I always knew Robin had anxiety in social situations. She acknowledged it in our first session. What became clear after her meltdown, however, was that she actually fit the criteria for what is known as Avoidant Personality Disorder. People with this diagnosis have a lot of social anxiety and trouble being open with anyone due to their fear of being rejected or evaluated negatively. When Robin began to tell me things she had never told anyone before, it became clear this pattern fit. Her revelation several weeks after she got out of the hospital that she was back to “faking it” with her friends and family and had them convinced she was “fine,” confirmed it for me. Being vulnerable in any way caused anxiety for her. She was clearly more comfortable faking it, even though this caused her to feel alone and isolated. This was all consistent with avoidant personality traits.
To be assigned a diagnosis, people must meet the criteria outlined by the most current version of the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association. All mental health providers, at least those in the United States, are familiar with this book and the “personality disorders” described within it. In my opinion “personality disorder” is a terrible label. It just sounds bad. I hate the whole notion of having to label people at all. But diagnostic labels do act as a form of shorthand to communicate quickly among providers of mental health services what is going on for a particular client. Personality disorders indicate a combination of personality traits that interfere with someone’s functioning in a significant way. The label informs the provider about the most helpful approach to treatment.
Borderline Personality Disorder describes a pattern of intense and unstable relationships, impulsive behavior and difficulty managing strong emotions. People with this pattern tend to get angry easily, self-mutilate, experience suicidal thoughts and worry excessively about being abandoned by the people they care about. They often quickly become very dependent within their relationships.
I never believed Robin had borderline personality disorder, despite her difficulty managing strong emotions and her tendency to self-mutilate. It just didn’t fit. Her relationships were neither intense nor unstable. Her self-mutilation and suicidal thoughts were isolated to times when she was biologically depressed, and getting her on the right medication always stopped her self-destructiveness. She did not usually do anything impulsively except when she was drinking alcohol, and was rarely angry. In fact, she usually obsessed for a long time before doing anything outside of her usual routine.
The whole question of which personality disorder diagnoses fit for Robin became very relevant after her meltdown. The staff in the hospital believed she had borderline personality disorder. I, obviously, did not. Dr. Greene, who had been treating Robin for years, even put “borderline personality traits” on the discharge summary after her hospitalization.
Why did it matter? Because the effective approach to treatment is very different for clients who fit the pattern of borderline personality disorder than for those who do not. I had treated many people with this diagnosis. It is crucial in therapy to maintain clear interpersonal boundaries, to educate clients about boundaries (they usually have not been taught this before), and to process the dynamics between therapist and client in order for people with borderline personality disorder to learn how to have healthy relationships.
When Robin had her meltdown and her behavior began to resemble that of someone with this diagnosis, I was confused. This was not the Robin I had known for ten years. I had a huge dilemma on my hands. My gut was telling me Robin’s emotional isolation, consistent with avoidant personality disorder, was contributing to her severe, suicidal depression. I felt like I needed to extend my boundaries and be more available to Robin in order to help her feel connected to another person, and that this was likely the only thing that would keep her alive until we could get the biology of her brain stabilized.
If I was wrong and she really had borderline personality disorder, to extend the boundaries while she was already so unstable could have been disastrous. Because people with this pattern have usually not experienced healthy relationships, if therapists extend boundaries inappropriately or at the wrong time (which they often do with these clients because their needs are so great) it can lead to terrible situations in which clients get overly dependent and then emotionally destabilized. Therapists then end up needing to set firmer limits to regain a healthy balance in the relationship, which causes the client to feel shamed and abandoned. I had made this mistake while I was a therapist-in-training and had subsequently seen colleagues do so, with painful consequences all the way around.
In March 2003 I needed to make a crucial decision about Robin’s treatment. Her life was at stake. The fact that Dr. Greene and the hospital staff all thought she had borderline personality traits, caused me to question myself. I did not want to do the wrong thing and make things worse for Robin. So I did what all therapists should do when they are unsure and the stakes are high. I consulted my professional support network.
