OFFERING NEW HOPE

OFFERING NEW HOPE – PSYCHOTHERAPY WITH PEOPLE WITH PERSONALITY DISORDERS
DR.K.SOHAIL – 2016

‘Working with people with personality disorders has been one of the most challenging but also one of the most rewarding experiences of my professional life.’

Sohail
CONTENTS

1. Personality
2. Personality Disorders
3. People with Personality Disorders
4. Seven Special Challenges
5. Personality Disorders and DSM Classification
6. People with Schizoid Personality Disorder
7. People with Obsessive Compulsive Personality Disorder
8. People with Borderline Personality Disorder
9. Recent Advances
10. Psychotherapy with People with Personality Disorders
11. A different language for each patient
12. Therapy with Maria and Jimmy
13. Jimmy and Maria’s stories
14. Hierarchy of Defense Mechanisms

 

1. PERSONALITY

“Your personality is your whole character and nature.” Collins Dictionary 2005

“The set of emotional qualities, ways of behaving, that makes a person different from other people.”Webster Dictionary 2010

 

2. PERSONALITY DISORDERS

“Personality disorders involve patterns of behavior, mood, social interactions and impulsiveness that cause distress to one experiencing them, as well as other people in their lives.”

Canadian Mental Health Association 2014

 

“Personality disorders are a class of mental disorders characterized by enduring maladaptive patterns of behavioral, cognition, and inner experience, exhibited across many contexts and deviations markedly from those accepted by the individual’s culture. These patterns develop early, are inflexible, and are associated with significant distress or disability.”

DSM V 2015

 



3. PEOPLE DIAGNOSED WITH PERSONALITY DISORDERS

As a psychotherapist, when I hear the words ‘people diagnosed with Personality Disorders’, I think of life long emotional and social suffering. When I talk to mental health students I share with them that people with mental health problems can be divided into three broad groups. Those diagnosed with:

1. Psychotic Disorders,
2. Anxiety Disorders and
3. Personality Disorders.

People diagnosed with Psychotic Disorders include people who suffer from schizophrenia or bipolar disorder. Many of them need antipsychotic medications to treat their psychotic episodes and control their symptoms of hallucinations and delusions. In lay person’s terms, these people have had a nervous breakdown and might need to be admitted to a hospital for treatment.

Those diagnosed with Anxiety Disorders include people who suffer from chronic anxiety and panic disorder. Anti-anxiety medications and different forms of behavioral and psychological interventions are prescribed to reduce their anxiety.

The third group consists of people with Personality Disorders. Some of them experience emotional suffering and willingly go to see a therapist to get help, while there are others who cause social suffering and do not realize that they have a serious mental health problem. They cause suffering for others as they are difficult to live and work with. They often feel okay themselves but people around them do not feel okay. Since many of them do not realize they have a serious problem, they do not go to see a therapist to get help. Many times they wait until there is a major crisis in their life, such as, losing their job, losing their significant relationships, or getting in trouble with the law, before they realize they need help.

Although I have talked about three groups of people with serious emotional problems, that does not mean they are mutually exclusive. There are people who have only Personality Disorders and there are those who are also diagnosed with anxiety and psychotic episodes as well as Personality Disorders. Such people need a complex care plan for their complex and complicated lifestyle. Some studies have shown that nearly 60% of all psychiatric patients struggle with Personality Disorders.

 

4. SEVEN SPECIAL CHALLENGES OF THOSE DIAGNOSED WITH  PERSONALITY DISORDER

Over the decades I have been reflecting on the special challenges those with Personality Disorders face and the unique approaches needed to be taken to help them cope with their life struggles. Let me briefly share seven challenges:

1. IMMATURE COPING MECHANISMS

When individuals in this group face stressful situations in life they experience a crisis because they have not developed mature coping mechanisms. Sigmund Freud, father of psychoanalysis, presented a hierarchy of defense mechanisms from the most immature to the most mature. Those diagnosed with Personality Disorders use immature defense mechanisms like acting out and splitting [these defense mechanisms are explained at the end of the chapter].

1. POOR SELF ESTEEM

Many struggle with poor self esteem. They do not think highly of themselves. Some believe they are an utter failure and are prone to judging rather than accepting themselves. American psychiatrist, Harry Stack Sullivan used to believe that low self esteem is the corner stone of people’s emotional problems and that we need to help patients improve their self worth, self confidence and self esteem if we want them to recover and lead a happy, healthy and successful life.

1. UNHEALTHY RELATIONSHIPS

Many are plagued with unhealthy relationships, in particular, they struggle with initiating and maintaining relationships because they face difficulties in communication. In addition, they find it hard to resolve their emotional and social conflicts. Unfortunately, their relationships often end unexpectedly and they feel sad, frustrated and angry because their relationships remain unsatisfactory. They cannot cope with crises with their dear ones.



1. POOR CONNECTION WITH SOCIAL SYSTEMS

Social systems are challenging for them. Whether it is their family, work or community, they struggle all their lives. Sometimes they are not aware the extent to which they upset people. It is not uncommon for them to be unexpectedly fired from work or get into legal trouble.

1. SELF DESTRUCTIVE PATTERNS

A pattern of self destruction can be common through all their lives. Rather than becoming their own best friends, they become their own worst enemies. Since some of those patterns are unconscious, they have difficulties correcting them without professional help.

1. DRUG ADDICTIONS

Some become alcoholic while others get dependent on street drugs. Such dependency is physical as well as psychological. They become part of a peer group that abuses drugs. That is why it is very hard for them to say good bye to drugs. They require special addiction counseling to cope with that serious problem.

1. NO MEANING IN LIFE

There are many individuals diagnosed with Personality Disorder who have lost their sense of meaning and purpose of life. With no sense of direction, they feel lost and confused. It is sad to see that so many of them have no hobby, no passion, no ambition and no dream in life. They do not live, they just exist. Some feel so helpless and hopeless that they become suicidal.

