THE AMERICAN JOURNAL OF PSYCHOANALYSIS 35:269-277 (1975)
SEVERE PERSONALITY DISORDERS IN AN I N S T I T U T I O N A L SETTING William Abruzzi One of the major mental health problems of our culture is the treatment of socalled character disorders, or severe personality disorders. The typical adolescent delinquent-unable to control his own behavior and verbal reactions, unable to conform to any kind of societal expectation pattern, and either unable to gain the insights necessary to accept responsibility for his own behavior or unable to utilize those insights constructively once they have been gained=is familiar to anyone who has worked in the mental health field in the last decade or two. Most of these patients fit into one or another personality-disorder category (e.g., inadequate, passive-aggressive, schizoid, passive-dependent, etc.). I should like to report on the thousands of such young people I have observed over many years, the theoretical and programmatic impression received from these observations, and the conclusions I reached as to how such young people are best handled (for their own psychic well-being, as well as for the well-being of the institution, program, family, or therapist involved with them). I should also like to report on an attempt that has been made to put those tenets into operation in a residential setting. The goal of this paper is to encourage others to try this approach with sociopathic, delinquent, personality-disordered, or "borderline" children and young adults (I use these labels only to identify such patients to all of us who use descriptive titles in our work). My original impressions were derived from dealing with adolescents and young adults for many years. This involvement included working in a college health center, rL~nning a college health-education program, speaking on hundreds of college campuses, and acting as a public-school physician for many years. I have also been involved in setting up and directing health facilities at youth festivals whose participants totaled more than a million; in initiating, consulting in, and continuing sixty-five crisis-intervention centers; and in treating many young people in my capacity as consultant to "sit-ins," civil-rights marches and demonstrations, and the peace moratoria. My initiation and direction of drug-education programs for national, state, city, and community groups and my participation for twenty-two years in ambulatory detoxification of drug abusers provided more data.
William Abruzzi, M.D., Psychiatric Consultant, Confederation of Crisis Control Centers; Visiting Psychiatrist, Columbia University. 269
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My impressions were translated into actual operation at Blue Heaven Farms, a residential program for drug-dependent and sociopathic children and young adults, run under the combined aegis (or chaos) of NACC (New York State Addiction Control Commission) and the Addiction Services Agency of New York City (since almost all of the residents were from New York City). I have seen no reports in the literature of a therapeutic program that first was evaluated, that then instituted this type of "strong limit setting," "no punishment," behavioral modification approach, and that was then reevaluated. Of course, beginning with a thesis, and admittedly a bias, it is difficult to claim much in th e way of conclusions or scientific proof. The Character-Disordered Patient: Behavior Patterns
Frequently in the history and evaluation of these patients there is evidence that they have on many occasions carried unreal or excessive expectations for people, objects, and life situations. When these expectations are not met, there follows disappointment, rage, and self-destructive behavior which becomes the life pattern of the character-disordered or "borderline" patient. The antisocial behavior of these patients continues to provoke punishment throughout life; it seems to demand punishment from everyone. Invariably, many of these patients have schizoid tendencies. These tendencies are usually demonstrated by proiection. Because of their primitive guilt, these patients tend to project their own feelings of unworthiness onto the rest of the world. It is everyone else who is bad, who is persecuting them, who is causing them to have repeated problems and troubles and conflicts. These patients also fear their own loving. Many of them are concerned about the. results of their needing and loving. Since needing and loving have in the past almost always resulted in desertion or punishment, it must be their loving per se that is destructive. The fear to love and to trust evokes more introversion, more withdrawal, and more escape from realities and responsibilities. These are the results of concern for their destructive loving patterns. When things are good and are going welt, these patients very often demonstrate superior strengths, even if many of these strengths are neurotic-level ones. However, when they are frustrated again, when their expectations are excessive and cannot be realized, their rage is unbounded. Their object relations are poor. They see people as objects who are there primarily to help meet their needs. But they cannot utilize that insight welt, either because of their fear that the effect of their love will be desertion, punishment, or destruction, or because they have overriding superegos that constantly punish them for their seemingly excessive rage and/or desire for love. As Melanie Klein has stated, object relations become much more than simple memories. Instead they become internalized. Their tragic memories of personal relations in the past (remember that most of their object relations led eventually to desertion, punishment, or destruction) become internalized
