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I Hate You – Don’t Leave Me: Understanding the Borderline Personality
By Jerold J. Kreisman, M.D., & Hal Straus. New York: Avon Books, 1989, 207 pages, $6.99.
I Hate You – Don’t Leave Me: Understanding the Borderline Personality (Kreisman & Straus, 1989) is a book that provides a solid overview of the etiology and treatment of borderline personality disorder (BPD). It is written on a level that both psychotherapists and clients can understand, and it breaks up the presentation of information with case study examples. Because of its integration of theoretical material and practical application, it would be a valuable bibliotherapy resource.
The book begins by highlighting the hallmark characteristics of BPD, describing the patterns of stormy relationships and cognitive splitting that are exhibited by many people with the disorder. It uses the eight criteria from DSM-III-R as the basis for diagnosis. They are: unstable and intense interpersonal relationships; impulsiveness in potentially self-damaging behaviors, severe mood shifts; frequent and inappropriate displays of anger; recurrent suicidal threats or gestures, or self-mutilating behaviors; lack of clear sense of identity; chronic feelings of emptiness or boredom; and frantic efforts to avoid real or imagined abandonment (p. 8). The authors explain these criteria in detail, illustrating them with stories of actual borderline clients. The use of cases is helpful because it personalizes the information and makes it more understandable and accessible to the reader.
The authors note that Borderline Personality Disorder is one that is often “masked” by other disorders, and this can make it difficult to diagnose. The book compares BPD to a series of other related disorders, including schizophrenia and depression. It not only describes the distinctions between BPD and these other disorders, but it also explains that BPD is often marked by comorbidity.
A large section of the book focuses on the etiology of BPD, exploring the contributions of family relationships, biological factors, and societal influences in the development of the disorder. BPD tends to span generations in families, and is most often passed down from mothers to daughters. Familial factors that are thought to be linked to the development of BPD include disturbed parent-child relationships, violence, and abuse (p. 47). The authors also describe the current culture as a “borderline society” that promotes BPD because of its fragmented structure, changing gender roles, increased divorce rates, and greater geographical mobility (pp. 63-64).
The last three chapters deal with treatment and coping skills. There is an emphasis on communicating with the borderline client, and the authors present a system designed to facilitate this. It is called Support Empathy Truth (SET), and it is a three-part method of interacting (p. 101-103). The first stage, Support, is a personal statement of concern about the borderline person, focusing on the speaker’s own feelings and desire to help. The second stage, Empathy, is an acknowledgment of the person’s feelings. The third stage, Truth, recognizes the existence of a problem and addresses more practical issues of how to solve it. The authors present a series of case vignettes in which the SET system is used to defuse unstable situations. In addition, they provide suggestions about how to cope with certain scenarios and characteristics of the borderline patient.
Finally, the book explores several different treatment options for clients with BPD. It discusses exploratory therapy, supportive therapy, group therapy, family therapy, expressive therapies, pharmacotherapy, and different levels of hospitalization. It also emphasizes the relationship of the therapist with the borderline client and addresses the important issues of transference and countertransference that are likely to come up in therapy.
For many borderline clients bibliotherapy may be a helpful addition to psychotherapy because it would promote active participation in the therapeutic process even when the client is not actually in a psychotherapy session. This is especially important with borderline clients, whose lack of object constancy can lead them to feel abandoned by people who are not physically present. The authors describe a woman who carried a newspaper article that contained quotes from her psychiatrist and referred to it when she was under stress. They explain, “Seeing her doctor’s name in print reinforced his existence and his continued interest and concern for her” (p. 53). In the same way, the assigned reading of a bibliotherapy book would remind the patient of her therapist’s involvement and commitment to therapy. I Hate You – Don’t Leave Me actually encourages the use of bibliotherapy books for this reason. The beginning of this book could be helpful to clients with BPD. The first few chapters provide more general information about the disorder and its development. Reading these chapters could help the borderline client by giving her information about the disorder and lessening her sense of being alone. However, this book may not be the best resource available for borderline clients themselves. A person who has BPD would benefit more from reading a book that deals directly with managing her own feelings than from one that advises others about how to deal with her.