From this description it is understandable why so many mental health professionals are reluctant to work with these people as they can be very demanding and challenging. Many such patients are angry and disruptive, play staff against each other and are self destructive. Many mental health professionals get so overwhelmed and frustrated that they give up and send them to another facility hoping that some other professional will take care of them.

 

5. PERSONALITY DISORDERS AND DSM CLASSIFICATION

The DSM classifications of Mental Disorders have seen a number of changes in the last few decades related to this Diagnostic Category. There are three changes from DSM 1 to 5 that are significant.

The first change is that in DSM 1 and 2 there were some Personality Disorders [Inadequate, Cyclo-thymic, Passive Aggressive, Explosive and Asthenic] that do not exist in DSM 3, 4 and 5. On the other hand, there are some Personality Disorders

[Schizo-typal, Borderline, Avoidant and Narcissistic] that do exist in DSM 5, but did not exist previously..

The second change is that in DSM 4 Personality Disorders were diagnosed under Axis 11 while Psychotic conditions like Schizophrenia and Bipolar Disorder were diagnosed under Axis 1. In DSM 5 such classification has disappeared. Now psychotic disorders and Personality Disorders are included in the same category. In DSM 5 there are ten Personality Disorders.

The third change is that in DSM 5 Personality Disorders are divided in three clusters.

Cluster A Personality Disorders:

1. Paranoid Personality Disorder
2. Schizoid Personality Disorder
3. Schizo-typal Personality Disorder

Cluster B Personality Disorders:

1. Anti-social Personality Disorder
2. Borderline Personality Disorder
3. Histrionic Personality Disorder
4. Narcissistic Personality Disorder

Cluster C Personality Disorders:

1. Avoidant Personality Disorder
2. Dependent Personality Disorder
3. Obsessive Compulsive Personality Disorder

 

6. SCHIZOID PERSONALITY DISORDER

Individuals diagnosed with Schizoid Personality Disorder have some or all of the following characteristics. They:

1. are shy, withdrawn and painfully introverted. They prefer to be alone than in the company of others and avoid social activities, as they find them quite stressful.
2. have difficulties in initiating and maintaining close relationships. When people approach them to be friends, they turn their offers down.
3. do not know how to have emotional communication with their dear ones. They think more than they feel.
4. lack awareness of how their personality affects others. That is why their friends and family members perceive them as cold and insensitive.
5. like to be with those people who make less emotional demands on them as they feel overwhelmed by emotional expectations of others. They prefer to interact with a small number of shy, schizoid and introvert people.
6. avoid all close relationships, for the most part. However, there are others who wish to have friendships but do not approach people as they are afraid they will be rejected.
7. prefer to engage in solitary activities, which includes jobs where they have to work alone.
8. are indifferent to social norms and traditions. They are reluctant to engage in birthday parties, anniversary dinners and funeral ceremonies. Even when they go they prefer to keep to themselves and try to leave early.
9. prefer, in their sexual life, to masturbate than engage in romantic relationships. And even when they engage in romantic relationships they would rather have casual sexual encounters rather than engaging in emotionally intimate loving relationships.
10. have limited capacity to express positive or negative emotions towards others.
11. have a rich inner life of fantasies and imagination, despite their limited social life. Because of this rich imagination some become artists and writers, expressing the feelings they cannot express in real life, through their art and literature.

When we ask experts why people suffer from Schizoid Personality Disorder, some say that there are genetic factors involved. Many of those diagnosed have a family history of people who suffer from schizophrenia or schizoid personality disorder. There are others who believe that those children, who do not get sufficient nurturing and unconditional love from their parents and do not develop a close bond with their mothers as children, later on in their lives have a tendency to develop Schizoid Personality Disorder.

Although Schizoid Personality Disorder is a different condition than schizophrenia, individuals with Schizoid Personality Disorder under stressful conditions are more vulnerable to have a psychotic break down and suffer from schizophrenia.

There are also some mental health professionals who believe that we should just accept those men and women who prefer to be alone and do not feel lonely. If they are happy in their solitary life we should not label them as abnormal. They feel that in a world that admires extroverts, individuals who have introverted characteristics are usually judged and perceived as eccentric. While there are other experts who believe that having close emotional and loving relationships in life is a sign of mental and emotional health and those people who cannot have such relationships are unhealthy and need professional help to have a fulfilling life. They believe that many people with Schizoid Personality Disorder do not realize that they suffer from a serious emotional problem for which they can get professional help and improve their quality of life. They may not feel they suffer but their dear ones suffer because of their coldness, indifference even insensitivity.

In my social life I have met many writers, artists and creative people who believe that their shy and introvert personalities play an important role in their creativity. They think they create more in their solitary life. They are reluctant to get professional help as they believe that if they became more social and engaged more in social activities they might lose their creative potential. They know they are eccentric but they love their eccentricity. They believe that artists, writers and novelists need to spend extended periods of time by themselves, to create their masterpieces.

7. OBSESSIVE COMPULSIVE PERSONALITY DISORDER

People diagnosed with Obsessive Compulsive Personality Disorder have some or all of the following characteristics. They:

1. are perfectionists. Whatever they do, they want to do it well. They have high standards and high expectations from themselves and others.
2. are preoccupied with cleanliness. They keep everything clean and get distressed if things are untidy or unclean.
3. are very particular about time. They strive to be punctual as they hate to be late.
4. have a keen interest in keeping track of their money. They know exactly their bank balance, what they earn and what they spend. Not knowing these details is upsetting.
5. have high morals and a keen sense of right and wrong. They always want to do ‘the right thing’ and get distressed when others do not follow the rules. In many cases their conscience is highly developed.
6. are idealists. They have high ideals in their lives and try their best to achieve their goals and ideals.
7. are highly organized in every aspect of their lives.