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factors in the development of all future object relations, so that withdrawal, fear, and loneliness again intercede. Another reason for their fear of relationships and for their sense of futility and impotence, goes back to their lack of self-esteem, their lack of any concept of their own worthiness. If they are really as bad as they seem, then everything is futile and hopeless, and they themselves are powerless to effect change. Adler has pointed out that the difference between these patients and many schizoid and schizophrenic patients is that these patients are "often able to form rapid, intense, engulfing relationships from which they expect a great deal and are almost invariably disappointed." I have never been quite sure whether this is a real or apparent difference. We do see these children with personality disorders usually at a very young age. They are still trying out their personal relations. They are still attempting to overcome the experiences of the past. They are still hopeful that maybe their love wi//not cause desertion or destruction or punishment. Maybe the defense mechanisms of schizoid and schizophrenic patients are more sophisticated, more finely honed, more practiced. Maybe it it just that they have already given up on making attempts, and have made the introverted withdrawal and escape toward the womb. Traditional Therapeutic Approach: Problems and Solutions
In the past, it has been the temptation of many therapists and therapeutic facilities to punish the character-disordered patient for his antisocial behavior, for his tantrums, for his insults, and so on. In the many therapeutic programs in which i have consuited or at which I have taught, the prevailing attitude appears to be something like, "We have to teach these children about discipline and punishment because that's what the world is about, and if they learn it here they may be able to tolerate it out there." The fact of the matter is that discipline and order become ends in themselves. We need to prove over and over that the patient cannot "put something over on us," that he has to learn "respect," and that his "misbehavior will not go unpunished." Again, chances are that almost everyone who dealt with the patient previously reacted either by deserting him or by punishing him. As an infant, he was punished by life situations, by genetics, by family, and so on. In school he was punished because he was never able to conform to the regulations and expectations of the school situation. He was also punished by law enforcement and by other people in the street. Therefore, the therapist's ability to tolerate the patient's provocations and to resist the temptation to be aggressive, to be punitive, or to desert the patient is most important. As Adler said so well: "This capacity, plus the effectiveness with which limit setting is defined and carried out, are the cornerstones of successful management of the severely character-disordered patient." Destructive situations of anxiety and tension are created by the punishment cycle. This anxiety serves only to increase the deep-seated hostilities
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and frustrations which probably gave rise to the patient's antisocial behavior in the first place. In the absence of punishment and by use of desensitization, behavioral modifications, and other techniques, the patient can be helped not to repeat self-destructive behavior patterns. He can be enabled to temporize his needs in a more realistic manner; to postpone the gratification of those needs when necessary; to modify his expectations so that they are less stringent and more realistic; and to verbalize his feelings, his hostilities, and his resentment, instead of sublimating or acting on his feelings by means of escape or aggressive behavior. Once we have helped a patient to see and concede the repetitive nature of his pattern of behavior, we can help him to accept his share of responsibility for that pattern. Once the patient has acknowledged his role in producing the double bind or the dilemma, one step toward a contract can be made between the therapist and the patient, and therapy can continue. Another problem in the therapeutic relationship with the character-disordered patient is the therapist's interference with the therapeutic progression, in other words, many therapists expect therapy to be progressive, constant, and "upward bound" at all times. The fact of the matter is that therapy is rarely upward bound at all times; there are downward slips, there are times of regression, there are periods of countertransference difficulties, all of which temporarily delay the therapeutic program, but all of which may in the long run be essential to it. In these patients particularly, because of their charm, intelligence, and areas of strength, any kind of behavioral regression is seen either as' "failure" for the therapists or willful sociopathic behavior on the part of the patient, since their strengths lead the therapist to expect so much of them. Even in therapeutic roles we may not speak of these patients as "bad children," but we frequently think of them in that way. In the midst of a staff discussion, we talk about patients "who have been subjected to extremely difficult reality situations," and "who are exhibiting tremendous anxiety and tension, .... who are under great stress and who need a lot of supportive help." But when we deal with these children, we may unwittingly become punitive parents. This is particularly true with therapists who feel that they have been supportive with the child until this episode of "bad behavior." It may very well be that the staff member has aroused in the child too many feelings of hope, followed by excessive expectations, followed by disappointment. The patient does not really want to hope any more. because hope and love have been painful and destructive experiences. However, when the patient does demonstrate his anger and rage against this particular kind of staff member, this reinforces the staff member's feeling that the patient is willfully misbehaving. Each staff member must also examine his reactions to character-disordered children from the point of view of envy. The staff member may be jealous of the patient's seeming ability to act out his or her unending expectations of instant gratification.
