Abstract
Recent years have seen the publication in this journal of two papers outlining the principles and practice of the therapeutic community [1,2], a commemoration of the 40th anniversary of the publication of Tom Main's The Ailment [3], and a ‘prospective psychotherapy outcome study’ [4] from a small residential unit in New Zealand incorporating many therapeutic community principles. In different ways, each of these papers addresses the question of the optimal provision of residential psychotherapeutic treatment for patients with personality disorder.
A further paper by Beatson [5] reviewing the psychotherapeutic treatment of patients on the narcissistic-borderline spectrum, emphasises the importance of treatment matching the individual patient's needs, and that successful outcome is likely to require many years of therapeutic work. Beatson also summarises the research evidence in support of what has long been inferred by psychoanalysts and psychotherapists from clinical experience: namely, that the roots of severe disturbance of the personality can usually be traced back to the nature of infant experience and the quality of early maternal attachment.
This paper describes the therapeutic community treatment of a patient presenting with brief episodes of psychosis on the background of personality disorder with borderline features. It has two aims: first, to provide a description of the patient's treatment in sufficient detail to illustrate the psychotherapeutic potential of the functioning therapeutic community; that is, to attempt to illustrate the principles of a ‘therapeutic community’ approach in practice.
The second aim is to offer the case history as evidence for the potential efficacy of the psychodynamically informed management of patients with personality disturbance associated with symptomatology of sufficient severity to necessitate inpatient treatment. The method of scientific investigation currently favoured within psychiatry is an empirical one, involving the observation and measurement of selected phenomena across samples, under standardised conditions, in order to obtain data that may be subject to tests of statistical significance. Such methodology is applicable to psychotherapy research, but there are well recognised difficulties [6]. The case history, in contrast, represents an instance of an historical method of scientific investigation, and offers an alternative source of scientific data which can bear upon the question of the efficacy of a treatment [7]. In a case history inference about causality is made on the basis of observation of the apparent linkage of phenomena by cause and effect, along with consideration as to whether the hypothesized causal mechanism seems plausible, and takes adequate account of other possible factors.
In the present case, an attempt is made to demonstrate the link between the patient's clinical improvement and processes taking place as a result of his participation in the therapeutic milieu, which included individual therapy.
Patient B: background
B, a 31-year-old single male, requested admission to a private hospital with therapeutic community facilities. Five years earlier he had first presented to a psychiatrist with recurrent depression and received treatment with antidepressant medications including lithium. Eighteen months earlier he returned to live with his parents, and subsequently there had been three admissions, each of several weeks, to a psychiatric unit for treatment of episodes of acute illness with mood disturbance and psychotic features.
Although presenting mostly as depressed, on one occasion, in a rage, he had destroyed property in his parents' house, and was described as being ‘in the manic phase of a bipolar disorder’. There was a family history of psychiatric disorder; three second-degree relatives were said to suffer from ‘manic depression’. Medication at admission was lithium carbonate (serum level = 0.8 mmol/L), fluoxetine 20 mg, and zopiclone 15 mg for sleep.
B said he had chosen to come to this hospital because he hoped to discover how much of his problems was due to ‘mental illness’ and how much due to ‘emotional baggage’. He felt his difficulties had really begun at age 17 following a low-speed motorcycle accident in which he sustained a fractured femur, but no other injury. The fracture required plating, and although healing was satisfactory, pain persisted and B became depressed. When the pain was fully investigated several years later, an osteoid osteoma was diagnosed and further surgery required. Despite eventual resolution of the physical symptoms, B felt he never fully recovered mentally. He continued to feel frustrated, depressed, ‘blocked emotionally’, and alienated from relationships and the world around him.