Many people with Obsessive Compulsive Personality Disorder do not realize how they affect other people. Their sense of organization and orderliness can be perceived as controlling by people around them. That is why these people can have interpersonal difficulties with people they live or work with.

These individuals can be prone to depression. Since they have high expectations for themselves and others, they get easily disappointed and then get depressed.

While many suffer because of their clinical condition, there are some who use it to their advantage and choose a profession where their disability becomes an asset. For example, they can become excellent organizers of events or businesses. I know a lady who used to be unhappy because of her disorder but then she chose to become a librarian and excelled in her profession to become the head librarian. Her sense of organization that was disliked by her friends and family members became her greatest asset and her colleagues appreciated her organizational expertise.

8. BORDERLINE PERSONALITY DISORDER

When the diagnosis of Borderline Personality Disorder was first introduced, it was strongly opposed by many doctors and nurses, psychiatrists and psychologists. They dismissed the diagnosis, calling it the waste paper basket diagnosis, which meant that all those patients, who did not fit in any other category, were called Borderline Personality Disorder. But gradually the diagnosis acquired more understanding and now the diagnosis is used by many clinicians.

Those diagnosed with Borderline Personality Disorder have some or all of the following characteristics. They:

1. are emotionally unstable as they are prone to make impulsive decisions in life. Most of them have stormy emotional lives. They are like those teenagers who do not think before they act and later on regret what they said or did. They do not think and do not care about the consequences of their actions. Once they are in an emotional crisis, it takes them longer to recover.
2. have a wide range of painful emotions. They can be anxious or sad, but the most prominent affect is anger. They are habitually angry and irritable.
3. act very needy, in their emotional and romantic relationships. Their friends or lovers feel controlled and trapped because they have a fear of abandonment. They ask for so much reassurance that their friend or lover feels uncomfortable.
4. have strong reactions to events. They either love or hate. They are either very pleased or very displeased. One day they idealize something, the next day they devalue the same thing.
5. feel so emotionally labile that it not uncommon for them to have suicidal feelings and gestures. Many times they do not want to kill themselves, they are just so desperate that they do not know what to do and impulsively cut their wrists or take an overdose.
6. have impulsive behavior that has a wide range. Impulsivity can be with food and drugs, even sex. They can have casual sexual encounters to feel good about themselves.
7. have unresolved issues about their identity. They feel as if they are missing something and they want to add things from outside to fill their inner void. But in many cases it does not work. They move from one thing to another, from one friend to another, from one lover to another to feel complete, to feel a whole but in many cases they are unable to sustain those relationships.
8. may have a history of trauma. Some researchers and clinicians feel that many people with Borderline Personality Disorder were physically, emotionally or sexually abused in their childhood, and that abuse plays a significant role in their psychopathology.
9. may have neurologically immature brains. Some neurologists believe their nervous system takes longer to mature. Others believe they have smaller and more active amygdalas than normal people. That is why they have strong emotional reactions leading to emotional instability. They also have less developed pre-frontal lobe the area of the brain that controls emotional outbursts.
10. could also be sensitive to their hormones Some endocrinologists also believe that for women with Borderline Personality Disorder changes in estrogen levels affect their labile moods.

 

9. RECENT ADVANCES IN PSYCHOTHERAPY WITH PEOPLE DIAGNOSED WITH PERSONALITY DISORDERS

When we review the recent advances in psychotherapy with people with Personality Disorders, we realize that there are three different forms of treatment that have become popular in the last few decades.

1. Psychodynamic Therapy. Sigmund Freud had pioneered psychoanalysis of neurotic disorders. Over a period of time, long term analytical therapy evolved into short term dynamic therapy. Both long and short term dynamic therapies have been used in helping people with this diagnosis.
2. Dialectical Behavior Therapy. After the popularity of Cognitive Behavior Therapy, some therapists modified it, transforming it into Dialectical Behavior Therapy [DBT] and used it for people with Personality Disorders. DBT is most popular and effective with people with Borderline Personality Disorder.
3. Combination Therapy. Those therapists who are eclectic use a combination of psychodynamic therapy and Dialectical Behavior Therapy as they like to integrate different forms of therapy. Some therapists also use medications to control psychotic symptoms for short periods of time.

All three forms of therapy have been used in different clinics, hospitals and day treatment centers all over the world. In the Netherlands one review showed that, “All treatment centers offered treatments with varying theoretical orientations, such as psychodynamic orientation (27% of all given treatments), a cognitive behavioral orientation (21% of all given treatments) or an integrative orientation (combining different theoretical frameworks, 52% of all given treatments) (Ref 1)

When we review the results of these therapies we find that short term therapies are more effective in reducing the symptoms, decreasing self destructive behaviors and learning new skills, while long term therapies produce global changes in personality. Most reviews show that short term and long term outpatient therapies are more effective than long term inpatient therapies for people with Personality Disorders.

Some researches have highlighted that short term therapies show better results for short periods but in the long run the outpatient long term therapies show better results.  Eva Horn et all write, “Within the first year after the start of the treatment, the short term therapy group showed better results than the long term group in terms of psychiatric symptoms, whereas at 3-year follow up, the long term group even exceeded the short term group in terms of treatment success…long term therapies aim for ‘global changes by affecting the patient’s long-term vulnerability to stressors’, requiring more time to achieve good results.” (Ref 2)

There was a time most therapists were pessimistic about the prognosis of people diagnosed with Personality Disorders. With the passage of time ‘continued evidence that psychotherapy is effective, increases optimism about the prognosis of these disorders [Personality Disorders]’. (Ref 1)

REFERENCES

 

1. Horn Eva et all Effectiveness of Psychotherapy in Personality Disorders Not Otherwise

Specified: A Comparison of Different Treatment Modalities

Clinical Psychology and Psychotherapy  2014

 

2. McCain Shelley and Pos Alberta Advances in Psychotherapy of Personality Disorders:

A Research Update Current Psychiatry Reports 2007, 9: 46-52

 

10. PSYCHOTHERAPY WITH PEOPLE DIAGNOSED WITH PERSONALITY DISORDERS

Over the decades I have met many mental health professionals, whether nurses or social workers, psychologists or psychiatrists who were surprised that I, not only like working with people with personality problems, but also produce good results. They were curious why I chose to work with these individuals and what is the secret of my success? Let me try to answer those two questions.