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Furthermore, these patients are exceedingly skillful, whether on a conscious or an unconscious level, in making staff members feel impotent, in provoking them, in making them feel as if their efforts are useless, and in creating tension and friction between them. The staff members may frequently be saying, "After all l've given you, after all I've done for you, after all the help and therapy I've administered to you, how could you behave this way, or do this thing, or perform this badly?" And in problems which are simply the results of institutional stress or natural periods of regression, during which the patient appears to be excessively demanding, expectant, hopeless, or even suicidal or self-destructive, very often a staff member may feel rejected and inadequate. Frequently the response is retaliatory fury, which takes us right back into the punishment cycle. Staff disunity over permissiveness or punishment can be accentuated by the patient's splitting of proiections so that various staff members are receiving different projections from him. The staff at this point has to be exceedingly careful not to assume that each view of the patient is necessarily a complete or correct one. The staff members who receive the negative aspects of the splitting projections have their sense of inadequacy, frustration, impotence, and rage accentuated. Blue Heaven Farms Program
At a residential therapeutic community in New York State an attempt was made to put some of these concepts into operation. A total of eighty-four drug-dependent "children" with personality disorders, between the ages of nine and twenty-three, were seen and treated over a nine-month period. Sixty percent of them were black, forty percent were Puerto Rican, and three white children were intermittently in attendance. Almost all of them were from New York City, had lived exceedingly traumatic lives, and were in trouble with family, school, and/or the law before admittance to the program. Their social histories contained broken families, severe illnesses, alcoholism, drug addiction, and so on. Almost all of the children had some history of drug abuse, although they had not necessarily been apprehended on that count. When the program was instituted at Blue Heaven Farms and put into operation, the following were found to be the "problems" with the "juvenile delinquents." Almost daily, there were conflicts between patients that resulted in injury. The AWOL rate was from one to two clients a day. Despite the fact that the educational opportunities within the residential community were sorely inadequate, it had been possible to place three children in the public school program. The inadequacy of the "on the grounds" school program was based on: (1) the inadequate funding of all such programs; (2) the very riature of the character-disordered child, vis-a-vis demand for punishment, resentment and rejection of authority, restlessness, poor impulse control, demand for instant gratification, poor self-image, and so on; and (3) the complete failure of the educational system with these young people in the past.
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In addition, there were daily incidents of rock and stick throwing, resulting in broken windows, broken doors, holes in walls, and the like. No child was in a regularly scheduled treatment session. Punishment, corporal and otherwise, was used as a regulatory device. Rejection became a method of dealing with a difficult situation; the clients could be summarily dismissed from the program in the event of rule infractions and so on. A resolution of these problems was attempted by the following changes and improvements in methods and operations. The staff was upgraded so that some degree of professionalism was apparent. Each patient was assigned to at least a weekly therapeutic session. A recreational treatment or "activity-therapy" program was instituted. Rejec-/ tion was eliminated. With strong support and extensive supervision, the staff was able to deal with the young people without needing to use discharge from the program as a problem-solving device. In fact, children who had left the program prior to favorable discharge were actually sought out and urged to return. Punishment was eliminated as a modus operandi. Professional attention was given to the legal concerns of the clients who were remanded to the program by juvenile court and criminal courts. All the bench warrants and legal materials which had lain unread in clinical folders were investigated, and efforts were made to have the judicial process serve the patient's best interest. The patient's family was involved in the therapeutic process. A working relationship was established with the family, the family was involved in a closer and more informed relationship with the clinical program, and there was mediation before, during, or after home visits, so that these visits did not constitute countertherapeutic experiences. We then attempted to institute the beginnings of a positive behavioral modification program which involved strong limit setting, no punishment, and leverage coming from (1) the enhanced interpersonal and clinical relationships described above and (2) a reward system. There was an eight-month observation period of the new program. At the end of six months, during a two-month period of data collection, there were only two conflicts between clients that resulted in injuries, and both these injuries were minor. The AWOL rate dropped to less than two per month. There were no incidents of deliberate rock or stick throwing, and no walls, doors, or windows were broken in that twomonth period. All of the children were in regular therapeutic programs with a treatment plan and with a qualified therapist. Twenty children were enrolled in public school programs. A student government was in the process of formation. Almost onethird of the clients were working. An internship program with several major universities was agreed upon, and an alternative education program had been devised for clients who could not manage public school and whose educational program had to be given on the premises. It might be important to point out that these gains were achieved despite an operating budget of approximately $4,000 per client per year. This amount was all inclusive