B was the youngest sibling. He expressed ambivalent feelings towards both parents, particularly his mother, and thought she may have been depressed following his birth. His childhood experience he remembered as reasonably satisfactory, although he stated he had become ‘a worrier’ by 10 years of age. At school he did well academically, but when he attended university he felt socially anxious to the point that he left and took up casual employment. After several years he returned to university, obtaining high grades in his first year, but again found the environment too stressful and withdrew from studies. For the subsequent 5 years he was in stable employment. He had experienced brief heterosexual relationships.
B presented with a somewhat staring gaze, and little spontaneous facial expression. He seemed frustrated. He spoke hesitantly, sometimes breaking off in the middle of a sentence; ‘My mind just goes blank’, he explained. Otherwise there were no specific psychotic symptoms and depression was not marked.
The initial impression was of B's considerable and constrained anger, and the presence of significant personality disorder. After a period in an assessment ward B was transferred to a therapeutic community ward where the emotional issues could be further explored.
The treatment
The treatment lasted 18 months in total, the first 6 months as an inpatient, followed by a year attending the hospital's day psychotherapy program. While attending the day program B was resident in the hospital's on site self-care facility for 8 months, and subsequently resident outside of the hospital. Throughout this time, B was seen in individual therapy twice weekly by the author.
The most striking aspect of B's treatment was an intense rage which emerged and found expression in repeated episodes of psychological decompensation associated initially with psychotic features.
From the beginning an attempt was made to establish an exploratory approach in the individual therapy. B experienced the associated lack of direction and overt reassurance as a source of considerable frustration. He felt further frustrated by his inability to express himself with ease or fluency. Within the therapeutic community ward he quickly formed a powerful and important attachment to a female nurse. In an early individual therapy session he spoke about the reassurance this relationship offered him. He then described an incident when, as a teenager, he had attempted to communicate something to his mother but had felt dismissed by her. He had been overwhelmed with anger, and said to himself, ‘I'll never speak to her again!’. The following therapy session he did not attend, stating later that he ‘probably forgot’. Exploration of this material in the next session clarified his angry wish to dismiss his therapist. He wanted a ‘perfect listener’, a role he felt his therapist would never satisfy. Moreover, his therapist was male; B believed a female therapist, like the nurse, would provide what he really needed. He expressed doubt as to whether this difficulty could be resolved. In the next session, B talked with some insight about a ‘split’ in himself that he feared would never be resolved.
At the beginning of the treatment B demonstrated the existence of this ‘split’ in his division between the ‘good’ nurse and the ‘bad’ therapist. His intense transference need for a ‘mirroring’ maternal response apparently represented the reactivation of an unmet infant need, and the associated experience of frustration and rage seemed close to consciousness. Powerful dependence and splitting are characteristic features of the borderline personality organisation, and suggestive of its early developmental origin.
B's need for uncompromised ‘mirroring’ in interpersonal relationships was intense and his therapist's attempted interpretations were often experienced as a poor substitute for the ‘maternal’ attention he felt was needed. At worst, when they offered no immediate relief or reassurance, they were experienced as provocative and persecutory. Despite this, B showed both a capacity to think about and a wish to understand his difficulties, and the exploratory approach was able to be maintained.
Two months after admission, B's rage toward another patient in a group therapy session led to him punching a wall. The following day he entered his individual therapy session visibly stressed, tense and angry. His frustration mounted during the session until he broke a piece of furniture in the room. This act seemed to represent the giving up of a desperate attempt to hold his rage in and hold himself together, and over the next few hours his mental state became psychotically disorganised, with fragmentation and blocking of the stream of thought. The risk of further aggressive behaviour necessitated transfer to a secure unit in another hospital.
B spent several days in this unit and his mental state was markedly impaired. He looked tense and bewildered, and was only able to articulate fragmented thoughts with difficulty. There was no evidence of hallucination or delusional disturbance of thought. He later described how his mind had felt ‘caught in pincers’. Continuity of the individual therapy was maintained by his therapist visiting the secure unit. The impairment of B's thought process necessitated the adoption of a supportive role of simply being with the patient, often in silence. Thioridazine at approximately 1 g/day contributed to the settling of his mental state, and was continued in a reducing dose upon return to the therapeutic community.