Many mental health professionals do not like working with individuals with Personality Disorders because such patients are very demanding and challenging, need long term care and are very frustrating as they show very slow progress. Many professionals get quite distressed when they have to deal with the persistent anger and self destructiveness, even the suicidal behavior of such patients. Dealing with these individuals has extra challenges. It is not uncommon for inpatient staff to divide in two groups, reflecting the splitting defense mechanism of the patients. Some staff members become angry while others become sympathetic. Some professionals consider them ‘mad’ and ‘sad’ while others consider them ‘bad.’ Mental health professionals seem to burn out quicker working with this group.  

I have also noticed that many hospitals are not very sympathetic to people with this diagnosis. Unfortunately many become the revolving door patients as they are in and out of many hospitals. I have met patients who were admitted to different hospitals for short durations 30 to 40 times in their life time. Such patients fall through the cracks of the mental health systems as they do not get the continuity of care they need.

I gradually realized that these people needed very specialized care. I was drawn to work with them and created Creative Psychotherapy Clinic in 1995 to address the needs of this population and their families. In our clinic, initially, Anne Henderson and now Bette Davis, my two colleagues and co-therapists, helped me create and develop this specialized program. In addition, Bette and I have co-authored a series of Green Zone Books to help our patients and their families.

What is the secret of our success? Let me share a few highlights of the principles and process of our program to answer that question.

1. Following a Physician Referral, an Intake Screening Process is scheduled with Bette by phone. She assesses each person according to our admission criteria and chooses those who are not only suitable but also motivated and ready to receive therapy.
2. After some time on the waitlist, individuals begin therapy. The assessment continues in the first weeks and months of therapy, so that our program is tailored specifically to each person’s needs. In the first year we focus on intensive dynamic therapy after which we continue with maintenance supportive therapy. Some of our psychotherapy patients graduate after a few months while others graduate after a few years of therapy.
3. We offer combination therapy, typically beginning with individual therapy, after which we add relationship, family and group therapy, as the needs of the patients  evolve as the patient grows.
4. Therapy starts with the focus of relieving the emotional pain and suffering taking the patient from 1/10 to 5/10 after which we focus on the individual’s personal growth, taking the patient from 5/10 to 10/10. We help our patients reach their highest wellness potential focusing, not only on relieving symptoms, but also improving quality of life.
5. The principles of Green Zone Philosophy help our patients help themselves. They become self aware and make significant changes, creating a healthy and happy, peaceful and successful life for themselves, that we call Green Zone Living.
6. Individual therapy is provided by one therapist, while relationship and family therapy may be provided by one or both therapists depending on the complexity of the issues and relationship dynamics. Group therapy is always lead by two therapists representing a two parent family model. Bette and I, as group leaders, add to the quality and care of our patients. They receive different feedback from two therapists who have different personalities, philosophies and life experiences. Bette grew up in Newfoundland while I grew up in Pakistan.
7. Bette and I feel comfortable appropriately sharing our personal stories with our patients. We have developed an awareness of the fine line between sharing overly personal details and being too detached.  Such a practice has helped our patients develop a deeper connection with us. It has allowed us to do more intensive therapy and help our clients’ make more profound changes in their lives.
8. Bette and I meet regularly to reflect on our roles as co-therapists and make personal changes so that we keep our morale high as psychotherapists.
9. Patients are asked to reflect regularly and keep a diary and then process significant passages from their diary in individual and group therapy sessions.
10. At the end of therapy, individuals are invited to write a graduation summary of their therapy reflecting on the therapeutic journey from the beginning to the end, thus identifying different milestones in therapy. We have included graduates success stories in our books as new patients find those stories a source of hope and inspiration.

 

11. ‘A DIFFERENT LANGUAGE FOR EVERY PATIENT’

There is no doubt that a proper diagnosis of the clinical condition is quite helpful for a therapist to understand the dynamics of the problem and plan an effective treatment plan. But every diagnosis has its limitations especially when it comes to people who struggle with Personality Disorders. Over the decades diagnoses have changed and classifications have evolved. Presently DSM 5 classification has 10 Personality Disorders. In my clinical practice I have seen that only a small number of people suffer from just one Personality Disorder. There are far more patients who have a mixture of characteristics belonging to different Personality Disorders. There are many who also have symptoms of neurotic and psychotic disorders. Additionally, there are others who struggle with addictions and there are still others who have a history of physical, emotional or sexual abuse. All these features make the diagnosis and treatment of Personality Disorders quite complex and complicated.

A wise therapist knows that each individual, couple and family is unique and needs a unique form of treatment that evolves with the growth of the patient. Carl Jung remarked that although he had his own unique style of treatment but he also benefited from the methods of Sigmund Freud and Alfred Adler when needed. He wrote in 1961, “We need a different language for every patient. In one analysis I can be heard talking the Adlerian dialect, in another the Freudian.”

In our clinic we tailor therapy according to the needs of our patients. We try to create a special therapeutic relationship with our patients as we know that emotional changes occur in the womb of a trusting and healing relationship. Let me share a story to highlight this point.

 

12. THERAPY WITH MARIA AND JIMMY

I remember the first time I met Maria and Jimmy. Both of them were very concerned about their three year old daughter who was having fainting spells. They had seen their doctor who had done all kinds of tests but all the results came negative. The doctors could not find any medical reason for her fainting spells. They believed it was psychogenic.