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in that it supposedly incorporated the educational, emotional, and I~hysical needs of each client. But there were tremendous educational, medical, dental, and visual defects in many of the children, and there were no funds for correcting those problems, all of which affected their psychological development. There was no tangible support from the community or board of directors. A constant problem was the intransigence of the nonclinical staff, who were historically and traditionally wedded to the confrontationpunishment approach in dealing with "troublesome" children. In fact, we can go further and say that despite seminars and distribution of written materials, there was no understanding on the part of the nonclinical staff of the difference between a passivedependent, exaddict-type personality and the character-personality disorders that we were seeing in the delinquent, sociopathic children. Stanton and Schwartz's classic work defined the deleterious effects of covert staff disagreement on patient care. We know that the primitive defense mechanism of borderline patients tends to bring about and accentuate overt and covert disagreements within the staff, which can lead to the staff's doing to the patient what the patient may fear most. A therapeutic approach contains a very definite capacity to set limits emphatically without punishing the patient, while at the same time clarifying with the patient and the staff the complexities of patient-staff interaction. Kernberg and many others have referred to the behavior of severe personalitydisordered patients as stemming largely from primitive defensive operations (such as splitting and primitive forms of regression, in particular, projective identification, devaluation, etc.) and have discussed the effects of those mechanisms and conflicts on the patient's therapeutic experience. "These patients distort the interpersonal situation in terms of their intrapsychic conflicts, activate latent conflicts among staff, and contribute to inducing the temporary regression in the group processes-an important modality in short-term treatment units." We have tried to point out that the therapist and the therapeutic setting constantly walk a tightrope with such clients. If there is no effective limit setting, unchallenged regression occurs to the extent that the acting-out conflicts within the therapeutic setting perpetuate the patient's gratification of his own pathological primitive needs. On the other hand, excessive limit setting obscures the patient's psychopathology. Continually stressed is the periodic, systematic analysis of the patient's behavior by the treatment team. With the patient present, an interpretation of his behavior is made in an attempt to help the patient realize his responsibility for tl~at behavior and to help him understand that the behavior is self-injurious. Some assistance is given by the staff in setting up behavior-modification patterns for the patient. The successful limiting of the patient's antisocial behavior allows the patient and the staff the opportunity to do the work it agreed upon, that is, "to explore in a safe setting some of the issues that brought the patient to the treatment facility," and to clarify some of the patterns that the patient could not recognize before. The patient
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must learn that he cannot destroy the object (in this case, the staff member, the staff as a whole, or the therapeutic program) or be destroyed by it, no matter how much he may wish this or fear it. The therapeutic unit that can struggle with its own retaliatory fury with such patients and that can learn the value of nonpunitive limit setting is in a position to offer this kind of experience. The fact that these patients are expert in provoking the very abandonment and destruction that they fear is a burden on the staff that is attempting to offer good treatment. "The staff's response to the challenge of these patients determines whether they can offer the patient a new kind of experience or only a reconfirmation of the projections they are so expert in eliciting from the people who have been involved with them." Conclusions
Aside from some of the problems encountered in the Blue Heaven Farms Program, my experience and observations lead me to conclude that the success of any therapeutic program for sociopathic or delinquent children and young adults with personality disorders depends upon first having an awareness of problems and conflicts and issues and how all of these affect the patient's sense of well-being and ability to function. Then there must develop an enhancement of the ability to verbalize that awareness and to verbalize those frustrations, conflicts, and angers. Finally, there must be encouragement of the development of insight into how the anger and the frustration and the pattern of living developed, how they have affected the patient's emotional stability, and the pressures that have come down on him as a result. All this must be followed by positive behavioral modification. A well-structured therapeutic program, clarification of immediate reality, and a combination of an interpretive and psychotherapeutic, yet limit-setting, milieu approach is considered to be an effective rehabilitative experience for such patients.
REFERENCES Adler, G. "Valuing and Devaluing in the Psychotherapeutic Process." Arch. Gen. Psychiatry 22 (1970):454-463. Adler, O. "Helplessness in the Helpers." British Journal Medical Psychology (in press). Friedman, H. J. "Some Problems of Inpatient Management with Borderline Patients." American Journal Psychiatry 126 (1969):299-307. Kernberg, O. "The Treatment of Patients with Borderline Personality Organization." Int. Journal Psychoanalysis 49 (I 968):600-619. Bion, W. R. "The Differentiation of the Psychotic from the Nonpsychotic Part of the Personality." Int. Journal Psychoanalysis 38 (I 957):266-275. Kernberg, O. "Psychoanalytic Object-Relations Theory, Group Processes and Administration (Toward an Integrative Theory of Hospital Treatment)." The Annual of Psychoanalysis (in press).
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Pinderhughes, C. A. "Understanding Black Power: Processes and Proposals." American Journal Psychiatry 125 (I 969):I 552-I 557. Stanton, A., and Schwartz, M. The Mental Hospital. New York: Basic Books, 1954. Winnicott, D. W. "The Use of an Object." Int. ,aournal Psychoanalysis 50 (1969):711-716.
