CASE 47

BORDERLINE PERSONALITY DISORDER:

_ THE CASE OF ROBERTA F.

"I'd like to make an appointment, please," she murmured softly into the
telephone. .
"Certainly. May I have yqur name, please?"
"No, I'd rather not ... "
"I'm sorry, but we need your name in order to schedule you with a
therapist."
"I don't see why that's necessary. Don't you people have some kind of
thing about confidentiality?'' ·
"Yes, we don't give out information about our clients without their
written permissi9n. Still, we need to have your name in order to set up an
appointment."
"I suppose if I had the money to pay for a private therapist, I wouldn;t
have to go through all of this. My name is Roberta."
Roberta arrived fifteen minutes late for her first appointment. Her
therapist, Dr. T., was impressed with how thin and gaunt the young
woman appeared. When he inquired as to why she had requested coun-
seling, she said that her boyfriend had told her to come-the choice was
his, not hers. She didn't feel she needed any help. Dr. T. asked her why she
thought her boyfriend had decided she needed counseling. She replied,
"because of these," and rolling up the right sleeve of her white blouse, she
revealed a line of small circular burn marks that started about three
inches above her wrist and meandered up her inner arm with an inch or
two space between each burn.
"Are those cigarette burns?" Dr. T. asked.
"Yes," she whispered.
 PERSONALITY DISORDERS ~ 0..-- 341

"Where else do you have them?"

Silently, she touched her chest and her belly and then drew her fingers
lightly up the inside of her left arm.
Dr. T. paused and ~hen said, "Your boyfriend thinks you should get
help to stop burning yourself, but you're not at all sure that you agree. Is
that right?"
"Very perceptive, doctor."
Noting the sarcasm in Roberta's voice, Dr. T. knew that his next com-
ment would have to be chosen carefully. In an instant, he decided against
commenting upon her apparent anger and said instead, "perhaps we
could explore together the meaning and value that the burning has for
you. so that you can become clearer in your own mind about whether
you'd like to give it up. Would that be okay?"
Roberta ,considered before replying, "maybe. We'll see."
Over the next seven months, Dr. T. met with Roberta twice a week.
Their sessions were unpredictable and stressful for the therapist. Some-
times Roberta was almost mute, seemingly too depressed (or ·sometimes
too angry) to speak. At other times she was sarcastic and demeaning to-
wards everybody and everything~ including Dr. T. Occasionally she
seemed lively and energized, quite normal in fact. Her warm; engaging
behavior in these sessions bordered oh the seductive. Even then, she could
twm in an instant, becoming angry or hurt. Through the storms and the
silences, Dr. T. learned some of Roberta's history.
Roberta· was the third child, and only girl, in her family of four chil-
dren. Her father ran an automobile scrap business in the small midwest-
ern town in which they lived. Her mother kept the business's financial
books but otherwise did not ·work outside the home. While the family
was not exactly poor, rteithei were they financially comfortable. They had
ample food and warm clothing-( often passed down within the .family) but
little in the way of luxuties. · ·
Roberta's father worked long hours, spending his free time -hunting
and fishing with his .friends and sons. Her mother worked hard as well
and often seemed tired and edgy. While Roberta's parents didn't argue
much, she discovered when she was about eleven that her father had been
having a long-term affair with a woman from a neighborirlg town. Ap-
parently, her mother had decided for reasons of her own not to confront
or leave him, but rather to suffer his separateness in silence. Roberta re-
members that dinnertimes were eerie, with conversations that kept to
"please pass the potatoes," and "this meatloaf isn't as good as the last one
you made." She sometimes felt that she lived in a household of strangers.
. "Roberta was a shy, clingy child from the start," her mother would
later say. She had been easily upset by loud noises and changes of routine.
The tumult and disorder created by her two older brothers seemed to
 342 ----co.,__ CHAPTER EIGHTEEN

