Social learning theories contend that personality differences

Social learning theories contend that personality differences are due to learning experiences and differences in how a person thinks about a given situation, including their perceptions, expectations, beliefs, and goals. For example, Julian Rotter proposed that to predict how a person is likely to respond, you would need to have information about three aspects of their thinking: the psychological situation (how a person interprets a situation); expectancy (whether they expect a response will lead to reinforcement); and reinforcement value (how much a person values a particular outcome or reward that could result from the response).

Give three specific examples/pieces of evidence from the case study to show how Anna’s personality difficulties (related to Borderline Personality Disorder) could be explained and/or predicted by Rotter’s concept of the psychological situation. In other words, provide three examples/pieces of evidence that point to circumstances in the case study in which Anna’s thoughts, feelings or behavior reflect her interpreting a situation in a way that may differ from the perceptions of others

case study:

ANNA’S STORY

Anna leaned against Enrique, traced the tattoo on his arm with her finger, and closed her eyes, infused with a calmness and safety in his embrace. Their lovemaking had been particularly passionate that afternoon, and Anna was surprised by the force of her sexual response to him. Even now, as she rested her cheek against his shoulder, she felt a twinge of pleasure at the memory and giggled. “It’s good to be loved by such a kind man,” she thought. She glanced over at the clock on the kitchen wall, suddenly remembering that she had promised her mother to be home by 5:00. Anna’s mother was old-fashioned, “from the old world,” Anna often said to her friends when they wondered why a 22-year-old woman had a curfew.

Enrique remained sprawled on the couch, smoking a cigarette, while Anna rushed around his apartment, gathering up her shoes, jacket, and purse. “See you later, babe,” he said as Anna darted out the door. “Give me a call about this weekend. ” While Anna was inserting the key into her car, the tranquillity that had washed over her minutes earlier suddenly vanished. The thunder began to roll inside her again, quickly gaining momentum, exploding in rage when she realized what had happened. The voice in her head started pestering her, encircling Anna like a twister: “He doesn’t love me. He’s just using me. Over and over. I’m like his mistress. He couldn’t even get off the couch to say goodbye to me the way he should. If he loved me, he would never treat me this way. I’m gross to be with him like that. I gave him my virginity. I gave up my dream for him. ”

She stormed back into the apartment and screamed at him. Enrique was startled by the abrupt change in Anna, but he had seen this happen to her before. He tried to reassure her and tell her he loved her, but he knew that it

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was useless once she got into one of her tirades. He figured she was still angry at him for seeing Joleen ten months ago. He had forgiven her for stalking his apartment for hours until they emerged and then breaking in through the window and smashing pictures and trashing the place. He didn’t understand why she couldn’t just put the whole thing behind her.

Anna cried all the way home, driving at top speed. At home, when she noticed that her younger sister, Marja, was wearing one of her shirts, Anna once again flew into a rage. She hurled paperback books at her, pulled her hair, and punched her. “I do everything for you. You do nothing for me. I hate you,” she screamed. Marja pulled herself away from her sister and slammed her bedroom door behind her.

Slam! To Anna that closure was like a steel door locking her out of the world and trapping her in a room of emotional pain. She wanted to scream to her sister to stay and not leave, but the words would not come out of her mouth. No one understood anyway. “You’re too sensitive,” her parents, ters, friends, and boyfriends had always told her, and Anna knew those lines were a code that really meant: “We can’t take you anymore.” Anna believed that she had two sides of her: a “good me” and a “bad me.” The good side, however, was trapped, like now, and the bad side faced the world.

If she could just get away from her own pain, put it away, or dig it out. Anna pulled out the pocket knife she had from camp in the sixth grade and made small slices on her arm. She watched the blood form red spots on her white skin. As it had in the past, the sight grounded her in some strange way, and she began to calm down.

