Hospital treatment of borderline patients

Defining Borderline Patients: An Overview

This review of the descriptive literature on borderline patients indicates that accounts of such patients vary depending upon who is describing them, in what context, how the samples are selected, and what data are collected. The authors identify six features that provide a rational means for diagnosing borderline patients during an initial interview: the presence of intense affect, usually depressive or hostile; a history of impulsive behavior; a certain social adaptiveness; brief psychotic experiences; loose thinking in unstructured situations; and relationships that vacillate between transient superficiality and intense dependency. Reliable identification of these patients will permit better treatment planning and clinical research. Reprinted from Am J Psychiatry 1975; 132:1-10, with permission from American Psychiatric Association Publishing. Copyright © 1975.

Mechanisms of defense in clinical ethics consultation

Clinical ethics consultants respond to a multitude of issues, ranging from the cognitive to the emotional. As such, ethics consultants must be prepared to analyze as well as empathize. And yet, there remains a paucity of research and training on the interpersonal and emotional aspects of clinical ethics consultations-the so-called skills in "advanced ethics facilitation." This article is a contribution to the need for further understanding and practical knowledge in the emotional aspects of ethics consultation. In particular, I draw attention to defense mechanisms: what they are, why they exist, and how we might work with them in the setting of ethics consultation.

Burnout amongst clinical and counselling psychologist: The role of early maladaptive schemas and coping modes as vulnerability factors

Psychologists are subject to multiple competing emotional demands that increase the risk of burnout. Research has demonstrated that burnout arises from both organizational and personal factors, including psychologists' personal beliefs and coping. Preliminary research indicates that early maladaptive schemas (EMS) are associated with high burnout, yet, to date, the role of EMS and associated coping responses (maladaptive coping modes [MCM]) in predicting high burnout amongst psychologists has not been investigated. Four hundred forty-three psychologists completed a self-report online questionnaire comprising the Maslach Burnout Inventory-emotional exhaustion scale (EE), Young Schema Questionnaire, and Schema Mode Inventory. The two most common EMS amongst psychologists were unrelenting standards and self-sacrifice. There was substantial indication of burnout, with 18.3% in the high range and 29.6% in the moderate range of EE. The most common MCM were detached protector and detached self-soother. Controlling for demographics and job demands, EMS accounted for an additional 18% variance in EE. MCM accounted for an additional 6% beyond the variance explained by demographics, job demands, and EMS. Practical recommendations are suggested to reduce psychologist burnout.

A psychoanalytically oriented combined treatment approach for severely disturbed borderline patients: The Athens project

A psychoanalytically oriented combined treatment is considered beneficial for severely disturbed borderline patients, especially during an acute crisis. The proposed treatment comprises hospitalization and specialized psychotherapeutic inpatient treatment, individual psychoanalytic psychotherapy, and psychiatric management. It is important to take into account that during inpatient treatment, projective identifications and splitting mechanisms are activated, involving different members of the therapeutic personnel or other patients. The mental health team--the psychiatrist, the nurses, the assigned psychotherapist, and other members of the therapeutic personnel--should work together in the context of teamwork in order to explore transference and countertransference manifestations. This function promotes empathy and understanding of the patient's inner difficulties. A combined treatment approach can help the patient stabilize his or her condition and develop awareness and motivation for undertaking long-term treatment and individual psychoanalytic psychotherapy, with the prospect that therapy will be maintained after the patient's discharge.

The application of dialectical behavior therapy for patients with borderline personality disorder on inpatient units

Inpatient treatment of individuals with borderline personality disorder (BPD) is typically fraught with difficulty and failure. Patients and staff often become entangled in intense negative therapeutic spirals that obliterate the potential for focused, realistic, and effective treatment interventions. We describe an inpatient treatment approach to BPD patients which is an application of Dialectical Behavior Therapy (DBT), a cognitive-behavioral therapy for patients with BPD which has been shown to be effective in reducing suicidal behavior, hospitalization, and treatment dropout and improving interpersonal functioning and anger management. The inpatient DBT staff creates a validating treatment milieu and focuses on orienting and educating new patients and identifying and prioritizing their treatment targets. Inpatient DBT treatment techniques include contingency management procedures, skills training and coaching, behavioral analysis, structured response protocols to suicidal and egregious behaviors on the unit, and consultation team meetings for DBT staff.

