Family therapy and some personality disorders in adolescence

To prevent an endless debate between those supporting an intrinsic deficit versus an environmental deficit, the adolescent's problem has been seen here as both an individual problem and the metaphorical expression of a family problem. The intricacy of this two-faceted problem appears vividly with borderline and immature adolescents. Both the adolescent and family have, among other problems, difficulty separating. The approach described here focuses on that particular aspect; each therapeutic step is geared toward the adolescent's separation-individuation. Concerning the course of therapy, restructuring is perceived as the first therapeutic step and a prerequisite to work on such issues as delineating personal and family problems and improving communications. The approach is not, though, a panacea for the treatment of all personality disorders in adolescence and should not preempt the use of other approaches. As reported by Esman (1989) in regard to borderline adolescents, there is enough variation in the syndrome to allow the use of a variety of treatment approaches. Involving the family may not be feasible, and the adolescent sometimes must be removed from a detrimental family situation. The family of the immature or borderline adolescent is often seen as untreatable but what the therapist wants to accomplish and is ready to share often paves the way to effective intervention (Offer and Vanderstoep, 1974). The therapist must be ready to struggle with the family and with himself. The therapist has to be courageous, patient, and optimistic. The intervention is usually done on a middle-term basis with encouragement to the family to consult again if needed. The approach may thus appear obsolete at a time of a "quick-fix" culture. Family therapy can be a powerful tool with very disturbed, personality-disordered adolescents. The family approach must be flexible and based on a psychodynamic understanding of the problems. As so many of these cases fail to respond to the usual treatment and make therapists and institutions feel powerless, looking at the intervention from another angle can be refreshing. The experience can be rewarding for the adolescent, as she is becoming emancipated from the family, and for the parents, who facilitate the process. Working with these families is difficult but can also be rewarding for the clinician. Hours spent with them gives access to the subjective experiential reality that makes the substance of behavior and may allow the exploration of shadowy areas of the human condition. Family therapy becomes, then, a journey full of pain, uncertainties, and wonder for both the family and the clinician.