SEVERE PERSONALITY DISORDERS IN AN I N S T I T U T I O N A L SETTING William Abruzzi One of the major mental health problems of our culture is the treatment of socalled character disorders, or severe personality disorders. The typical adolescent delinquent-unable to control his own behavior and verbal reactions, unable to conform to any kind of societal expectation pattern, and either unable to gain the insights necessary to accept responsibility for his own behavior or unable to utilize those insights constructively once they have been gained=is familiar to anyone who has worked in the mental health field in the last decade or two. Most of these patients fit into one or another personality-disorder category (e.g., inadequate, passive-aggressive, schizoid, passive-dependent, etc.). I should like to report on the thousands of such young people I have observed over many years, the theoretical and programmatic impression received from these observations, and the conclusions I reached as to how such young people are best handled (for their own psychic well-being, as well as for the well-being of the institution, program, family, or therapist involved with them). I should also like to report on an attempt that has been made to put those tenets into operation in a residential setting. The goal of this paper is to encourage others to try this approach with sociopathic, delinquent, personality-disordered, or "borderline" children and young adults (I use these labels only to identify such patients to all of us who use descriptive titles in our work). My original impressions were derived from dealing with adolescents and young adults for many years. This involvement included working in a college health center, rL~nning a college health-education program, speaking on hundreds of college campuses, and acting as a public-school physician for many years. I have also been involved in setting up and directing health facilities at youth festivals whose participants totaled more than a million; in initiating, consulting in, and continuing sixty-five crisis-intervention centers; and in treating many young people in my capacity as consultant to "sit-ins," civil-rights marches and demonstrations, and the peace moratoria. My initiation and direction of drug-education programs for national, state, city, and community groups and my participation for twenty-two years in ambulatory detoxification of drug abusers provided more data.
William Abruzzi, M.D., Psychiatric Consultant, Confederation of Crisis Control Centers; Visiting Psychiatrist, Columbia University. 269
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My impressions were translated into actual operation at Blue Heaven Farms, a residential program for drug-dependent and sociopathic children and young adults, run under the combined aegis (or chaos) of NACC (New York State Addiction Control Commission) and the Addiction Services Agency of New York City (since almost all of the residents were from New York City). I have seen no reports in the literature of a therapeutic program that first was evaluated, that then instituted this type of "strong limit setting," "no punishment," behavioral modification approach, and that was then reevaluated. Of course, beginning with a thesis, and admittedly a bias, it is difficult to claim much in th e way of conclusions or scientific proof. The Character-Disordered Patient: Behavior Patterns
Frequently in the history and evaluation of these patients there is evidence that they have on many occasions carried unreal or excessive expectations for people, objects, and life situations. When these expectations are not met, there follows disappointment, rage, and self-destructive behavior which becomes the life pattern of the character-disordered or "borderline" patient. The antisocial behavior of these patients continues to provoke punishment throughout life; it seems to demand punishment from everyone. Invariably, many of these patients have schizoid tendencies. These tendencies are usually demonstrated by proiection. Because of their primitive guilt, these patients tend to project their own feelings of unworthiness onto the rest of the world. It is everyone else who is bad, who is persecuting them, who is causing them to have repeated problems and troubles and conflicts. These patients also fear their own loving. Many of them are concerned about the. results of their needing and loving. Since needing and loving have in the past almost always resulted in desertion or punishment, it must be their loving per se that is destructive. The fear to love and to trust evokes more introversion, more withdrawal, and more escape from realities and responsibilities. These are the results of concern for their destructive loving patterns. When things are good and are going welt, these patients very often demonstrate superior strengths, even if many of these strengths are neurotic-level ones. However, when they are frustrated again, when their expectations are excessive and cannot be realized, their rage is unbounded. Their object relations are poor. They see people as objects who are there primarily to help meet their needs. But they cannot utilize that insight welt, either because of their fear that the effect of their love will be desertion, punishment, or destruction, or because they have overriding superegos that constantly punish them for their seemingly excessive rage and/or desire for love. As Melanie Klein has stated, object relations become much more than simple memories. Instead they become internalized. Their tragic memories of personal relations in the past (remember that most of their object relations led eventually to desertion, punishment, or destruction) become internalized
SEVERE P E R S O N A L I T Y D I S O R D E R S IN AN I N S T I T U T I O N A L SETTING