overwhelm her. Mrs. F. often felt smothered by Roberta, whose needs f~r
soothing and reassurance seemed endless. What Roberta remembers is
that "my mother was never there for me. My father spent time with my
brothers. Nobody spent time with me."
Mrs. F. has heard these complaints from Roberta many times over _the
past ten years. Her reaction is mixed, composed of equal parts astomsh-
ment, resentment, and guilt. Looking back, she doesn't see how she could
have done more, as busy as she was and as isolated as she felt, but Rober-
ta's blaming seems always to hit home anyway. ·
Roberta's early school years were uneventful from her paren~s' per-
spective. She attended regularly and got acceptable grades, unhke ~er
brothers whose academic performances were marginal and whose social
behavior at school left much to be desired. M.r. F., himself a bit of a "hell-
raiser" in his own youth was tolerant of his sons' misbehaviors, despite
his wife's silent disapproval. Still he and his wife were both grateful that
Roberta seemed to be achieving some measure of success without the
constant surveillance their sons seemed to require.
Roberta's own recollections of these years belied the surface calm. "I
always got picked on," she told Dr. T. bitterly. "The kids didn't like me
because I wore my brothers' clothes. At lunch I sat by myself. That's when
I learned the difference between the 'haves' and the 'have-nots.' Even
the teachers pushed me away, despite my doing everything they asked me
to do."
In fourth grade, something even •worse happened. Roberta's oldest
brother, Sam, turned fifteen and began babysitting his younger siblings
two evenings .a week while ·his.mother went to Bingo and his father was
out with "the boys." On one. of these evenings, a few weeks after he'd
started babysitting, Sam decided to ''help" Roberta with her bath. Over-
riding her protests with the statement that he was in charge while their
parents were gone, he demanded that she stand naked in front of him so
that he could "make sure I was clean." Gradually, over the next several
months1 Sam's demands escalated. He watched her undress. He watched
her urinate. ·By spring he had begun to masturbate as he ,w atched her.
Roberta hated Sam for what he was doing. His behavior embarrassed,
shamed, and sickened her. But she was also afraid of him. She knew from
. .

her own experience that he would slap or even punch her if she were
uncooperative. Sam said, and she agreed, that her parents would blame
her if she told them what he had been doing. So she cooperated, and in
doing so came to feel even more worthless, dirty, and unlovable than she
had felt before.
~ot _until the next winter di~ the situation gradually change. Sam got
a g1rlfr1end who often kept him company while he babysat. On these
 evenings he left R b
PERSONALITY DISORDERS ~o- 343

out, leavin Rob o erta alone. More and more often, -Sam himself went
second oldg b e~a and her younger brother in the care of Steve, the
was l · eSt. rot er, who basically ignored her. By summer, when Sam
. a md0st eighteen and Roberta was fourteen, the abuse had virtually
Stoppe .
St ill, the prolonged trauma had taken its toll. Roberta feeling desper-
ate· fo
. r a ttention
· and acceptance, a:nd having been taught' how finally to
j~t It, became sexually active at age fifteen. She had believed her boy-
nend really loved her, and she was emotionally devastated when he
dropped her after going to bed with her twice. It was then that Roberta
fir st burned herself-in response to overpowering feelings of self-loathing
and fury.
Thu~ bega? an addictive pattern in which .Roberta responded to pain-
ful fe_eltngs with self-destructive behavior that produced immediate relief
but; in the long run, contributed to her self-hatred. She burned herself
whenever she felt mistreated, isolated, or depressed. She told Dr. T. that
she usually felt a lot better after she did it, but that the peaceful feeling
gradually eroded over the course of a few weeks, giving way to increasing
emotional discomfort .as she .absorbed innumerable slights, insults, an-
noyances, hostilities, smirks,' sneers, and snubs from her co-workers -at
the supermarket, where she now ·worked as a checkout clerk, and from
her brothers.
Externally, Roberta was living·· a fairly normal life.as.-others saw her.
She still lived at home-an attempt to share ·an apartment with an ac-
quaintance right after high school ·hadn't worked out ..She had a social
life of sorts-an ever-changing assortment of people to do things with,
but she declined to call any of them friends.
She even had a boyfriend. ·Richard, a twenty-five-year-old high school
drop-out, was both possessive and abusive. He and Roberta went to bars
on weekends and both invariably drank to the ·point of drunkenness.
Typically, under the influence of alcohol, he'd get angry at Roberta for
some real or imagined flirtation and was not above slapping or shoving
her against the wall. Roberta felt that Richard both loved and needed her.
Abuse was far preferable to neglect.
Lately, Roberta had become increasingly concerned about h~r weight.
She'd seen Richard staring at other women, and she was convinced that
he thought she was,fat. When sh~ looked in the mirror, her thighs looked
r waist appeared thickened. She reported to Dr. T. tha.t she
h uge a nd he b .. d l .
had recently lost twenty-three pounds y exerc1smg an severe y restnct-
in her food intake, but still she felt fat. Whenever she got on th~ scale
gd d · red that she had lost another pound or two, she expenenced
an ths~lovet. .and relief that burning herself produced, but the feeling
the ex 1 ara ion
344 CHAPTER EIGHTEEN

