An Attachment Theory Approach to the
Short-Term Treatment of A Woman With
Borderline Personality Disorder and
Comorbid Diagnoses

University of Texas at Austin
Abstract: The current case study highlights the treatment of “Thelma,” a 48-year-old
woman of African American and Hispanic descent who was diagnosed with borderline per-
sonality disorder (BPD), major depressive disorder, post-traumatic stress disorder, and
bulimia. An attachment theory approach was used to elicit core structure change in
Thelma’s BPD symptoms after traditional modern cognitive approaches proved ineffec-
tive. It was hypothesized that treating her Axis II disorder would actually serve to reduce her
Axis I symptoms. The attachment approach entailed a shift toward second-order change
processes, a shift away from problem-solving approaches, a focus on the quality and inten-
sity of the relationship, and a more relaxed approach to boundary setting in the context
of treatment. The approach did appear to reduce many Axis I symptoms including self-
mutilation, suicidal ideation, and binging and purging behaviors and appeared to improve
her interpersonal functioning.
Keywords: borderline personality disorder; attachment; constructivist; comorbidity
Borderline personality disorder (BPD) is the most common personality disorder in clinical settings (Widiger & Frances, 1989). However, it remains difficult to treat. Onereason is the fact that BPD is often comorbid with other diagnoses. Individuals with BPDare often at increased risk of developing other Axis I diagnoses such as major depression(Pilkonis & Frank, 1988; Reich & Noyes, 1987; Sullivan, Joyce, & Mulder, 1994;Zimmerman & Mattia, 1999), panic disorder (Reich & Noyes, 1987; Zimmerman &Mattia, 1999), bipolar disorder (Benazzi, 2000; Kay, Altshuler, Ventura, & Mintz, 1999),eating disorders (Gartner, Marcus, Halmi, & Loranger, 1989; Matsunaga et al., 2000),post-traumatic stress disorder (PTSD; Zimmerman & Mattia, 1999), and substanceabuse disorders (Driessen, Veltrup, Wetterling, John, & Dilling, 1998; Nace, Davis, &Gaspari, 1991; Nace, Saxon, & Shore, 1983; Verheul, van den Brink & Hartgers, 1998; CLINICAL CASE STUDIES, Vol. 2 No. X, Month 2006 1-DOI: 10.1177/1534650105283417 2006 Sage Publications Zimmerman & Mattia, 1999). As many of these studies indicate, individuals withcomorbid diagnoses have poorer prognoses and more complicated treatmentpresentations.
There is a growing body of evidence that suggests attachment theory may play a role in the developmental etiology of BPD (Bender, Farber, & Geller, 2001; Laporte &Guttman, 1996; Liotti & Pasquini, 2000; Lyddon & Sherry, 2001; Paris, 1997, 1998;Sabo, 1997; Sherry, Lyddon, & Henson, in press; Sinha & Watson, 1997; Zanarini &Frankenburg, 1997). Risk factor research has provided some evidence of this relation-ship by outlining some of the specific types of threats to attachment during childhood.
For example, people with BPD have a higher incidence of trauma and abuse, particu-larly sexual, at a young age, repeated, and intrafamilial (Laporte & Guttman, 1996;Sabo, 1997). These clients have also experienced a higher incidence of parental neglect,early separation and loss, parental psychopathology, and social disintegration (Paris,1997, 1998). The parenting that occurred when these clients were children is oftendescribed as overprotective, inconsistent, or demanding, providing the child with verylittle sense of stability or structure by which to regulate his or her emotions (Laporte &Guttman, 1996). Some researchers even speculate that because caregivers are ofteninconsistently available during traumatic childhood events, the emotional neglect andabsence of other adult attachment figures may be as powerful as actual traumatic eventsin the development of the personality style (Sabo, 1997).
Attachment theory’s principle concern is with the role that enduring affectional bonds between child and caregiver play in shaping one’s personality and life (Bowlby,1969; Lopez, 1995). Central to attachment theory is the concept of cognitive workingmodels of self and others (Bowlby, 1973). These working models help to organize cogni-tion, affect, and behavior in close relationships and to shape self-image (Bowlby, 1973).
Working models of the self consist of one’s expectations about one’s own ability to elicitneed-meeting responses from a caregiver. Working models of others consist of one’sexpectations about the accessibility and responsiveness of one’s caregiver (Bowlby,1973). According to Bowlby (1973), it is the confirmation of these early working modelsthrough subsequent interpersonal relationships with both caregivers and othersthroughout development that determines the persistence of cognitive schemas aboutoneself and others. In the case of personality disorders, the hypothesis is that the qualityand intensity of the client’s attachment experiences are so detrimental over time thatindividuals from these families ultimately grow to anticipate their worlds in much thesame way they did as children. As a result, their personality structure becomes domi-nated by assimilative, feedforward mechanisms that become fixed and inflexible to newinformation encountered in adulthood. In other words, these individuals anticipatetheir environments in ways that become self-confirmatory over time, searching forconfirming rather than disconfirming evidence related to interpersonal interactions(Lyddon, 1993; Mahoney, 1991).
