The consultation request came as a message left on the psychologist's answering machine, which began: "Hi, Doctor. This is Jane, the nurse over at Ashton Manor. There's a patient here whom I'd really like you to see. Her name is Lenore, and if you can't come and do something with her soon, I'll probably murder her."
The psychologist was able to stop by the skilled nursing facility on her way home, intending to look over the resident's chart and to set up an appointment for the assessment and consultation. As this was late in the day, a new group of nurses and aides had arrived for the evening shift. The charge nurse greeted the psychologist warmly and asked whom she had come to see. When told the resident was Lenore, and that the call to come in had seemed quite urgent, the nurse responded incredulously: "Lenore? I don't understand it. She hasn't been here that long, but she seems to be a sweetie; no bother. I don't know why you'd be called in about her."
The defense of splitting is central in the repertoire of those with a personality disorder in Cluster B, especially for those with Borderline Personality Disorder (BPD). The reality of the individual with BPD is notable for affective and cognitive experiences and distortions, which shift with remarkable alacrity to the extremes. There is no gray. People and events are experienced as all good or all bad. The splitting transcends multiple relationships and venues, typically wreaking havoc.
Many, perhaps most, individuals who develop a personality disorder have themselves experienced a seriously disordered childhood. Lenore's early history was no exception. She and her identical twin sister, Maureen, were their parents' only children, born when their parents were in their late 30s, considerably older parents than the norm in the 1920s.
Their parents had developed a strong relationship pattern over the more than 12 years of their marriage. The pattern was dysfunctional but comfortably familiar. Lenore's father was tough and distant, having poor regard for women. While always holding a job, he was a weekend drunk, becoming more argumentative and nasty as the weekend progressed. Most of his ire was taken out on his wife, but as the girls got older, they were included as objects of his frustration and rage. Lenore's mother would tolerate her husband's abuse, knowing that by Monday morning he would "clean up and fly right" again. She tried intermittently to protect the girls, but mostly she modeled helplessness and despair. On a few occasions when Lenore's father got especially out of control and the physical violence escalated, their mother took the twins to a cousin's house nearby for a day or two until the situation at home cooled off, at which point they would return home. The tacit rule was that no one would speak about their father's drinking or abusive behavior, or about the fear and inconsistency that permeated their lives. So the girls came to act this out, each in a very different way.
When the twins reached adolescence and became visibly sexual beings, their father's rage would be as easily directed at them as at their mother. As destructive as this was, by taking it, they felt they were in some way protecting their mother in a way that she was never able to protect them.
Lenore's way of dealing with her internal anguish and the helpless victimization at home was to run away, which she began doing at the age of 14. She would stay out of the house for 1 or 2 days, ultimately 3 or 4, and then return, tired and bruised, from the streets or from her own hand. By this time she had started to smoke cigarettes and to burn herself with the lit end. Her forearms and upper arms were marked by blisters, receding into small red circles. This behavior served as a release valve for her feelings of rage which were often threatening to explode. Feeling pain was a way to stop feeling pain.
When she was on the streets, she would engage in sex with anyone who offered to buy her a meal, give her smokes or whiskey, or tell her he loved her. When she would return home, her mother would most often ignore her. At other times, she would yell hysterically, wailing about the worry and concern Lenore's absence had caused. These emotional outbursts would often follow an especially brutal weekend at the hands of her husband.
Maureen's way of handling her pain was very different from her twin's. She did not physically run away. Rather, she learned to stay very still and not flinch, even when her father molested her, which he came to do. But she ran away inside, withdrawing to a point of dissociation, to a place where she felt no pain. In time, the memories became blurred as though through gauze, and in yet more time, vanished altogether. Intermittently she would refuse to eat, starving herself with the magical promise of retreating into a little child's frame.
When Lenore was 17, she left home for the final time. She took a job at a deli shop, waiting on tables and serving behind the counter. She was intelligent and learned fast and was calmed by the repetitive structure of the work. The older couple that owned the shop liked Lenore and allowed her to occupy a room in an apartment above the shop for little rent. And of course she was able to eat very well at no cost. Occasionally she would feel the need to run, and would stay out all night, but the couple was willing to indulge her little slips as they increasingly came to count on her as an employee and a young all-around helper. On the occasions when they would challenge her behavior, she would fly into a rage and threaten to kill herself if they in any way implied that they might dismiss her. Of course her threats kept them in line, precisely what they were intended to do.