Self-inflicted wounding. 2: Identification, assessment and management

The spectrum of conditions associated with self-inflicted wounding and their presenting features were outlined in the first part of this article (Moffatt, 1999). In part two, the assessment and management of self-wounding patients is discussed. Manipulative behaviour can be a barrier to treatment, as well as a disruptive force within the healthcare team. Awareness of its effects are essential to the successful development of a therapeutic relationship. However, the current possibilities for effective treatment of self-wounding are limited, and there is an urgent need for more research into both its causes and the various management options available.

The lived experience of countertransference in psychiatric/mental health nurses

The purpose of this study was to evolve a structural description of nurses' experience of countertransference. The phenomenological method was chosen for the study. The sample consisted of 5 participants who met selection criteria. The participants gave audiotaped descriptions of their experiences in caring for patients for whom they experienced countertransference. The lived experience of countertransference emerged from the findings of this study as a process of the continuous growth of self-awareness. Initially, the experience entailed the struggle to abandon objectivity, emotional neutrality, and therapeutic omnipotence. It was the abandonment of these principles that enabled the nurse to begin to use the self's experienced emotions therapeutically in interactions with patients. For the participants, the feelings aroused in the self came to be understood as having meaning within the concept of countertransference and thus, came to be understood as normal responses to caregiving. It is the continuing ability of these nurses to transcend this normal, human response, and to use their growing self-awareness to provide an appropriate level of care to the patient, that is the hallmark of the lived experience.

A behavioral comparison of female adolescent inpatients with and without borderline personality disorder

Patients with borderline personality disorder (BPD) are thought to have problematic hospitalizations. This study seeks to examine this phenomenon in adolescence by documenting the specific problem behaviors exhibited by patients, and the staff interventions in response to these behaviors in patients with and without BPD. Data were collected from the charts of 81 hospitalized adolescent girls regarding restraints, seclusions, incidents of self-abuse and aggression, incidents of signing the intent-to-leave form, nonroutine drug and/or alcohol screens, and discharges against medical advice. The two groups were compared using the analysis of variance (ANOVA) statistic for continuous variables and the chi-square statistic for the categorical variable. A follow-up multivariate ANOVA (MANOVA) was performed using the length of stay as a covariate. The BPD group displayed significantly higher rates of certain behaviors per day, but not of others. The length of stay was significantly higher in the BPD group. Further analysis indicated that some of the behavioral differences between the two groups may be due to the effect of the difference in length of stay. The data also suggest that while most BPD patients behave similarly to other patients, there may be a subset of BPD patients who behave in an extreme manner while hospitalized. BPD patients may display more of certain problematic behaviors than non-BPD patients in the hospital. However, it is hypothesized that these differences in hospital behavior may be largely due to the different lengths of stay between the two groups or to an acting-out subgroup of BPD patients.

MMPI variables predictive of schizophrenia in the Copenhagen High-Risk Project: a 25-year follow-up

Moldin et al. (1) have identified a cluster of Minnesota Multiphasic Personality Inventory (MMPI) scales that discriminate adolescents at risk for schizophrenia from those not at risk. The present study examines how well Moldin's scales predict schizophrenic decompensation in a sample of 207 Danish adolescents at high genetic risk for schizophrenia. Subjects were assessed using a modified, 304-item MMPI in 1962 (mean age= 15.1 years) and diagnosed in 10-year and 25-year follow-ups. Premorbidly, schizophrenic subjects (n=31) scored higher than subjects with no mental illness on the frequency (F) and psychoticism (PSY) scales. When paranoid and non-paranoid preschizophrenics were separated, three scales (F, Pz (paranoid schizophrenia) and PSY) significantly discriminated paranoid preschizophrenics. Discriminant function analyses confirmed these results. It is concluded that the MMPI may be useful for identifying schizophrenia premorbidly.