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factors in the development of all future object relations, so that withdrawal, fear, and loneliness again intercede. Another reason for their fear of relationships and for their sense of futility and impotence, goes back to their lack of self-esteem, their lack of any concept of their own worthiness. If they are really as bad as they seem, then everything is futile and hopeless, and they themselves are powerless to effect change. Adler has pointed out that the difference between these patients and many schizoid and schizophrenic patients is that these patients are "often able to form rapid, intense, engulfing relationships from which they expect a great deal and are almost invariably disappointed." I have never been quite sure whether this is a real or apparent difference. We do see these children with personality disorders usually at a very young age. They are still trying out their personal relations. They are still attempting to overcome the experiences of the past. They are still hopeful that maybe their love wi//not cause desertion or destruction or punishment. Maybe the defense mechanisms of schizoid and schizophrenic patients are more sophisticated, more finely honed, more practiced. Maybe it it just that they have already given up on making attempts, and have made the introverted withdrawal and escape toward the womb. Traditional Therapeutic Approach: Problems and Solutions
In the past, it has been the temptation of many therapists and therapeutic facilities to punish the character-disordered patient for his antisocial behavior, for his tantrums, for his insults, and so on. In the many therapeutic programs in which i have consuited or at which I have taught, the prevailing attitude appears to be something like, "We have to teach these children about discipline and punishment because that's what the world is about, and if they learn it here they may be able to tolerate it out there." The fact of the matter is that discipline and order become ends in themselves. We need to prove over and over that the patient cannot "put something over on us," that he has to learn "respect," and that his "misbehavior will not go unpunished." Again, chances are that almost everyone who dealt with the patient previously reacted either by deserting him or by punishing him. As an infant, he was punished by life situations, by genetics, by family, and so on. In school he was punished because he was never able to conform to the regulations and expectations of the school situation. He was also punished by law enforcement and by other people in the street. Therefore, the therapist's ability to tolerate the patient's provocations and to resist the temptation to be aggressive, to be punitive, or to desert the patient is most important. As Adler said so well: "This capacity, plus the effectiveness with which limit setting is defined and carried out, are the cornerstones of successful management of the severely character-disordered patient." Destructive situations of anxiety and tension are created by the punishment cycle. This anxiety serves only to increase the deep-seated hostilities
272
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and frustrations which probably gave rise to the patient's antisocial behavior in the first place. In the absence of punishment and by use of desensitization, behavioral modifications, and other techniques, the patient can be helped not to repeat self-destructive behavior patterns. He can be enabled to temporize his needs in a more realistic manner; to postpone the gratification of those needs when necessary; to modify his expectations so that they are less stringent and more realistic; and to verbalize his feelings, his hostilities, and his resentment, instead of sublimating or acting on his feelings by means of escape or aggressive behavior. Once we have helped a patient to see and concede the repetitive nature of his pattern of behavior, we can help him to accept his share of responsibility for that pattern. Once the patient has acknowledged his role in producing the double bind or the dilemma, one step toward a contract can be made between the therapist and the patient, and therapy can continue. Another problem in the therapeutic relationship with the character-disordered patient is the therapist's interference with the therapeutic progression, in other words, many therapists expect therapy to be progressive, constant, and "upward bound" at all times. The fact of the matter is that therapy is rarely upward bound at all times; there are downward slips, there are times of regression, there are periods of countertransference difficulties, all of which temporarily delay the therapeutic program, but all of which may in the long run be essential to it. In these patients particularly, because of their charm, intelligence, and areas of strength, any kind of behavioral regression is seen either as' "failure" for the therapists or willful sociopathic behavior on the part of the patient, since their strengths lead the therapist to expect so much of them. Even in therapeutic roles we may not speak of these patients as "bad children," but we frequently think of them in that way. In the midst of a staff discussion, we talk about patients "who have been subjected to extremely difficult reality situations," and "who are exhibiting tremendous anxiety and tension, .... who are under great stress and who need a lot of supportive help." But when we deal with these children, we may unwittingly become punitive parents. This is particularly true with therapists who feel that they have been supportive with the child until this episode of "bad behavior." It may very well be that the staff member has aroused in the child too many feelings of hope, followed by excessive expectations, followed by disappointment. The patient does not really want to hope any more. because hope and love have been painful and destructive experiences. However, when the patient does demonstrate his anger and rage against this particular kind of staff member, this reinforces the staff member's feeling that the patient is willfully misbehaving. Each staff member must also examine his reactions to character-disordered children from the point of view of envy. The staff member may be jealous of the patient's seeming ability to act out his or her unending expectations of instant gratification.