Anna often wondered why she was so sensitive. Is it because she was born in Poland and moved to this country when she was five? She has only vague memories of Poland, but she can recall the terror she felt boarding the plane for the United States with her mother, father, and two sisters. Her mother cried when the plane took off, and her father sat next to her, impassive while he read the newspaper. At other times she wonders if being so weak and sick when she was small made the difference. Her father had to take time off of work to drive her to her medical appointments because her mother didn’t drive. She loved those days when her father would stay by her bed, read her stories from Poland, and sing her songs from his childhood. He always worried about her health. Perhaps he worried about losing her the way he had lost his four brothers to sickness in Poland.

After Anna got stronger, her father reverted to his former behavior. They had little money, and he worked hard. He put in sixty-hour weeks on the line at a manufacturing plant, and when he was home, he rarely talked to his wife or daughters, spending most of his free time off in his room building model airplanes. Anna missed their special times together, and she tried hard to draw his attention to her, without success.

Anna’s mother never seemed to mind that her husband gave her little attention, focusing on raising her daughters and keeping the house instead. She was charged with disciplining the children because her husband did not want

she was still anen her for stalking :ing in through the didn’t understand

home, when she her shirts, Anna at her, pulled her nothing for me. I her sister and

ling her out of the wanted to scream Dt come out of her her parents, sisa knew those lines •e. ” Anna believed The good side, world. way, or dig it out. le sixth grade and red spots on her some strange way,

because she was five? She has only felt boarding the two sisters. Her ext to her, impasnders if being so er father had to ents because her ould stay by her is childhood. He losing her the

er behavior. They weeks on the line talked to his wife building model he tried hard to

gave her little atouse instead. She ancl did not want

Anna’s Story

to be burdened with that. Most of the time she was patient with her daughters, perhaps too lenient at times, but occasionally she would become overwhelmed. It was not easy to raise three girls in a small apartment without any money in a foreign country. Sometimes she spanked them with a hairbrush or a belt when they didn’t obey.

She did her best to treat all the girls equally, but she had particular problems with Anna, who was irritable even as a baby. On countless occasions her mother had to referee fights Anna started with her sisters for inconsequential reasons. She prayed that Anna would grow out of her difficult stage as she got older, but it only seemed to worsen. Anna’s friendships were rocky throughout junior and senior high school. Her mother knew the pattern well: Anna would become enamored of a new friend, and the two would spend all their free time chatting on the phone or going shopping at the mall together. Suddenly, without warning, Anna would become furious at her best friend, cut her out of her life, and rant and rave about her to her mother. Anna would be hard to handle at these times. At other times Anna adored her family and friends and was willing to do anything for them.

Anna was embarrassed by her mother and wished that her mother had been more like her “American” friends’ mothers, who could drive and were busy with activities outside the home. Her mother dressed “funny” and spoke English with a thick accent. Anna also resented her mother for being passive and helpless. Anna wished that her father wouldn’t criticize her mother so often, but she always thought her father was so much smarter than his wife. She sometimes wondered secretly why he had married her. His family had had status in their little Polish town, and her mother was a poor girl from the “other side of the tracks.” Her mother’s family didn’t approve of her father, and shortly after their marriage, her father began feuding with her mother’s side of the family. Her father tells Anna that he just “cut them out” of his life, and he has never spoken to those family members since.

Anna wished she could get along better with her sisters, but their calm and rational approach to life infuriated her at times. When they told her to “calm down” or to “stop being so psycho,” Anna hated them. Why didn’t they feel as intensely as she did? Anna repeatedly asked herself. Stella, who is two years older than Anna, planned to attend graduate school in another city in the fall. Anna admired her sister for being so smart and beautiful that she never had trouble finding or keeping a boyfriend. Marja, her younger sister and her mother’s favorite, annoyed Anna because she always wanted to tag along with her. Anna fought with both her sisters, although the most bitter conflicts were with Stella. She was particularly angry with Stella because she had advised her to abandon her dream of being an actress. Looking up to her sister, Anna believed that she knew what was best for her, so she did not pursue an acting career. Now Anna is resentful because she thinks that her sister’s advice was wrong but that it’s too late for her to have a future as an actress. Anna wants Stella out of her life, which is why she cut her face out of the photographs taken at the family reunion last year.

