I Hate You—Don't Leave Me (24 page)

Short-term hospitalization usually lasts for several days. A complete physical and neurological assessment is performed. The hospital milieu focuses on structure and limit-setting. Support and positive rapport are emphasized. Treatment concentrates on practical, adaptive responses to turmoil. Vocational and daily living skills are evaluated. Conjoint meetings with family, when appropriate, are initiated. A formalized contract between patient and staff may help solidify mutual expectations and limits. Such a contract may outline the daily therapy program, which the patient is obligated to attend, and the patient's specific goals for the hospitalization, which the staff agrees to address with him.

The primary goals of short-term hospitalization include resolving the precipitating crises and terminating destructive behaviors. For example, the spouse of a patient who has thoughts of shooting himself will be asked to remove guns from the house. Personal and environmental strengths are identified and bolstered. Important treatment issues are uncovered or reevaluated, and modifications of psychotherapy approaches and medications may be recommended. Deeper exploration of these issues is limited on a short-term, inpatient unit, and is more thoroughly pursued on an outpatient basis or in a less intensive program, such as partial hospitalization (see page 174). Since the overriding concern is to return the patient to the outside world as quickly as possible and avoid regression or dependence on the hospital, plans for discharge and aftercare commence immediately upon admission.

Today, extensive hospitalization has become quite rare and is reserved for the very wealthy or for those with exceptional insurance coverage for psychiatric illness. In many cases where continued, longer-term care is indicated, but confinement in a twenty-four-hour residence is not necessary, therapy can continue in a less restrictive milieu, such as partial hospitalization. Proponents of long-term hospitalization recognize the dangers of regression to a more helpless role, but argue that true personality change requires extensive and intensive treatment in a controlled environment. Indications for long-term confinement include chronically low motivation, inadequate or harmful social supports (such as enmeshment in a pathological family system), severe impairments in functioning that preclude holding a job or being self-sufficient, and repeated failures at outpatient therapy and short hospitalizations. Such features make early return to the outside environment unlikely.

During longer hospitalizations, the milieu may be less highly structured. The patient is encouraged to assume more shared responsibility for treatment. In addition to current, practical concerns, the staff and patient explore past, archetypal patterns of behavior and transference issues. The hospital can function like a laboratory, in which the borderline identifies specific problems and experiments with solutions in his interactions with staff and other patients.

Eventually, Jennifer (see chapter 1) entered a long-term hospital. She spent the first few months in the closet—literally and figuratively. She would often sit in her bedroom closet, hiding from the staff. After a while she became more involved with her therapist, getting angry at him and attempting to provoke his rage. She alternately demanded and begged to leave. As the staff held firm, she talked more about her father, how he was like her husband, how he was like all men. Jennifer began to share her feelings with the female staff, something that had always been difficult because of her distrust of and disrespect for women. Later during the hospitalization, she decided to divorce her husband and give up custody of her son. Although these actions hurt her, she considered them “unselfish selfishness”—trying to take care of herself was the most self-sacrificing and caring thing she could do for those she loved. She eventually returned to school and obtained a professional degree.

The goals of longer hospitalization extend those of short-term care—not only to identify dysfunctional areas but also to modify these characteristics. Increased control of impulses, fewer mood swings, greater ability to trust and relate to others, a more defined sense of identity, and better tolerance of frustration are the clearest signs of a successful hospital treatment. Educational and vocational objectives may be achieved during an extensive hospitalization. Many patients are able to begin a work or school commitment while transitioning from the hospital. Changes in unhealthy living arrangements—moving out of the home, divorce, etc.—may be completed.

The greatest potential hazard of long-term hospitalization is regression. If staff do not actively confront and motivate the patient, the borderline can become mired in an even more helpless position, in which he is even more dependent on others to direct his life.

Partial (or day) hospital care is a treatment approach in which the patient attends hospital activities during part or most of the day and then returns home in the evening. Partial hospital programs may also be held in the evening, following work or school, and may allow sleeping accommodations when alternatives are not available.

This approach allows the borderline to continue involvement in the hospital program, benefitting from the intensity and structure of hospital care, while maintaining an independent living situation. Hospital dependency occurs less frequently than in long-term hospitalization. Because partial hospitalization is usually much less expensive than traditional inpatient care, it is usually preferred for cost considerations.

Borderlines who require more intensive care, but not twenty-four-hour supervision, who are in danger of severe regression if hospitalized, who are making a transition out of the hospital to the outside world, who must maintain vocational or academic pursuits while requiring hospital care, or who experience severe financial limitations on care may all benefit from this approach. The hospital milieu and therapy objectives are similar to those of the associated inpatient program.

As we shall see in the next two chapters, treatment of BPD usually combines standardized psychotherapeutic approaches and medications targeting specific symptoms. While at one time BPD was thought to be a diagnosis of hopelessness and irritation, we now know that the prognosis is generally much better than previously thought. And we know that most of these patients leave the chaos of their past and go on to productive lives.

The process of treatment may be arduous. But the end of the journey opens up new vistas.

“You always spoke of unconditional acceptance,” said one borderline patient to her therapist, “and somewhere in the recent past I finally began to feel it. It's wonderful. . . . You gave me a safe place to unravel—to unfold. I was lost somewhere inside my mind. You gave me enough acceptance and freedom to finally let my true self out.”

Specific Psychotherapeutic Approaches

There is a Monster in me. . . . It scares me. It makes me go up and down and back and forth, and I hate it. I will die if it doesn't let me alone.

