Tuesday, March 4, 2014

An Outpatient Approach to Treating Mothers with Borderline Personality Disorder and When Hospitalization May be Necessary

Treating Mothers Who Have BPD Extensive empirical evidence supports a psycho-educational intervention for the identified patient as well as the spouse and children (Cohen et al., 2008). Psycho-educational information about childhood developmental stages and milestones from infancy forward would aim to reduce family stressors and risk of relapse (Cohen et al., 2008; Gunderson et al., 1997). A systems-based approach in treating mothers with BPD would encourage the patient to form or join a support network comprised of other mothers with BPD (Cohen et al., 2008). Presently no manualized form of structured treatment exists, although treatment models have been proposed, and at least one peer reviewed article has been written (Stepp et al., 2012) on the efficacy of treating the entire family. In-Patient Hospitalization for Suicidal Patients with BPD Many people with Borderline Personality Disorder cannot afford ongoing psychoanalysis, and may require hospitalization during a crisis. Further, psychoanalysis may prove to be more harmful than beneficial to patients in crisis, because inherent transference and countertransference problems can derail therapy altogether (Gabbard, 2000). In addition, insurance and managed care companies are less likely to pay for long-term psychoanalytic therapy than the more time-limited cognitive behavioral treatment (Gabbard, 2000). Therefore, hospitalized care is often a crucial component of a good outcome for patients severely impaired by BPD (Gabbard, 2005). A three-step model has been proposed (Ogden, 1979) for BPD patients who have been admitted to a hospital in-patient treatment program, based on the following concepts of projective identification (Gabbard, 1990; Goldstein, 1991; Sandler, 1987): (1) the self-or object representation is unconsciously projected from the patient onto the treater, (2) the treater unconsciously identifies with the patient’s projected self- or object representation, and (3) the treater psychologically processes the projected material, which then becomes modified and re-introjected by the patient. Patients tend to recreate internalized patterns of attachment, perhaps in an attempt to master previously experienced trauma (Gabbard, 1988). Patients with BPD may try to provoke hospital clinicians to gain both the auspice of control and the mastery of similar situations which had eluded them in early childhood (Gabbard 1988). The four forces theorized to contribute to the patients’ perpetuation of transference patterns are: (1) to actively master previous traumatic experiences that he or she was passive in (Pine, 1990), (2) to maintain attachment patterns (Gabbard, 2005), (3) to invite help from others who could protect them (Gabbard, 2005), and (4) to transform their lives (Sandell, et al., 2000). Conflicting and therefore irreconcilable self- and object representations become split off from the patient and projected onto hospital staff members. Rather than merely a defense mechanism, projective identification of fragmented and externalized self- and other material serves as a potent way for patients to communicate, and expresses their hope for a better outcome from a repeated and familiar pattern (Gabbard, 1988). Guntrip (2011) refers to this as “the object and self both being transformed into the fantasy relationship for which the patient longs.” Although unable to verbalize their internal experiences, nevertheless inpatients may be able to evoke similar experiences with hospital staff as an unconscious way of managing affect and primitive anxieties that exert psychical pressure (Gabbard, 1988). There are four identified primary features involved in the phenomenon of splitting that inpatients undergo: (1) the splitting is unconscious; (2) dependent on the patient’s internal object representations, different staff members are perceived differently and, sometimes, these differences are dramatic in their projection; (3) through the process of projective identification staff members react to these projections by taking on the projected aspects; and (4) treaters’ opinions of the same patient can become polarized to the point of causing frictions and falling-out among the staff during discussions (Casement, 1990; Gabbard, 1989a; Ogden, 1987). Corrective measures should include assuring the patient that the treater can tolerate and manage intense feelings without the retaliation or abandonment the patient had experienced in similar situations in the past. Rather than reacting, the treater instead responds to the patient, reducing the patient’s primitive anxieties. This, in turn, stops the patient from having to split, or disavow, painful introjections. Initially, the treater may attempt to contain the patient through a willingness to serve as the patient’s “bad object.” The treater can subsequently vent privately to colleagues to discharge any anger provoked by the patient. Treaters who lack the internal resources to prevent a harsh reaction to the patient may be characterologically unsuited to implement the holding and containing process the patient needs in order to change (Brune, et al., 2010; Carter, 2006).

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