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Furthermore, these patients are exceedingly skillful, whether on a conscious or an unconscious level, in making staff members feel impotent, in provoking them, in making them feel as if their efforts are useless, and in creating tension and friction between them. The staff members may frequently be saying, "After all l've given you, after all I've done for you, after all the help and therapy I've administered to you, how could you behave this way, or do this thing, or perform this badly?" And in problems which are simply the results of institutional stress or natural periods of regression, during which the patient appears to be excessively demanding, expectant, hopeless, or even suicidal or self-destructive, very often a staff member may feel rejected and inadequate. Frequently the response is retaliatory fury, which takes us right back into the punishment cycle. Staff disunity over permissiveness or punishment can be accentuated by the patient's splitting of proiections so that various staff members are receiving different projections from him. The staff at this point has to be exceedingly careful not to assume that each view of the patient is necessarily a complete or correct one. The staff members who receive the negative aspects of the splitting projections have their sense of inadequacy, frustration, impotence, and rage accentuated. Blue Heaven Farms Program
At a residential therapeutic community in New York State an attempt was made to put some of these concepts into operation. A total of eighty-four drug-dependent "children" with personality disorders, between the ages of nine and twenty-three, were seen and treated over a nine-month period. Sixty percent of them were black, forty percent were Puerto Rican, and three white children were intermittently in attendance. Almost all of them were from New York City, had lived exceedingly traumatic lives, and were in trouble with family, school, and/or the law before admittance to the program. Their social histories contained broken families, severe illnesses, alcoholism, drug addiction, and so on. Almost all of the children had some history of drug abuse, although they had not necessarily been apprehended on that count. When the program was instituted at Blue Heaven Farms and put into operation, the following were found to be the "problems" with the "juvenile delinquents." Almost daily, there were conflicts between patients that resulted in injury. The AWOL rate was from one to two clients a day. Despite the fact that the educational opportunities within the residential community were sorely inadequate, it had been possible to place three children in the public school program. The inadequacy of the "on the grounds" school program was based on: (1) the inadequate funding of all such programs; (2) the very riature of the character-disordered child, vis-a-vis demand for punishment, resentment and rejection of authority, restlessness, poor impulse control, demand for instant gratification, poor self-image, and so on; and (3) the complete failure of the educational system with these young people in the past.
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In addition, there were daily incidents of rock and stick throwing, resulting in broken windows, broken doors, holes in walls, and the like. No child was in a regularly scheduled treatment session. Punishment, corporal and otherwise, was used as a regulatory device. Rejection became a method of dealing with a difficult situation; the clients could be summarily dismissed from the program in the event of rule infractions and so on. A resolution of these problems was attempted by the following changes and improvements in methods and operations. The staff was upgraded so that some degree of professionalism was apparent. Each patient was assigned to at least a weekly therapeutic session. A recreational treatment or "activity-therapy" program was instituted. Rejec-/ tion was eliminated. With strong support and extensive supervision, the staff was able to deal with the young people without needing to use discharge from the program as a problem-solving device. In fact, children who had left the program prior to favorable discharge were actually sought out and urged to return. Punishment was eliminated as a modus operandi. Professional attention was given to the legal concerns of the clients who were remanded to the program by juvenile court and criminal courts. All the bench warrants and legal materials which had lain unread in clinical folders were investigated, and efforts were made to have the judicial process serve the patient's best interest. The patient's family was involved in the therapeutic process. A working relationship was established with the family, the family was involved in a closer and more informed relationship with the clinical program, and there was mediation before, during, or after home visits, so that these visits did not constitute countertherapeutic experiences. We then attempted to institute the beginnings of a positive behavioral modification program which involved strong limit setting, no punishment, and leverage coming from (1) the enhanced interpersonal and clinical relationships described above and (2) a reward system. There was an eight-month observation period of the new program. At the end of six months, during a two-month period of data collection, there were only two conflicts between clients that resulted in injuries, and both these injuries were minor. The AWOL rate dropped to less than two per month. There were no incidents of deliberate rock or stick throwing, and no walls, doors, or windows were broken in that twomonth period. All of the children were in regular therapeutic programs with a treatment plan and with a qualified therapist. Twenty children were enrolled in public school programs. A student government was in the process of formation. Almost onethird of the clients were working. An internship program with several major universities was agreed upon, and an alternative education program had been devised for clients who could not manage public school and whose educational program had to be given on the premises. It might be important to point out that these gains were achieved despite an operating budget of approximately $4,000 per client per year. This amount was all inclusive