never lasted very long. Lately, she often felt dizzy and weak from lack of
fo0d, but she found this strangely comforting. '"At last," she thought," I'm
really doing it."
Aside from getting some sense of her history, Dr. T. made little progress
during the therapy. Roberta seemed unable to maintain a comfortable
distance from him, vacillating between feeling uncomfortably dependent
and completely unconnected and untrusting. She confided once that fre-
quently she spent hours prior to a therapy session ,thinking about ~hat
she .would tell him and how he would react. Often she made up things
just to see what he would say. She continued to express great deal of
self-loathing and the frequency of burning remained essent~ally the·sa°:1e.
Dr. T.'s suggestions that Roberta try a medication that m1~ht help with
her depression and her impulsively self-destructive behavior were m~t
with complete resistance. She seemed to take these as attempts to get rid
of her-"you just want to give me pills, because you can't stand to talk
to me." .
After a while Roberta's boyfriend tired of her alternating moods and
her ceaseless demands for attention. Upon discovering that he had been
seeing ·another woman behind her back, she became enraged and impul-
sively swallowed all the pills in her medidne ,cabinet-a combination of
aspirin, cold medicine, and muscle relaxants. A few minutes later, she
called and left Richard a message on his answering machine, telling him
what she had done. Luckily, he ·came·home shortly thereafter and called
911. Later. that ,day, after getting her stomach pumped; Roberta was ad-
mitted to the psychiatric unit of her local hospital.
During the two weeks she was in,the hospital, Roberta•was seen daily
by a psychiatrist. She also attended a therapy group where she was an-
grily mute. Attempts to get her, to participate in occupational therapy or
other ward activities .were unsuccessful. Shortly before her release, Dr..T.
visited Roberta. to·help prepare her for the transition back to outpatient
therapy. During .that visit, she·confided that she was still suicidal . and in
fact, intended to kill herself as soon as she was released. This pl~ced l)r.
T. on the horns of a difficult ethical dilemma. On the one hand, his duty
wa~ to _protect Roberta from harm. On the other, he was bound by the
obhgat1on to keep Roberta's communications confidential. Further. he
knew tha_t _Roberta had set him a test, but he was unable to figure' out
wh~t dec~s1on would co_nstitute the right one. He suspected that he had
been put m a lose-lose Sltuation.
. ~r. T. decided to notify the ward staff of Roberta's intentions. His de-
c1s1on enraged . f who. berated. him for violating. her confident'1a1·ity
. Roberta,
and f or trymg. to inter. ere with her nght
. to make an independe
· n t d ec1s1on
· ·
whether to live or die. Dr. T. spoke with the nurse in charge of t h e unit, ·
 PERSONALITY DISORDERS 345

a~d l~ft ~itb the sounds of Roberta yelling and cursing at him reverber-
anng 1n his ears. The next day, the hospital psychiatrist called Dr. T. and
su~d that he not visit again, since his visit the preceding day had
obVtously upset Roberta. The following morning Dr. T. received a letter
from Roberta, firing him as her therapist. Despite his attempts to follow-
up, he did not hear from her again.