The current case study investigates the use of attachment theory in the treatment of a 48-year-old, never married woman of African American and Hispanic decent. Toprotect client confidentiality, the pseudonym Thelma will be used during the discussionof the case. The case sought to determine whether Thelma’s Axis I symptomatologywould be reduced by focusing on the treatment of her BPD using an attachmentapproach. Treatment centered around providing a secure base for Thelma’s explorationinto her own interpersonal and intrapsychic problems. It was hoped this approach wouldprovide disconfirming evidence regarding insecure attachment schemas, ultimatelyshifting assimilative cognitive structures into accommodative cognitive structures capa-ble of organizing new information in healthy, secure, more adaptive approaches thatreduced her Axis I clinical symptoms. In addition, because the therapist’s position was a1-year term appointment, the current case study seeks to provide this information from abrief therapy model. Client self-report and therapist observation were used to measuretreatment effectiveness.
Thelma was referred by her psychiatric caseworker because she was in need of more extensive, long-term psychotherapy. She had had this case worker since receivingpsychiatric disability status through the federal government, which enabled her to beexcused from any formal employment because of the stress it would have created for her,potentially complicating her psychiatric condition. According to her caseworker and tothe client, Thelma had a long-standing depression with few periods of little, if any relief.
In addition, she had a history of suicidal, self-mutilating behavior. Thelma indicated thatshe often engaged in this behavior when she either felt no one was listening or when heremotions were becoming overwhelming and hard to identify. Physical examinationrevealed more than 100 scars and marks on her arms from cutting, self-mutilating behav-iors. Thelma often talked about the fact that her mother, twin sister, and other membersof her family were emotionally manipulative and controlling. In addition, she disclosedthat she had been sexually molested repeatedly by both of her brothers when she wasyounger. She also indicated that she had no contact with her biological father, and herstepfather was an alcoholic. Because of these experiences, she avoided associated stimuliby rarely leaving the house or by not becoming involved in romantic relationships. Shewas also hypervigilant to her immediate surroundings. She reported a long-standing his-tory (8 years) of an eating disorder, bulimia, that continued to cause problems for her atthe time of referral. Physical examination revealed sores in her mouth, tooth chipping,and tooth decay as a result of repeated purging behaviors. However, despite this myriadof clinical symptoms, it was her BPD diagnosis that was most problematic for her, andher clinical symptoms could be easily understood in this context. Thelma often engaged in frantic efforts to avoid abandonment through dysfunctional approach-avoidancebehaviors. Her interpersonal relationships outside her mother and twin sister were virtu-ally nonexistent. Her relationships with these two family members were intense, unsta-ble, and constant sources of disappointment for her. She exhibited an unstable sense ofself in some core areas of identity including difficulties reconciling her biracial identityand discomfort with her gender identity. She engaged in impulsive spending and bingeeating behaviors, displayed recurrent suicidal and self-mutilating behaviors, andcomplained of depression and dysphoria as well as chronic feelings of emptiness,hopelessness, and futility.
Thelma was an identical twin and also had two older brothers and an older sister.
She did not know her father, who her mother stated was Hispanic in ethnicity, at all dur-ing her life. She had a stepfather, who was an alcoholic, for much of her adolescent life.
She suspected he sexually abused her but indicated she could not fully remember. Shedid remember him being emotionally abusive. She stated that both of her brothers sexu-ally molested her. She said her twin sister described experiencing the same treatmentfrom them. She reported that when she disclosed this information to her mother, hermother told the client that it was her fault. According to the client, her mother consis-tently placed the sons above the daughters, especially above the client’s needs and wel-fare. During the time of treatment, the client was not sure where her oldest brother andsister were as they had both broken ties with the family. The client described having aclose relationship with her twin but also described treatment from her twin as similar tothat from her mother. On several occasions, her twin would spend her paycheck oncocaine and other drugs and expect Thelma to loan her money for her living expenses,which Thelma often did, reporting that she felt guilty if she did not help her sister. Shewas rarely repaid. Both her mother and her twin sister often manipulated Thelma by try-ing to make her feel guilty when she did not want to do things for them such as loan themmoney, even though Thelma was on disability and a very fixed income. In addition, hermother withheld love and affection if Thelma did not take care of her physical, emo-tional, and financial needs. Because of Thelma’s intense needs for closeness and fear ofabandonment, these tactics proved to be effective.
Thelma reported never having had a romantic relationship or a consensual sexual relationship with another person. She also expressed no desire for these things, indicat-ing that her abuse had left her with intrusive images of inappropriate sexual behavior.
