The angry/ impulsive child
The other child mode in BPD is that of the ‘ angry/impulsive child'. The beginning of therapy is often overshadowed by desperation (Little Nora) and shame (punitive parent).Because of this, one does not often see the angry/impulsive child in the beginning of the therapy.
Angry Nora is a furious, frustrated and impatient young child (approximately four years of age) who has no regard or consideration for others. When in this mode, the patient is often verbally and, at times, physically aggressive and acrimonious towards others including her therapist. She is incensed that her needs are not met and her rights go unacknowledged.
Angry Nora is convinced it is better to take all you can or you will end up with nothing at all. She is convinced she will be taken advantage of. She is not only furious, but also wants everyone to see just how badly she has been treated. She does this by attacking others (verbally or physically), hurting herself, attempting to kill herself, or even others, as a form of revenge. This, of course, is the extreme form of Angry Nora. A milder way in which Angry Nora may show the therapist her anger is by not attending sessions or stopping therapy all together.
While the differences between the angry child and the angry protector are not always clear, they can usually be observed in how the anger is presented. The angry child is impulsive and unreasonable. She refers to issues that are completely unrelated and irrelevant. The angry protector is more controlled and more likely to be cynical than furious (see Chapter 9 ‘ Treatment Methods for the Angry/Impulsive Child'for a sample dialogue).
Outbursts of rage are impulsive and unexpected. Should these take place during a session, the therapist should attempt to remain calm and tolerate the anger. He should only limit the display of anger when the patient threatens to damage persons or property, or when the expression of her anger is so humiliating that the therapist feels his limits are violated.
The purpose of therapy is to teach the patient that she can be angry, but that there are other ways to express this emotion than the impulsive and extreme manner she currently adheres to.
A second characteristic of this mode is the impulsive way BPD patients try to get their needs met. The patient may, for instance, have sexual contacts with people she doesn't really know, in an attempt to get a feeling of being of value and cared for. Other examples are impulsive buying, impulsive alcohol or drug use, and impulsive eating. Such behaviours are related to this mode when they are impulsive (the patient did not really contemplate the long - term risks), often motivated by a sort of rebelliousness against the punitive mode, and have the aim of need satisfaction. Alcohol and benzodiazepine use, especially in combination, might lead to a loss of (the already problematic) inhibition of these kinds of impulses. The general aim of the treatment is that patients learn to acknowledge their needs (instead of trying to detach from them) and develop healthier ways of getting their needs met.
Treatment Methods for the Angry/Impulsive Child
The angry child requires a safe therapeutic relationship in which clear boundaries are set by the therapist (see Chapter 4 , ‘ Setting Limits'). Within these boundaries the angry child should be able to express her anger (see Chapter 5, ‘ Anger') and also learn appropriate assertiveness (see Chapter 7, ‘ Skills Training and Role Play'). This entire topic of anger is usually faced later on in therapy, as the patient does not dare to express these emotions early in therapy out of fear of the punitive parent or rejection by the therapist. At times, the patient is so frightened of her own aggression that she does not show up for the session at all. In this case the therapist can call her at the time she should have had her session and discuss her fears with her. He can try to reassure her that he will not be shocked or punish her when she becomes angry, but rather help her express her anger. If the patient fears becoming uncontrollable and accidentally hurting the therapist, they can agree that if she loses control, she can temporarily leave the room only returning once her rage has diminished. A better method is to show her how to vent her anger by, for example, hitting a pillow. The therapist demonstrates this by actually physically hitting a pillow and shouting. In doing so he encourages her to do the same, always keeping a pillow close at hand should her anger fl are up. In this way the patient gets the message that anger, no matter how strong, is acceptable. However, the expression of this anger must take place in a non - damaging manner. This allows many patients enough security to express their anger more and more often.
If the patient is unable to get in touch with her feelings of anger, it is the job of the therapist to help her (see Chapter 5 , ‘ Anger').