Anna’s eyes grow misty as she thinks about Mr. Thompson, her high school acting teacher, the only person who could understand her. He praised her abilities, making her believe that she was special and talented. She can still recall the excitement of being on stage, the lights shining on her and the audience paying full attention to her.

Anna blushes when she recalls Mr. Thompson’s kind face, because he was her first “crush.” The boys in high school were immature and only after one thing, in Anna’s estimation. She thought she loved her first boyfriend in high school, but when he tried to get her dress off one night, Anna ended the relationship abruptly because she realized he only wanted her for sex. She became despondent following that breakup and took a bottle of aspirin. She had so much stomach pain that she begged Stella to take her to the emergency room. After pumping her stomach, the physician insisted that Anna be admitted to the psychiatric unit for further evaluation. Anna spent the night in the locked unit, throwing a tantrum and furious at her sister for allowing the doctor to incarcerate her. The next day Anna’s mother and father arranged for her to come home.

Shortly after that incident, Anna met Enrique, who was a substitute math teacher at her high school and eight years older than she. Even though he had a steady girlfriend, he consoled Anna following her breakup. Anna felt she had finally met someone who could understand her and comfort her. At first, she only wanted to be his friend, but it got to the point where she couldn’t stop thinking about him, and she continued to monitor his whereabouts for one year.

After Anna graduated from high school, Enrique and Anna began dating. Anna thought Enrique was older and wiser and could teach her a lot about life. She didn’t want to lose her virginity to him, but he told her it would make her a more powerful actress if she tapped into her sexual energy, so she relented. Although their lovemaking was passionate and fulfilling, Anna experienced a great deal of guilt over it. She became clingy and jealous of Enrique and suspected that he had another girlfriend, so she began parking her car outside his apartment, keeping surveillance for hours. One evening he exited his apartment with another woman, and Anna broke in through a window after they had driven away, smashed photographs of him, and took her pictures and things away.

Enrique forgave Anna and severed ties with the other woman, but the turbulence in their relationship did not remit. Anna tried to go on with the relationship, but she had difficulty controlling her insecurity and jealousy, and eventually her feelings became so intense that she would erupt in anger. Enrique became exasperated with Anna’s outbursts, and he often ignored her at those times. This only angered Anna further. She didn’t understand how she could love and hate a person so powerfully like that, and she didn’t know what to do with these conflicting feelings. “It’s as if one side wins and the other side loses,” she explained it to herself.

Assessment

hompson, her high and her. He praised d talented. She can ling on her and the

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nna began dating. Ich her a lot about told her it would xual energy, so she ulfilling, Anna exand jealous of Enbegan parking her ne evening he exin through a winhim, and took her

woman, but the to go on with the rity and jealousy, ld erupt in anger. often ignored her t understand how d she didn’t know side wins and the She loved Enrique, but she knew he was making plans to leave the city to take a better job. Anna panicked at the thought of his leaving, and she was angry that he could betray her in this way. After the incident at his apartment, she decided to remove any reminders of herself from his home, so he wouldn’t have a hope of being her boyfriend. As far as she was concerned, as long as he was going to leave her, she had to obliterate him from her life. She told her sister that Enrique was dead to her.

She wished that she could go to church like her mother and pray for help. Anna’s family was devoutly Catholic, and Anna moved in and out of involvement with the Church. At one point she became immersed in a fringe group of Charismatic Catholics, participating in marathon weekend retreats and extensive service to the organization. She cut off ties with the group rather abruptly when one of the group leaders chose another woman to assist him with one of the outreach activities. After that, Anna rejected the Catholic religion and declared herself an atheist.

Her mother was very worried about her daughter’s outbursts. She had pleaded with her to do something, but Anna was worried about the financial burden of professional help. She only worked part time as a nanny for a Polish family from her mother’s church. She hadn’t worked full time since she was fired from her clerical job because of a “personality clash” with her boss. When her mother agreed to pay for some counseling, Anna finally made an appointment to see a counselor.

WHAT DO YOU THINK?

