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Working with Borderline Personality Disorder at Riggs


Borderline Personality Disorder: A Conversation with M. Gerard Fromm, PhD, ABPP

How do you work with BPD at Austen Riggs?
A person in a borderline state has had trouble in their primary relationship of dependency in life. Setting up an intensive psychotherapy invites them to depend on their therapist, thereby creating a situation, a charged situation to be sure, where the problems can be felt first hand and talked about. We can connect what happens in the therapy to the therapeutic relationship itself, and to other people in the patient's life. So you have a way of working with the trouble in the immediacy of the therapeutic relationship, including sorting out what's the patient and what's the therapist and a building of what some theorists call "reflective functioning or "mentalization.” By that we mean the capacity - often not achieved in a chaotic home life - to think about what might be going on in the mind of the other person. Who is bringing what to the dynamic? Where is the reality, and where are there distortions in thinking? What we often see are spikes of feeling at boundary moments, including the end of the therapy hour, and those are major opportunities to sort out what the patient has done with this in their mind and where that comes from.
But this kind of relationship trouble is a precarious and sometimes life-threatening experience for people - and something they've been living with for a long time. So it's important that we also have people here the patient can go to after the therapy hour, so that they don't have to be alone. The nursing staff is critical, as is the patient community. At some level, a borderline person feels troubled all the time - unstable, insufficient - but the patient community invites you into alternative roles, where, say, you're putting together an evening of some activity, or voting on something in a community meeting. Also, when the person's feelings break out into action rather than language, it happens in a context of others and in our program, a group of patients meets with you about that.
Say a person really loses it, and cuts himself. At Riggs, we have a series of patient-run work groups. One is called the Task Group, which gets referrals about troubled or troubling behavior. So now this person sits down to discuss with a small group of their peers what happened, the effect of what happened on the rest of the community, how other people have dealt with that impulse, what was going on in the social situation that upset the person, and so on. This can really change a person's perspective, because he or she has let loose with something very angry, without a second thought that there are other people who will feel the effect of it.
And now you have those other people speaking back, saying things like, "When you did that, I was reminded of what happened in my home when my father got drunk, fell on the floor and was bleeding all over the place. It really got to me - then and when you did it." For people who are caught up in their own minds, it comes as a huge surprise to see how other people are affected. This creates a tension, but I think a healthy tension. It humanizes the target, so to speak, and reminds people that there is something - a human community - there for them, that they actually care about, and that they have a responsibility to, something larger than themselves.
Another aspect of Riggs that's extremely helpful for the borderline patient is the openness of the setting. This isn't just a physical fact: that patients can come and go as they wish, and that there are no locked doors and no privileging system. It is also a structuring value. The openness of the setting represents a foundational recognition of the independent authority of the patient. Patients like this are so vulnerable to a kind of regression that can become a chronic way of being. They're so likely to say, in effect, "I will trade my capacities for your care." And that's just deadly. The open setting requires people to take up their authority for their daily lives and to hold onto their strengths, at the same time that they are getting in touch with their vulnerabilities. In an open setting, patients are invited collectively to contribute to the running of the hospital - holding elected leadership positions, running meetings, weighing in on the issues. They keep the place going. People, especially with the kind of relational instability we're talking about, are desperate to belong. They want a community, and that tempers things when times get tough.
A borderline person can look really bad and then bounce back and look really good. You've got to have a setting that allows for that range. A corollary to this aspect of the community program is the activities department. Many of these patients are enormously creative, but they haven't acquired a real ability to use language to master and express emotion. So the Shop, where there are materials, where it's non-verbal expression, is hugely important.
The last important piece here is family work. What's really interesting is that very often the person who becomes the patient has been carrying this intensive feeling forever, but has never talked with their family about it. If you're lucky, and you can get the family to come and feel supported enough themselves, they can have some conversations about what went on between them that become really helpful in the long run.
This six-part series, exploring borderline personality disorder, is taken from an interview, conducted by former Erikson Scholar Joshua Wolf Shenk in 2009, with M. Gerard Fromm, PhD, ABPP, a senior consultant to the Erikson Institute for Education and Research at the Austen Riggs Center.