When using imagery rescripting situations from the patient's past, in which she was very angry but was not able to do anything about this anger, the therapist makes sure that the punitive parent cannot harm the patient. He can do this by, for example, creating an unbreakable see - through wall or bars separating the angry child from the punitive parent. Another possible solution is that he ties up or holds back the punitive parent. By doing this he gives the angry child or healthy adult the opportunity to express her anger. If she is unable to do so, the therapist can also do this for her. He can physically show anger (e.g. hitting a pillow) and encourage her to do so with him.
After this type of imagery exercise it is important to discuss an emergency plan with the patient and decide on different alternatives for dealing with the punitive parent should it return and seek revenge outside of the sessions.
Sometimes, soon after participating in this type of exercise, the patient will feel the need to hurt herself or possibly attempt suicide as punishment for expressing her angry emotions. Should this threaten to happen, the patient can call her therapist or other health care workers. If, however, the therapist has doubts about her ability to actively call for help, he can ‘ check up'on her by making telephone appointments and asking how she is doing during these calls.
BPD patients often have a number of irrational thoughts surrounding feeling and/or expressing anger. These irrational thoughts are excellent material for treatment with cognitive therapy. Observing how ordinary individuals deal with anger is helpful in building an understanding of how to express anger in a normal way.
First the patient must practise expressing mild irritations and anger during sessions and later outside of the sessions (also see Chapter 7 , ‘ Skills Training and Role Play').
This can take the form of an experiment in combination with challenging dysfunctional thoughts. If she appears to have problems with anger and restlessness at home and cannot directly place where this anger comes from, it is likely to be residual anger from her past which is not yet ready to be processed. Physical activity is helpful in curbing this unrest. Some patients find hitting a pillow or boxing bag helpful while others use sports as a form of release. While one patient may prefer using sports to release this anger, another patient might frantically clean the house. The therapist can use the following session to explore aspects that elicited this rage.
Anger leads to insomnia in some patients. Occasional use of benzodiazepines can help break this cycle as the patient runs the risk of exhaustion, and when she is overly tired her ability to deal with the punitive parent mode is compromised.
However, in most cases the use of benzodiazepines is not recommended as they have the side effect of unbridling the patient and can actually increase the chances of uncontrollable fits of rage. Antihistamines may be a better alternative as sleep medication.
One should not underestimate the risk of the presence of the punitive parent, particularly once the session is completed. The therapist must never forget to talk about this possibility at the end of a session in which the angry child was present.
The angry child can evoke more negative reactions from the therapist than the other modes. Because of this, the therapist must take care to keep his own reactions under control particularly when the angry child's aggression is directed towards him. He must do his best to view the patient as a child in the middle of a tantrum, stomping her foot in anger. Should he not succeed in controlling his own anger and respond to her attack with a counter - attack, the patient will no doubt begin to feel rejected (abandoned child). Another risk is that the therapist wants to pull away from the patient because he cannot stand her anger. This is not to say that the therapist should not set limits to the patient's aggressive behaviour. While he must tolerate her feeling angry, he need not tolerate all forms of expressing this anger. In doing so he does not reject her anger, but rather discusses with her which part of it is realistic and what is unrealistic. On the other hand, if the therapist actually does become frightened of his patient, he must investigate whether he is dealing with an angry child or an angry protector. In either case, he must ensure that the necessary boundaries and limitations are clear in order for him to feel safe again.
Angry Nora can also turn towards self- injury and suicide as a way of showing anger. In this mode she does not intend to punish herself, but to take revenge on those around her who have unjustly hurt her. In rare cases the patient may also threaten to kill these individuals who have wronged her. When a patient threatens suicide and/or murder, the therapist is put under an enormous strain and must again set very clear boundaries and enlist the involvement of a colleague (see Chapter 8 , ‘ Suicide and Self- Injury').www.psychspace.com心理学空间网