April 16, 2015
This is just a story. Perhaps a parable. Names and key circumstances have been changed to protect the privacy of its characters.
More than twenty years ago, while I was in psychiatric residency training at a state hospital, I was assigned a patient, Livvy, with whom I would do long-term psychotherapy with the help and guidance of my supervisor, the ward psychiatrist.
He, my supervisor, had been a practicing child and adult psychiatrist during the more than thirty years since we had been college dormitory acquaintances in Chicago, whereas I had practiced family medicine, and later occupational medicine. Until we met again at a California State Hospital, we had had no idea that we lived and worked most of our lives within a few miles of one another in the Bay Area.
George is a really nice man, and reconnecting in the role of master and pupil was, I believe, as great a pleasure for him as it was for me. Therefore I believe that his choice of psychotherapy patients for me was with excellent intention. And I had the impression that while he would not have made that specific choice for a freshly-minted medical graduate, he was confident that at 59, I would not be psychologically damaged by taking on in psychotherapy a very difficult woman with a severe personality disorder.
I detected a slight crinkle of mischief in George’s eyes as he described my new patient, which I suspected was because she was immensely challenging and he was planning to have some fun watching me try to figure how to deal with her.
In her case summary, referring to her earlier history, I had written the following: “Livvy’s behavior on the ward has been characteristically borderline, with self-cutting, obsessive exercise, rages, splitting, turbulent relationships, food-binging and melodramatic and histrionic displays of emotion, mostly anger and pathos. She has had months at a time of one-to-one therapy with Doctors X, Y and other staff, often characterized by shouting and crying that could be heard all over the ward.”
Before she became my patient I had seen Livvy around the ward, an athletic-looking young woman with shoulder-length light brown hair, not tall, with a level, dark-eyed, appraising gaze. Passing me in the halls she may have nodded in acknowledgement, full lips not smiling perhaps, but with a confident expression on her freckled face, a face that I learned could grow red and contorted during outbursts of anger.
When the professional staff got wind that I was to begin psychotherapy with her they begged me to reconsider, saying that her histrionics made it impossible to work in any nearby office or space. As they predicted, after a few quiet minutes of preliminary questions during our first meeting, which I had purposely scheduled to take place in a glass, “fishbowl” meeting room next to the nurses’ station, Livvy began to rant and rave, shouting and gesticulating in a most intimidating and frightening way. Feeling myself become flushed, frightened, angry and defensive, I sat back, closed the chart and, when she paused, said, “When you shout and accuse, it scares me and I’m unable to think clearly. I have a professional responsibility to think clearly when I‘m working with you and I can’t do that if I’m busy being scared. Moreover, this is a job for me. I’m paid to help you as best I can, but no one pays me enough to be screamed and shouted at, so I’m going to stop now and try again in two days at the same hour. I will work with you as long as we are talking. Every time you scream and shout we will stop.”
Staff who knew her well told me that by angering her I had assured she would never be back for another session with me. I told them, “Oh, she’ll be back. She’s a Borderline, and what Borderlines want is to hang on — and fight!” Livvy showed up two days later, on time. We worked together for the next year and she never again raised her voice or was belligerent or intimidating towards me.
Borderline Personality Disorder is one of a group of what are called Attachment Deficit disorders, thought to be related to a lack of intimate connection, usually with the mother, during the first few months of life. Sometimes the mom is distant, disinterested, drunk or psychotic. Sometimes the baby is so angry and demanding that the mom is afraid to be around it. The result is as if the baby’s unmet need to be loved is fused with a rage generated by its persistent or recurring sense of being neglected and abandoned. I think rage must predominate over fear because for an infant, not to be tended could literally lead to death, and it must feel as though it is being annihilated by its own mother. Subsequently in a Borderline’s life, important attachments are fused with the need to express that inchoate rage.
When babies are very, very young they don’t actually realize that the mother that picks them up in the morning is the same person that put them down the night before. If the mother is neglectful or hurtful one day, and guiltily over-solicitous the next, the baby may literally develop the idea that there is a Good Mom and A Bad Mom. Later in life this may lead the child to think of people to whom she is very close as good and wonderful; until some need or desire is thwarted, after which they are seen as utterly traitorous and bad: a pattern of perception called, “splitting”. Best friends can become worst enemies with a single, sometimes seemingly trivial act. For a Borderline, there are no grays, with good and bad traits, virtues and failings, existing in the same person.
