Borderline Personality Disorder and Hospitalization.pdf

Borderline Personality Disorder

and Hospitalization

Freda Baron Friedman

SUMMARY. This chapter reviews and discusses the issues and contro-

versies related to the hospitalization of suicidal patients with a diagnosis

of borderline personality disorder. It highlights the challenges faced by

both the clinical staff and a prototypical patient during a hospitalization.

Included are a discussion of the transference and counter-transference

that arise during inpatient treatment, the stressors on the staff as well as

on the patients themselves. The chapter offers suggestions for en-

hanced in-hospital treatment, including increased collaborative deci-

sion-making, clear and realistic short- and long-term goals for

patient and family, and increased supervision and ongoing education of

staff. doi:10.1300/J200v06n01_07 [Article copies avaitable for afee frotn The

Haworth Document Delivery Setvice: l-800-HAWORTH. E-mcnl aldtess: <doaMivery@

KEYWORDS. Borderline personality disorder, hospitalization, contro-

versies about treatment, suicide, suicidal ideation, transference and

counter-transference, staff/nursing stressors

INTRODUCTION: TWO CASE STUDIES

Amy came to her Tuesday afternoon therapy session and reported

that she had cut herself that same morning with a kitchen knife, creating

[Haworth co-indexing enlry note]: "Borderline Personality Disorder and Hospitalization." Friedman,

Freda Baron. Co-published simultaneously in Social Work in Menlat ttealtti (The Haworth Press) Vol. 6, No.

1/2,2008, pp. 67-84; and: Borderline Personality Disorder: Meeting the Chatlenges to Successful Treatment

(ed: Perry D. Hoffman, and Penny Steiner-Grossman) The Haworth Press, 2008, pp. 67-84. Single or multiple

copies of this article are available for a fee from The Haworth Document Delivery Service [1-800-

HAWORTH, 9:00 a.m. - 5:00 p.m. (EST). E-mail address: docdelivery@haworthpress.com].

Available online at http://swmh.haworthpress.com

doi:10.1300/J200v06n01 07

BORDERLINE PERSONALITY DISORDER

a three inch-long horizontal cut that had bled for half an hour. Amy had

decided it didn't need stitches, and indeed, by the time she atxived at her

session, the wound had stopped bleeding. She also reported to Dr. B, her

therapist, that she had stopped feeling like cutting and really was ok

now. This morning she had been upset with her boyfriend and his plans

to go away for the weekend with his brother; now, she had made plans

with someone and had made up with her boyfriend.

Still, Dr. B. was very concetned and wanted to hospitalize Amy be-

cause of the cutting. In the two months she had worked with Amy, this

was the third tirne she had cut herself. The therapist felt that Amy was at

risk this weekend, what with the boyfriend away, and the therapist plan-

ning to leave town herself. She posed the concern to Amy, who said "It

makes no sense to hospitalize me now for cutting myself this morning...

I absolutely have no urge to cut myself now and feel much more in con-

trol. I can put my knives away, call my friend if I'm upset and I'll be

ok." Dr. B. was not so sure.

What she knew about Amy was that she had been in therapy for the

past 10 years with about ftve different therapists. She had been hospital-

ized several times before for suicidal ideation and cutting, but had not

previously demonstrated any severe life-threatening behaviors . . . not

yet, thought Dr. B. Amy had some stability in her life now: her own

apartment, a responsible job for the past few years and a declining credit

card balance. Although her relationships tended to be rocky, this current

boyfriend relationship had been lasting significantly longer than previ-

ous ones. She had stopped drinking several months ago and attended

AA irregularly, but usually at least once a week.

Amy's therapist was in a quandary. She knew that Amy definitely

didn't want to go into the hospital. A coerced admission would affect

their working relationship. At the same time. Dr. B. had had a traumatic

experience with another patient, Monica, several tnonths earliet; and

was inclined to be much more conservative and cautious.

Monica, an off-again, on-again long-term patient of Dr. B's, had had

bouts of depression and anxiety. Once every few weeks, she would call

in sick, stay in bed all day, withdraw from friends and sink into depres-

sion, hopelessness and suicidal ideation. But the next day, she'd pull

herself together, carefully and expertly apply her makeup and go out to

dazzle colleagues and clients. For the past few weeks, Monica had been

experiencing increasing difficulty concentrating at work and was hav-

ing more feelings of insecurity about her work and her relationship with

her partner. She had been spacing out her medications so that they

Ereda Baron Eriedman

would last longer and had recently cancelled several appointments with

Dr. B.

Monica's psychiatrist decided to hospitalize her briefly for medica-

tion re-evaluation and adjustment. Her only previous hospitalization,

some 20 years ago for similar issues, had been followed by several de-

cades of fairly solid functioning and stability. Monica was hospitalized

this time for three days, having adjusted quickly and well to a new medi-

cation regime. She had a therapy session the next day with Dr. B and re-

ported that she was definitely feeling better and was ready to resume

work on a more consistent basis.

Forty-eight hours later, Monica took a near-lethal dose of Tylenol

and alcohol and then called a good friend to say she wasn't feeling well.

