I Hate You--Don't Leave Me - Jerold J. Kreisman [78]
Hospitalization
Borderline patients constitute as much as 20 percent of all hospitalized psychiatric patients, and BPD is far and away the most common personality disorder encountered in the hospital setting.8 The borderline’s propensities for impulsivity, self-destructive behaviors (suicide, drug overdoses), and brief psychotic episodes are the usual acute precipitants of hospitalization.
The hospital provides a structured milieu to help contain and organize the borderline’s chaotic world. The support and involvement of other patients and staff present the borderline with important feedback that challenges some of his perceptions and validates others.
The hospital minimizes the borderline’s conflicts in the external world and provides greater opportunity for intensive self-examination. It also allows a respite from the intense relationships between the borderline and the outside world (including with his therapist), and permits diffusion of this intensity onto other staff members within the hospital setting. In this more neutral milieu the patient can reevaluate his personal goals and program of therapy.
At first, the inpatient borderline typically protests admission but by the time of discharge may be fully ensconced in the hospital setting, often fearful of discharge. He has an urgent need to be cared for, yet at the same time may become a leader of the ward trying to control and “help” other patients. At times he appears overwhelmed by his catastrophic problems; on other occasions he displays great creativity and initiative.
Characteristically, the hospitalized borderline creates a fascinating pas de deux of splitting and projective identification (see chapter 2 and Appendix B) with staff members. Some staff perceive the borderline as a pathetic but appealing gamin; others see him as a calculating, sadistic manipulator. These disparate views emerge when the patient splits staff members into all-good (supportive, understanding) and all-bad (confrontive, demanding) projections, much like he does with other people in his life. When staff members accept the assigned projections—both “good” (“You’re the only one who understands me”) and “bad” (“You don’t really care; you’re only in it for the paycheck”)—the projective identification circle is completed: conflict erupts between the “good” staff and the “bad” staff.
Amid this struggle the hospitalized borderline recapitulates his external world interpersonal patterns: a seductive wish for protection, which ultimately leads to disappointment, then to feelings of abandonment, finally to self-destructive behaviors and emotional retreat.
Acute Hospitalization
Since the 1990s, increasing costs of hospital care and greater insurance restrictions have restructured hospital-based treatment programs. Most hospital admissions today are precipitated by acute, potentially dangerous crises, including suicide attempts, violent outbursts, psychotic breaks, or self-destructive episodes (drug abuse, uncontrolled anorexia/bulimia, etc.).
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