Upon his recovery and return from the secure facility, B seemed more able to express his ongoing frustrations. In a session, he stated that the nurse, unlike his therapist, knew what to say to ‘dissipate the frustration’. On this, and similar occasions, attempts to interpret B's dissatisfaction in terms of a maternal transference or a presumed infant experience, often merely intensified his frustration and sense of impasse. The therapist's countertransferance experience was that of being an inadequate mother, unable to provide anything that could be experienced as good enough. In an attempt to move beyond this persecutory transference, the therapist asked B if he had ever observed a mother with a baby. Yes, said B, he had recently visited a friend with a new baby, and remarked how ‘amazingly in tune’ with the baby the mother had seemed. At this point the tone of the session shifted: B seemed able to identify with the baby held in the mother's ‘reverie’ [8], and for once to experience his therapist as being in tune with him; able to ‘dissipate’ rather than aggravate his frustration.
Along with occasional such moments, when B experienced a sense of positive connection in the therapy, he also began to intermittently experience painful feelings of loss and sadness. He reported a dream which seemed to represent his need to feel securely held before he could allow such experience: he was crying freely while being held by a woman, but when she let him go he stopped crying.
The most immediate difficulty, however, remained B's anger, and the predominant theme in the sessions remained his frustration with the therapist he had been assigned. Not only was therapy a source of frustration, but the nature of the therapeutic community experience is such that the patient is forced to deal with potentially frustrating social realities [2]. An incident, precipitated by experiences of rejection and ‘being ignored’ by other patients occurred where B punched a hole in the wall of the ward. He described a ‘big mess of anger and frustration’ inside him, then entered a second psychotic episode. After discussion both within the therapeutic team and the larger staff group, it was decided to attempt management within the unit rather than by transfer to the secure facility. This attempt, necessitating individual nursing and the use of thioridazine in substantial doses, proved successful.
B later described this experience as different and more painful than the first psychotic episode. He had a sense of his mind going to pieces, and found it difficult to believe he would recover. Nevertheless, clear changes were now observable since admission and seemed particularly to have followed this second episode of fragmentation. At times he was more spontaneous, and more capable of managing social interactions, as if some diminution of the ‘block’ in his mind had occurred. He stated that he was feeling stronger and made a tentative plan for discharge from the hospital in 1 month. This, however, appeared premature, and when B spent a period on leave with his family his own emotional responses threatened to overwhelm him; he cut short his leave and returned to the hospital feeling fragile and hopeless.
As an alternative to discharge, B expressed interest in moving to the day psychotherapy program, making it possible for him to live on site in the hospital's self-care residence. This was supported by the clinical team, despite uncertainty as to whether he was ready to take such a step. The move did prove difficult, and in retrospect B's wish to move on contained elements of a manic defence, a denial of recognition of the extent of his ongoing dependence and need for support and containment. He was soon struggling with a sense of abandonment upon leaving the inpatient community, and with the demands of the intensive insight directed day psychotherapy program.
B was nevertheless more able to tolerate his feelings of vulnerability and despair, acknowledging in a session that he could see some value in the therapy process of exploring painful emotional experience rather than simply trying to avoid it. Stresses in his relationships in the self-care house and his ongoing experience of deprivation with his therapist, who he complained kept him on a ‘starvation diet’, led to renewed and intense feelings of frustration, but B continued to express these in words rather than action.
When a third episode of decompensation occurred after several weeks' residence in the self-care house, this was managed with a brief readmission to the therapeutic community unit, intensive nursing supervision, and the use of thioridazine. Although B expressed fear of losing control of his anger, this did not occur. He was visibly more distressed than previously, and was able to cry freely while being comforted by the female nurse with whom he maintained a special relationship; an enactment of the need previously expressed in the dream. Later, in a therapy session, he described how he had experienced this both as an enormous relief, and as an achievement. He was then able to experience further sadness in the session, and his statement that he did not wish it to end reflected his greater sense of being held within the individual therapy.