One of my closest friends, Giselle, was a fellow psychologist with much more experience than me. I trusted her to tell me if she thought I was making a mistake. She said something to me that made all the difference. I will be forever grateful to her for her wise words.
“I hate that I’m so unsure about what to do,” I said to Giselle. I filled her in on the whole story of Robin’s history and my dilemma. “I’ve known this person for ten years. She’s never before acted like she has borderline personality disorder. I really think it’s all about severe depression and social isolation, and her obsessive-compulsive symptoms are causing her to be stuck in self-destructiveness. I feel like what she needs is for me to be very available until she is stabilized. But I don’t want to disregard what everyone else thinks and make things worse if I am wrong!”
Giselle then said what I needed to hear. “Sharon,” she calmly said, “You have known this person for ten years. If she had borderline personality disorder, you would have known it by now.”
Of course! Giselle was right. Personality disorders are pervasive and do not easily change. I had enough experience that I would have felt clear a long time earlier if this was an issue for Robin. Giselle’s calm, validating statement allowed me to take a huge leap of faith and to trust my gut, even though many people might have thought I was making a mistake if they knew what I did.
At the time I was talking to Giselle, Robin was still taking care of her nephew. She was scheduled to return to work in a few days and was very anxious about it. She was skipping doses of her medication, rationalizing it, and drinking alcohol. She had only promised to stay alive until her brother and his wife returned from their vacation. I felt like I needed to do something to make it harder for her to seriously consider suicide.
What was the huge intervention my gut told me to do? I told Robin how much I cared about her. It was as simple as that. It was not something I previously would have done…with any client. But, I thought Robin needed to know, for sure, that at least one person in the world would be very upset if she killed herself. She had rationalized that her family members would “grieve and move on.” They did not have an opportunity to correct this mistaken belief because she was not even letting them know she was still depressed, let alone suicidal. So, as the only person Robin was being open with about what she was feeling and thinking, I needed to try to help her understand the impact her suicide would have.
“Robin, I need to tell you something,” I said. “I am guessing you would never expect me to say this, but I am probably just as worried about you ditching me as you were about me ditching you.”
“What do you mean?” asked Robin.
“I don’t usually tell my clients how much I care about them. But I want you to know I care about you very much. I’ve always liked working with you, and I believe we connected ten years ago for a reason. I believe there is a reason you ended up in my office the day you were hospitalized, instead of killing yourself. I think we are supposed to keep working together. I’ll be really upset if you kill yourself. I feel bad about our misunderstanding that made you think I would ditch you. I feel somewhat responsible because I should have been talking to you about our relationship all along and I should have helped you to be more open with me. I’m so glad you are now telling me how you really feel. It doesn’t make me respect or like you less. In fact, it makes me respect you more because I have a much better understanding about how strong a person you are. I’m amazed you were able to do your job so well, even though you were so depressed.”
Robin said nothing. She listened and stared at the floor. Her leg was bouncing, as usual.
“I also want you to know I intend to be much more available than I was in the past. I know you need to feel connected to someone right now, and that you can’t be honest with your friends or family. Because I care about you and don’t want to lose you, I’m happy to be that person. I know you are worried about becoming too dependent. We’ll keep talking about that. It will become clear once you are feeling better how much contact is right. You’ll need to eventually work on being open with the other people who care about you. I’ll help with that.”
Robin seemed to be paying close attention to what I was saying, although it clearly made her uncomfortable. “I have a hard time letting people know how I feel,” she said.
“It’s okay.” I reassured her. “I know you care about me and what I think. I just want you to know what I think, so you don’t have to wonder. What I think is that you are an amazing, smart, funny person who has a lot to give to other people. I am really sorry you are feeling so depressed right now.” I told Robin the best way she could show me she cared was to commit to continuing to work with me in therapy, and give it a chance to make a difference.
“Knowing how you feel puts me in a bind. It makes it harder for me to think about killing myself,” she reluctantly said. Good, I thought. Thank God. She went on, “I can’t promise anything, but I have no plans to kill myself at this point. I’m going to try to get back to work. I think it would take something bad happening for me to kill myself.”