Lenore had many boyfriends, but none lasted. Initially she was agreeable, actually quite charming to suitors, but in time they would say or do something to induce panic in her, which she would act out in rage to save her life; accusing, threatening, and always inducing chaos into the relationship. After several such episodes, most of her lovers would cut and run, but one stayed. This was Jack, who came to work as the short-order cook, in time becoming the manager and ultimately the owner of the deli.
They courted briefly and were married. This began a relatively settled period for Lenore. Her impulsivity, affective lability, and self-harming behaviors became calmed in the steady presence of Jack and their work together at the deli. Indeed, Lenore's passionate and enthusiastic tendencies were put to good use as the couple modernized the deli and developed a thriving business. They had two children, a girl and then a boy who died shortly after his birth. Lenore would have no more babies after that. Her mothering was inconsistent, alternating between being overly close and attentive, and being remote and unavailable. Fortunately for their daughter, Jack's temperamental evenness served as a counterbalance to Lenore's erratic behaviors. Their daughter grew up well with the support of the jovial ambience at the deli where she spent much of her childhood.
Lenore was stable until her twin's suicide at age 35. Maureen had been in and out of psychiatric institutions for much of her adult life, leaving Lenore feeling painful survivor's guilt, which overwhelmed her when her twin died. Her profound grief was experienced as blinding rage evolving into a psychosis, which was transient and resolved quickly. She was hospitalized and received shock treatments, which were a major psychiatric treatment at that time. A lengthy stay in the hospital, and perhaps the treatments, appeared to quiet her demons and to contain her. When she returned home, she appeared thinner, weary, and noticeably less animated.
Things changed dramatically after her husband's death and the sale of the deli, which soon followed. Lenore's somewhat subdued demeanor now deteriorated significantly. She became irritable, critical, and demanding. She would call her daughter numerous times during the day to complain about anything and everything, often directing the conversation to provoke a squabble that she ended by slamming down the receiver, or by accusing her daughter of not caring and being unconcerned about her welfare. "What difference does it make to you? You don't care if I live or die."
A smoker all her life, Lenore ultimately developed emphysema. This, in addition to hypertension and coronary artery disease made her life become more circumscribed. She began to drink more in the evenings alone, which did not mix well with either her multiple medications or her impulsive tendencies. Lenore's daughter, a career woman in a responsible position, would visit her mother infrequently because the visits were marked by angry hostility, manipu-lativeness, and veiled threats of self-harm. When, during one visit, it became apparent that Lenore was at real risk, her daughter, through the family physician, arranged for Lenore to be hospitalized for evaluation and stabilization. This was not a courtesy admission, as Lenore actually was at risk. She was smoking while using oxygen, was drinking alcohol abusively, and was not taking her medications reliably. The hospital determined that because of hardening of the arteries, her mental status was mildly compromised. This, in conjunction with her aggressive outbursts and emotional lability, led to the recommendation that she be discharged to a nursing home where she could be monitored and provided a constant level of skilled care. Lenore was furious but agreed to go for a while, actually feeling somewhat relieved to be spared the isolation of living alone. At least in the nursing home there would be company and new people to care for her and to love her.
Initially she was pleasant to the staff and other residents. She would ask questions about their lives and expect that they would do the same. But quickly events began to irritate her. She would become angry if an aide cut her stories off or attention to her seemed too brief. She became very aware of who among the staff were really interested in her, and who didn't like her and couldn't wait to get away from her. These quickly became the good guys and the bad guys.
Lenore became very jealous of other residents who, she perceived, got more attention, better service, or more food than she did. In time, this jealousy escalated to rage and acting out. Lenore began to take food from these residents' plates, resulting in her being banned from the dining room for the next meal or the next day. Soon she was eating most of her meals in her room. This made her even more angry to the point where she would throw her food tray across the room or, on one occasion, physically lash out at the dietary aide when she came to remove Lenore's tray.
Her favorite nurse and aide were on the same late afternoon shift. For them, she had a smile and was charming. They were both baffled by the report from the other shifts and did not agree with the punishment of barring Lenore from the dining room. At mealtimes when they were on duty, Lenore was allowed to eat with the other residents, who mostly ignored her and gave her wide berth.