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in that it supposedly incorporated the educational, emotional, and I~hysical needs of each client. But there were tremendous educational, medical, dental, and visual defects in many of the children, and there were no funds for correcting those problems, all of which affected their psychological development. There was no tangible support from the community or board of directors. A constant problem was the intransigence of the nonclinical staff, who were historically and traditionally wedded to the confrontationpunishment approach in dealing with "troublesome" children. In fact, we can go further and say that despite seminars and distribution of written materials, there was no understanding on the part of the nonclinical staff of the difference between a passivedependent, exaddict-type personality and the character-personality disorders that we were seeing in the delinquent, sociopathic children. Stanton and Schwartz's classic work defined the deleterious effects of covert staff disagreement on patient care. We know that the primitive defense mechanism of borderline patients tends to bring about and accentuate overt and covert disagreements within the staff, which can lead to the staff's doing to the patient what the patient may fear most. A therapeutic approach contains a very definite capacity to set limits emphatically without punishing the patient, while at the same time clarifying with the patient and the staff the complexities of patient-staff interaction. Kernberg and many others have referred to the behavior of severe personalitydisordered patients as stemming largely from primitive defensive operations (such as splitting and primitive forms of regression, in particular, projective identification, devaluation, etc.) and have discussed the effects of those mechanisms and conflicts on the patient's therapeutic experience. "These patients distort the interpersonal situation in terms of their intrapsychic conflicts, activate latent conflicts among staff, and contribute to inducing the temporary regression in the group processes-an important modality in short-term treatment units." We have tried to point out that the therapist and the therapeutic setting constantly walk a tightrope with such clients. If there is no effective limit setting, unchallenged regression occurs to the extent that the acting-out conflicts within the therapeutic setting perpetuate the patient's gratification of his own pathological primitive needs. On the other hand, excessive limit setting obscures the patient's psychopathology. Continually stressed is the periodic, systematic analysis of the patient's behavior by the treatment team. With the patient present, an interpretation of his behavior is made in an attempt to help the patient realize his responsibility for tl~at behavior and to help him understand that the behavior is self-injurious. Some assistance is given by the staff in setting up behavior-modification patterns for the patient. The successful limiting of the patient's antisocial behavior allows the patient and the staff the opportunity to do the work it agreed upon, that is, "to explore in a safe setting some of the issues that brought the patient to the treatment facility," and to clarify some of the patterns that the patient could not recognize before. The patient
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must learn that he cannot destroy the object (in this case, the staff member, the staff as a whole, or the therapeutic program) or be destroyed by it, no matter how much he may wish this or fear it. The therapeutic unit that can struggle with its own retaliatory fury with such patients and that can learn the value of nonpunitive limit setting is in a position to offer this kind of experience. The fact that these patients are expert in provoking the very abandonment and destruction that they fear is a burden on the staff that is attempting to offer good treatment. "The staff's response to the challenge of these patients determines whether they can offer the patient a new kind of experience or only a reconfirmation of the projections they are so expert in eliciting from the people who have been involved with them." Conclusions
Aside from some of the problems encountered in the Blue Heaven Farms Program, my experience and observations lead me to conclude that the success of any therapeutic program for sociopathic or delinquent children and young adults with personality disorders depends upon first having an awareness of problems and conflicts and issues and how all of these affect the patient's sense of well-being and ability to function. Then there must develop an enhancement of the ability to verbalize that awareness and to verbalize those frustrations, conflicts, and angers. Finally, there must be encouragement of the development of insight into how the anger and the frustration and the pattern of living developed, how they have affected the patient's emotional stability, and the pressures that have come down on him as a result. All this must be followed by positive behavioral modification. A well-structured therapeutic program, clarification of immediate reality, and a combination of an interpretive and psychotherapeutic, yet limit-setting, milieu approach is considered to be an effective rehabilitative experience for such patients.
REFERENCES Adler, G. "Valuing and Devaluing in the Psychotherapeutic Process." Arch. Gen. Psychiatry 22 (1970):454-463. Adler, O. "Helplessness in the Helpers." British Journal Medical Psychology (in press). Friedman, H. J. "Some Problems of Inpatient Management with Borderline Patients." American Journal Psychiatry 126 (1969):299-307. Kernberg, O. "The Treatment of Patients with Borderline Personality Organization." Int. Journal Psychoanalysis 49 (I 968):600-619. Bion, W. R. "The Differentiation of the Psychotic from the Nonpsychotic Part of the Personality." Int. Journal Psychoanalysis 38 (I 957):266-275. Kernberg, O. "Psychoanalytic Object-Relations Theory, Group Processes and Administration (Toward an Integrative Theory of Hospital Treatment)." The Annual of Psychoanalysis (in press).
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Pinderhughes, C. A. "Understanding Black Power: Processes and Proposals." American Journal Psychiatry 125 (I 969):I 552-I 557. Stanton, A., and Schwartz, M. The Mental Hospital. New York: Basic Books, 1954. Winnicott, D. W. "The Use of an Object." Int. ,aournal Psychoanalysis 50 (1969):711-716.