She appeared to struggle with her gender identity in that she dressed androgynously,kept very short hair, and never wore makeup. At one point, she remarked she wasuncomfortable with her gender, but was uncomfortable discussing these issues in anydetail.
Sherry / ATTACHMENT THEORY TREATMENT OF BPD Thelma’s treatment history was quite lengthy. She had been receiving services for 18 years, but because she was on psychiatric disability and using Medicaid for payment,previous treatment had largely consisted of monthly 20 to 30 minute visits to her psychi-atric caseworker and 30 to 45 minute visits to her psychiatrist every 3 months. These visitsprimarily focused on medication effectiveness and side effects and basic skills training.
When talk therapy was available to her, temporary professionals such as postdoctoral fel-lows and psychiatric residents who desired the additional training usually provided it.
She had been prescribed Prozac, Paxil, and numerous other antidepressants in the pastwith little or no success. From time to time, she attended day treatment programs, whichusually consisted of group therapy and more one-on-one attention. However, at the con-clusion of these programs, she was often unable to transfer what she had learned in treat-ment to her day-to-day living. She had been hospitalized numerous times to the pointthat the staff on the psychiatric unit knew her by name. Because of this, when she pre-sented for treatment on the inpatient unit, the staff typically placed her on the temporaryobservation unit for 24 hours and then released her the next day. The reasoning given forthis protocol was her BPD diagnosis.
Because the treatment site focused primarily on medication management, few standardized assessments were available. In addition, being a public hospital, there werefew financial resources from which such instruments could have been purchased if sodesired. However, given that Thelma was of multiple minority status, many of the cur-rent traditional assessment instruments did not seem appropriate because they had notshown consistently reliable results with these diverse populations and had not beennormed on such populations. Treatment effectiveness was measured primarily in termsof reduction of hospital visits and increased overall psychological stability as reported bythe client and witnessed by the therapist. Her Axis I and Axis II diagnoses, as well asrelevant associated criteria, were as follows: PTSD: Exposure to traumatic event and fear and helplessness; re-experiencing of event in intrusive thoughts; avoidance of stimuli (sex, relationships, leaving the house);increased arousal (difficultly concentrating, hypervigilance).
Major depressive disorder, severe without psychotic features, recurrent, in partial remission: Depressed mood; diminished interest; psychomotor retardation; suicidal thoughts; lossof energy; feelings of worthlessness; difficultly concentrating.
Bulimia nervosa, purging type: Lack of control over eating following by purging.
BPD: Frantic efforts to avoid abandonment; intense interpersonal relationships with family members and inability to develop and maintain long-standing friendships; identity dis-turbance; impulsive spending and binging; recurrent suicidal and self-mutilatingbehavior; affective instability; chronic feelings of emptiness.
Based on 2 months of assessment and many failed initial attempts at modern cogni- tive interventions aimed at treated her Axis I symptoms (homework assignments,journaling, investigating irrational thoughts, etc.), it was decided that a more effectiveapproach might be to address some of the core driving forces in Thelma’s personalitystructure. In addition, it was determined that her resistance to the modern cognitiveinterventions was primarily because of mistrust and insecurity in the therapeutic rela-tionship, which was likely grounded in an insecure attachment schema developed froma history of emotional neglect and sexual abuse by primary attachment figures in her life.
It was determined that if Thelma were to experience relief in any of her clinical Axis Isymptoms, she would first need to reorganize her insecure attachment schema around amore secure worldview.
As noted in the theoretical and research section, BPD is often associated with a number of Axis I comorbid diagnoses. This was the case for Thelma as well. It appearsthat having BPD can compromise what could have otherwise been sufficient egostrength and psychological resources for combating the clinical symptoms of Axis I disor-ders. Therefore, it would stand to reason if the personality structure of BPD could beimproved, this may in turn reduce Axis I symptomotology. When Thelma did notrespond to traditional modern cognitive approaches, instead of labeling this as resistance,it was determined that the approach was simply not meeting her current need, whichwas to learn to develop a securely attached and trusting relationship with anotherperson.
Lyddon (1990) refers to this therapeutic approach as a focus on second-order change. First-order change, sometimes produced when therapy focuses on the Axis Isymptomotology, refers to “any change in a system that does not produce a change in thestructure of the system” (p. 122). Such efforts do produce symptom reduction, butbecause there has been no core structure or system change, this change often does notlast, and the client eventually returns to pretreatment levels of functioning once treat-ment is terminated. This is what appeared to happen to Thelma during the many daytreatment experiences she had. She would experience some symptom reduction duringthese times while she was involved in day treatment, but she would not be able to transferwhat she had learned to her day-to-day, long-term functioning. In contrast, second-orderchange is change whose occurrence alters the fundamental core structure of the system.