            When I took the history of the couple, I realized that Maria and Jimmy had serious marital conflicts. As parents they could not agree on how to discipline their children. Their conflicts started with the first son, they amplified even more with the second son, and now with the third child – a daughter, the conflicts were at their peak. I wondered whether the daughter was getting torn between the parents, a dynamic that is referred to as triangulation.

            Their family conflict reminded me of Murray Bowen, who in his Family Systems Theory, stated that many times children react to the tension between the parents and become triangulated. Surprisingly, Bowen had treated many children without seeing the children. He only worked with the parents. As the tension decreased in the parental relationship and the couple could resolve the conflicts peacefully, the child got better. So I started working with Maria and Jimmy. As they resolved their conflict about their daughter she started getting better and stopped having fainting spells. Both of them were happy with the results. I was pleasantly surprised too.

            Not surprisingly, as the tension regarding their daughter decreased, the tension regarding the sons started to increase. Maria and Jimmy also did not see eye to eye regarding disciplining their sons. Jimmy believed Maria was too soft and their sons were walking all over her. Maria believed Jimmy was too harsh and she had to protect her sons from their father. At times Maria believed that Jimmy was abusive, while Jimmy believed Maria undermined his authority as the father. Both of them blamed each other for their parental problems.

            When the tension increased I was afraid they might become violent with each other. So I suggested a temporary separation. In the beginning Jimmy was reluctant to leave but then finally he left and moved in with his parents. When he left the family home, the dynamics changed. Maria gave a sigh of relief, but Jimmy felt mortally wounded as he felt he was kicked out of his own home. He felt humiliated and embarrassed.

            Following the separation I began seeing Jimmy and Maria separately. They were both angry for different reasons. After staying with his parents for a while Jimmy bought another house. Maria complained Jimmy was not paying child support. Jimmy complained he had no access to his own house. For a while their condition got worse before getting better.

            Then one day Jimmy called Maria to tell her that his mother was in the hospital. She was dying. Jimmy’s mother loved Maria. So Maria went to the hospital and took care of her. When Jimmy’s mother died, it was very sad but for them a blessing in disguise as it brought them closer. But that coming closer was short lived. The resentment re-surfaced again. They were again angry with each other.

            Alongside individual therapy I suggested group therapy, so they both started coming to different groups – one to Monday evening and the other to Tuesday evening group. Group therapy helped both parties. They not only obtained supportive feedback from other group members, but also dynamic feedback to see their own roles in the family conflict rather than just blaming the other party.

            At one stage I invited all three children and had a session with them. They believed that their parents fought because of them. Amazingly, their children predicted that one day when they would leave home, their parents will get back together and live happily ever after. I was impressed by their insights in to the family dynamics.

            Then Maria had another crisis. Her father, that she loved dearly, got sick and died. She had to fly to Ireland to be with her family. While Jimmy and Maria were separated Maria met a man who showered her with affection and she was smitten by him. They had a short relationship. She loved the attention she was missing in her marriage.

            While Maria’s love affair was in the honeymoon stage her mother got sick. When she flew to Ireland again to see her mother, her mother told her that she had received a sympathy card from Jimmy. That touched Maria’s heart. She realized that underneath all that anger and resentment there was considerable love for Jimmy. Under the ashes there were still some sparks.

            Then Jimmy experienced a mini breakdown. He started having flashbacks about his childhood. I helped him get in touch with his repressed anger and articulate his abuse. One day he brought his diary. Let me share a few paragraphs of that diary.

 

The abuse started at about the age of 7 and continued into my young adult life.

Physical, emotional, verbal, economical and mental abuse, a full smorgasbord served to me on a daily basis. I had my nose broken; teeth knocked out, and criticized about my looks, friends, schooling, generally anything I tried to do.

I can remember at the age of 11 the impact of being smashed in the face with an object resulting in   blood gushing from my nose like a fountain; and without missing a beat he promptly informed me that “if you tell the bad things would happen”. 

From that day I suffered from breathing problems.  Also suffered from sporadic bleeding and at the age of 15, an E.N.T specialist treated the bleeding problem but the only way to improve respiration would to break my nose and reset it ….I never bothered to have the surgery.

At 12 years of age , I remember walking to the bus stop with him, I was singing minding my own business when suddenly  and with great force  a school bag  full of books  was delivered to my face.  As I removed my bloody hand from my damaged jaw I noticed a tooth in the palm of my hand. 
Again he said “You better not tell”.

I was also knocked out cold as a result of being pushed down a flight of stairs. I can remember waking up in my crying mothers arms as he stood there calling me a faker.

As I started to earn and save money he turned his sights on extracting any amount he knew I had, and used manipulation and verbal threats to get what he wanted.

Name calling was a daily occurrence – idiot, useless, ugly. He also would say things like “no wonder you have no friends”, whatever negative remark he could think of.

The most hurtful thing I began to experience was, no adult would do anything about it. No matter whom I told, I was seen as a snitch, whiner and liar.  Everyone liked him and thought he was a great guy, and for the most part he was, and at my age now I realize we were just kids, and adults couldn’t be bothered. I felt helpless.

At such young age with no tools to handle my dilemma, the self-blame game began.  I began to alter my behaviour, internalizing everything. I stopped talking and  thought, ‘don’t rock the boat’,   ‘go with the flow’, ‘say “yes” it’s easier’. I basically stopped growing and became what everyone else wanted me be.  

 

            When Jimmy processed his abuse in individual and group therapy he transformed his breakdown into a breakthrough. He distanced himself from his abuser, who was his older brother, and realized how his childhood abuse had affected his personality and his relationship with his wife and children.

While Jimmy was going through a major transformation in his personality, Maria also went through a soul searching phase. Her mother’s death was a wake up call and she reviewed her marriage and family life. She realized she did not want to leave her family. She realized that she could not discipline her teenage children on her own and needed Jimmy’s support. She also realized that she was not in love with this other man and wanted to come back to Jimmy.