1. Personality disorders are pervasive patterns of maladaptive functioning that often impair interpersonal relations. If you were Anna’s friend, how would you explain to her why she had difficulty getting along with people? What “maladaptive” behaviors would you point out to her?
2. What role, if any, did the family’s migration experience play in Anna’s development? What about her early illness? How might these events have contributed to difficulties in interpersonal functioning?
3. Enrique had cheated on Anna and taken advantage of her naivete to have sex with her. Could Anna’s vehement response to him be a normal reaction to a dysfunctional relationship? Why or why not?

Assessment

After an initial structured interview with Anna, the psychologist arranged for a number of assessment procedures. She also arranged for a family consulta-

tion in order to meet with Anna’s sisters and parents.

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The psychologist juggled two preliminary hypotheses. She noted from the initial intake interview that Anna had a history of strained relationships and difficulty controlling her angry responses, the precipitant to her seeking treatment. Clearly, her difficulties in interpersonal functioning were far from transitory. Although Anna was concerned about her temper, she placed a good deal of the blame for her social difficulties on the deficits of others. This information led the clinician to wonder about the presence of a personality disorder. She also noted a recent exacerbation in Anna’s anger and despair and questioned whether Anna’s current struggles with emotional control were related to a mood disorder. Recognizing that anger and interpersonal difficulties also can be part of a mood disturbance, the clinician was careful to assess for both Axis I and Axis Il disorders. She also was careful to take the cultural background of the client into consideration during the ment process.

Anna completed two personality inventories that are used widely by psychologists for diagnostic purposes: the Minnesota Multiphasic Personality Inventory (MMPIO) and the Millon Clinical Multiaxial Inventory 2 (MCMI2). The MMPI-2 revealed that Anna was not guarded in her response and that she was willing to disclose her emotional difficulties. The MMPI-2 reports T-scores on nine clinical scales, with a T-score of 65 or above considered to be clinically significant. Anna scored highest on the scales relating to family discord and impulsive and rebellious behavior (Scale 4; T = 75), to unusual thinking and social alienation (Scale 8; T = 70), and to anxiety and obsessions (Scale 7; T = 75). People who have a similar profile to that of Anna often have come from chaotic family situations and thus have learned that the world around them is not safe and that the people around them are untrustworthy and rejecting. Such individuals lash out angrily first, to guard against real or imagined rejection. They may be viewed as odd because their thinking is peculiar. They sometimes engage in unlawful activities. Understandably, the combination of these features makes personal relationships difficult for a person of this profile.

On the MCMI-2, which assesses personality clusters and severe personality disorders, Anna obtained a significantly high score on borderline personality disorder, with elevated scores in the narcissistic and histrionic personality pattern categories. Anna’s scores for severe and chronic depression were low on both the MCMI-2 and the MMPI-2. Her score of 17 on the Beck Depression Inventory (BDI) was not significant, particularly since she did not elevate on the depression scale of the objective personality tests.

The structured interview indicated that Anna had made suicidal gestures on at least one occasion and that these gestures usually followed a relationship upset. Anna indicated that these were impulsive and desperate reactions that were not intended to end her life. She also admitted to using self-injurious behavior such as cutting herself to manage her overwhelming feelings. She admitted to occasional feelings of panic, with increased pressure on her chest and a tightening in her throato She denied any ritualized behavior or

She noted from lined relationships :ant to her seeking 1ing were far from Iper, she placed a deficits of others. :sence of a person* na’s anger and cleemotional control and interpersonal nician was careful vas careful to take during the assess-

sed widely by psfr Dhasic Personality entory 2 (MCMIher response and The MMPI-2 reor above considscales relating to . 4; T = 75), to unanxiety and oble to that of Anna have learned that ‘und them are unily first, to guard odd because their activities. Underjnal relationships

nd severe personborderline peric and histrionic d chronic depresscore of 17 on the :icularly since she onality tests.

suicidal gestures lowed a relationesperate reactions ) using self-injuri{helming feelings. pressure on her lized behavior or

Case Conceptualization

need to check. She denied having visual or auditory hallucinations, although she did describe experiencing negative voices in her head that degrade her and attack people close to her. Anna maintained that she recognized these voices as part of her and not coming from outside herself. She did say that at times she felt removed from her body, as if she were watching herself in a movie. There were no indicators of substance abuse, from either the objective test results or the interview data.