It would appear that finding a way to elicit core-structure, second-order change in BPD Sherry / ATTACHMENT THEORY TREATMENT OF BPD clients may be a pathway to lessening the effect of Axis I comorbid diagnoses in this pop-ulation and thus increasing the quality of life for these clients. According to Lyddon(1990), a proactive or developmental change in cognitive structures is required for sec-ond-order change. In other words, therapy should focus on approaches in which thecore cognitive system from which the client operates shifts from utilizing assimilativeprocesses (integration of experiences into existing cognitive structures) to accommoda-tive processes (developmental change in cognitive structures). Such therapy is likely toprovide learning opportunities by presenting information disconfirming long-standingassimilative cognitive assumptions and providing a therapeutic environment conduciveto reorganization around newer, more accommodative cognitive structures. Identifyingthe developmental etiology behind existing cognitive structures that have become dys-functional over time is an important piece in the second-order change process. Becausethe fundamental tenets of Thelma’s system appeared to be related to assaults on herattachment security during her development, an attachment theory approach to treat-ment appeared to be an appropriate course. The ultimate goal was to try to establish newcognitive working models of others as being trustworthy and more predictable through asecure, predictable, close relationship with her therapist. It was hoped this would lead tothe establishment of a secure base from which other interventions and treatmenttechniques could stem and long-term learning could be achieved.
Regarding Thelma’s specific attachment schema, she appeared to support Sherry et al.’s (in press) empirical findings. These findings support the notion that people withborderline personality traits have been shown to possess preoccupied and fearful adultattachment schemas. This indicates an overall negative view of the self and a vacillatingpositive and negative view of those around them. It appears that people with borderlinepersonality features may be highly invested in others, often displaying intense separationanxiety when relationships are not secure. It is this strong investment (i.e., positive view)in others, while still having a negative view of the self, that leads to a preoccupied attach-ment, especially during times of stress or separation. At the same time, people with bor-derline personality features often have personal histories that reinforce an idea that theycan never fully trust others nor hope to gain all of the affection and support they need(Millon, 1996). This appears to explain the fearful attachment (a negative view of othersaccompanied by a negative view of the self) found in people with BPD traits (Sherryet al., in press). Related, Thelma seemed to typify Millon’s (1996) “discouraged border-line” subtype of BPD. As such, Thelma attached herself to her mother and twin sisterwith whom she could display affection, loyalty, and thoughtfulness. However, like thediscouraged borderline prototype, these attachment figures were unreliable anchors,and Thelma was excessively attached to people who could not provide a secure base forher, resulting in her security being in constant jeopardy. Coupling Sherry et al.’s (inpress) findings with Millon’s (1996) discouraged prototype may help in understandingmuch of the “black and white” thinking that is common with people with BPD.
The tenuousness of Thelma’s attachment figures is particularly apparent when one considers the fact that Thelma’s mother could not, and arguably from Thelma’s per-spective would not, protect her from sexual predators in the family and was herself anemotionally abusive figure in Thelma’s life. Thelma’s twin sister is another example ofsomeone to whom Thelma felt an excessive attachment but who could not provide asecure, healthy relationship example for Thelma. Because of these unpredictable, inse-cure attachment relationships, Thelma lacked psychological resources that would haveotherwise protected her from psychic insult resulting in a core working model of self thatwas steeped in self-doubt, sadness, lack of initiative, helplessness, hopelessness, andpowerlessness.
An attachment theory approach was implemented after 2 months of traditional modern cognitive behavioral therapy aimed at treating her Axis I symptoms was ineffec-tive. Once it was determined that an attachment theory approach would be utilized,changes were made in Thelma’s treatment. Cognitive behavioral homework exercises,keeping a food journal for her eating disorder, and similar approaches were no longerused. Despite the encouragement to engage in such exercises during the first 2 monthsof treatment, Thelma would not participate. Her lack of participation was consistentwith her passive style in that she would never overtly object to assignments or requests;she would simply not do them with little or no explanation. Attempting to implementthem during session was no more productive. From a countertransference perspective,this was creating tension in the therapeutic relationship insofar as the therapist felt frus-tration toward Thelma. However, instead of framing this behavior as resistance, it wasinstead decided that this behavior was important information indicating that Thelmawas not at a place where she was able to address the pathways to her depression or ante-cedents to her binging and purging behaviors. Her needs appeared to be much moredevelopmentally based and simplistic: the need to trust and connect with another indi-vidual. Using this simple need as a guide for the therapist, therapy was initially spent withfew objectives other than getting to know one another. Most salient in this attachmentapproach was the humanistic stance of unconditional positive regard and acceptance ofher. From there, past and present relationships with significant people were explored,particularly those with her sister and her mother. Although her relationships with hermother and sister were quite destructive from time to time, there existed such an anxiousattachment with them that dissolving these relationships was not an option. In addition,she had few if any other social support networks in place. Instead, the focus of this aspectof her treatment was on setting appropriate limits with them rather than encouragingautonomy. The hope was that the earlier phase of the therapeutic relationship providedher with a new working model of others through a secure attachment relationship withher therapist that would be a framework for healthier relationships with significant oth-ers in her life. It was also hoped that this would produce a second-order change processthat would provide a foundation from which she could draw when she was transferred toher new therapist on termination.