B again appeared to make gains linked to this third episode. This pattern suggested that the episodes of fragmentation constituted part of a therapeutic process; that the psychic disintegration was a necessary precondition for reintegration. B's increasing capacity to bear painful emotional experience, and rage, in consciousness seemed attributable both to his being held safely through these acute episodes, and the containment achieved between episodes through understanding of his own psychological processes.
From this point B seemed to have a greater sense of the problem as existing inside himself. Although he continued to struggle with feelings of deprivation and frustration in relationships, he could consider his own contribution rather than simply project all difficulties, attributing them to the failure of others. At times he experienced intense loneliness and despair. He continued to experience his therapist as a block to progress, but was increasingly able to reveal his thoughts in the therapy. B's growing wish to understand his difficulties was reflected in his speaking with his mother about his infant experience. She confirmed that she had been depressed for at least 18 months after his birth.
A fourth breakdown was precipitated by intense rage with another patient in the self-care house. This episode, also managed with brief inpatient admission, was less severe. In a therapy session, B described emerging out of this episode with a feeling as though he was reconstructing a wall around himself. The problem with this wall, he reflected, was that it seemed to prevent ‘anything coming up’ from inside him.
For some time B felt there were no satisfying relationships anywhere, and was even angry with, and hostile towards, the female nurse. In a session, he reflected upon the way his anger alienated him from other patients in the day psychotherapy program. This insight into his authorship of his own difficulties reflected a developing depressive awareness. There were periods of intense sadness and despair, on occasions accompanied by suicidal thoughts.
Two further significant ‘breakdowns’ occurred and were managed by brief readmission to the inpatient community. The last occurred while B was living outside the hospital and attending the day psychotherapy program, and was precipitated when the female nurse left the hospital for extended leave. B's capacity to experience the pain of this loss seemed evidence of therapeutic gain. The changed nature of the episodes themselves was also evidence of gain; these were less severe, the psychotic features were no longer obvious, the risk of aggressive behaviour had receded, and B's experience was increasingly of pain as well as anger.
B's own discharge from the program and the termination of his therapy followed not long after. As this approached, he was aware of, and talked in sessions about, his capacity to block his emotional responses to his leaving. In the last therapy session, he spoke realistically about his increased sense of spontaneity, while recognising that he still felt an inner block, and expressing doubt that he could ever become fully well. He felt both hope in having made progress, and despair at the sense of limitation he continued to experience.
Follow-up
Three years following discharge, there have been no further hospitalisations. B has recently recommenced individual psychotherapy, and reports further progress.
Formulation of case and treatment
The patient presented with a history of recurrent disorganised psychotic episodes associated with impulsive behaviour, on the background of longstanding depression and the sense of his self as incomplete. His capacity for intimacy was impaired, and mature reciprocity in relationships was lacking. Descriptions of the psychotic episodes suggested that they were neither bipolar nor schizophreniform in nature, and the diagnosis of bipolar disorder was incorrect. They appeared to be regressive episodes, of the sort sometimes associated with borderline personality disorder, and fulfilling the DSM-IV criteria for brief psychotic disorder.
In object relations terms such a presentation suggests failure of the ‘good enough’ [9] experience of the maternal function in early development, an inability to integrate this early experience of deprivation/frustration, and a consequent failure to satisfactorily negotiate the ‘depressive position’ [10] and acquire a sufficiently coherent self experience. The apparent history of maternal postnatal depression suggested a possible origin of the developmental disruption. On the basis of this tentative aetiological formulation, an initial psychotherapeutic treatment approach was adopted, with ongoing assessment of the patient's capacity to benefit.