            I remember the session in which I asked Jimmy to share his diary of abuse with Maria. That session was significant because Jimmy’s diary connected the dots for Maria and she could feel more compassionate for Jimmy.

            After Maria and Jimmy went through their soul-searching separately, I realized that both of them were ready to have a genuine and serious dialogue with each other about their relationship. Within a few months their relationship improved. Maria and Jimmy learned to communicate better and resolve conflicts peacefully as both of them had resolved their anger and resentment. They could also see how their children were able to manipulate them. Finally they started working together as a team. As parents they started to support each other. Maria challenged her children when they were disrespectful of their father and Jimmy supported Maria when children were unreasonable with their mother. The children responded well to both of them. Finally their marital and family relationships improved. In the last few months Jimmy and Maria are spending more and more time together. Now their marital relationship is affectionate and loving and their family life is peaceful. It was hard work for both of them but it was worth it. As a therapist it was a challenging family to work with but in the end it was very rewarding. Now I feel optimistic that their children will not be sitting in another psychiatrist’s office when they grow older. They saw their parents struggle but they also saw how they were successful in resolving their conflicts peacefully. Family therapy can be very demanding but also very rewarding.

I chose this story for my essay because Jimmy struggled with Personality Disorder all of his life. His personality disorder was expressed in poor communication skills, angry outbursts and dysfunctional family relationships. His behaviour led to serious marital and family problems. Jimmy was unaware how his traumatic childhood experiences and physical and emotional abuse had affected his personality and lifestyle. After dealing with his past abuse in therapy he was able to heal and create loving relationships with his dear ones. It was hard work but in the end it was all worth it. Maria loved him so much that she did not give up on him and their family and in the end reaped the rewards of her patience, hard work and resilience.

            When I asked Maria and Jimmy to reflect on their therapy, they wrote the following stories for other couples to read, reflect and benefit from their experiences. They want to offer hope to other struggling couples and suggestions how they can get the professional help they need to save their marriage and re-create a healthy, happy and peaceful family life. They want other couples to give their love another chance.

  Note: We have changed the names to respect their prvacy.

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13. JIMMY AND MARIA’S STORIES

 

MARIA’S STORY

 

This is a journey of friends, lovers, spouses and parents to three children that in just over 4 years moves on to a story of separation, animosity, legal threats and a lengthy course of therapy.

Jimmy and I started out meeting at a young age. I was 18 years old and an immigrant. I was in my new country, Canada, in search of myself – excited and scared at all the possibilities the future held. I got a job, started college and decided on nursing as my career. I met Jimmy on a pub night through college and soon after a dating relationship started.

He was interesting, musical and talented in so many areas that I was not. He was introverted where I was extroverted, and so a beautiful friendship started and continued for 6 years before I asked him to marry me. We married and worked equally as hard at getting our careers and our home in order, before we decided to bring children into our relationship.

This marriage was to be blessed with three healthy children. Like most marriages the boat of easy sailing was not quiet destined to be ours. Our youngest daughter began having fainting spells and this went on for over 3 years. Nothing critical, we were careful in our watch of her so she never got injured.  But during these years that our daughter had these spells, I noticed a big shift in Jimmy’s behaviour towards the family and me. He became much more anxious, nervous, upset and would get easily angered at some of what seemed minor upsets to me. I would try and talk to him about some of these outbursts but always started to feel like I was being dismissed or unheard and this would frustrate me.

I prodded and poked for so many years as I watched his frustrations and anger escalating higher and higher. I noticed myself shutting down and not talking about my feelings to him as much, and at times, at all.

Unknown to me, this breakdown in communication was to have such huge consequences further down the marriage. Yes, we carried on as husband and wife, parents, nurse, engineer but the spark which had always been our friendship was burning out.

I felt myself getting more frustrated, even angry at times because I just didn’t understand it , to me and my mind all I kept seeing was how blessed we were and how grateful we should be . For me I felt we had everything – three healthy children, our own physical health, a home, careers and our family, but what was missing was sense of peace and security.

Changes came with this loss of love and security. Hence what came next in their absence was tension, anxiety and lack of trust. Thankfully Jimmy and I still had enough love for each other and respect for our own family that we sought help in the form of therapy.

 

Our therapy started out by me talking with my family doctor about my own issues and then about his issues or what I thought were his issues. Anger management was suggested by our family doctor for  Jimmy, he reluctantly agreed and started sessions but with no great results. After that we were finally referred to a different therapist one that showed great patience and a very individualized kind of therapy. It started out as marriage counselling together and then individual sessions and went to a separate group therapy each weekly, of which we both have continued for years. The road to fixing our relationship, or to getting a new kind of relationship, back has been difficult and continues.

All this therapy ,years of it, helped  keep us together but still very much apart on the friendship level. I was very frustrated, somehow impatient of why it was taking us so long in putting our marriage back together. It seemed to me things got worse before they ever got better. All of us were suffering under the one roof in the absence of peace, security, trust and love.

It was suggested that we live apart for a while by our therapist but we denied it would help, and added a pot full of anger to it as well. And so I hired a lawyer and filed for legal separation and Jimmy was asked to leave the matrimonial home.

I put in my head that our marriage was over and I should move on and find what I was desperately in search of and that was Peace. I had had enough; I was slowly feeling my self slip away for who I was. I thought it would all get better with him gone. Enter a legal process and you very quickly realize some of the worst pain is just about to arrive.

I got Jimmy out of the house but the painful thoughts of getting him out of my life was more than I could emotionally bear, as strong as I may have presented myself during this time, I knew I was falling closer and closer too heartbreak and despair.

 I stalled, I wasn’t quiet sure of why I kept stalling just something in me did. I even dated one man for a few months, I think now in hindsight to see if this would help me get over Jimmy, it didn’t. I finally allowed myself to feel sad, heartbroken and uncertain.