Sherry / ATTACHMENT THEORY TREATMENT OF BPD The secure attachment stance was especially important during times she tested this stance through suicidal gestures and self-mutilation, theoretically in an attempt toelicit responses from the therapist that were familiar and comfortable and that reinforcedthe status quo of a negative working model of the self and somehow prove to herself thatothers cannot be trusted. Instead these were learning opportunities for her that rein-forced the notion that she could be sad, disappointed, hurt, or even angry without losingcare and concern from her therapist and that she need not be vengeful or manipulativeor hold a grudge to secure that care and concern.
Thelma was seen usually once a week, but sometimes twice a week, for a period of 10 months, all for 1-hour sessions. She rarely cancelled or no-showed and was almostalways on time. Thelma presented for inpatient treatment on her own three times duringher treatment. However, only one of those times resulted in admission to the long-terminpatient unit. She improved greatly after this hospitalization, when she remained onthe unit for about a month. She was seen almost daily while she was hospitalized.
Toward the end of treatment, she participated in a group therapy experience in additionto individual therapy to provide her additional opportunities to seek out secure attach-ments and form a social support network.
As noted earlier, for the first 2 months of treatment, Thelma had a difficult time articulating her feelings or even identifying possible antecedents to her condition. It tookseveral months to get a clear picture of her presenting problems because of her trust anddisclosure issues. On the surface, she had clinical symptoms stemming from sexualabuse and trauma, an eating disorder, suicidal and self-mutilating behavior, depression,and having been an adult child of both an alcoholic stepfather and an emotionally con-trolling and emotionally neglectful mother. However, the consequences of this created awoman with a loss of a sense of self, a pervasive mistrust and uncertainty of the worldaround her, an inability to trust or regulate her own emotional reactions to stimuli,chronic and treatment-resistant depression, and self-hatred. Considering the fact thattreatment would be less than a year, her many presenting problems needed to be triaged.
Decreasing her suicidal and self-mutilating behaviors was most important as this had todo with her safety. However, correlated with this, her deeper issues of trust and loss of selfalso needed to be addressed, insofar as they could be in a 10-month period, to create afoundation for future treatment with another professional and to begin to address thecore issues driving virtually all of her other symptoms. Because of Thelma’s history ofemotional and sexual abuse, and inconsistent and unpredictable emotional attach-ments, it was anticipated there would be times that Thelma might sabotage this security by acting out with suicide attempts or self-mutilation. Therefore, on-going, frank discus-sions about her safety and weekly contracts regarding her safety were essential. Oftensuch discussions can come across as legalistic or impersonal attempts at controlling cli-ent behavior. However, using an attachment theory approach, these discussions oftenincluded the therapist’s disclosures about the therapist’s feelings about Thelma, thesense of loss the therapist would feel if something happened to her, and sincere concernand sadness that Thelma felt poorly enough to consider endangering her life. In con-junction with this, the therapist would often ask Thelma what was and was not workingfor Thelma in the context of the therapeutic relationship that might be contributing tothese feelings and a joint meaning-making process ensued to identify Thelma’s needsand the ways in which therapy might be able to address them. This appeared to giveThelma a sense of empowerment, a feeling she rarely endorsed as being a part of her cur-rent life course. Initially, several cognitive techniques were implemented in an attemptto relieve the intense depression she reported. If given in homework format, she wouldcome back the next week having not attempted the exercise. If given in session, shewould simply reply, “I don’t know,” and look to the therapist for the next move. Clearlythese approaches were not working for her. There appeared to be a more pervasive,developmental aspect to her functioning, and approaches aimed at targeting only hersymptoms did not address any of the core systems driving those symptoms. At this pointin therapy, it was decided that traditional modern cognitive approaches would bereplaced by an attachment approach to treatment.
Once it was decided that attachment theory would be the best approach for Thelma, the goal of these early sessions shifted to simply getting to know Thelma. Ther-apy sessions often consisted of talking about world events, the weather, or events in herlife, and at times the therapist shared events in her life. There was no attempt to avoidpainful, emotional issues, but at the same time there was no agenda to expose or uncoverthem either. The conversation was allowed to flow casually at Thelma’s pace. Over time,Thelma began to disclose more and feel more comfortable with the therapist, and even-tually she was able to discuss more painful issues more openly.
