Occupational Therapy With Borderline Patients

Diane Gibson

• Publisher: Routledge
• Year: 2014
• ISBN:
  9781317840589
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This volume discusses and reviews the current knowledge in the concept and management of activity groups designed for borderline patients, who are defines as those with "self-destructive and maladaptive interpersonal relations."

Inpatient Management of the Borderline Patient

Carol A. Kaplan MS, RNCS

Carol A. Kaplan is Assistant Director in the Nursing Department at The Sheppard and Enoch Pratt Hospital in Towson, Maryland.

ABSTRACT. Patients with a borderline personality organization evoke unique problems and treatment dilemmas among members of an inpatient treatment team. The first section of this article addresses the many problems and complexities involved in the management of borderline patients in an intensive inpatient psychiatric setting. The second section describes guidelines, approaches, and therapeutic interventions aimed at reducing destructive influences and maximizing treatment outcome.

PROBLEMS IN MANAGING THE BORDERLINE PATIENT

Patients with a borderline personality organization have unique character problems that make treatment extremely difficult. A tumultuous course of hospitalization is characterized frequently by repeated self-destructive and other acting-out behavior, a complex splitting process between the patient and the hospital social structure, and growing tension and conflict among staff. Some cases develop into an escalating, contagiously destructive spiral which eventually results in the discharge or transfer of the borderline patient in intense turmoil; leaving behind a severely fragmented treatment team struggling to resolve its differences.

What is it about the borderline patient that makes inpatient management so complex, problematic, and entangled with provocative treatment dilemmas? Patients with a borderline personality organization are often negativistic, demanding, self-destructive, and prone to a multitude of acting-out behaviors within a therapeutic milieu. Furthermore, these patients manifest: little capacity for anxiety, poor frustration tolerance, an inability to tolerate delay, and poor impulse control. They frequently have an insatiable need for special attention, and they enter the psychiatric unit communicating a sense of entitlement which evokes angry reactions from patients and staff. They present an exquisite sensitivity to rejection and criticism, as well as a suspicion and mistrust which often barely falls short of a bona fide paranoia. Borderline patients also frequently express the need to control and to be controlled and the need to exploit and to be exploited.^1,2

The aforementioned behaviors present a challenging clinical picture, but such a cluster does not provide a complete explanation of what is so uniquely complex about treating the borderline patient. The significant dynamic features which distinguish the problems in management of the borderline patient involve the defense mechanisms of splitting and projective identification. Treatment teams comprised of highly skilled, clinically sophisticated staff members can be torn asunder by this defensive structure; hence providing a reenactment of the inconsistent, frustrating, and, at times, rejecting environment of the patient’s earlier years.³

Projective identification is a process in which the patient projects various parts of himself onto various staff members. These staff members are often appealed to at a level outside of their awareness, and they may therefore act, or feel like acting, like the projected parts. For example, a patient projects onto a staff member cruel, punishing parts of himself. The projection reverberates with something in the staff member which had been submerged, and the staff member will tend to react to the patient in a cruel, sadistic, and punishing manner. Likewise, staff who have received idealized projected parts of the patient will tend to respond in an overly involved, protective, indulgent manner.⁴ An example of projective identification can be demonstrated by an interaction the author recently had with a nurse. Ms. T was describing her relationship with a borderline patient who had been on the unit for approximately three weeks. She explained that the patient had become negativistic and increasingly demanding, stating that her demands had no bounds. She then said that for the past week, the patient had been constantly referring to Ms. T as “Nurse Ratchett,” and if that was not difficult enough, the patient was also regaling new patients on the unit about what a tyrant Ms. T was. Further inquiring made it clear that soon after the patient had cast Ms. T into “Nurse Ratchett’s” role, Ms. T started to react to the patient in a far more rigid manner than is typical for her, and indeed, the bulk of her interactions with the patient were now focused on policy adherence and strict limit setting. Although outside of her awareness, Ms. T was on her way to repeating a script straight out of the movie, “One Flew Over the Cuckoo’s Nest.”