It is very difficult for anyone to have a friendly or loving relationship with a Borderline. Or a parental, supervisory or therapeutic relationship. Any perceived slight, oversight or betrayal is likely to trigger an explosive disruption. One of the things a Borderline fears most is abandonment. They soon learn that in any relationship abandonment is a likely outcome. It is as if some Borderlines are intentionally provocative, as if it might be better to get the betrayal and abandonment over with. At the same time they are endlessly manipulative, in an effort to control the relationship and the other person in it.
Here was the odd thing about Livvy’s nine-year stay at the state hospital: she had merely been convicted of shoplifting laxatives, twice from the same supermarket. The first instance of shoplifting was treated as a misdemeanor, carrying less than a one-year sentence. The second instance is a felony, punishable by up to more than a year in prison. Livvy somehow managed to convince her lawyer that because she had once been diagnosed as bulimic, she should plead Not Guilty by Reason of Insanity (the eating disorder), in order to be sent to the state hospital rather than to prison.
In California, a person sentenced to confinement in a mental institution under Penal Code Section 1026 maybe released if restored to sanity, or after being confined for the length of the longest prison sentence for the crime. Livvy would almost certainly have been sentenced to a far shorter term in prison than the eventual length of her confinement to the state hospital. Moreover, when she had been released conditionally a couple of years into her commitment, she managed to get her self returned to the hospital within just a few weeks.
I had been puzzled by her calm indifference to the paradoxical duration of her confinement until one day in a session when it hit me.
“You aren’t here because you cant leave, Livvy; you got yourself into this hospital because no matter what you do here, the staff can’t leave you!”
While in the hospital, Livvy’s abandonment fears were assuaged and her relationships, for the first time, were stabilized on her terms. No matter what she might do, and no matter how much they might want to, the people around her simply had to stay and make the best of it.
I wish I could say that with that insight Livvy’s life changed and that she lived happily ever after, but that didn’t happen.
We did good enough work together over the following seven months that she was able to leave the hospital on a second “conditional release” to be followed as an out-patient by her county’s mental health clinic. At her request, my supervisor and the hospital director arranged for her to be able to make the hundred-mile trip back to the hospital about twice a month to continue therapy with me, which she did for about another year. At my suggestion she got a beautiful black and white dog with an intelligent face and soft fur, someone, I had thought, who would provide unconditional love and would never willingly leave her.
The following Christmastime she saved up the medications prescribed by the county clinic doctors and took an overdose, but was discovered before she died. She was in a coma and on a respirator for a week, and when I saw her weeks afterwards she had a tracheostomy scar. We talked for another few months, including about suicide, and then she decided she didn’t need to come back any more. She seemed like she was in a peaceful state of mind, and the fact that she was able to calmly end that phase of her relationship with me was, I thought, a sign of improved relationship health.
Livvy was, at that time, an attractive college graduate in her mid thirties. She continued to give me the impression, via occasional letters and e-mail, that she was doing well enough. I responded to each with friendly, supportive, professional encouragements, among which, I suppose, there were occasional insights that might have been useful to her. But at the next Christmas she took her life, again with saved medications, this time taking enough that she would not be found alive.
Six months later Livvy’s mother came to see me. She thanked me for working with her daughter, and she brought me a banker’s box full of Livvy’s writings from the time she was a small child until she had grown up and left home. She said she hoped they might reveal something that might help me help a future patient like her. When I was finished with the box of writings, she said I needn’t return them.
The box sat in my office for more than a month, but eventually I made time and read every one of the hundreds of writings, as much as anything to honor the hopes and feelings of a parent whose child was of about the age as my own daughters. Livvy’s mother’s hope, I judged, was that her daughter’s life, despite its brief, turbulent course, might thereby have had meaning and value.
As it happened, although there was great poignancy in reading the writings of a little girl dead too soon, I didn’t find any clear warning signs or antecedents of her disorder among them. Still, by being willing to sit and talk to me rather than act out her rage, Livvy had already given me many deep insights into the workings of her fatal illness.
I kept the banker’s box for a while, then took its contents to a shredding service.
Oh, … you’re worrying about the dog. Livvy arranged for the dog to be safe before she killed herself. Some may have felt relief at her death, or mixed feelings of loss and deliverance, but of course the dog simply missed her terribly.