Because this book devotes several chapters to communicating and coping with a borderline patient, it may be more appropriate for friends and family of individuals with BPD than for clients who are themselves diagnosed with the disorder. However, this book could easily be incorporated into therapy with such clients. The techniques described in the later chapters focus on dealing with a person with BPD, and these could be especially helpful. It is recommended that clients read the entire book in order to get a better understanding of the development and presentation of BPD, but the most beneficial emphasis would likely be on how they can interact with the borderline individuals in their lives.
The five vignettes that are used to demonstrate the SET strategy could serve as a starting point for understanding how these techniques are applied. Each one describes an interaction between a person with BPD and a significant other in his or her life. It outlines the steps of SET and provides possible responses and ways of handling the situation. Because of the turbulent nature of borderline relationships, it is important for others involved in these relationships to understand how to communicate effectively with friends and family who have BPD. The SET techniques can easily be practiced with clients in psychotherapy, possibly through role-playing, and they can be encouraged to use these communication skills in their interactions outside of sessions as a kind of homework. Psychotherapy sessions could include an examination of clients’ use of these techniques and their effectiveness, working to refine the use of these techniques so they would be appropriate for each client’s particular situation.
This book could be beneficial for friends and family members of borderline patients because it helps them to better understand the disorder and learn good communication skills. However, there is an important caveat that should be considered when recommending this book to clients. It emphasizes the role of family members in the development and maintenance of BPD. Therefore, a psychotherapist has to be careful when using this book in treatment with family members of borderlines, especially if they exhibit signs of BPD as well. It is important not to assign blame, and family members (particularly parents) may feel that they caused the disorder. If these feelings come up in psychotherapy, it is important to work through them with the client.
I Hate You – Don’t Leave Me is a good resource for a number of reasons. A major strength of the book is its use of cases to illustrate the major points. Some of these cases provide examples of borderline behavior in certain situations, while others are more general life histories. This helps the reader to get a broad sense of the typical borderline patterns as well as an understanding of specific types of behavior. The cases personalize the book and can also give the reader an opportunity to identify with some of the people presented, whether they have BPD themselves or know people with the disorder. This is important because it provides a feeling of universality, letting readers know that they are not alone in their troubles. In addition, the cases are written informally and break up the heavier, more theoretical material.
Another asset of this book is the fact that it is not only informative, but also practical in application. A good example of this is the inclusion of the SET system. The first half of the book functions to deliver information, and the introduction of SET techniques in Chapter 6 marks a change to a more practical realm. The reader is provided with specific strategies to use in communicating with borderline patients in a variety of situations. This is important because it encourages readers to take action and continue the therapy work on their own. It also provides practitioners with concrete ideas to incorporate into treatment.
Although I Hate You – Don’t Leave Me is a good candidate for a bibliotherapy book, it has its drawbacks as well. One of the problems is the book’s endorsement of psychiatrists as the best possible providers of treatment for BPD. One of the book’s authors is a psychiatrist, so it is understandable that his personal bias might come through. A more objective and impartial review of available treatment options would have been preferred. Certainly, different clients need different types of treatment, and one specific mode or orientation will not meet the treatment needs of all individuals.
An additional criticism is that this book focuses too much on the concept of a “borderline society.” It is necessary to understand the societal factors relevant to the development of BPD, but the increase in the divorce rate and the changing roles of women are not the most important problems to consider. Social and cultural factors do have an effect on families, but it is interpersonal relationships that have the most impact on BPD. The way this information is presented exaggerates the role of society and makes it seem like BPD is a very common disorder.
One final point is that the book uses DSM-III-R criteria, which are now outdated. This is minor, however, because the most recent DSM-IV-TR criteria are only slightly different, with some changes in wording and the addition of a ninth criterion. This last criterion is “transient, stress-related paranoid ideation or severe dissociative symptoms” (American Psychiatric Association, 2000, p. 710). These minor changes do not significantly alter the diagnosis and they do not impact the book’s strategies for coping with individuals suffering from BPD.
Overall, I Hate You – Don’t Leave Me could be helpful as a bibliotherapy resource, especially for clients who are friends and family members of people with BPD. It provides information about the development and presentation of the disorder, and it gives practical strategies for coping. The book is punctuated by case studies that further illustrate the concepts being discussed and give the reader a deeper understanding of borderline functioning. Although it has some small drawbacks, this book may be a useful resource for bibliotherapy.
Reference
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.