Case Conceptualization

The clinician noted that interpersonal relationships had presented special challenges for Anna at least as early as adolescence. Initially hopeful and excited about a relationship, Anna inevitably would experience conflict and/or betrayal, resulting in a rupture in the relationship. Feeling abandoned, Anna would experience overwhelming rage or depression. These deficits in sustaining close ties, coupled with impulsive behavior and unstable moods, suggested the presence of a personality disorder to the clinician, with the features of a borderline personality disorder (BPD) most prominent.

Borderline personality disorder has long intrigued researchers and clinicians, and a number of explanations for its development have been offered. Current conceptualizations embrace a multifaceted approach to understand* ing this disorder, which considers genetic predisposition, constitutional vulnerability, early childhood development and object relations, social and cultural factors, and cognitive schemas.

Anna’s mother told the clinician that Anna was different from her sisters and that as a baby she was irritable and very difficult to soothe. It is likely that Anna had a constitutional vulnerability to abnormally high levels of irritability, which has been hypothesized in people with BPD (Stone, 1995). Other research (Coccaro, 1989) points to low serotonin levels, which are associated with difficulties in modulating aggression, in conjunction with high norepinephrine levels, which are associated with increased risk taking and sensation seeking, to account for the impulsive behavior typically found in people with BPD. Anna’s difficulties in controlling her intense emotions and the impulsive behavior that she engages in when these feelings overwhelm her may in part be explained by these constitutional and biologic factors.

It is unlikely, however, that Anna’s predisposition to aggressive and impulsive behavior alone can account for the development of this disorder in Anna. There is a hypothesized link between childhood sexual and physical abuse and the subsequent development of BPI) (Herman, Perry & van der Kolk, 1989; Ogata, et al., 1990). Was Anna abused as a child? She denied any sexual abuse, and her mother’s physical punishment was intermittent. Her father was emotionally unavailable and uncomfortable with intimacy, but from the interview data, the clinician could not conclude that he physically or sexually abused his daughter. Anna’s family could be characterized as

what noted researcher Linehan (1993) has called an “invalidating environment,” an unempathic and occasionally physically abusive family. The unspoken parental message that Anna internalized was that displays of emotion were unacceptable, an unfortunate situation for Anna, who was temperamentally prone to intense emotions. When Anna’s father explained to Anna that he had “erased” his wife’s family from his life following a transgression, Anna further learned that conflict was equally intolerable and to be avoided. The sum of this was that Anna began to mistrust her own feelings, which were labeled as unacceptable, and did not learn how to soothe herself when they arose in her.

On the other hand, when Anna did display intense emotions, she occasionally would receive the attention and help she needed, especially from her mother. Her mother rescued her, but she also was the “disciplinarian” who doled out physical punishment in an erratic manner. While healthy individuals are able to integrate divergent aspects of people, Anna could not reconcile her mother’s contradictory nurturing and punitive behavior, and she resorted to splitting the good and the bad to cope with it. In this way, Anna’s mother became all good, until she did or said something that “hurt” Anna; then she became mean. Anna viewed other people in her life in a similar way: her sisters, her high school boyfriend, and Enrique.

When people failed to meet her expectations, Anna’s “all or none” thinking did not allow her to integrate these negative experiences with past positive ones, so people became all good or all bad to Anna. This is what often happened with her sisters. One week Anna idealized Stella and admired her wisdom and intelligence. The next week Stella fell off the pedestal, lost her credibility, and became the object of Anna’s ire. Anna also had difficulty integrating the negative and positive parts of herself; this is what she meant when she said that she had a “good me” and a “bad me,” two parts that occupied completely separate rooms.