An analysis of the concept of countertransference

A knowledge of countertransference is a necessary step in using it therapeutically in the nurse-patient relationship. However, this concept, which has its roots in psychoanalytic theory, has been applied to nurses and nursing situations in an unhelpful and ambiguous manner. In fact, the term is often used to denigrate nurses without providing clarity as to what the components of countertransference are and how they might be understood and used therapeutically. As such, it is necessary to delineate the meaning of countertransference in its entirely as a concept suitable for nursing practice. Positive countertransference, negative countertransference, and empathy are the composite parts of the concept of countertransference. Through concept analysis, by using methods outlined by Rodgers (1989), Journal of Advanced Nursing, 14, 330-335, it is suggested that countertransference is an inescapable factor in the nurse-patient relationship. Furthermore, a comprehensive analysis of the concept of countertransference will assist nurses in recognizing it when it occurs and may enhance the use of the understanding gained to the benefit of the nurse-patient relationship.

Splitting on a pediatric consult liaison service

OBJECTIVE

Although the concepts of splitting and projective identification have been useful in explaining certain group phenomena on adult psychiatric and medical wards, their application to pediatric settings has not been addressed in the literature. The authors demonstrate that early identification, staff conferencing, and family/staff conferencing can diffuse these dynamics in an academic pediatric setting.

METHOD

The existing literature on splitting and projective identification is reviewed. Case vignettes are then used to illustrate the manifestations of splitting and projective identification in a pediatric setting and to demonstrate intervention strategies modified for children and their families from the adult literature.

RESULTS

Splitting and projective identification can be interrupted in pediatric settings with early identification, staff conferencing, and family/staff conferencing. The cooperation of pediatric clinicians is critical in the implementation of these intervention strategies.

CONCLUSIONS

The development of liaison support groups for pediatric residents and interdisciplinary treatment teams will enlist their cooperation in identifying splitting early, and in employing staff conferencing and family/staff conferencing to diffuse this group dynamic which, if left unchecked, can disrupt professional relationships and compromise the treatment of pediatric patients.

Brief hospital treatment plans for persons with borderline personality disorder: perspectives of inpatient psychiatric nurses and community mental health center clinicians

Despite growing recognition of the challenges inherent in helping persons with borderline personality disorder, systematic investigation of caring for this population in specific treatment situations is lacking. In this study, an innovative hospital treatment program for persons with borderline personality disorder was evaluated. Using an interpretive phenomenological approach, a team of researchers analyzed data from in-depth, individual interviews with inpatient psychiatric nurses and community mental health center clinicians (n = 13) and thereby identified a constitutive pattern, the paradoxes of helping. At a time when innovation in caring for persons with this disorder is sought, an examination of these paradoxes will help identify those practices to be abandoned, those to be extended, and those to be preserved.

Dimensions and predictors of change during brief psychiatric hospitalization

The effects of brief psychiatric hospitalization on patient functioning remain controversial and poorly defined. In this study, 217 subjects were evaluated for the changes they experienced during a brief admission (average length of stay 23.0 +/- 16.2 days). Significant improvements occurred in symptoms, global functioning, self-esteem, perceptions of others, and ego functioning. Better multidimensional outcome correlated with symptomatic improvement and preadmission functioning. No effects were found for age, gender, Axis I diagnosis, presence of an Axis II or Axis III disorder, prior hospitalization, severity of symptoms, length of stay, or payor group. During brief hospitalization, patients appear to improve in several areas of psychosocial functioning.

When the system is the problem, don't blame the patient: problems inherent in the interdisciplinary inpatient team

Organizational theory used in conjunction with the transference/countertransference paradigm enables members of the interdisciplinary team to look at treatment problems from two perspectives and to intervene at the appropriate level. Common problems of the team are poorly defined accountability, a lack of leadership, communication breakdowns, and boundary violations. Suggested interventions are education of team members about organizational theory, open discussion of contentious issues, and reinforcement of boundaries. The dynamics of the team are important and a team can benefit from self-examination through organizational theory.

Follow-up study on borderline versus nonborderline personality disorders

Using a semi-structured interview, 18 DSM-III borderline personality disorder (BPD) patients and 17 other (nonborderline) personality disorder (OPD) patients were compared blind 4 1/2 years after their index discharge. Although significantly younger and mostly single, BPD patients did not differ from OPD patients in the degree of overall psychopathology or in the level of psychosocial functioning and adjustment. They do not seem to represent a particularly severe personality disorder group. Those characteristics differentiating BPD patients from affective disorders and schizophrenia may be nonspecific regarding other personality disorder types. As such, more attention should be paid to cases of OPD in the future.