Describing the process of splitting in an inpatient setting, both positive and negative aspects of the patient’s feelings are projected onto different staff members, some of whom are seen as good and helpful, and others as bad and destructive. Frequently, the borderline patient judges staff members as being all good or all bad following a very brief acquaintance.⁵ The fluidity of role casting is also noteworthy, and it is not unusual for the long sought after “knight in shining armor” to be cast into the role of a cruel, horrible person an hour later. The mechanisms of splitting and projective identification help explain why different staff members see the same patient in very different ways.

Soon after the patient is admitted to the hospital, staff splitting is likely to begin if staff members become the recipients of the patient’s externalized conflict.⁶ The projection of the positive and negative feelings onto the environment divides the staff into two groups when this externalization takes place. An example of this process:

Oh, Mr. R is an inappropriate admission. Really, I don’t know what he’s doing in a place like this. I hear that he never established any kind of a therapeutic alliance during his last, rather lengthy, hospitalization, and in fact, he was finally asked to leave because of heavy drug dealing. It doesn’t seem to me as if anything has changed. He’s already hostile, manipulative, and demanding, and he doesn’t seem the least bit motivated to get into treatment.

A different staff member’s response when asked about the same patient:

Well, I had a long talk with Mr. R today, and he seems quite depressed. Judging from his previous records, it sounds as if he’s in a much different place this time. He was telling me about all of his family problems, and it sounds as though his parents have flat out rejected him.

Herein lies the beginning of a destructive splitting process which, in the case of Mr. R, would soon become an extremely difficult treatment situation. T.F. Main refers to this good and bad split as the formation of the “In group and the Out group.”⁷ Staff members in the In group engage upon a relationship with the patient which becomes closer than usual, and they have frequent discussions with the therapist outside of the usual team meetings and case conferences which concern the patient. These staff members are regarded by the patient and themselves as having a special understanding of the patient’s difficulties. Characteristic perpetuating features of this group are: the sentimental appeal from the patient (“I need you, you are my lifeline, you make me feel complete”),⁸ and in turn, the compelling arousal of omnipotence in the staff member. Special privileges and excessive time and attention are required of this individual by the patient and by the In group around him. These staff members become much more permissive and tolerant of the patient’s special demands than is typical for them, and their approach to the patient starts to become less dictated by their clinical judgments grounded in theory and more by the patient’s behavior. While these In-group interactional processes are gaining momentum and intensity, staff in the Out group are either openly disagreeing with the In group—or they’re talking among themselves with increasing criticism and blame of the In group’s handling of the situation. The Out group accuses the In group of being collusive, unrealistic, overindulgent, and ineffectual at limit-setting, whereas the In group speaks of the Out group as being rigid, punitive, suppressive, and insensitive to the patient’s psychic pain.⁹ It is not unusual for every treatment team member as well as some people outside of the treatment team to become aligned with a warring camp, each convinced that the other is totally mistaken concerning how the patient should be treated.¹⁰ In the meantime, the patient is likely to become increasingly disturbed, and this is frequently evidenced by acting-out and self-destructive behavior. The other patients on the unit are also not impervious to the destructive influences of this growing dissension. The effects of this process among the patient group can be manifested in several ways: increased acting out, withdrawal, fragmentation of the patient group which often parallels staff In-and- Out groups, and group scapegoating of the special patient. Additionally, there may be expressed veneration towards the patient with encouragement of and participation in his destructive behavior on the unit. Left unchecked, this devastating process eventually becomes unbearable for everyone involved. It is at this juncture that most often, the borderline patient is transferred to another facility, and this action is usually enough to rapidly restore some semblance of equilibrium to the milieu. Everyone has paid a price however, and unless much time and effort goes into attempting to understand the various components of this escalating spiral, it is reasonable to predict that the stage has been set for a repeat performance with a slightly modified cast.

