Journal of Gerontological Nursing

Mahler's Developmental Theory: TRAINING THE NURSE TO TREAT OLDER ADULTS WITH BORDERLINE PERSONALITY DISORDER

Anne Landesman, RN, BScN, MN

Abstract

Borderline personality disorder (BPD) is a pervasive pattern of instability of self-image, interpersonal relationships, and mood, beginning by early adulthood and presenting in a variety of contexts. These individuals have inflexible traits that impair social and occupational functioning throughout their lives (Wester, 1989). Individuals exhibiting this complex condition present profoundly difficult treatment issues not only for nurses and other health care providers, but also for the individuals with this disorder. In long-term care, where most nursing staff do not have the understanding and expertise needed when interacting with older adults with BPD, the challenges are immense. Furthermore, literature on the relationship between age factors and BPD is scant, with little attention being paid to what symptoms these individuals exhibit later in life (Rosowsky & Gurian, 1991). Yet, staff who treat older adults with BPD in long-term care faculties often have health repercussions such as tension, exhaustion, and burnout.

Margaret Mahler, a developmental theorist, describes the psychological birth and development of the human being in her discussions of the separation-individuation theory (Mahler, Pine, & Bergman, 1975). Understanding the separation-individuation developmental process has relevance in understanding BPD. Mahler emphasizes the Rapprochement subphase of separation-individuation as significant in the possible development of individuals with BPD. If the relationship between mother and child is inconsistent and the mother is not attuned to the child's needs, dysfunction can occur. Exploring this component of Mahler's theory can assist in better understanding elderly individuals with BPD. This article discusses the theoretical perspectives of Mahler's separation-individuation process and its relatedness in understanding and working with elderly individuals with BPD in long-term care. An actual case study will be presented to illustrate ways for nurses and other team members to effectively work with individuals with BPD in an institutional setting.…

Borderline personality disorder (BPD) is a pervasive pattern of instability of self-image, interpersonal relationships, and mood, beginning by early adulthood and presenting in a variety of contexts. These individuals have inflexible traits that impair social and occupational functioning throughout their lives (Wester, 1989). Individuals exhibiting this complex condition present profoundly difficult treatment issues not only for nurses and other health care providers, but also for the individuals with this disorder. In long-term care, where most nursing staff do not have the understanding and expertise needed when interacting with older adults with BPD, the challenges are immense. Furthermore, literature on the relationship between age factors and BPD is scant, with little attention being paid to what symptoms these individuals exhibit later in life (Rosowsky & Gurian, 1991). Yet, staff who treat older adults with BPD in long-term care faculties often have health repercussions such as tension, exhaustion, and burnout.

Margaret Mahler, a developmental theorist, describes the psychological birth and development of the human being in her discussions of the separation-individuation theory (Mahler, Pine, & Bergman, 1975). Understanding the separation-individuation developmental process has relevance in understanding BPD. Mahler emphasizes the Rapprochement subphase of separation-individuation as significant in the possible development of individuals with BPD. If the relationship between mother and child is inconsistent and the mother is not attuned to the child's needs, dysfunction can occur. Exploring this component of Mahler's theory can assist in better understanding elderly individuals with BPD. This article discusses the theoretical perspectives of Mahler's separation-individuation process and its relatedness in understanding and working with elderly individuals with BPD in long-term care. An actual case study will be presented to illustrate ways for nurses and other team members to effectively work with individuals with BPD in an institutional setting.

SEPARATION-INDIVIDUATION PROCESS

Separation-individuation refers to the development sequence through which human infants move from "the twilight state of neonatal life to a tuning into the world of reality and the achievement of a sense of separate individual entity" (Edward, Ruskin, & Turrini, 1981, p. 3). Separation signifies differentiation, distancing, boundary formation, and disengagement from die mother. Individuation denotes evolution of the intrapyschic autonomy, psychic structure development, and personality characteristics. Mahler (1972) describes an objecdess phase of development preceding separationindividuation, which she calls "normal autism and the symbiotic phase." However, these early phases of Mahler's theory of development are not discussed further in this article. Rather, an emphasis is placed on deviant negotiation of separation-individuation.

Normally, infants have a powerful innate drive for individuation; however, the libidinal availability and nurturanee of the mother is vital. "As is the case with any intrapyschic process, this one reverberates throughout the life cycle" (Mahler, 1972, p. 333). The principle psychological achievements in this process occur during the period from 4 to 5 months to between 30 and 36 months of age - more specifically, the separation-individuation process.