The correctness of this clinical approach seemed confirmed by subsequent developments. When further episodes of decompensation were precipitated after admission, observation over time suggested that they represented part of a process of reintegration within the patient's mind through the emergence into consciousness of previously unconscious emotional states. The patient found these episodes bewildering and terrifying; however, perceptible changes in psychological functioning seemed to be linked to them, and each breakdown seemed to facilitate further psychological development. This pattern of improvement out of the episodes of decompensation is consistent with Rosenfeld's psychoanalytic observation, that acute confusional states in patients with psychotic processes tend to precipitate change in the patient's overall clinical state; a change which may be towards either improvement or deterioration, depending on the way in which the disorganised experience is dealt with by the patient and others [11].
Several important factors contributing to the outcome of the treatment could be identified. The capacity of staff and the environment to contain [8], confront, and place realistic limits on the expression of the patient's rage, while avoiding punitive retaliation, was crucial. This function allowed the safe emergence of primitive emotional elements, thereby facilitating the development of the patient's own capacity for containment. As well as the individual therapy, the patient was involved in a variety of therapeutic relationships and processes within the community, most important of which was the relationship with the female nurse. The ability of the nursing staff, and in particular the nurse by whom the patient felt supported and understood, to regulate their relationships to provide the necessary emotional support, while not fostering the emergence of idealised transferences and thereby contributing to the split between therapist and nursing staff, was essential in the provision of optimal containment. The maintenance of this collective integration within the treatment team probably ensured the viability of both the individual therapy, and the treatment as a whole.
The nurse was initially able to accept, and therefore able to meet, the patient's need of an object embodying hope, and an idealised transference figure. Later, when the patient experienced inevitable disappointments and frustrations in this relationship, the nurse's psychotherapeutic understanding was such that she was equally able to accept the patient's anger, and thus remained a predominantly good object. This relationship was important to the patient throughout the treatment, and was consciously felt to be more so than that with his individual therapist.
The potential interactive effect of a therapeutic community setting with individual psychotherapy is well illustrated in the management of the patient's episodes of psychotic decompensation. The supportive nature of the community provided a degree of holding that individual therapy alone could not. The patient seemed to need to let go of a rigid and deadening way of holding himself together, and this was initiated by the breakdowns and the emotional catharsis associated with them. The treatment environment was flexible enough to accommodate to this process, and an emotional freeing up resulted, with diminished anxiety, and an increased capacity for self-expression. This facilitated individual therapy, and the experiences of the breakdowns also provided valuable material for exploration therein; once these experiences could be thought about, they could be understood as meaningful reactions connected to both present and past. The individual therapy contributed to the gradual growth, evident during treatment, in the patient's capacity for conceptual thought, self-reflection, and psychological understanding; this increasing ‘psychological mindedness’ contributed in turn to the development of the patient's capacity for emotional self containment, and hence to the decrease in severity of the breakdowns.
Although it has not been possible to present all the supporting clinical detail, the following formulation was arrived at by the end of treatment: the patient's infantile experience with a depressed mother appeared to have resulted in an unintegrated ‘psychotic rage’, split off from consciousness. The psychological equilibrium that had been maintained through childhood was destabilised as a consequence of the motorcycle crash at age 17. Loss of control of the motorcycle, the injury, and the consequent dependence, constituted a destabilising narcissistic injury. The accident probably also represented the frightening consequences of the loss of control of unconscious aggression. The frustrating complications of the injury and enforced dependence upon mother and family would seem to have activated unconscious anxieties about dependency and the latent hostility, and a chronic state of depression and loss of confidence supervened. This variable state of depression persisted many years until the patient returned to the family home, perhaps because of unresolved dependency needs towards the parents. The frustration experienced in this situation finally resulted in a breakthrough of rage into consciousness, associated with an experience of psychotic fragmentation.