 My losses during these three years of pain were huge. I lost my marriage to separation and my mother-in-law to a fairly sudden death. My parents died 7 months apart. And our children lost three grandparents and went through the separation of their parents in the space of two years.

The grief of losing so many loved ones and Jimmy coming forth honestly about where some of his greatest anger stemmed from being bullied as a child and a teenager put so many things into a new perspective for me.

By giving myself permission to allow all the pain, uncertainty and loss, I began to understand that guardian angels and my ever-patient therapist, in their own way, stalled me. They all knew better than I did that a journey of divorce was most likely not the right choice of action for me.

 So now a new journey begins, slowly on, where peace has a path, hope is bright and trust grows like a well-watered garden.

Jimmy and I are dating, and friendship enters daily into our lives once again, allowing the luxury of each other’s company and all that being in good company affords. It allows peace, happiness and laughter.

I’m no longer in a rush to have to try and fix things or absorb the issues of others as deeply as I did. I realize I sometimes took on too much and it takes too much out of me, leaving my mind, soul and body empty.

I have always been a kind person and hope always to be kind but must remember to first be a little kinder to myself in order to continue a more loving king journey through life.

My relationship now with Jimmy is stronger, more honest and more loving as a dating couple and as parents on a more united front.

My advice to anyone going through a tough relationship is to stop, stall as best you can so you have the time to work out all your emotions, for there will be many. Seek the advice of a good therapist. Don’t stop at the first one, if it is not working for you. It may take a few ’til you find who is right for you and your partner. Don’t quit on your friendship if you know you once really had that. The fact that Jimmy and I were friends first has a lot to do with staying the distance, to re-uniting us, to being back to being partners, It was our foundation.

I have never been more grateful in my life to our therapist, his team and the group of which I am a member. I am thankful for his advice, good counsel, his patience and his belief over the years of dedicated service of which continues. Healing is like a turtle, slow and steady, it is how I hope to proceed in my relationship.

 

JIMMY’S  STORY

I learned a lot of things in therapy but one of the things that stands out the most is how difficult it is for me to articulate my feelings, which contributed to the breakdown of the marriage.  If I think back to the beginning of the relationship we were very much in love. We were friends. We never fought about anything.  The biggest changes started after the kids were born. Seeing Maria give birth to our first child changed my whole view on the relationship. It was truly magical to see our first son born, truly unbelievable.  I felt a need to protect my family as a father, and I also began to feel inadequate. Seeing what a mother endures to bring life into this world could humble the biggest of egos.  From that day on I questioned if I would be capable of fulfilling the role of being a Father, I wonder if Maria would really need me, motherhood came so naturally to her.

I had never met a girl like Maria, she was outgoing, free-spirited, courageous, independent and very loving .We started out as friends and remained as such. We spent a lot of time together and got along very nicely. Maria had this way of lifting my spirits, not only was I happy in her company, she made me feel like I could do anything. I have to admit there were times in my marriage when I felt like the luckiest man in the world.

 The biggest struggle in the marriage for me was trying to help support Maria’s free spirit without it looking like I didn’t care. I feel like I failed here the most, at least that’s my perception. Maria has a lot of energy and it just seemed to me like she needed more than I could give her. I felt like a failure. To this day I still feel like my actions to support her independence make her insecure in the relationship. I really don’t like playing games in my marriage, friendships or with my family but given the right bate I will bite.

The fighting got pretty bad. Maria would often ask me to leave the house for the night. Leaving your home brought on a whole new set of feelings to deal with, this just compounded what I already had to deal with.

 It was very heartbreaking, trying to love someone the wrong way. Not knowing how to deal with my sadness I unconsciously used anger to cover it up. Sadness, I interpreted as weakness, and as a father I wanted to be strong. Therapy has shown me that I can choose how to deal with situations. I realize you can’t control your feelings all the time but I can choose how to express them positively.

I also began to learn that present situations can bring up negative feelings from our past. Therapy helped me to deal with resentment and unresolved issues from my childhood and teenage years. The birth of our third child brought new challenges to the marriage.

 Our daughter experienced fainting spells not long after being born, this only added to my feelings of insecurity. She suffered from blackouts for over 3 years and no conclusive medical diagnosis was giving for most of that ordeal. My daughter’s situation made me feel helpless. There is nothing worse than watching your child suffer.

During our first appointment with Sohail, we did inform him of our daughters fainting spells and he felt the situation would improve if, as parents, we improved. Sohail originally communicated with us as a couple but shortly after separately, to gain an understanding of how our relationship had reached this point. With my confidence slowly eroding and my marriage in trouble I was glad to have someone to talk to about it.  I was encouraged to write down my feelings and at first found this to be very difficult but very rewarding.

Sohail suggested group therapy. Group was an excellent avenue to retrain myself emotionally and mentally. My trust slowly grew the more I attended group and I viewed them as a Family. It was here in the new family I could express myself, my thoughts, emotions and even my talents. I noticed before the beginning of every group session Sohail would announce his expectations. He expected everyone to listen and respect each other. I approach my real family with the same respect. I have a mental picture of our home free of anger, disrespect, and judgment. Group taught me how to listen to my biological family patiently, respectively; it taught me how to handle my emotions.

Another step towards building a healthy relationship that Sohail suggested, was living apart while we worked at the relationship. And so on Oct 22nd2012 I moved out of the matrimonial home. Living on my own made me realize that I am in control of my happiness, I choose how to handle things, I choose how to express myself.

One major issue was how we acted as parents. We were divided and were encouraged to act as a duo and not two individuals. We were encouraged to only make decisions after consulting with each other. I had previously underestimated how hurt Maria was when I made decisions on her behalf without taking her opinion into account. Remedying this further helped to heal our relationship.

