Richard, 44 years old, was referred by his doctor who felt that he had a major drinking problem. Initially, Richard resisted seeing himself as a problem drinker and preferred the idea that he was depressed. Richard exhibits impulsive binge behavior, engages in frantic efforts to avoid feelings of loneliness, shows a pattern of unstable and intense interpersonal relationships, displays inappropriate anger, and manifests extreme mood swings.
Nevertheless, it appears that Richard has no significant medical problems or medical history. Richards’s mother died when he was 10 and his father sent him to a private boarding school, feeling that he could not manage to bring up his son by himself. Richard felt that he was abandoned by both of his parents ? by his mother who died and left him and by his father, just when he had most needed his love, companionship and support. He has had three marriages, each of which ended when his wife left.
Typically, each woman grew tired of his continual drinking binges and all that went with his alcoholism: getting fired from job after job, not being a father to his children, being abusive both verbally and physically to her and being extremely dependent on her. Consequently, Richard thinks that he did not have what it takes to keep a wife and eventually grew increasingly bitter towards women since they all left him when he needed them the most. In the aspect of his work, he feels a great deal of anger towards his former boss who fired him.
He complains that when he was broke his boss took his job away from him and didn’t offer him support. Thus, in his eyes, important men always let him down including male friends who broke contact because of his drinking. Diagnosis (based on the criteria of manifestations), Psychodynamic Analysis, Use of Free Associations, Theoretical Treatment and Conclusion Based on the manifestations presented on the overview of Richard’s case, we can classify him to belong in the group of Psychiatric Disorders known as Personality Disorders.
Personality Disorders are “pervasive chronic psychological disorders” characterized by an individual’s unique psychological traits and inability to form or maintain interpersonal relationships that revolve around the sphere of family, friends, and work environments ((MentalHelp. net, 2001). Richard’s salient manifestations are further classified into the Borderline type of Personality Disorder. Dombeck (2001), in his article “Borderline Personality Disorder Symptoms” enlisted the following symptoms, which are usually seen in persons with this state:
• “Frantic efforts to avoid real or imagined abandonment. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation • Identity disturbance: markedly and persistently unstable self-image or sense of self • Impulsivity in at least two areas that are potentially self-damaging (e. g. , spending, sex, substance abuse, reckless driving, binge eating) • Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior • Affective instability due to a marked reactivity of mood (e. g. , intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) A chronic feelings of emptiness • Inappropriate, intense anger or difficulty controlling anger (e. g. , frequent displays of temper, constant anger, recurrent physical fights) transient, stress-related paranoid ideation or severe dissociative symptoms” (Criteria summarized from: American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association. ).
Hence, as we can see in the aforementioned clinical manifestations, Richard can truly belong in this type of disorder. A question may be generated in our minds as to the factors that can trigger the occurrence and aggravation of this disorder in an individual. In line with this, we can device the Psychodynamic approach, which will lead us to trace and analyze the advent of this condition to a person. According to Ballas (2006), one of the root causes or risk factors of Borderline Personality Disorder (BPD) is abandonment issues in childhood. As we can observe, we can directly relate this factor to Richard’s case since he perceived her mother’s death and his father’s decision to send him to the boarding school as abandonment.
This issue has affected him in these ways: when his mother died, there was somewhat a feeling of loss as any individual could have when a loved one passes away. However, this feeling was aggravated by the decision of his father. Instead of comforting him, sending him away was the remedy because his father in turn had doubts if he can bring up his son properly. The decision of father was not helpful to the grieving Richard who absolutely by that time needed the support system to help him make it through. Further, this may have caused a significant anxiety, which can prompt the Richard’s disorder.
Hence, this disorder as anxiety-related. As defined by Gale (1998), anxiety is an unconscious strategy in which an individual would want to avoid a negative stimulus in view of the fact that it causes a somewhat threat on his or her ego integrity. This must have played a role in Richard’s condition. In this way, defense mechanisms are the way to unleash their feeling within. Defense mechanism is defined and expounded as a psychological mechanism to lessen tension and to protect the ego from potential threat. Defense mechanisms can help an individual cope with anxiety or it can also be harmful.
The defense mechanisms that we will be dealing with are still based on the definitions on the same article. As we can evaluate Richard’s symptoms, we can clearly discern the defense mechanisms that he used. Denial was one of them. It was characterized by his resistance to the fact that the doctor said that he has a major drinking problem. Denial was his attempt to eliminate the threatening information that he was confronted. Projection was also used in the aspect of his unsuccessful marriages. It was characterized by blaming his wives who left him to cover up the feeling of inadequacy as a husband to them.
In other words, he projected his mistakes to other people. He also used displacement as a defense mechanism, as revealed by his an abusive husband and father. On the other hand, he exhibited five of the criteria for the disorder: impulsive binge behavior, frantic efforts to avoid feelings of loneliness, inappropriate anger, pattern of unstable and intense interpersonal relationships and extreme mood swings. The use of free association is helpful in this case as it can help to connect the details of the Richard’s thoughts and experiences.
According to Chiriac (translation by Cristea, 2008), in her article “About the Free Associations Method”, free associations are useful in a way that “thoughts are autonomously activated by chance verbal associations, influence conscious psychic life in a frequently dramatic manner and the task of psychoanalysis is to bring such complexes to the surface of conscious mind and eventually integrate them into the patient’s life”. Thus, Richard’s thought may have been unveiled and interpreted by the doctor with the use of this method. Levin (2001) shared some important details in the treatment of BPD in her article in MentalHealth. et.
She said that the treatment of choice for BPD, as with most personality disorders, is Psychotherapy. Further, it must be noted that making contract with the individuals with suicidal attempts is essential and must be taken as an initial action. Medications may be prescribed. However, there are still controversies on this matter. She also emphasized that the therapists or the clinicians must be firm in handling this individuals because BPD patients are difficult to deal with. As she recommended, the most successful and effective comprehensive approach to date has been Marsha Linehan’s Dialectical Behavior Therapy.
This psychotherapy seeks to teach the client how to learn to better take control of their lives, their emotions, and themselves through self-knowledge, emotion regulation, and cognitive restructuring and is often conducted within a group setting. In addition, hospitalization will also be of great help since it provides a highly-structured environment necessary for the individual’s independence. As with this disorder, medications are not specifically prescribed. Nevertheless, some medications such as antidepressant and anti-anxiety agents may be necessary to alleviate associated symptoms.
Hence, Levin (2001) also emphasized the importance of self-help and support groups for patient’s suffering from this disorder. Therefore, a sufficient understanding of the case has been achieved by those aforementioned points that have been discussed. We have traced how Richard has gotten his condition through a careful analysis of the objective manifestations, which have been presented in the overview of this study. We can associate how the events in Richard’s childhood contributed to the intrapsychic conflicts and anxiety that had developed in him in the course of time.
We have utilized some defense mechanism that he used in order to protect his ego from anxiety-provoking stimuli. In this way, we knew how his past had greatly affected his interpersonal relationships, which include that of his previous wives and even on his children. Moreover, the symptoms that he manifested were useful in order for us to identify the disorder that he is into and so we knew that he has five of the necessary criteria to classify him in the Borderline type of Personality Disorders.
On the hand, the use of free association method is valuable to recognize the underlying details behind Richard’s disorder. Finally, we learned how psychotherapy is necessary to treat his psychiatric condition, how support-system plays a vital role in achieving proper treatment goal and how hospitalization is necessary to facilitate structured environment for Richard. Thus, we learned how the living environment can truly impact a person’s psychological aspect, or should we say his integrity as a holistic being, throughout his lifetime.