ACA Blog

Jill Presnell
Sep 13, 2012

The Inpatient Therapist: The “Borderline Brigade” (Reactive disengagement Part 1)

[Note: this is a long blog but I believe it is an important issue for all Counselors] Recently, during morning report as the nurses were being assigned their patients for the day, a relatively new day nurse looked at her list and groused “great, I have the Borderline Brigade.” My jaw clenched. Several staff members looked at me, knowing that these kinds of derogatory references infuriate me. I held my tongue, choosing to pick my battles.

Stigma and the pejorative use of labels exist within the mental health profession. Nowhere is this more prevalent than on an inpatient unit. Research shows that inpatient staff expresses more judgmental feelings toward patients than any other group of “professionals.” This is particularly true with reference to individuals with borderline personality disorder, addictions, and psychosis.

Individuals admitted to acute inpatient units do not possess the social supports, coping skills or identity strength required to manage the degree of external and internal distress they are experiencing. As a result, these folks often display extreme methods of engaging their world which are desperate attempts to regain a sense of control and stability. They frequently project their internal states onto unit staff. Staff members become bodily representations of the therapeutic hospital setting. Whether this is perceived positively or negatively depends on the person’s situation.

On our unit, day staff working on the floor (typically 2 nurses, one psychiatric technician, 1 adult therapist and 1 adolescent therapist) work 12 hour shifts with up to 26 patients. Engagement for such an extended period of time can become dangerous to one’s emotional and mental health. This is particularly true if there is a lack of training, support, supervision, teamwork, and personal wellness. As a result, staff can create subconscious methods of physical and emotional disengagement. These self-protective measures can include spending excessive amounts of time in the office, using sedation (medication) as a first response to patient distress, and using pejorative labels and diagnoses as a means of justifying reactive responses.

Borderline Personality Disorder (BPD) is the most frequently applied diagnostic excuse for disengagement. “Borderline” is a common codeword within the profession for individuals (most often women) whose inpatient behavior requires the highest amount of emotional and physical engagement from staff. These patients often display desperate, crisis-prone, and attention-drawing behaviors. Examples are patients who display intense mood fluctuations and reactivity; who frequently approach staff to report sudden suicidal or self-harm thoughts; or who engage in any attempt to self harm while in the hospital. Workers become frustrated at the ineffectiveness of typical interventions to quickly curb these behaviors. Sometimes this begins a pattern of officious, inflexible and aggressive reactions toward these patients. This frustration, in its most extreme expression, can lead to “malignant alienation,” a form of reactive interaction which is characterized by hypercritical contact and complete therapeutic disengagement from the person. Malignant alienation is a common precursor to inpatient suicide.
It has been my experience that most patients whom staff members label “borderline” do not meet the diagnostic requirements. When individuals whose interpersonal, intrapersonal, affective and reactive patterns do in fact fall into the nebulous BPD category, they are commonly misunderstood by staff as being strategically manipulative and attention seeking. Training about this disorder is crucial to the development of therapeutic interaction.

An extremely high percentage of admitted people with BPD have a history of childhood sexual abuse. This generally creates a deeply internalized sense of “badness” and intense psychological pain which breaks through when the person experiences aloneness (this experience can occur even when the individual is surrounded by people). Encounters with these internal states often lead to sudden self-destructive desires or behaviors. In the same way, the individual will use increasingly desperate measures to avoid feeling alone (or being abandoned). People with BPD have developed amazingly creative unconscious psychological defenses to prevent encountering their pain. One of these defenses is to psychologically exist in an eternal “now.” Their emotional and mental state in any given moment is experienced as always having happened. This experience of an “eternal now” influences splitting responses (and is the reason why strategically planned out manipulation is unlikely). Those around them become players in their present internal drama. (There is so much complexity to this kind of personality that I can’t adequately capture it in a blog).

Therapeutic interaction in these situations requires that we have a high tolerance for ambiguity and inconsistency as well as strong interpersonal boundaries. It is and unavoidable fact that we will at some point be drawn into the person’s drama. This is not a sign of failure or weakness. In fact, it gives us a glimpse into the powerful struggle occurring within the person. Managing the anger, fear, embarrassment, resentment or other uncomfortable feeling that arise after these interactions is crucial to self-care. Additionally, the experience may lead us to question our own internal stability. It is critical that supervision be available to assist in this process. It can help if we view these experiences as opportunities for self-exploration and increased clinical development.

It’s important to understand acute inpatient treatment is not the setting necessary to promote sustained recovery. In fact, longer hospital stays often lead to behavioral regression (for multiple reasons, some of which are iatrogenic). Placing our expectations of “improvement” onto individuals with BPD leads to anger and resentment, especially considering the fact that many of these folks have multiple hospitalizations. Alienation and judgmental reactions actually feed the patient’s sense of unacceptability and can perpetuate self destructive behaviors. It’s important that we don’t overreact to or be shocked by these behaviors. The best plan is to address safety needs in a manner consistent with what is required while displaying the same level of rapport used in non-crisis situations. The individual may play out defenses by unconsciously attempting to draw us into a confrontive or caretaking stance. Either reaction is untherapeutic. Rescue fantasies put a therapist as severe risk for burnout, especially when working with people with BPD.

I realize that this has been a long blog. I went into greater depth because extremely negative attitudes toward people with BPD are common among providers in all treatment settings. These individuals understandably create feelings of incompetence, ineffectiveness and instability in therapists. Being aware of the effects of working with BPD is crucial to preventing anti-therapeutic attitudes and interactions.



Jill Presnell is a Counselor in Northeastern Pennsylvania as well as an advocate for the provision of recovery oriented mental health services.

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