by Robert J. Lanz, LCSW
Ginnie was a woman in her mid-forties whose self-destructive behavior included cutting herself. She would show up at the ER frequently after having done it. No one believed she really liked cutting herself, because she always seemed unhappy about it. I believed that for Ginnie, not cutting herself was so much worse than cutting herself that she really didn’t have a choice. She told me every time she showed up that she had to make that terrible feeling of emptiness go away so she could at least feel something. The most obvious thing to feel and the easiest to manufacture was pain. Ginnie knew what everyone knows but only a few actively pursue; there is always an object or a person close at hand that can cause hurt when you need to be hurt. You can make a relationship go bad with self-destructive behavior and end up getting deserted. That causes pain. You can take too many drugs, eat too much food or have sex with anyone willing to have sex with you then antagonize them until they are moved to violence. Or, you can slice your arms with a knife over and over until there is only scar tissue left that’s too tough to cut. Then you can go for the throat. The tissue is softer, the effect is certainly more dramatic, and for that reason, delivers the desired effect.
Ginnie had done all of those things and had made other desperate attempts at creating artificial feelings. She frequently overused mind-altering medications, consumed in such a way that the mind-altering was almost mind destroying. Her thinking and judgment would fall apart, shredding her impulse control, which brought the pain provokers into play. It was not uncommon to see Ginnie show up stoned on something, bleeding from an important body part and crying over the demise of a significant relationship. As if her problems weren’t obvious enough, she would also fling blood at people, curse at them and do everything possible to alienate herself from the professional caregivers who were paid to put up with just about anything.
The bible for defining psychiatric disorders is called the Diagnostic and Statistical Manual for Mental Disorders (The DSM). It details every diagnosis anyone could possibly present, including No Psychiatric Disorder. Like any good bible, there is nothing in its purview it doesn’t attempt to identify. In general, the major psychiatric disorders are divided into three classifications: thought disorders (disturbances in the way people think, such as schizophrenia and other psychotic presentations), mood disorders (disturbances in the way people feel, such as major depression, bipolar disorder) and finally, personality disorders (disturbance in the way people act). These personality disorders were called character disorders in some previous editions of the DSM, but that term was deemed too judgmental, and more acceptable words were substituted. That always seemed a little strange to me, because the manual was set up as the ultimate in judgmental texts. I guess that even though we make judgments about patients that will forever effect their lives, we try to be nice about it.
This is especially true with the personality disorders, because this group is generally not so depressed or confused that they can’t manage some retaliatory action against the person who made the diagnosis. And it is not uncommon for patients with these disorders to retaliate against their therapists in some way or another. It is even expected, not because they lack character, but because they display a disorder. Hence, the use of the favored neutral term, “personality disorder”, although I never heard any psychiatrists using such a benign term to refer to patients who stalked them, sued them or woke them up on a regular basis after finding their home phone numbers somehow.
Personality disorders are characterized by long standing behavioral traits that are resistant to change, and many of those diagnosed with these unfortunate traits do not feel they warrant a diagnosis. In fact, many of them feel that everyone else does. I guess if it comes down to “I’m paranoid” or “they’re after me” it would be a lot easier to accept the problem residing with “they” rather than “I”. And if all of “them” are after “me” then I must be special and everyone likes to be special. If your reality checking devices aren’t functioning well, you can come to believe that the problem is elsewhere and the whole damn world should go into in therapy until they all start to see things your way.
A particularly devastating diagnosis in this spectrum is that of Borderline Personality Disorder. This unfortunate disorder shares the symptoms, although to a lesser degree, with mood and thought disorders, adding to them significant behavioral problems. These patients suffer from depression, although not severely enough to warrant a diagnosis of major depression, but certainly enough to cause them problems. They have difficulties with reality testing and thought organization much the same way a patient with a major thought disorder would have, but only on some occasions does their level reach psychotic proportions. The severity of their symptoms does not warrant a diagnosis of schizophrenia. The personality characteristics that develop are among the worst that anyone could have. They lie, cheat, steal, manipulate, misuse drugs and alcohol, and sabotage their love relationships. They have frequent encounters with the police, can’t keep jobs, and in general, alienate even their closest friends and family members.