Thelma’s suicidal gestures and self-mutilating behavior continued from time to time. Twice she admitted herself to the hospital preemptively before she hurt herself. Forthis, she was praised for taking care of herself. However, in one instance, she left therapyafter a seemingly typical session, returned home, cut her wrists, and called the therapiston the phone to report the incident. According to her, there had been some financialstressors that became overwhelming that led her to this decision in large part because of Sherry / ATTACHMENT THEORY TREATMENT OF BPD the financial strain her family often placed on her. Mobile crisis was called, and she wastaken to the emergency room for stitches. Before she could be admitted to the psychiat-ric unit, she left the emergency room against medical advice and returned home. At thispoint, the sheriff was called to her home with mobile crisis to have her admitted to thehospital. This was about 6 months into her treatment, and there was concern on the partof the therapist regarding what further progress could be made with the 4 monthsremaining. Overall, she had been showing improvement in her mood and her ability totrust in the therapeutic relationship. However, she continued to display affective insta-bility, with this current suicidal gesture being an outcome of this pattern. One thing thathad not been tried was a serious reevaluation of her psychotropic medication. Therefore,when she presented to the hospital for the current suicidal gesture, it was decided thatshe be admitted to the long-term inpatient unit to accomplish this. She stayed on theinpatient unit for about a month. This was a difficult and disorienting month forThelma. During this time she had several self-mutilating episodes and one suicidal ges-ture that was carried out in between 15-minute suicide watch checks. The therapistshifted approach somewhat and encouraged Thelma to start thinking about her treat-ment as being in large part in her control and affected by her decisions. During this time,she was seen daily by her therapist to reinforce the notion that she would not be aban-doned, despite her attempts to test the security of the relationship with her suicidal ges-tures. During this time, she was placed on the mood stabilizer Depakote, and herimpulsiveness and depression began to lift. She was discharged with no suicidalideation.
Once Thelma was on an effective medication regiment and individual therapy was progressing, she began to attend a therapy group. Because individual therapy would beterminating in a few months, group therapy was chosen to help her practice some ofthese attachment skills with other individuals while still having the secure base of indi-vidual therapy from which to return. Thelma attended two group therapies, a suicidesupport group and trauma group. Her individual therapist and group therapist were thesame, and although this is typically considered unconventional, in this particular case itappeared to be appropriate. Thelma was able to use individual therapy as a place to pro-cess some of the cognitive working models of others she was experiencing in group ther-apy. Often she would misinterpret someone’s actions as being against her or not “likingher.” The therapist was able to offer alternative explanations and encourage Thelma totest out new theories and assumptions in the following group session. It was a struggle forThelma to be outgoing in group. Her only sources of social support up to that time wereher mother and twin sister and now her therapist. However, in time, she was able to openup a bit more and take more chances socially. By the end of the group experience, theskills she learned in the group generalized to her meeting and creating a new friendship with a woman in her apartment building. This was the first time Thelma had been ableto develop a friendship in several years. At this point, Thelma reported less suicidalideation and depressive feelings, less instances of eating-disordered behavior, and moreepisodes of happiness.
The transfer process began from the beginning as Thelma was given gentle reminders as to the time-limited nature of our time together. However, about 1 monthbefore our final termination, we had several sessions with Thelma’s new therapist as wellas several individual sessions. This gave Thelma the opportunity to discuss with me herfears and concerns about the new therapist and also test her assumptions about her inter-actions during the initial meetings. In addition, at this time a joint agreement among thethree parties was made so that Thelma would be able to contact me in letters through hernew therapist from time to time. This way the new therapist could help Thelma balanceher need to stay connected to the old therapist with her need to attach and make thera-peutic strides with the new therapist. It was important that as the therapist, I was preparedto return her letters in kind or not agree to this arrangement. The last couple of weeksThelma saw her old therapist and her new therapist individually but separately until theold therapist had left her position permanently.
Several things appeared to be most paramount as she transitioned to a new thera- pist. First, Thelma was concerned that her therapeutic gains would disappear and shewould regress to prior levels of functioning as she had in previous attempts at therapy.
This was an important learning moment for Thelma as she was encouraged to see hergains as real core structure changes in who she was and that such insights and changescould not suddenly disappear. Second, as termination became closer, it was important tohelp Thelma understand that two people can have a healthy goodbye. It was importantto dispel the notion that goodbye was synonymous with abandonment or anger. Helpingher understand that there were pieces of each other we would take with us and wouldalways have and cherish was essential. As a way of making meaning about this, weexchanged meaningful, inexpensive gifts to provide her a transitional object to keep thisin mind. Such gifts were purely symbolic in nature and did not present a conflict of inter-est, a financial hardship, or a sense of undue obligation for the client. Third, highlight-ing how she had been able to form additional attachments outside of the therapeuticrelationship was important in creating a sense of self-efficacy for her in terms of creatingher own attachments without her therapist’s assistance. The relationships she developedthrough group and in her apartment building were evidence of this. Fourth, and relatedto this, was her ability to form a close attachment with her new therapist. Although it wasanticipated this would be a slow process and at times difficult for her, it was hoped itwould be less difficult than when she first began treatment 10 months earlier.