Inpatient and day hospital treatment of the borderline: an integrated approach

An integrated treatment approach to the severely ill borderline patient is outlined. Treatment is conceptualized as a process of progression along a continuum of decreasing levels of care. This involves an inpatient, day hospital, and outpatient phase of treatment. During the treatment process, there are many progressions and regressions. The overall goal is to give the patient an increasing sense of separateness, autonomy, and self-reliance.

The assessment of suicide risk in the general hospital

The assessment of suicide risk is a central activity of the general hospital psychiatrist for patients admitted following a suicide attempt and others who are identified after admission as being potentially suicidal. While biologic and psychosocial measures have some long-term predictive value, there is no valid measure to predict acute suicide risk. The lack of a valid measure does not, however, relieve the clinician of the obligation to perform an appropriate assessment. Pertinent appellate case law decisions not that the evaluation and record keeping must be "adequate," though no definition for adequate standards is provided. This paper presents issues that are considered so fundamental for suicide assessment that failure to obtain and record such information would potentially constitute inadequate practice. These areas include: the patient's statement regarding current suicidal ideation and planning, the presence or absence of delirium, psychosis and depression, what the patient says it makes sense to do, confirmation by a third party, and global formulation. The guidelines in this paper are presented with the intention of establishing the basis for optimal clinical care and for minimizing legal vulnerability in the evaluation of the potentially suicidal patient in the general hospital.

The inpatient treatment of the borderline personality disorder: a critical review and discussion of aftercare implications

The literature on inpatient treatment of adult borderline personality disorder is reviewed. The controversy regarding the use or avoidance of the regression which can accompany hospitalization is discussed. It is suggested that this literature is not specific enough. There is insufficient attention to definition of terms, clinical heterogeneity and the longitudinal course of the illness. As well, the ahistoric approach to the hospitalization of these patients serves to reinforce characteristic ego deficits. Recommendations regarding the use of long or short-term length of hospital stay are not substantiated by formal research. It is suggested that greater emphasis be placed on aftercare issues. The stabilization of the patient, outpatient therapist, and aftercare system are described as important goals of inhospital care.

Ethical and management considerations in factitious illness: one and the same

The literature on factitious illness raises many ethical problems regarding diagnosis and treatment. The author briefly reviews ethical issues in factitious illness and argues for viewing these patients as autonomous citizens, capable of accepting responsibility for their behavior. Some factitiously ill patients psychologically resemble those with borderline personality disorder, and ethical implications are developed. In a case example, the author illustrates how good clinical management assists with the resolution or prevention of these ethical dilemmas.

Problem patients in a psychiatric inpatient setting. An explorative study

A total of 26 psychiatric inpatients (5.8% of all admissions) in an intensive treatment unit were identified as problem patients by nursing personnel. Reasons for such identification were behavioral pathology of the patient, difficulties of the staff in the relationship with the patient, and insufficient therapeutic progress, and the use of inappropriate therapeutic methods. Compared with a control group, the problem patients were psychotics or personality disorders. They presented more behavioral pathology, were prescribed more medication, and experienced decisively longer hospitalizations, although they profited less from their hospitalization. Follow-up investigation revealed that the majority did not earn their own living, otherwise they were no more poorly socially adapted than the discharged controls. The suicide proneness of problem patients was high. In the treatment of these patients the necessity of adapting the therapeutic standards and expectations is of the utmost importance.

Milieu concepts for short term hospital treatment of borderline patients

In contrast to the extensive literature on the outpatient treatment of the borderline patient, there exists only a handful of articles which address the complexities of hospital treatment. This paper will focus on aspects of the milieu for short term (less than three months) length of stay hospital treatment.

Supportive containment in the hospital care of treatment-resistant borderline adolescents

Psychotherapeutic treatment of borderline patients is characterized by threats to maintenance of the therapeutic alliance during periods of regression. Hospitalization provides ego support and limits to help sustain the alliance, but for some patients traditional hospital approaches are not adequate. This paper describes a specialized treatment approach for managing treatment-resistant borderline adolescents in a hospital setting. The approach provides supportive containment through a restricted environment and enforcement of patient dependency on treatment staff. Patients gradually gain freedoms as their self-regulation increases. Success rates with this approach are raised to a level comparable to that attained with less difficult patients.