These folks, despite their need, run from help the way the most of us run from them after we’ve known them for a while. That’s how Ginnie was. And that’s how she came to my attention on several occasions over the years.
The first time I saw her as a patient, I was asked to do a suicide evaluation because she had come to the ER with wrists lacerated badly enough to indicate suicidal intent, bleeding profusely and needing stitches. I was pretty fresh in the ER then and she was about to initiate a lesson in my on-the-job training. When I asked about the lacerations, she denied that she was trying to kill herself, although she conceded, she had, on occasion, cut herself with just that intention.
“What could you have had in mind, if not death, when you cut yourself so deeply in the spot where most people cut to kill themselves?” I asked innocently.
“Tension reduction,” was the quick and easy answer.
“Tension reduction?” I repeated to be sure I was hearing this correctly “Yeah. I don’t want to be dead. I want to feel alive.”
I was having a little problem following her line of thought so I asked for a further explanation.
“You’re kinda new at this aren’t you?” she asked.
Hey, who’s being interviewed, I thought. But I’m not one to be evasive even at times when I probably should be, so I answered the best way I could, honestly.
“I guess so. What do you think would be the most helpful thing for me to know?” I asked, a question I posed to most patients at one point or another. I had known this patient for about five minutes and she was already leading the discussion.
“I’m a Borderline, Bob. I hurt myself. Sometimes I hurt myself when I’m sad. Sometimes I hurt myself when I’m nothing.”
“Nothing? How can you be nothing?”
“Nothing is worse than depression,” she said patiently. “It’s the worst heartache of all because there is nothing. There’s no pain. There’s no love. There’s no anger. Nothing. Maybe a little fear that the nothing won’t go away. Sometimes I try and create a something by taking drugs. If that doesn’t work, I’ll start a fight. Adrenaline is something. That gets me in trouble, though so I try not to do it. Sometimes when the nothing gets too bad, I cut myself. Then I feel something.”
“Pain,” I observed.
“The pain of cutting is less than the pain of nothing,” she told me. “Nothingness is terror. Nothingness says I am no one. I don’t exist. I get so scared that I don’t exist; I cut myself and come to the ER and talk to someone like you. I’m here talking to you and you’re listing to me. Obviously, I exist.”
“And where do I fit into all this?”
“You seem like a nice guy. You seem to care about how I feel. You listen without interrupting me and don’t act like I’m crazy. You’re my reality check and I think I can trust you. I’m not crazy, but sometimes I can’t tell. If I act crazy, then everyone says I am, but I’m not.”
“You’re confusing me.”
“Of course I am. Try thinking about what it must be like over here where I’m sitting.”
Ginnie went home that night, although the doctor thought I was a little crazy to accept her story at face value. I became apprehensive and spent the next few days reading the local paper, fearing I would find news of a dead woman named Ginnie who, after being misdiagnosed and released from a local ER, had gone home and cut her wrists and died. I never found the story so I suspected that she was all right.
My suspicions were confirmed a few months later when she returned with more deep cuts to both arms. I didn’t feel I needed any more education, so I just asked how she was doing and if she needed to come into the hospital for a few days. She answered that she didn’t. She was sutured again and on her way. The only thing different about her this time was that she seemed to have lost a few pounds and now she had more stitches on her already well-tracked arms. Again, the doctor was a little suspicious about my brief assessment. I didn’t tell him, but after my first lesson, it seemed pretty obvious to me that Ginnie was able to make her own assessments and that she was being honest with me, as I had been with her.
A year later Ginnie was back in the ER, pale and emaciated. She had cut her wrists again and told me she had been using lots of cocaine for the last eight months. She looked terrible and her clothes were crusted with dried blood, the cuts already trying to heal themselves despite their severity. She had been depressed and angry when she cut her wrists this time. She wasn’t just feeling nothing and needing to feel something. She was feeling terrible and needed that to stop, so she tried to kill herself, came to the hospital and asked for help.
“This time I was trying to kill myself Bob. I’m out of control. If you don’t lock me up, I’ll be back. Dead.”
I locked her up. She thanked me and made me promise to visit.