It should be noted that an attachment approach is process oriented. There were several concepts during treatment that became salient parts of this attachment, process-oriented approach. Using Bowlby’s (1969, 1973) conceptualization of attachment, ashift toward the quality and intensity of the relationship instead of the quantity or contentof sessions was one core concept throughout the process. This ultimately dealt with thesincerity of our relationship and my availability to Thelma. Similar to this, the perspec-tive of typical therapy to solve or have the client solve problems was replaced with thegoal of shifting Thelma’s core structure of working models of others to a steady, secure,and positive view. In Thelma’s case, once an attachment theory approach was imple-mented, there was very little focus, direct treatment, or discussion of her Axis I symptomsunless it was pertinent to how she was doing in the context of providing a secure base forher. This approach is especially pertinent with clients with BPD because they so oftenare unable to actually or definitively solve the core issues that bring them in to therapy.
Resisting temptations to solve takes enormous pressure off of the therapist and can bemore validating for the client as well. Related to this shift is the focus on second-orderchange mentioned earlier. Shifting the client’s attachment schema represents second-order, core structure change for the client. A final shift was again toward attachmentbuilding but away from strict boundary setting. As other mental health professionalswere observed interacting with Thelma through the treatment course, it was found thatmany preferred very strict boundary setting with Thelma to the point that she was trulyunable to express her true feelings or be heard by them. This brought to mind the possi-bility that many mental health professionals enter therapeutic relationships with clientswith BPD with an already existing assumption that they will test boundaries and behaveinappropriately. When boundaries are set using an attachment approach, the phrase“choose your battles” comes to mind. What is important for the therapeutic relation-ship? For the client’s safety? And for the outlined treatment goals? Boundary setting withthese clients should not be a way the therapist uses to manage his or hercountertransference reactions.
With most BPD clients, there are numerous complicating factors, particularly around the issues of safety and triage. Thelma’s safety issues were rarely life-threatening.
Even with the suicide attempt that resulted in her hospitalization, it was not a life-threatening gesture. However, there is always the fear that even suicidal gestures by cli-ents may take an unexpected turn and be far more life-threatening than even the clienthad intended. These safety issues needed to be addressed on an on-going basis.
A second complicating factor was the presence of so many Axis I symptoms. At times, particularly when her binging and purging was at its worst, it was difficult to resist the temptation to address those issues directly. There were times during the treatmentprocess that some behavioral and cognitive-behavioral interventions were tried again.
However, these continued to be ineffective, and the decision to approach treatmentfrom an attachment perspective gained more validity.
A final complicating factor was that the therapist’s position was a 1-year position at the center. In one way, this position was a benefit to Thelma. Because the position waspaid for by outside funding, the therapist was able to see Thelma as frequently and for aslong as needed with virtually no restrictions from Medicaid. However, on the otherhand, it seemed antithetical in some ways to advocate for short-term, attachment-basedpsychotherapy. How can a therapist create a secure base with the constant threat of ter-mination? There were times, particularly prior to her hospitalization, when there wasconcern that no lasting gains would be noted after the 10-month treatment time spanand that it would take longer than 10 months to undo the 48 years of insecure attach-ment confirmation that had occurred during Thelma’s lifetime. The issue of termina-tion was a necessary topic of conversation throughout treatment. It was important to setup realistic expectations about the duration of the therapeutic relationship. Terminationwas framed for Thelma as an experience for her that people can be present and also needto leave, and this had nothing to do with anything intrinsically wrong with her. However,the most important aspect of this issue when deciding to go forward and implement theattachment approach in such a limited time frame dealt with Bowlby’s (1969, 1973)original conceptualization of attachment. He indicated that it was the quality and inten-sity of the attachment experience that was important, not the quantity or content. It wasthis assertion that allowed for the attachment approach to continue forward despite thetime limitation.
There were few managed care considerations for Thelma during this treatment because the therapist was being funded by an outside source, thus leaving complete con-trol of the therapy to the therapist. However, this obviously had not always been the case,and some of Thelma’s difficulties in trusting and forming therapeutic relationshipscould in part be attributed to the managed care she had received in the past. BecauseThelma was receiving services through her government disability (Medicaid), resourceswere extremely low. Psychotherapy in such situations is considered a luxury and is rarelyan opportunity. Therefore, much of Thelma’s previous treatment consisted of medica-tion management only, and therapy was only an option during times of crisis forThelma. This was a potential complication because Thelma had been in need of inten-sive psychotherapy for a long time and now was faced again with only transient, time-limited treatment by a therapist who would only be available to provide treatment for 10months.
