Borderline State

The borderline state—an altered mental state, characterized by some of the following: extreme emotional distress and search for relief, regression, misinterpretation of the statements and intents of others, rigid demanding expectation of the attention of others, confusion and psychosis; in some cases this state has been experienced by others as a near insatiable, voracious and angry hunger for placation and satisfaction of (perceived) needs.

Note. The concept of the borderline state may seem to be a resurrection of the old idea – the borderline between neurosis and psychosis. However, the spark for the concept has been direct observation of the acute difference between the normal and the acute, dysregulated presentation of a number of borderline patients.

Borderline Personality

The personality—psycho-physiologically predisposed to stress and to enter the borderline state when stressed. The personality may be seen as bi-stable. This bi-stability explains the friendly and normal behavior of the patient who had recently been threatening to find a way to kill himself or herself and to hurt caregivers who got in the way. The bi-stability also makes the disorder difficult to understand / accept for the presentation appears to be that of an otherwise normal person who uses his or her episodic dysregulation to some kind of external and overt gain and who ought to be able to snap out of their silliness.

Here, the borderline personality (disorder) may be taken to be roughly as defined in the literature (DSM etc) and is further conceived of as encompassing a predisposition to enter the borderline state. It is interesting that Marsha Linehan and others (including the European system of diagnosis) conceive of the disorder as typically emerging in individuals who (1) have an innate biological tendency to react more intensely to stress than is normal and who take longer to recover and (2) were raised in abusive environments in which completion normal psychological growth did not occur and in which the individual’s self-concept may have been continually disvalued and invalidated.

I have noticed some resistance to these ideas—a resistance whose source seems to be that it gives the borderline an ‘excuse’ for his or her behavior; however, since the biological component is a tendency and not a necessity and since it does not constitute the whole explanation, Linehan’s ideas provide no ‘excuse.’ Instead, the position may be taken that a valid theory of the development of the borderline gives both patient and staff a perspective from which to accept the individual and address the patterns of thought, emotion and behavior. Borderlines do improve – sometimes with treatment and sometimes simply with aging (‘maturing.’) The likelihood of improvement must depend on the severity of the disorder, on the presence of other disorders, and on the borderline’s personal (intrapsychic) resources. These thoughts are of course not offered as a proof of Linehan’s reasonable view; the consensus in the literature appears to be that the view has some reasonable validation and that the validation stems in part from the relative success of Linehan’s approach to treatment (an inference that is probable rather than necessary).

The borderline is often experienced as manipulative. Is the borderline truly manipulative? Perhaps. Given the psycho-physiological profile of the borderline the emergence of—perhaps subconscious—manipulation is a natural secondary characteristic. Of course, this observation does not and is not intended to rule out the presence or likelihood of overt and conscious manipulation superposed on dysregulated emotion. The presence of manipulation does not imply the absence of a true disorder that requires treatment and that is difficult to treat. However, the presence of manipulation may make the caregiver think that there is no disorder to treat; this merely enhances the odds of more treatment encounters of greater lengths of time… The intent to this diversionary paragraph has been to encourage a suspension of certain kinds of reactionary judgment that may help staff adjustment and enhance outcome by permitting treatment to begin.

Variety of presentations

Variety of presentations – the presence of the syndrome may co-occur with a variety of other traits which begins to explain the variety of presentations. The syndrome may co-occur with the major mental illnesses, with other personality syndromes (antisocial etc.,) with high intelligence to developmental delay, with and without autism, and with and without addiction.

The Cases of Gandhi and Joan of Arc

It has been suggested that Gandhi and Joan of Arc had borderline traits and the sometime implication is a rejection of the standard positive assessment of the positive accomplishments of such historical figures.

It is likely that a common judgmental attitude (see ‘Staff,’ below) is behind such assessments. A purpose of this section is suggest reflection i.e. self-criticism regarding judgment. Suspension of judgment is a normal prerequisite to growth of understanding. (Calling someone judgmental may be seen as judgmental however I am using the term in the sense of a tendency to come quickly to a judgment and not as a tendency to negative or angry judgment).

Not every individual with borderline personality attains the status of a Gandhi or a Joan of Arc. Therefore the remarkable character of the historical figures is not automatically negated by the presence of, e.g., borderline traits. However, reassessment of the historical figures and conclusions drawn from their stories may be indicated.

Note also that the ability to enter altered states of psyche is not the prerogative of individuals with a psychiatric diagnosis.

Staff

Treatment of the borderline is difficult, often frustrating. Frustration may be increased by helplessness of the individual relative to the institution.

Therefore, the attitude of the individual staff member is crucial in their adjustment to the situation. The borderline may draw extreme reactions including love and hate; and the lovers may hate the haters. It is important to note that reaction to the patient may not be conscious or explicit but may be displayed in tone of voice and so on. Not all reactions are as extreme as love and hate. Intolerance is one reaction; and the borderline, especially, reads it even before he or she or the staff member is consciously aware of it. The staff member owes it to him or herself to examine his or her reactions… and to the patient to recognize that, while ‘healing’ is possible it is often extremely slow and halting and, also, that the true target of the ‘borderline rage’ is not staff. It is not the purpose of this paragraph to judge staff reactions but to suggest that it is possible to alter one’s reactions over time in a way that is beneficial to the individual staff member.