Robin was scheduled to start work a couple days later. We made plans to meet after she finished her first day. Something told me, though, to call her before I left work on the day I had told her I cared about her. I was concerned about how she might be reacting to my intervention of being honest.
“I’m glad you called,” she said. “I’ve been trying to decide all afternoon whether to call you. I’m more anxious. I don’t know if it’s because of our conversation earlier or whether it’s because I’m thinking about going back to work.”
“Probably both,” I said. I wasn’t surprised to hear she was more anxious.
“I’m not used to people talking about strong feelings. It makes me uncomfortable. And I feel pressured to do things I don’t feel able to do.” She was referring to me asking her to eat more and to commit to not killing herself.
“I am pressuring you about those things. I’m sorry, but I’m still concerned that being self-destructive in any way…not eating, skipping medications and drinking will just get in the way of you feeling better. And I don’t want you to kill yourself.” I told Robin I was sorry about throwing so much at her, especially just before she was supposed to go back to work. But, I also told her I had felt strongly I needed to say what I had said. We talked a few minutes longer and she assured me of her intention to refrain from drinking and to take her medication as prescribed.
I went home that night and worried. I wasn’t surprised that being open with Robin had caused an increase in anxiety. I was relieved she immediately said it was harder for her to think about killing herself. But that was certainly no guarantee of anything. I was just hoping I had not made things worse for her. I imagined how awful it would be and how bad I would feel if she destabilized as a result of my intervention.
Robin returned to work half-time on March 13th, the day after her brother and sister-in-law returned from their cruise. We met later on that day. She had more trouble sleeping the night before in anticipation of what might happen, and said she was tired. She said she had been very anxious upon returning to work, but that the reactions from her co-workers were positive. While she was in my office, I paged Dr. Greene, who said she could take extra anti-anxiety medication temporarily to make the transition back to work easier. We made plans to talk briefly on the phone the next day after she finished work.
“I’m just tired,” Robin said on the phone that day. “Work was okay, but exhausting. I had to go to two court hearings this morning. It was stressful.” She said she had talked to her co-workers in a team meeting about her absence from work, and that this had gone okay but made her very anxious. She sounded more depressed than I had heard her sound for a while, and I commented on it.
“I don’t have any plans for the weekend,” Robin said. “I’m worried I’ll have too much time to think.” I got into typical therapist mode, and started problem-solving how Robin could get through the weekend. In hindsight, I wish I would have reacted differently. I was having as hard a time in some ways as Robin was in terms of changing my pattern.
“Why don’t you call your friends or family members and make plans to get together this weekend?” I suggested.
“I’ve already spent too much time this week faking it,” Robin said. “I don’t really want to be around people.” Oh no! This was not good. I did not like what I was hearing. I kept making suggestions. Robin humored me and talked about some things she could do to keep herself busy and distracted.
“How are your suicidal thoughts?” I asked, somewhat afraid of what I would hear.
“They’re still there,” she said. “But I’m not planning to do anything. I think it would take something catastrophic happening to push me to that point.”
“Will you call me if that happens?” I asked.
“Of course I’m not going to call you at home,” said the Robin who, for a moment, sounded familiar.
I was concerned enough about how depressed Robin sounded, that I talked to her about a medication adjustment. The antipsychotic medication, Geodon, was definitely helping her sleep. But she was still so depressed. I paged Dr. Greene and he agreed she should increase one of the two antidepressant medications she was taking. She agreed to do so, and we confirmed our two planned appointment times for the following week.
At 4:00 pm that day, after I finished seeing my last client for the week, I checked my voice mail. There was a message from Robin.
“I went to my parents’ house to tan this afternoon, and then I learned it’ll cost much more than I thought to fix Chuck’s (her Jeep) engine,” Robin said on the voice mail, sounding more upset than I had heard her sound in quite some time. “When I heard that I just started crying and couldn’t stop. I’m going to drink until I pass out!”