Lenore demanded to be taken out several times a day for a cigarette break. This was an inconvenience to the nursing home as it required that a staff member be assigned to Lenore to disconnect her from the portable oxygen and accompany her to an outside, screened-in area where smoking was permitted. Lenore was allowed three such breaks each day. She would, in anticipation of these, place herself in front of the nursing station and verbally, loudly, harass the staff if they were a minute late to take her outside. While waiting, she would make lewd and derisive comments to other residents who were speaking with staff at the station. She was especially likely to pick on the more cognitively impaired residents, calling out terrible things to them. Her repeated verbal abuse of one such resident—a gentle, meek woman favored by the staff—became the active precipitant of the call for a consultation: "If you can't come and do something with her soon, I'll probably murder her."
The consultant began by meeting with the staff to identify Lenore's problem behaviors, defined as those behaviors that were most disturbing to the staff and caused most interference with her care. Staff initially identified the following behaviors:
■ She rarely had any visitors because her daughter disliked coming to see her and was often angry at her mother for excessive, angry phone calls. This put pressure on the staff to socialize with her.
■ She was verbally abusive to staff and to other residents.
■ She yelled if her needs weren't met immediately.
■ She split the staff, so that they argued among themselves about her care.
The next phase identified the antecedents and consequences of these problem behaviors. When she got angry with staff, she placed angry phone calls to her daughter. The consequences of this were that Lenore's daughter avoided visits and became angry with the staff for not being more attentive to her mother and making sure
Lenore didn't make excessive calls at inappropriate times. The staff then became angrier with Lenore and less likely to want to attend to her. The maladaptive pattern was identified and discussed.
The next aspect of the consultation was to share Lenore's story (her personal history) to encourage staff to get to know her and how she might feel and think. This knowledge would provide a context for her behaviors, even the most irritating ones. What might be the message of such behaviors? For example, stealing food might mean, "I need to be fed. I'm hungry for attention and love. If you won't offer it, I'll take it. I need sustenance to survive."
The next aspect of the consultation served to explore the effect of Lenore's behaviors on the system of the nursing home. The staff was encouraged to identify those resident traits that they most valued, and alternatively those that made their jobs most difficult. How did they feel about these residents? What was the effect of these feelings on their behavior? The concept of splitting was discussed, including its adaptive and maladaptive functions.
The consultation then moved toward an intervention/treatment plan. The staff was asked to note everything that had been tried with Lenore. The effect of these attempts was appraised as either having helped, worsened, or had no effect at all on the behavior. The tendency to do things over again, only more vigorously, when not successful, was talked about as being universal. Understanding this opened up staff to trying something new and to discontinuing responses to Lenore that had not been helpful in the past.
Last, the problem behaviors were reviewed and ranked in terms of their negative effect. The questions to the staff about each specific behavior were addressed. How would you know if this gets better? How would improvement be identified?
These then become the intervention goals. Each goal was then operationalized and its probability of success anticipated. A goal was selected to work on and a treatment intervention was delineated and agreed on. Staff understood that all staff had to be on board, and that the response to Lenore's behavior had to be consistent among staff and across shifts. The first goal selected for Lenore was food stealing.
The intervention was outlined as follows: Lenore would be seated at a table with other residents who were sufficiently cogni-tively intact to support appropriate socialization and conversation. A staff member would sit at the table. The presence of a staff mem ber would serve three functions: To model appropriate communal dining skills (including eating off one's own plate only, and asking for extra food if desired), to facilitate conversation at the table, and to talk with Lenore directly, asking her questions to draw out what she could positively and literally bring to the table. When this was successful (operationalized as 4 successive days with no food stealing), the staff member would then just accompany Lenore to the table and connect her conversationally with her dining mates. When this was successful (a week without food-stealing incidents), the staff member would then simply bring Lenore to the table, settle her, and withdraw.
In addition, after each successful meal, the staff member would give Lenore positive feedback, complimenting her on her behavior and rewarding her with a few extra minutes of conversation and attention.
Although the intervention would be somewhat labor intensive for the short term, all agreed that it would be worthwhile if successful. A follow-up meeting with the consultant was scheduled to review the effect of the intervention on Lenore's behavior and on the staff.
The interventions for the other goals followed this same pattern: goal selection, operationalization of its effectiveness, implementation, assessment, and feedback. With each achieved success, the staff became more unified, proficient with the protocol, and committed to behavioral interventions. Staff came to appreciate that, especially with the more intractable personality disordered residents, the greatest positive change is often most readily achieved through a small change by the system.
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