The staff member’s own personality and psychic resources are crucial in adjustment to and care and treatment of the borderline patient.

Staff reaction and treatment. Staff reactions to the borderline individual are among the factors that are instrumental in the containment of borderline rage and ‘successful’ treatment of the borderline patient. Thus staff owe it to the hospital milieu –patients and the treatment team– to examine and channel their reactions.

This is not necessarily easy –it is some times assumed that staff can be computer-like– to respond with algorithmic precision. However the personality –the self– of each individual staff member is a source of both reaction and insight – his or her weakness and strength. Staff members will have a range of abilities – flexibility, insight, ability to direct their own attitudes. It can be reasonably assumed that staff are more flexible than patients but it does not follow that uninitiated staff will understand the extreme difference between the borderline and him or herself and may therefore judge the borderline according to his or her own standards of conduct. Many staff come to the hospital milieu with little understanding of the borderline patient and no training in adjustment of their reactions to patients… and one of the characteristics of splitting is the potential to force self and other into stand off positions that are frustrating and counter-therapeutic.

I have found it useful to cultivate an attitude of caring in balance with detachment –caring for the individual and detachment from the dramatic behavior– useful in psychiatric care in general and especially in relation to the borderline patient. I have occasionally been criticized for this detachment and perhaps I should (and do) review my attitude. ‘Suspension of judgment’ may be a better term than ‘judgment.’ The function of detachment is to be available to myself (I like to have a life of my own,) to staff, and to all patients. A formula might be, care for the person, listen to the drama but do not get involved in it. Every once in a while I find myself slipping (usually when tired).

This is a crucial area in which hospital leadership may intervene (education regarding personality disorder, counter-transference issues).

It is interesting that in this short note the longest section is this one regarding staff.

Leadership

Leadership is also crucial in setting up treatment or management plans that cover inpatient and outpatient services to individual borderline clients. I think it is important to have as many people involved – information gathering and reaction adjustment – even though it is understood that the final plan is formulated by leadership. It is probably also important to realize that the treatment of borderlines is a kind of ‘no man’s land’ where there are ‘best practices’ but there are always shades of grey regarding a comprehensive in / out patient plan. Leadership – individual staff relations are two way: team leaders involve and train workers while workers understand the complexities and limitations placed on leadership.

Treatment Planning Factors

Nature of the borderline – treatment of the personality (long term; placement, cognitive-behavioral e.g. Linehan’s DBT, medication) vs. cues (intermediate; e.g. cognitive) vs. state (short term; hospitalization only when essential, limits and attention, medication – differences from the maintenance regimen may be indicated; some people think that the regimen should not be changed.) Omissions from note (perhaps to be included later) – co-occurring conditions, variety of treatments, latest information, are not taken up in this initial document whose objective is ‘framework.’ These considerations, personality frameworks (models – Plato to DSM IV,) their limitations, need to integrated. Note the tendency of models to be flat – to not consider the vertical and dynamic aspect.

Placement – there is consensus that extended hospitalization is counter-therapeutic, even reinforces the disorder, that ‘best practice’ includes community placement with brief hospitalization when absolutely necessary.

Consistency, continuity and learning – in/outpatient, admission to admission, shift to shift, staff to staff, leadership and line; continuity of treatment planning.

Treatment planning and training – attitude and transference, participation of all providers and patient in treatment planning leads to creativity and consistency; treatment planning requires not only information but understanding, formulation but intensity, comprehensiveness but focus, establishment but evolution.

Human and moral perspective – in the exercise of care it is important to recognize that the borderline has the right to therapeutic intervention and not merely interventions aimed at keeping him or her alive at all cost, even at the expense of the patient’s humanity; that said it is recognized that even disregarding economic and legal concerns the proper treatment of the severe borderline presents difficult choices.

Milieu perspective – the focus in this note is inpatient treatment. In the exercise of care and protection of patient’s rights it is important to remember, in the face of the abusive character and behavior of some borderline clients, the rights, care and safety of all patients and the safety and care of staff. (It is too often assumed –even in courts of law– that psychiatric staff should expect and suffer exposure to unsafe conditions. Apart from the practical point that safety permits and encourages better treatment, it is a moral point that staff have a right to expect reasonable protection from unsafe conditions just as judges and law enforcement are afforded instruments of safe conduct. I wonder whether the sometimes cavalier attitude toward safety of psychiatric staff has something to do with cultural attitudes toward mental illness… I should add that I am not here intending to be critical –or even discussing– of the hospital environment in which I work).

Comprehensive – some limitations in options stem from the ‘box’ within which activity occurs; spend time on creating options, consider all factors: medical, legal, economic, political.

Involve all parties including workers and patient – the patient will understand options and the need for clear and accurate communication; documentation of all communication.