The biggest turning point for me was when Sohail recommended that I acknowledge the depth of my commitment to the relationship and refrain from leaving it. You see, most of our fights ended in threats of abandonment. My decision to reassure Maria that I was not leaving slowly gave her the confidence to express her feelings. I consciously made an effort to reaffirm this commitment regularly. While the act of getting married contained our lifelong vows to one another, marriage is a lifelong commitment that requires continual work. Maria and I regularly demonstrate our affection and our trust in each other.

The way I handle conflict today is very different. Before blaming Maria for anything, I question myself and take responsibility for my feelings. I acknowledge my feelings and give myself permission to feel them.

Undergoing counselling is one of the best decisions I ever made. Before meeting with Sohail, I felt desperate and thought that divorce might be my only option. Working with a professional helped me and my wife revaluate our relationship and learn how to prevent problems from escalating into anything insurmountable. For anyone going through similar difficulties, I would highly recommend counselling before getting a divorce.

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14. HIERARCHY OF DEFENSE MECHANISMS:

 

DEFINITION

Defense Mechanism is an unconscious mechanism, that human mind uses to deal with anxiety and stress.

HISTORY

When we study the history of psychiatry and psychotherapy we become aware that Sigmund Freud was the first clinician who introduced us to the concept of defense mechanisms. He primarily focused on those adult patients who suffered from neurotic disorders and identified their defense mechanisms. After his death his daughter Anna Freud psychoanalyzed children and identified more defense mechanisms. After the deaths of Sigmund Freud and Anna Freud there have been many other psychoanalysts, psychologists and psychotherapists including Otto Kernberg and George Viallant, who made valuable contributions to the field of psychotherapy and defense mechanisms.

THREE GROUPS

Rather than going into academic discussion we can say that defense mechanisms have a hierarchy and can be divided into three groups, from the most immature to the most mature.

GROUP A: These defense mechanisms are the most immature and pathological defense mechanisms and are used by the people who suffer from psychotic conditions like Schizophrenia and Manic Depressive Illness. Let me share one example.

One defense mechanism used by people suffering from Schizophrenia is called Psychotic Projection. In this mechanism the patients project their undesired painful feelings to the other person. A patient who hates her husband and feels guilty about it can project her feelings to him.

Rather than saying I hate you she says You hate me and believes it. Many such patients, who suffer from Schizophrenia, start believing that other people not only hate them but are also going to hurt them or poison them to kill them. Sometimes such patients want to be admitted to the hospital to be protected from such people.

GROUP B: These defense mechanisms are immature and are used by people suffering from Personality Disorders like Borderline Personality Disorder.

One defense mechanism used by people suffering from Borderline Personality Disorder is called Splitting. Such people cannot accept that a person can be good and bad at the same time. They are like children who see their mom as all good or all bad. When such children are happy with their mothers they say, “Mom, I love you” and when they are unhappy they say, “ Mom, I hate you.” They cannot understand and appreciate that mom is not perfect and can have both good and bad qualities. Most children integrate the good and bad as they grow older and have a realistic appreciation of other people but People with Borderline Personality Disorder do not. Even when they are teenagers they are immature like children.

I remember a patient who told her father one day that he was the best father in the world but the next week when she was angry with him told him that he was the worst father in the world. Such a patient was using the defense mechanism of Splitting and seeing her father as all good or all bad.

Another way of expressing such defense mechanism is by splitting between two parents. For such patients one parent becomes all good and the other parent becomes all bad. Such splitting can cause serious arguments and fights in the family. It is not uncommon for the nurturing parent to be sympathetic and the disciplinarian parent to be angry with the same teenager. One parent wants to forgive the misgivings while the other parent wants the teenager to face the consequences of her actions.

When patients suffering with Borderline Personality Disorder are admitted to the hospital the family dynamics are reproduced in the psychiatric ward. Half of the staff is sympathetic to the patient while the other half is quite angry. One half of the staff wants to keep the patient longer in the hospital while the other half wants to discharge [ even kick her out] her as early as possible.

Because of such frustrations and challenges many psychiatrists and psychotherapists are reluctant to look after patients who suffer from Personality Disorders especially Borderline Personality Disorder.

One other immature defense mechanism that people suffering from Personality Disorders use is called Acting Out. When such patients are angry with a person, rather than sharing their displeasure in a healthy and constructive way, they express it outside the relationship in a destructive way. That is why such defense mechanism is called Acting Out. Such teenagers can go outside the school or home and express their anger by getting into a fight in the street with other teenagers or breaking a window in the nearest shopping mall and get arrested for petty crimes.

GROUP C: Such mature defense mechanisms are used by healthy and well adjusted people. One such mature defense mechanism is called Sublimation. People who use Sublimation find socially acceptable and respectable way to express their unacceptable wishes. For example a man can become a famous boxer or wrestle to express his aggressive impulses. A woman can become a well respected actress in films to express her desire to expose herself. Still another person can become an ambulance driver to channel his desire to drive fast, not follow the traffic rules and break the speed limits.

The more therapists become aware of the hierarchy of defense mechanisms the more they are able to understand their patients and help them learn healthy defense mechanisms. Healthy defense mechanisms are crucial in creating well adjusted, meaningful and successful lifestyles. Such knowledge is very significant for all those who deal with patients who suffer from different types of Personality Disorders. Sometimes it takes therapists many weeks, months, even years to properly diagnose their patients as their patients express different defense mechanisms in different crises. Since these defense mechanisms are unconscious patients are not able to report them to their therapists. Many patients with Personality Disorders present with symptoms of anxiety, depression or anger and many doctors or psychiatrists try to treat those symptoms with medications without realizing that such symptoms are just the tip of the iceberg. Those therapists who have a deeper understanding of their patients recognize the underlying defense mechanisms and are better able to help their patients and their families in creating healthy lifestyles.

In my clinical practice, looking after people with Personality Disorders, I have realized that such work is hard work but in the end it is all worth it. It is so rewarding to see patients changing their self destructive patterns into constructive lifestyles and transforming their breakdowns into breakthroughs.