—From the diary of a borderline patient

True life is lived when tiny changes occur.

—Leo Tolstoy

 

 

 

Borderline Personality Disorder is the only major psychiatric illness for which there are more evidence-based studies demonstrating efficacy from psychosocial therapies than for pharmacological (drug) treatments. Thus, unlike the treatment for most other disorders, medications are viewed as secondary components to psychotherapy. Not only have several psychotherapy approaches been shown to be effective, the arduous and sometimes extensive endeavor of psychotherapy has also been shown to be cost-effective for the treatment of personality disorders.
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Psychotherapy as a treatment for BPD has come a long way since the publication of this book's first edition. Spurred by rigorous research and constant refinement by clinicians, two primary schools of therapy have emerged—the cognitive-behavioral and psychodynamic approaches. In each category several distinct strategies have been developed, each supported by its own set of theoretical principles and techniques. Several psychotherapy strategies combine group and individual sessions. Though some are more psychodynamic, some more behavioral, most combine elements of both. All embrace communication that reflects SET-UP features that were developed by the primary author and discussed in detail in chapter 5:
Support
for the patient,
Empathy
for his struggles, confrontation of
Truth
or reality issues, together with
Understanding
of issues and a dedication to
Persevere
in the treatment.

Proponents of several therapy approaches have attempted to standardize their therapeutic techniques by, for example, compiling instructional manuals to help guide practitioners in conducting the specific treatment. In this way, it is hoped that the therapy is conducted consistently and equally effectively, irrespective of the practitioner. (An obvious, though perhaps crass, analogy may be made to a franchise food company, such as Starbucks or McDonald's, which standardizes its ingredients so that its coffee or hamburgers taste the same regardless of where it is purchased.) Standardization also facilitates gathering evidence in controlled studies, which can support, or refute, the effectiveness of a particular psychotherapy approach.

The underlying theory of standardization is that, just as it would make little difference who physically gives the patient the Prozac (as long as he ingested it), it would make little difference who administered the psychotherapy, as long as the patient was in attendance. However, interpersonal interactions are surely different from taking and digesting a pill, so it is probably naive to presume that all psychotherapists following the same guidelines will produce the same results with patients. Indeed, John G. Gunderson, MD, a pioneer in the study of BPD, has pointed out that the original developers of these successful techniques are blessed with prominent charisma and confidence, which followers may not necessarily possess.
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Additionally, many therapists might find such a constrained approach too inflexible.
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Although the different psychotherapy strategies emphasize distinctions, they possess many commonalities. All attempt to establish clear goals with the patient. A primary early goal is to disrupt self-destructive and treatment-destructive behaviors. All of the formal, “manualized” therapies are intensive, requiring consistent contact usually one or more times per week. All of these therapies recognize the need for the therapist to be highly and specially trained and supported, and many require supervision and/or collaboration with other team members. Therapists are more vigorously interactive with patients than in traditional psychoanalysis. Because these therapies are time and labor intensive, usually expensive, and often not fully covered by insurance (e.g., insurance does not cover team meetings between therapists, as required in formal DBT—see page 179), most of the studies exploring their efficacy have been performed in university or grant-supported environments. Most community and private treatment protocols attempting to reproduce a particular approach are truncated modifications of the formal programs.

It is no longer simply a matter of “finding any shrink who can cure me” (though it is possible, of course, to get lucky this way). In our complex society, all sorts of factors are, and should be, considered by the patient: time and expense, therapist's experience and specialization, and so on. Most important, the patient should be comfortable with the therapist and her specific approach to treatment. So the reader is advised to read the remainder of this chapter with an eye toward at least becoming familiar with specific approaches, as she will likely see them (and their acronyms) again at some point during the therapeutic process.

Cognitive-behavioral approaches focus on changing current thinking processes and repetitive behaviors that are disabling; this type of therapy is less concerned about the past than psychodynamic approaches (see page 183). Treatment is more problem-focused and often time-limited.

A system of treatment developed by Aaron Beck, CBT focuses on identifying disruptive thoughts and behaviors and replacing them with more desirable beliefs and reactions.
⁴
Active attempts to point out distorted thinking (“I'm a bad person”; “Everyone hates me”) and frustrating behaviors (“Maybe I can have just one drink”) are coupled with homework assignments designed to change these feelings and actions. Assertiveness training, anger-management classes, relaxation exercises, and desensitization protocols may all be used. Typically, CBT is time-limited, less intensive than other protocols, and therefore usually less expensive. The following treatment programs are derived from CBT.

Developed by Marsha M. Linehan, PhD, at the University of Washington, DBT is the derivation of standard cognitive-behavioral therapy that has furnished the most controlled studies demonstrating its efficacy. The
dialectic
of the treatment refers to the goal of resolving the inherent “opposites” faced by BPD patients; that is, the need to negotiate the borderline's contradictory feeling states, such as loving, then hating the same person or situation. A more basic dialectic in this system is the need to resolve the paradox that the patient is trying as hard as she can and is urged to be satisfied with her efforts, and yet is simultaneously striving to change even more and do even better.
⁵

DBT posits that borderline patients possess a genetic/biological vulnerability to emotional over-reactivity. This view hypothesizes that the limbic system, the part of the brain most closely associated with emotional responses, is hyperactive in the borderline. The second contributing factor, according to DBT practitioners, is an invalidating environment; that is, others dismiss, contradict, or reject the developing individual's emotions. Confronted with such interactions, the individual is unable to trust others or her own reactions. Emotions are uncontrolled and volatile.