There was clear evidence of improvement in the patient's mental functioning during the course of treatment, and the patient's subjective experience appeared to become much more coherent. As is often the case in the therapeutic community context, the treatment provided psychotherapeutic management of a process of regression which was already well underway at the time of presentation. In so doing, the treatment would seem to have helped create the possibility of a ‘new beginning’ [12] for the patient, but no claim is made that it was complete or constituted a ‘cure’. The block or ‘split’ within the patient's mind was less, but had not been fully worked through, as reflected in the only partial resolution of the split between therapist and nurse. The patient was only too aware of his continuing fear of intimacy and difficulties in negotiating relationships, and continued to experience anxiety and depression. Although able to acknowledge progress, he had hoped for more, and felt dissatisfied with many aspects of the treatment. Probably as a result of this ambivalence, it was some time following discharge before he felt able to risk further involvement in a psychotherapeutic relationship.
Role of medication
At admission, B was taking antidepressant medications (fluoxetine and lithium). As there was no clear evidence of benefit, they were withdrawn during the course of treatment.
Thioridazine played an important role in providing holding during episodes of decompensation, and was used in an attempt to reduce the risk of violence and to render the experience more bearable for the patient. After each episode thioridazine was reduced as soon as this seemed feasible. At times, the patient continued to take a small dose between episodes; however, there was nothing to suggest that the overall pattern of improvement could be attributed to the drug. At the time of discharge, B was taking 50–100 mg of thioridazine at night on an occasional basis.
Discussion
The borderline patient presents well-recognised difficulties in standard psychiatric inpatient settings, but the source of these difficulties can be understood in terms of the environment, as well as in terms of the patient. General psychiatric settings may present an unyielding barrier to the patient's projections, and be experienced as unreceptive and uncontaining. Processes of diagnosis and management often subserve defensive functions that contribute to ensuring the anxieties generated within staff in response to the disturbed patient remain latent. A diagnosis, for example, which necessarily locates the illness within the patient, can stand as a barrier between the patient's ‘madness’ and the staff's ‘sanity’. Such barriers maintain a sense of safety for staff but may not allow the patient to feel held.
In contrast, when staff attempt psychotherapeutic treatment of the borderline patient, the greater proximity to, and contact with, the patient's emotional experience activates anxieties to do with the staff members' own areas of ‘primitive’ or ‘borderline’ functioning. There is always the risk of staff then repudiating awareness of their own difficult or painful psychological responses, and projectively identifying these with the patient; what may have been a manageable situation will then be felt to be unmanageable. If, however, the staff are able to contain and think about their own anxieties the basis for constructive treatment is created.
At the same time, these patients are inevitably difficult and, as in the present case, real concerns, requiring realistic appraisal, about issues of safety and treatment viability often arise. In such circumstances, treatment can only be maintained through adequate clinical discussion of all issues and anxieties, to ensure broad consensus, and that the inevitable differences between staff do not activate major splits. Because the inner world of the borderline and psychotic patient is already split or fragmented, a treatment environment which recreates this is inevitably experienced as unsafe and may lead to deterioration. If the patient senses the treatment environment is both receptive and resilient, that it will not fragment or split in response to the patient, the risk of extreme behaviour is reduced.
The provision of this collective containing function by staff and institution is a basic and essential element in any effective therapeutic community treatment, and probably necessary for effective psychotherapeutic management in any inpatient setting. Establishing such a treatment milieu places considerable emotional demands upon staff, and ‘good enough’ containment is not easily achieved [1,2].
Conclusions
The case of a patient presenting with brief psychotic episodes and a borderline personality organisation treated psychotherapeutically in a residential context is described. There was clear evidence of clinical improvement during treatment which seemed, at least in part, attributable to the therapeutic approach of the treatment team.
Although the sometimes severe and disorganised clinical presentation of borderline patients, in this case with brief psychotic episodes, may make psychodynamic formulation difficult, any treatment approach that is not based upon a working formulation is likely to be compromised. The assessment and inpatient treatment of the borderline patient by psychological means requires a highly integrated and supportive treatment milieu, and a residential facility with a therapeutic community orientation is best suited to the purpose.
Footnotes
Acknowledgement
I am grateful to the patient for his generous permission to publish this material.