Other events in Anna’s family may help to explain why her normal development was impaired. The family’s early migration experience from Poland to the United States placed undue strain on the family system, isolating the mother and placing financial pressures on the father. This rupture from their homeland had hardly begun to heal when Anna became sick. The father provided Anna with unprecedented attention during her illness, forming an intimate bond that was later denied once she was restored to health. A less rejection-sensitive individual would experience disappointment that her father could not be with her more, but she would eventually accept and understand this change as part of her getting better. Anna could not recover easily from this experience and interpreted her father’s behavior as rejection and abandonment, forming early schemas of intimacy with others as dangerous. Such disturbances in early attachment patterns are common among people with BPD (Kernberg, 1988; Kohut, 1977).

Later, as an adolescent and a young adult, the slightest hint of rejection or betrayal activated Anna’s cognitive schema of mistrust, which triggered

idating environfamily. The unplays of emotion o was temperaplained to Anna a transgression, d to be avoided. feelings, which herself when

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Diagnosis

overwhelming feelings of rage and despair. When Anna suspected Enrique of cheating on her, she was consumed by a blind fury and turned to extreme measures of stalking and breaking into his house. At other times, Anna directed her intense emotions at herself. She had a history of cutting herself with a knife following breakups with boyfriends and interpersonal disappointments. Often these attempts in BPD patients are intended to regulate the emotional pain and not to end life (Linehan, 1993). People around Anna would state that she was “overreacting” and “too emotional” or “just trying to get attention,” but Anna would say that the intense feelings welled up in her so quickly and so vehemently that she had no control. She often felt shame after such outbursts and suicidal gestures. Although Anna’s history indicated that she used these strategies to ease her hurt, she is nonetheless at risk for suicidal behavior given her swift mood changes and her difficulties with impulse control.

Further, Anna had a tenuous grip on her own identity. It is quite normal at age twenty-two to have some confusion about identity, but Anna’s sense of her* self was fragile. She wavered between divergent images of herself: as good, as bad; as religious, as atheist; as seductive, as modest; and so on. She had poor personal boundaries and was easily influenced by those around her. Anna’s identity was diffuse, which was puzzling for those who lived and worked with her, and lent a certain unpredictability to their interpersonal relations.

Diagnosis

Anna’s history and the results of the personality testing were consistent with a diagnosis of borderline personality disorder (BPD). BPD is one of the personality disorders in Cluster B, the so-called dramatic and emotional group, which also includes narcissistic, histrionic, and antisocial personality disorders. Note that Anna’s test results pointed to narcissistic and histrionic traits. It is not uncommon for a person to share a number of traits from all three personality disorders in this cluster; approximately two-thirds of individuals diagnosed with one personality disorder meet the criteria for an additional one (Pilkonis et al., 1995). Michael Stone (1990) has called them “fellow travelers” (p. 222).

Generally speaking, BPD refers to a long-standing pattern of unstable interpersonal relationships, shifting moods and selfämage, and impulsive behavior that begins by early adulthood. DSM-IV requires five (or more) of the following to be present for a diagnosis of BPD:

1. Intense efforts to avoid real or imagined abandonment
2. Unstable interpersonal relationships marked by idealization and devaluation
3. Unstable self-image

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1. Impulsive self-destructive behavior (for example, shopping, sex, reckless driving, substance abuse, binge eating, and so on)
2. Repeated suicidal gestures or self-mutilating behavior
3. Unstable moods, characterized by sudden shifts
4. Feelings of emptiness
5. Intense anger with poor control over angry outbursts
6. Transient paranoid thinking or dissociative symptoms

Anna’s signs and symptoms fulfilled at least six of the nine criteria set out by DSM-IV. The most prominent features were her wavering perceptions of both her own identity and others’ and her inability to regulate her emotions, especially her anger. This made Anna extremely vulnerable to disappointment, since the slightest hurt erased all memory of previous positive interactions, leaving Anna full of anger and desperate to relieve the unrelenting pressure and pain. Linehan (1993), a noted researcher of BPD, has likened this vulnerability to having third-degree burns over 90 percent of the body. A person with BPD has no “emotional skin” (p. 69). A mere brush against that burn can send a person with BPD into emotional agony. Another hallmark of the BPD patient is a series of “parasuicidal” behaviors, which are suicide gestures and self-injurious behavior not intended to end the person’s life. Anna had been hospitalized for ingesting aspirin and had engaged in self-injurious behavior following interpersonal hurts.