Indications for hospitalization in the treatment of borderline patients

Hospitalization is an important component in the treatment of some borderline patients, yet features of the borderline syndrome make the decision to hospitalize a complex one. This paper considers alternatives to hospitalization as well as indications for use of the hospital in the treatment of borderline patients. The roles of brief hospitalization and of extended inpatient treatment are considered separately.

The multi-dimensional inpatient treatment of severe character disorders

Patients with severe character disorders present a special challenge to the clinician. Many can be helped with outpatient psychotherapy, often with the adjunctive use of medication. Some cannot, and need intensive inpatient treatment. An inpatient psychiatric unit in a general hospital is described which has been designed to treat such patients. The treatment makes use of a variety of therapeutic modalities. Psychotherapy is central and essential to the successful functioning of this therapeutic instrument.

The borderline patient in the general hospital

The usefulness of the general hospital inpatient service for the borderline patient is described. The short-term nature of most general hospital units requires a setting that facilitates the rapid establishment of a holding environment and the re-establishment of self-object transferences. Borderline patients have particular difficulty in accepting responsibility for their feelings and behavior and, instead, tend to blame themselves and others. An approach to inpatient care that defines expectations of both patient and family prior to and early in the admission of the patient is elaborated clinically and theoretically. Such an approach offers a way of working with the potential regression in borderline patients, especially around the important issues of responsibility and blaming. The staff's awareness of countertransference problems related to the patient and family as well as to the patient's therapist are described as important ingredients in successful work with these patients.

A short-term hospital program preparing borderline and schizophrenic patients for intensive psychotherapy

This paper explores the role of a short-term hospitalization program in preparing certain borderline and schizophrenic patients for intensive psychotherapy on an outpatient basis. I will begin with a description of the inpatient unit and next discuss some relevant theoretical issues regarding borderline and schizophrenic psychopathology. I will then describe how these issues are dealt with in the evaluation procedure, in individual psychotherapy, and in the milieu therapy provided by our program.

More than one borderline? The current status of the concept of borderline personality

Borderline Personality has acquired diagnostic respectability with its inclusion in DSM III. Descriptions of the syndrome by the major contributors to the field are reviewed and the criteria developed by Spitzer, Endicott and Gibbon (1979), and adopted for DSM III, are discussed. It is suggested that there may be an identifiable sub-group of patients with Borderline Personality Disorder who are best classified with the affective disorders.

The resident and the borderline in-patient: a supervisor's perspective

The problems of residents working intensively with borderline inpatients in a general hospital psychiatric unit area described. The resident feels pressure because of inexperience with intensive psychotherapy, and the high visibility of working in a closely supervised team setting. The border line patient baffles the resident with his defensive activity characterized by splitting, erotization, idealization, and negative therapeutic response. These difficulties complicate supervision, necessitating the supervisor's alertness to being caught in team splits or collusion with the resident's unrealistic hopefulness or nihilism. Supervision must actively address the resident's countertransference and the supervisor's counterresponses. Clinical vignettes illustrate the various problems.

An eclectic therapeutic community for the treatment of addiction

The Eclectic Therapeutic Community described in this report is a modification of a Jonesian Therapeutic Community to fit the immature character defenses of many addicted patients. The program emphasizes structures; that is, rules, policies, staff roles, therapeutic forums, program phases, and clear expectations to create living and learning situations in which addicts can model after staff and senior residents in the program. This modeling results in a development of a new perceptual style so that the addict patient is better able to clearly perceive his own behavior and the behaviors of others when involved in an emotional situation. The structures also protect the staff and patients against externalization and narcissistic injury. The program has developed out of consideration of recent psychoanalytic work with borderline and narcissistic personalities. A Gestalt therapeutic approach is employed because of its focus on perception of here and now social learning situations, ease of communication of the basic concepts and techniques, and most importantly because it focuses on clear perception when emotional.

The hospital and the borderline patient: management guidelines for the community mental health center

Controversy over the treatment of borderline patients in regression has frequently left underfined the practical approaches to hospital management of these patients. The nature and context of the regressive episode, and the implications of potential interventions for specific types of patients are basic considerations in formulating such an approach. Subgroups of borderline patients can be usefully distinguished on the basis of the major management problem to which each is particularly prone.