Ginnie was stabilized after a few days and went home. She would start a cycle again in which she had varying degrees of control, took her medications as prescribed and attended her therapy sessions. Whatever her psychological or biochemical problems were, they were under control for a while, then began to overwhelm her again and she came back to the ER. It had been about six months since her hospitalization and in a way, it was good to see her, to know that she was alive. She had gained about fifty pounds, about thirty more than she needed, but told me she had quit using cocaine. She told me she was having a little trouble controlling her appetite and now had substituted food for drugs. She still had the problems with depression and nothingness and was getting so desperate to feel something she cut her throat. She told me, once again, she didn’t want to die, she wanted to live and she wanted to live without drugs. So she cut her throat. I don’t know of any twelve step programs that included throat cutting as an alternative to relapse but Ginnie was sort of on her own program. To her, cutting her throat was preferable to going back to coke. Try explaining that to an ER doctor whose license is on the line.
Through the course of a lengthy and difficult relationship, I learned that even though I trusted Ginnie, nobody else did. They thought I was crazy and irresponsible to even think about letting her go home after cutting her throat. At one point, I explained to her that I needed to get a psychiatrist to evaluate her in order to take the heat off the ER doctor who needed to cover his ass. The professional courtesy he had been extending me and my assessments of Ginnie had reached its limit.
Ginnie didn’t like it. She begged and pleaded with me to help her. I told her that the help she needed was above my pay grade. She had gone too far this time. The psychiatrist on call came down to talk to her, and talk is all he did, not realizing he was making a big mistake by not listening to her. He was condescending toward her and condescending toward me in front of her which really pumped her up. She quickly made the transition from anger to rage and rage went right into action. She drove a number two pencil about an inch into the psychiatrist’s arm. I’d have to say he was a little too confident or not very perceptive for a guy in his business, allowing her to hold a potential weapon while he interviewed her. In his new role as an ER patient, he didn’t get much respect from the staff who had come to know Ginnie.
Ginnie was placed on an involuntary hold by the same psychiatrist she had stabbed and she went back in the psychiatric ward again. She made me promise to visit her, but the psychiatrist heard us talking and ordered me not to. Once he wrote the orders making her stay in the hospital, she was technically his patient and there wasn’t much I could do about it. Even though anything I did at that time probably would have helped their strained relationship, he was territorial and felt the need to get things back under his control. I’m not sure who I felt more sorry for, him for having her as a patient or her for having him as a psychiatrist.
Ginnie was released again a couple of weeks later and went to a halfway house. She was enrolled in a twelve-step program, a support group, and a socialization group. She received individual therapy and was prescribed antidepressant medications along with something for her anxiety. She was a model patient for about a month, and then she cut her throat again. This time she cut it so deeply, that when she arrived at the ER we had to call a trauma code because of her life-threatening situation. She was rushed to the OR for repair of her carotid arteries and nearly died. Later when she woke up she asked the nurse to call me and I went to visit her.
“I’m really scared Bob, I almost killed myself, “ she told me.
“What’s your psychiatrist say?”
“That asshole says he wants someone else to take care of me. What do you think?”
“I don’t know what to think. Nobody knows what to think. Nobody knows what to do.”
“Yeah, I know all that, but at least you care what happens to me.”
“That doesn’t seem to be enough. “It’s enough for me.”
“But you keep hurting yourself and someday you’ll go too far and kill yourself.”
“Yeah, I know,” she said. “But you’ll probably be there and that means something.”
I saw Ginnie about every six months for the next ten years. She had so many scars that even the most ardent body piercer would have judged her to be blatantly over the top. She had gained about a hundred and fifty pounds and fought her depression every day. She had been in jail three times, raped five times, overdosed eight more times and been in seventeen rehab and halfway houses. She had burned out seven psychiatrists and innumerable other mental health professionals. But she never gave up. In spite of her failings, she was truly a testament to the human spirit.
The last time I saw her, she was so obese and scarred that she was barely recognizable as the woman I first met ten years earlier. She was in the trauma room again, getting her neck sutured for the sixth time. She seemed glad to see me.
“Jesus, Ginnie what happened?”
“You know, Bob. I’m a Borderline. This is what I do.”
“Well, you’re scaring me. You can’t keep doing this. I never know what to do for you. Nobody knows what to do. Someday you’re going to kill yourself.”
“I’ll be OK, Bob. Don’t worry. I know you don’t know what to do, but you can’t give up. Never give up.”
Never give up. Never give up. Thanks Ginnie, I won’t.