She was taken to another hospital, at her insistence, and stabilized via

the Intensive Care Unit. Within several days, Monica began agitating

for immediate discharge, insisting that she was "totally better," and that

she would avoid the trigger to her suicide attempt [contact with her

mother]. She participated actively in therapeutic groups on the unit, and

appeared to be stabilized within a week. The multidisciplinary staff was

quite divided about keeping or discharging Monica. There were those

who felt she wasn't stable enough to keep herself safe and there were

those who felt that Monica was chronically unstable and would not ben-

efit from further hospitalization when she so clearly wasn't willing to

stay. Insurance coverage limitations and family pressure also tipped the

scales in favor of discharge. The disagreements about Monica's care

created significant tension for the unit staff, particularly since Monica

was relentless in her requests to be discharged. Dr. B. felt wary about

having Monica discharged so soon.

Patients like Amy and Monica are not uncommon among the popula-

tion of people with severe symptoms of borderline personality disorder.

According to many researchers in the field of BPD, 2-3% of the popula-

tion in this country meet criteria for BPD. Their use of mental health

services in this country is strikingly large: they represent about 10% of

all individuals who utilize outpatient mental health clinic services. Even

more striking, they account for 15 to 20% of all psychiatric hospital

admissions (APA, 2000).

The issues of hospitalization for such patients are complex and multi-

faceted. These include: contt oversy about the role of hospitalization for

patients such as Amy and Monica; the benefits and hazards of hospital-

ization, factors that influence effective treatment and that work against

it; obstacles to treating such patients; guidelines for helping to ensure

BORDERLINE PERSONALITY DISORDER

more effective treatment; and effective adjuncts or alternatives to hospi-

talization. A discussion of these issues is the focus of this chapter.

WHY THE HIGH RA TES OF HOSPITALIZA TION?

The suicide potential for BPD is among the highest in the psychiatric

population. One out of 10 chronically suicidal patients with BPD will

eventually commit suicide (Paris, 2004). This outcome is not generally

or readily predictable (Paris, 2004). Even higher is the level of suicidal

ideation for many people with BPD; it is chronic, fairly persistent and

occurs with startling frequency. For people with BPD who are accus-

tomed to fending off emotional flooding, suicidal ideation often be-

comes a deeply ingrained "coping mechanisrn." Many also engage in

behaviors that are potentially self destructive in order to fend off this

flooding, nurnb themselves, or to distract themselves from unbearable

etnotional pain. This combination of high rates of suicidal ideation cou-

pled with high rates of suicidal and parasuicidal behavior, leads tnany

clinicians, families and clietits themselves to seek what they may per-

ceive as the protection of a hospital unit. Patients like this are often

hospitalized to protect thetn from further self-harm.

In reality, however, hospitalization is often not the treatment of

choice for such patients. First, this protection is often illusory. An inpa-

tient treatment is of unproven value for suicide prevention and can of-

ten produce negative results. The patient may settle down quickly in a

contained environment, but not develop the strength and resiliency to

manage life's stressors outside the hospital any better than before ad-

mission. Hospitalization may give a false sense of security to patient,

treaters and family. The patient's intra- and interpersonal difficulties

may be exacerbated in the intense environment of an inpatient unit and

these may weaken the tenuous hold the patient may have had prior to

admission.

Second, it may well be that such patients are hospitalized more for

the benefit of the therapist, fatnily or supportive involved friends than

for the patient herself. TThe person or people who are the patient's sup-

ports may have been dealing with a barrage of crisis-laden phone calls

and/or self-destructive behaviors during the previous days or weeks.

They are often terrified that they will do the "wrong thing" in trying to

support and help the person in crisis. They may be burned out, or feeling

helpless after sleepless nights atid worried days. For such a person, for

her treaters, and certainly for her family and friends, life feels like a high

Ereda Baron Eriedman

Stakes roller coaster with no predictable or consistent twists and turns.

The only predictable pattern is the unpredictability: functioning well

one minute, falling apart the next. With hospitalization of their client or

loved one, there is the sense of insured safety, as well as some respite

from the terror of anticipating a tragedy.

Third, it is surprisingly difficult to determine when a client with BPD

is, and is likely to remain, at such a high level of risk of severe harm to

herself or another. The lability and volatility that often typifies someone

with severe symptoms of BPD makes periods of suicidal ideation fre-

quent. To distinguish between chronic suicidal ideation and active sui-

cidal ideation is a risk that many clinicians feel ill advised or ill

equipped to take.

THE CONTROVERSY OVER HOSPITALIZATION

It is because of these and many other reasons that hospitalization is an

issue of considerable debate among clinicians atid researchers in the

BPD field. A review of the literature (Paris, 2004; Rosenbluth, 1987;

Vijay, 2007) indicates that hospitalization is still an unresolved issue

and that guidelines for when to hospitalize someone with BPD are itn-

plemented inconsistently. Those who advocate hospitalization join with

Glenn Gabbard's comment: "When the patient is extretnely suicidal,

hospitalization is necessary, but most patients with BPD can do well

with a structured outpatient program involving individual and group

therapy and tnedication."

The hospital is viewed as^"a part of the therapeutic tools available"

(Gabbard, 2001) for the treatment of these individuals and should serve

to contain a crisis, specify a diagnosis and to prepare and reinforce a

rapid return in their community. Intensive day treatment has increas-

ingly becotne an evidence-based treatment alternative to full admission

(Paris 2004).

The American Psychological Association Practice Guidelines for

treatment of patients with BPD identify the following indications for

brief hospitalization:

• Itnminent danger to others

• Loss of control of suicidal impulses or serious suicide attempt

• Transient psychotic episodes associated with loss of impul.se con-

trol or impaired judgment

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