Some of Thelma’s changes were apparent at transfer. She began making friends with people in her apartment building and becoming more interested in interpersonalrelationships. She also began to wear dresses and some makeup and to style her hair infeminine ways. This appeared to be some limited evidence that she was developing partsof her self, particularly around gender. Her suicidal gestures had stopped, and shereported no longer feeling suicidal.
Following transfer, Thelma sent a total of four letters during a 2 ½ year period.
Often these letters were greeting cards commemorating a holiday of some kind. Some-times she wrote a personal note and updated me on her life and progress; other times shesimply signed her name. Each time a letter was received, a response letter was sent to her.
Although admittedly this is an unconventional approach, particularly with a client whohas BPD, it fits within an attachment framework and likely contributed to some of thepositive work that was subsequently done with her new therapist. She indicated in ourlast communication before this manuscript was written that she had stopped therapy 7months prior (about 2 years after our termination) because of knee surgery anddecreased mobility as a result. At the end of the 2 ½ year period, she had stopped herbinging and purging behavior completely and appeared to no longer meet the diagnos-tic criteria for bulimia. Although she had presented herself to the hospital a couple oftimes, these visits had decreased significantly and were primarily in times of stress whenshe needed extra support. In addition, she reported she no longer engaged in self-muti-lating behavior and was not suicidal. She also reported that she had lived for a time withher mother and for a time with her sister since termination. Although both of these livingarrangements were stressful, she felt positive about the extent to which she was able to setlimits with them, something she was unable to do before treatment because of her fearsof abandonment.
It is unknown the extent to which Thelma’s therapeutic gains can be attributed to her new therapist, her medication regiment, the attachment work, or simply time. Theseare all confounding factors when reviewing her recovery process. However, given thatshe had received 18 years of treatment that produced no such gains for long periods oftime, it is hoped that the attachment work at a minimum gave her a foundation fromwhich her new therapist, her medications, and time could all capitalize.
Her improvement using this approach calls into question a long-held managed care belief that personality disorders are (a) not treatable and (b) should not be coveredby mental health insurance plans. Not only was the approach aimed at her BPD effec-tive, it was able to be implemented in a relatively short amount of time. If one conceptu-alizes dysfunction dynamically rather than linearly, it makes sense to treat the parts of the self that appear to be driving the dynamic process of dysfunction rather than simply thesymptoms devoid of their context. This managed care view has permeated the treatmentcommunity whereby many professionals do not believe that BPD is treatable or recover-able. It is hoped that this study can provide some evidence from which to shift this view.
The primary recommendation to clinicians and students is to become familiar with Millon’s (1996) personality disorder subtypes. Although it is my belief that this treat-ment approach was effective for Thelma, this may have something to do with the factthat she was primarily a “discouraged” subtype of BPD according to Millon. Other sub-types may not respond as well to this approach, particularly the aspects of the approachthat allowed for more flexible boundaries during the treatment and after termination.
Second, although many students and beginning clinicians want experience work- ing with personality disorders, often the contexts of their service are time limited aspracticum students, interns, and postdoctoral fellows. However, approaches that aredepth-oriented can also be brief. Those interested in a more broad view of suchapproaches are referred to Ecker and Hulley (1996).
Finally, working with BPD clients can be extremely taxing emotionally. Limiting one’s caseload and making sure there is adequate supervision or consultation is essential.
Particularly with these clients, one’s countertransference can easily make its way into thetherapeutic relationship in ways that are not therapeutic for the client but that possiblyprovide the therapist with some sense of emotional release. For example, I have seeninstances in inpatient facilities where BPD clients are denied extra amenities that otherclients are allowed out of frustration and fear on the part of the mental health profes-sional that boundaries will be crossed. In actuality, it is likely more the fear of the mentalhealth professional about how to deal with these clients that precipitates these strictboundary-setting behaviors than it is about what is therapeutic and kind for the client. Aswith any client with any treatment focus, the careful scientist-practitioner is always test-ing hypotheses in the therapy. They ask themselves, “What do I hypothesize this clientwill gain if I use this particular intervention?” All of our behaviors toward our clientsintervene in their lives in some way, whether that is our intention or not. It is importantthat therapist’s behavior toward clients be a purposeful and goal-directed means ofincreasing the quality of life for them.
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Alissa Sherry, Ph.D., is an assistant professor in the Counseling Psychology Program at the University ofTexas at Austin. Her research interests include adult attachment, personality disorders, constructivist psy-chology, and issues pertaining to sexual orientation.



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