Thinking About the Case

What is "borderline" about borderline personality disorder? It was orig-

inally conceived of as a disorder that had elements of both neurotic (in
touch with reality) and psychotic (out to touch with reality) functioning,
and was therefore on the hypothetical "borderline" between the two
states. Our current classification system characterizes it as an enduring
behavioral predisposition that increases the likelihood of and exacerbates
a host of conditions like depression, anxiety disorders, somatization dis-
orders, dissociative disorders, substance abuse disorders, and eating dis-
orders.
Roberta's behavior patterns fit the criteria for borderline personality
disorder. She is impulsive, self-destructive and moody. Her relationship
with Dr. T. mirrors other significant relationships in her life in its intensity
and instability. Roberta alternates between idealizing those she cares
about and devaluing them. She is intensely frightened of losing them, yet
she pushes them away. She can't seem to maintain a comfortable emo-
tional distance from others. Her primary emotion seems to be anger, al-
though she is prone to feelings of emptiness and depression.
Conducting therapy with people with this disorder is challenging in
the extreme. Because of their difficulty maintaining a consistent level of
attachment, individuals with borderline disorder have enormous trouble
establishing a truly therapeutic relationship-one in which they feel val-
ued and safe. It is not uncommon for them to behave in ways which
provoke inappropriate behavior from people trying to help them. Thera-
pists may find themselves uncharacteristically uncertain about boundary
issues, tolerating gradually increasing demands for time and attention, or
becoming unduly rigid. They may struggle with strong feelings of fury,
attraction, or loathing for their client. Genuine violations of the therapist-
client relationship, like sexual contact between client and therapist, while
rare in general, are more likely to happen when the client ~as borderline
personality disorder than when he or_ she has most ot~er disorders.
Borderline disorder has become highly contr~versial on at lea~t three
counts , Fl·rst, it is· diagnosed much more often m women than m men.
346 --4Cl4o..,__ CHAPTER EIGHTEEN

This might reflect a genuine difference in prevalence, or it might reflect

gender-based bias in diagnostic practices. Second, the diagnosis ten~s to
carry a strongly pejorative charge. Clients with this diagnosis are avoided
by many mental health professionals because their care is so often unre-
warding. They are unlikely to be grateful and they often fa_il to impro~e.
Third, studies indicate that a large percentage of women diagnosed with
borderline personality disorder have a history of prolonged childhood
trauma-often in the form of physical or sexual abuse.
Dr; Judith Herman, an expert in traumatology, suggests that border-
line personality disorder is really a stigmatizing way of describing a kind
of chronic post-traumatic stress syndrome. One of her patients, quoted in
her book, Trauma and Recovery (Basic Books, 1992, p .. 128), describes
her own experience this way:

Having that. diagnosis resulted in my getting treated exactly the way I was
treated at home. The minute I got that diagnosis people stopped treating
me as though what I was doing had a teason. All that psychiatric treatment
was just as destructive as what happened before.
Denying the reality of my experience-.that was· the most harmful. Not
being able to trust anyone was the most serious effect .... I know I acted in
. ways that were despicable. But I wasn't crazy. Some people go around act-
ing that way because they feel hopeless. Finally I found a few people along
the way who have been able to feel OK about me even though I had severe
problems. 'Good therapists were those who really validated my experience.

Dr. Herman points out that adult abuse survivors show symptoms
similar to those shown by other survivors of ·chronic trauma, namely
Vietnam veterans who engaged in prolonged combat or were-prisoners of
war. She feels that the common component is psychological or physical
captivity. Borderline personality disorder will likely remain among the
most controversial and challenging disorders to understand and to treat
for some time. .