Acute Middle Phase

During the middle phase (Sessions 5-13), we worked on resolving Susan’s interpersonal problem areas. I continued to provide contextual psychoeducation about BPD and to explore with her how BPD influenced social functioning, and I repeatedly linked her symptoms to her role dispute and multiple role transitions. I began each session by asking: “How have you been feeling since we last met?” This opening question elicits affect and brings forth an interval history of events between sessions, as in this example.

susan: I’m nervous because the twins are staying over this weekend. therapist: Tell me more about that. What are you nervous about? susan: I just think it is too busy with all three kids, and my husband won’t pay attention to me and my daughter. I wish it could just be the three of us sometimes. therapist: What’s it like for you when you get nervous? susan: I get really irritable and I feel nervous—I can’t relax.

therapist: Have you told your husband how you feel, and that you would like to spend more time together without the twins? susan: I’ve tried, but he always gets mad.

At this point, I conducted a communication analysis, asking Susan to recount exactly what she said to her husband, how she said it, her husband’s response, how that made her feel, and how she then responded. The analysis revealed that Susan became irritable, argumentative, and anxious before the twins were to stay over, or when her husband announced that the twins were coming over on a day when she wasn’t expecting them. On occasion she would ask angrily, “Why do we always have to have them over?” In response, Mark would get angry and accuse her of not loving the twins, which would further enrage her.

I validated her feeling angry about the situation. I then reiterated that she had difficulty managing negative or uncomfortable emotions, explaining that people with BPD tend to feel overwhelmed by such feelings. I noted that her wish to have a break from the twins was appropriate—normalizing her anger and resentment. The goal was to express the anger effectively. It was not her fault that she was prone to angry outbursts, but she could learn to communicate her anger in a more moderate and effective way. I suggested that we explore ways to communicate her feelings so that her husband might better understand her needs. “What other options do you have?”

We role-played her telling her husband that she does care about the twins, but that she also enjoys having time with her husband and daughter. Further, the time without the twins is less hectic, and she would appreciate having a break, as she takes care of all three children several days each week. Role-play allowed Susan to rehearse both the content and the tone of her communication. She was then able to express this to Mark calmly, and he was somewhat more receptive. The sense that she had some control over her environment and her emotions, and had succeeded in a new approach, in turn improved Susan’s mood.

We explored her options:

therapist: How could you plan more for more time alone with your daughter and husband?

susan: I guess I could suggest that my husband’s parents take care of the twins one afternoon. They could sleep over at his parents’ house. therapist: That’s a great idea! What would it be like for you to suggest this? susan: I think I could do that. therapist: What could you say to him?

susan: I would say: “Would it be okay if the twins stayed with your parents one night, so we can have a night alone with our daughter?” therapist: How do you think your husband might respond? susan: I think he might be okay with it.

therapist: You sound hesitant. Are you concerned that he might not be okay with your asking?

susan: He may accuse me of not wanting to be with his children, like he always does.

therapist: What could you say if your husband does that?

susan: I guess I could tell him that I do want to be with them, but that sometimes I would like a little time alone with him and our daughter. I think it is important for our daughter that she has time just with us. therapist: How do you think he might respond?

With a little more confidence, Susan said: “That might work.” We then discussed contingencies: how she could react to different responses her husband might have at this point.

Susan often perceived her husband to be abandoning her. I noted that this tendency was a symptom of BPD, but wondered if her husband was, in fact, neglecting her at times. She found herself feeling very angry and abandoned when her husband was around the twins. She reported that on the weekends that the twins stayed with them, he “ignored” her and her daughter, and chose activities that only the twins would enjoy. When asked how she managed these angry feelings, she reported that she would become depressed, withdraw, and snap at him. She admitted also to a strong desire to cut herself, but felt unable to do so because her daughter was around. I asked why she wanted to hurt herself when she really felt angry at her husband. I connected this to BPD, a reflection of her difficulty managing anger that was valid and normal, but difficult for her to tolerate. I validated her wanting to spend her weekends doing activities that she enjoyed. Susan was able to acknowledge that her husband was not, in fact, abandoning her, but was not considering her needs as much as she would like.

We explored ways of handling this situation better. For example, she could initiate activities that she liked. I encouraged her to explore options, rather than providing them to her. We explored options for activities that she wanted to do and role-played suggesting these activities to her husband. Susan feared that if she suggested alternative activities, he would reject her ideas. I acknowledged the risk of rejection. Susan then decided it was unlikely that her husband would reject her suggestions and ultimately took the risk of suggesting family activities. Her husband was agreeable, which made her feel good. After this positive experience, Susan continued to suggest family activities.

Despite her attending sessions, better managing her anger reactions, and communicating more effectively, Susan reported that Mark remained emotionally distant. Susan felt that he did not recognize the efforts she was making to improve her symptoms and their relationship. We role-played asking her husband to be more supportive. She told him that she appreciated that he had endured a lot when she was having frequent temper outbursts, but that it would be helpful if he could acknowledge the progress she was making and support her efforts to better manage her anger. She also explained BPD to him and spontaneously gave him the book Stop Walking on Eggshells: Taking Your Life Back When Someone You Care About Has Borderline Personality Disorder, which she had discovered in a bookstore. Her husband conceded that he had been holding a grudge and not making the efforts he should have to improve their relationship.

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