This vulnerability is further exacerbated by the increased impulsivity characteristic of many people with BPD. When Anna was in pain, she had IiV grave difficulty controlling her responses, so she engaged in inappropriate, hurtful, and at times unlawful activity. Her breaking into Enrique’s apartment is an example. Although Anna’s behavior does not reflect a respect for others’ feelings and property, it differs from antisocial behavior, for she felt shame and guilt after her angry outbursts. (See Chapter 13 for a discussion of antisocial personality disorder.)

Did Anna have a coexisting mood disorder? Although this is a common occurrence among people with BPD, she did not display the signs and symptoms of a depressive disorder at the time she sought treatment. (See Chapter 5 for a discussion of major depressive disorder.) The clinician was careful to monitor her mood, however, since she had fallen into periods of despondency in the past.

Treatment and Outlook

Treatment for BPD has been problematic for therapists. A number of studies (McGlashan, 1986; Stone, 199()) suggest that there are no advantages to one type of treatment over another for the patient with BPD. Many other studies

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Treatment and Outlook

have shown that patients with BPD end their therapy prematurely (as judged by the psychotherapist) and often continue the search for a therapist with whom they feel a “fit” (Stone, 1995). This results in “therapist hopping. ”

Patients with BPD have long been dubbed “the most difficult patients”; this has been a most unfortunate stigma, since these patients experience enormous pain and require a great deal of support. Linehan (1993) has developed a form of therapy specifically for patients with BPD that she has called “dialectical behavior therapy” (DBT), which takes into consideration the opposing forces at work in people with BPD. Linehan advocates both acceptance of the person and a movement toward helping the patient change the maladaptive behaviors. DBT offers individual sessions for supportive therapy to convey the acceptance and mandates that clients also attend classes that teach cognitive and behavioral strategies for this change. Research studies examining the effectiveness of DBT support its effectiveness (Linehan, 1993).

The prognosis for Anna is fair. Her clinician, in keeping with Linehan’s suggestion that support and skills training be distinct, saw her for one hour a week in supportive therapy and enrolled her in a cognitive skills class for mood management. The individual therapy attempted to build a trusting liance, but this was slow to emerge and was checkered by stormy outbursts and disappointments. The clinician worked with Anna to gently confront her use of “all or none” thinking, which Anna used to manage her contradictory feelings toward others. Initially, she was quite compliant and complimentary toward her therapist, but when she ended the session on time and resisted Anna’s attempts at running over the hour, Anna bristled. She sent the therapist a letter during the week accusing her of only wanting Anna’s money and not caring about her. She expressed frustration that the therapist did not reveal more of herself to Anna but simply stared at her blankly while she poured out her most secret thoughts. She was unable to integrate the notion that the therapist could be quite concerned about Anna and also set limits around the therapeutic relationship. Her initial interpretation of the therapist’s silence was attentiveness, but later she construed it as withholding and remimscent of her father’s distant relationship with her.

The next session Anna came dressed in a long-sleeved sweatshirt, even though it was a sweltering summer day. She opened the session: “You see, I’m wearing long sleeves. I’ll tell you later why.” She had made superficial cuts to her forearms with a razor in response to her last interaction with the therapist. She was angry and hurt that the therapist would not make special exceptions for her, and she used the self-mutilation to manage those fierce emotions. She maintained that when she could see her pain that way, it made it more manageable. The therapist pointed out Anna’s black-and-white opinion of her, and although Anna initially protested, over time she was able to identify some of her extreme thinking.

The cognitive-behavioral class taught Anna some useful skills for managing her anger and sadness, as well as for challenging her black-and-white

thinking. Anna learned to keep an “anger journal” and to put words to her rageful feelings.

Anna remained in individual, supportive therapy for six months. As her alliance with the therapist became strengthened, Anna was less guarded. However, after a particularly emotional and positive session, she canceled her appointments and never returned. It is possible that the emerging intimacy with the therapist frightened her, so “one side wins” with intimacy, but “the other side loses” to fears of betrayal and abandonment.