal interactions. I explained that our sessions would focus not on the past but on her current relationships and difficulties, such as the problems in her marriage—a role dispute. I said that we would work together for sixteen weeks; at the end of that time, we would decide together whether it made sense for her to continue for another sixteen weeks. Based on her evaluation for study entry and my review of her symptoms, I determined that Susan met criteria for BPD. I gave her the diagnosis and the “sick role” (Weissman et al., 2007):
therapist: You have an illness called borderline personality disorder, which is treatable and not your fault ... From my perspective, borderline personality disorder means that you have trouble in handling relationships with other people and the strong feelings, such as anger and depression, that you feel in interacting with them. [1]
Susan reported having grown up in Florida and having spent little time either outside her hometown or apart from her family. She attended a local college and lived close to home. She had an older sister to whom she spoke a few times a year. Susan reported that her parents argued frequently when she was growing up and were never affectionate towards one another: “Sometimes it seemed as though they were leading separate lives" In recent years, her parents seemed to be getting along better. Until meeting her husband, she had felt very close to her parents and described her mother as her “best friend" Her parents initially disapproved of the marriage because of her brief engagement, her moving to the Northeast, and her husband’s previous divorce. At the time she began the study, she and her parents we getting along, although still not as close as they had been in the past. She denied knowing of psychiatric illness in her family.
When asked about past physical or sexual abuse, she admitted that from about twelve to fourteen years of age, a close family friend who visited with his wife several times a year would look at her in ways that made her uncomfortable, make inappropriate comments about her body, groped her, and tried to kiss her when he was alone with her in her bedroom on a couple of occasions. When asked if she remembered how she felt when this man behaved inappropriately she said, “I guess I was scared and confused." She reported never having told her parents or sister about what this man did, and that she stopped seeing him when her parents’ relationship with him ended abruptly after the man and his wife separated.
Susan reported that she had “no friends"; one woman whom she described as an acquaintance was the wife of a friend of her husband’s. She partly attributed her lack of relationships to her difficulty trusting people. She explained that she feared opening up to people lest they use what she told them against her in the future. In addition, she often felt that she did not know what to say in social situations. When asked if she had befriended other mothers with young children in her neighborhood, she said she had not because she feared that they would not like her, and that she did not know what to say to them. (I remarked to myself that this deserved exploration in future IPT sessions.) She reported spending her time alone with her daughter or caring for both her daughter and twin step-daughters.
Although she had few relationships with female peers, she reported that since beginning high school, she was “always dating someone" who tended to be “very controlling." Susan reported a history of relationships with men that had extreme ups and downs. The man she dated prior to meeting her husband had been physically abusive towards her and abused alcohol. Despite this, she often feared that he would leave her.
Susan had met her husband two-and-a-half years before at a Florida resort where they were each attending conferences for work. At the time, she was living in Florida, he in New Jersey. Beginning a long-distance relationship, they married after five months. The patient quit her job of ten years as an insurance broker and moved from her small Florida town to an upper-middle-class New Jersey suburb to become a stay-at-home wife and mother.
Susan had “always wanted to have children" and became pregnant shortly after marrying. Her pregnancy and delivery were normal and uneventful. She reported that she became depressed and anxious shortly after her daughter’s birth. Susan conceded that she had not expected that marrying her husband and becoming a stepmother would be so difficult. She had to take care of the twins three or four afternoons and nights each week and at least two weekends each month. The twins’ mother lived nearby. Since her husband and the twins’ mother worked fulltime, Susan spent more time caring for the twins than did their father and mother. She felt annoyed at having to spend so much time caring for them while receiving no appreciation or recognition from her husband. She told me she wanted to spend more time alone with her daughter and with her husband, but was unsure if her feelings were appropriate. I told her: “It’s normal for you to want that. You can trust your feelings about that. We can explore how you can spend more time without the twins.”
Susan reported that Mark had grown “emotionally distant” since their daughter’s birth. She explained that he was angry at her for her frequent anger outbursts in the past year. She described him as unsympathetic to her complaints about having to care for and spend so much time with his children—because, as he often reminded her, “You knew I had two children when you married me.”
At the end of the initial phase of acute treatment (Session 4), I suggested that we choose one or at most two issues to focus on. As in IPT for major depression, IPT treatment for BPD usually focuses on one of four interpersonal problem areas: a role dispute, a role transition, grief, or (if none of the preceding is possible) interpersonal deficits. I connected Susan’s symptoms of BPD as well as depression to her interpersonal situation in an IPT formulation (Markowitz & Swartz, 2007).
Inasmuch as Susan’s chief complaint focused on problems in her marriage, my formulation underscored that she was in the midst of a role dispute—her conflict with her husband about spending time with his daughters. I presented the formulation to susan:
therapist: It seems that the main difficulty you’ve been having is your conflict with your husband about spending time with his daughters. In IPT we call a marital conflict like yours a role dispute. You and he have very different ideas about how to handle a complicated family situation, and you’ve understandably been feeling ignored, hurt, and angry. There’s a connection between what’s happening in your life and what you’re feeling. Role disputes can trigger symptoms of borderline personality disorder and, conversely, symptoms of borderline personality disorder can make it difficult to handle role disputes. Your disagreements with your husband about his daughters make you angry, and since borderline personality disorder makes managing angry feelings difficult, you are struggling to manage this already difficult conflict.
At times you may handle things ineffectively, which will create further conflict and make you feel worse. On the other hand, if we can help you to understand and use your feelings effectively, that should make both the situation better and your mood better. Does that make sense to you? susan: Yes.
therapist: This is not your fault, and you can learn how to better manage this role dispute as well as the symptoms of borderline personality disorder. You are also in the midst of multiple role transitions—becoming a wife, a mother, and a stepmother, giving up your career, and moving from the South to the Northeast. Borderline personality disorder makes it difficult for you to manage such transitions as well. We should pick one, or at most two, problems to focus on in our work together. Perhaps we should focus on resolving your role dispute with your husband, since that seems to be bothering you the most; and, if we have time, we can address the transitions. Does this make sense to you?
This formulation made sense to Susan, who agreed that resolving the role dispute should be the focus of the treatment. We agreed that the role transitions would be a secondary focus, time permitting. This agreement on a focus led us into the second phase of treatment.
- [1] asked whether this made sense to her, and she agreed that it did. She reportedthat she had not heard of BPD until she was given the diagnosis in the ER and wasglad to hear that it was treatable. As she also met criteria for major depression inpartial remission, I provided psychoeducation about both syndromes and reviewedher specific symptoms. We discussed what BPD did and did not mean. I noted thatover the years the term had acquired an unfairly “bad reputation,” but that we couldbe hopeful about her improvement. By the end of the first session, Susan said she felthopeful that she would feel better and be able to improve her situation with her husband. I was somewhat concerned that Susan was so positive; I wondered if she wasexperiencing but unable to express uncomfortable or negative feelings like manypatients with BPD. In taking a thorough psychiatric history, I conducted an interpersonal inventory,a careful review of Susan’s past and current social functioning and social relationships. The goal of the interpersonal inventory is to help both the therapist and patientunderstand how the patient interacts with other people; to identify her social supports, if any; and to determine how recent relationships might have contributed to orhave been affected by BPD symptoms. Patients with BPD report that their angeroutbursts alienate people close to them and make it difficult to form relationships.They describe difficulty forming or maintaining relationships because they have difficulty trusting others. They may end relationships prematurely because they irrationally fear abandonment or feel unable to handle even a minor conflict. Theinterpersonal inventory provides a framework for understanding the social andinterpersonal context in which the borderline features present and should lead to atreatment focus.