There is much controversy in the literature surrounding the question of who triggers off whom in the splitting process. That is, does the borderline patient, given his proclivity to splitting, fall victim to preexisting staff conflict, or can the patient indeed be the lone provocateur of such upheaval in a system that does not already have its roots embedded in unresolved intra- and interstaff conflicts? Is the patient the catalyst or the powerful initiator? This question can easily lead to the pitfall of finger pointing and blame seeking which serves no useful purpose. Nonetheless, it deserves some consideration. It is the author’s opinion that it can go both ways. That is, a severely borderline patient can pave the way to serious splitting in a treatment team that is quite cohesive, and a team that functions maturely in the area of conflict resolution. This view is not supported by Stanton and Schwartz, who place primary emphasis on the hospital’s contribution to the problem.¹¹ The author also believes however that at times, the patient mobilizes splits which had been submerged in and among staff members. The patient is very sensitive to already existing conflict, and he knows how to manipulate. Common underlying conflicts which already exist in the system, and usually get mobilized by the system are:

1. Covert conflict between different departments within the hospital (e.g., medical and nursing).

2. Intradepartmental conflict at various hierarchical levels (e.g., medical supervisors and residents).

3. A conflict of ideologies (e.g., a family therapy orientation versus an individual, analytical approach to treatment).

4. Feelings of resentment and competition between the formal and informal decision-making structures within the hospital.

5. Latent conflict among staff on the unit (e.g., the novice staff member who resents the alleged rigidity of the head nurse and is therefore particularly vulnerable to forming a splitting alliance with the patient.)¹²

Book, Sadavoy, and Silver describe five common counter-transference responses that the borderline patient tends to evoke in staff:¹³

1. The patient “Bad” vs. the patient “Troubled.” That is, there is frequently the temptation to assess the patient as being manipulative and uncooperative rather than troubled, frightened, and possibly desperate. The patient who, upon admission, covers over his abandonment depression with a veneer of arrogance is sometimes labeled a manipulative psychopath who does not belong in the hospital.

2. The staff person who feels he can do no wrong. This stance occurs as a result of projective identification in which the borderline patient projects his all-good objects onto a staff member, hence creating an idealization of that staff person. The staff member receives gratification from this position, and may unknowingly maintain the idealization. This is often manifested by colluding with unrealistic demands made by the patient.

3. Intrastaff fragmentation and intrapatient conflicts. Again, this refers to the phenomena of staff acting out the patient’s intrapsychic conflicts through the mechanism of projective identification and splitting.

4. Feelings of hopelessness in patients and staff. Feelings of hopelessness are often communicated by the borderline patient as he begins to experience abandonment depression. Although this is not unique to the borderline patient, intense feelings of hopelessness may resonate in staff, and they may react by withdrawing from the patient at such times.

5. Therapeutic limit setting vs. sadistic control. Limit setting may trigger conflicts relating to one’s own aggression, and in an attempt to deal with these conflicts, staff may become either uncaringly lax or controllingly punitive around the issue of limit setting. Such extreme staff postures often become complicating features of inpatient treatment of the borderline individual. A lax approach to limit setting does not provide the patient with needed external controls, and it serves as an open invitation to regression. For example, Mr. R starts flaunting minor infractions, and staff members, while exasperated with his behavior, fail to take a firm stand and set limits consistently. Perhaps they don’t want to stir him up (“after all, it’s so minor”), or maybe they’re beginning to question themselves over what undoubtedly will...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Foreword
• An Historical Review of the Borderline Concept
• Occupational Therapy Treatment: Interventions with Borderline Patients
• A Theoretical Approach to the Treatment of Work Difficulties in Borderline Personalities
• Inpatient Management of the Borderline Patient
• Early Treatment Planning for Hospitalized Severe Borderline Patients
• Update of Borderline Disorders in Children