Mahler (1972) subdivided the separation-individuation process into four subphases: differentiation, practicing, rapproachment, and "on the way to libidinal object COnSIaUCy." Differentiation, the first subphase, begins at 4 to 5 months of age. It is described by Mahler as the process of hatching from the autistic shell. The young infants have become familiar with the mothering half of their symbiotic selves, exhibited by the social, unspecific smile. Stranger anxiety is characteristic at differentiation.

The practicing subphase occurs with the child's spurt in autonomous function, especially upright locomotion, occurring between 10 to 16 months. Separation anxiety is characteristic at the practicing subphase. Mahler refers to the third subphase of separation-individuation as rapproachment, occurring between 16 to 25 months of age. For the purposes of this article, the rapproachment phase will be explored in-depth.

Rapproachment: Normal Development

By the middle of their second year, junior toddlers become more aware, making greater use of their awareness of physical separateness (Mahler, 1972). Important emotional changes are occurring, and in the early part of rapproachment, there is increased evidence of separateness of the self from object (Edward et al., 1981). Aligned with cognitive growth, there is an increasing differentiation of the emotional life, with a noticeable waning of imperviousness to frustration.

Mahler also notes the child's relative obviousness of the mother's presence, which gives way to a constant concern as to her whereabouts, coined by Mahler (1972) as "active approach behavior'* (p. 337). Increased separation anxiety from the mother is observed. Mahler denotes this as a fear of object loss inferred from mother not being readily at hand when toddlers hurt themselves. This, coupled with the toddlers' ability to move away from their mothers and their cognitive growth, appears to result in an increased need for mother to share everything with them.

Renewed interest in the mother is the result of the child's growing perception, internally, of the mother's separate existence. The toddler woos the mother by bringing her toys and getting her interest and attention. When the toddler succeeds in acquiring the mother's attention, the frightening realization of being separated is temporarily staved off (Edward et al., 1981).

Rapproachment Crisis

Mahler (1972) maintains that, regardless of how insistent the toddler attempts to coerce the mother, they (i.e., mother and toddler) can no longer effectively function as a dual unit. The child actively resists separation from the mother. Verbal communication becomes more necessary as gestured coercion or mutual proverbial empathy between mother and child no longer suffice to attain the goal of satisfaction and well-being.

Realizing their love objects (i.e., parents) are separate individuals, the developing children surrender their delusions of grandeur, which often results in dramatic fights with the mother. Mother needs to be unobtrusively readily available to share some of the toddler's activities, yet at the same time, able to let go and gendy push the child toward further individuation and independence (Edward et al., 1981).

A deliberate search for and avoidance of intimate body contact ensues, with the wish for reunion and fear of engulfment occurring simultaneously. This "ambitendency" (Edward et al., 1981, p. 24), manifested by wanting to push away and hold on to mother, will later develop into true ambivalence. This crossroads has been termed "rapproachment crises" by Mahler (1972). Here, as a growing awareness of the existence of other children and social interaction begins, there are periods of indecision.

Thus, separation-individuation is the time the child develops a sense of self and a permanent sense of significant others, known as object constancy (Mahler et al., 1975). Furthermore, the child learns an integration of both bad and good as a component of a selfconcept. "Westin (1990) alleges that if the mother's behavior at the separation-individuation stage of the child's development is inconsistent or insensitive and unattuned to the child's needs, then dysfunction occurs.

Unusual traumatic experiences in the child's family life, or withdrawal of the mother, due either to some exigency of life or as a response to the child's increasing independence can be ominous during rapproachment. Excessive aggression at the rapproachment subphase may result in the mother's retaliatory aggression toward the child, or her failure to help modulate the phase-specific spurt of aggression in the child (Edward et al., 1981). Where aggression predominates, it can lead to over-reliance on the splitting mechanism that ultimately interferes with uniting good and bad object representations. The child may introject the mother as bad, leaving assimilation representations of the mother as criticizing, disapproving, or other negative representation in the mind. Successful resolution of this subphase, bringing the conflict between the need for the mother and the need for separation and individuation to a head, are central developmental requirements for avoidance of subsequent severe psychopathology (Greenberg & Mitchell, 1998).

BORDERUNE PHENOMENA AND SEPARATION-INDIVIDUATION

Borderline personalities are individuals whose ego functions are impaired to varying degrees and whose affects tend to overwhelm them rather then serve as signals. Their inability to tolerate delay or maintain impulse control interferes with adaptation, and their levels of object relatedness lead to frequent disturbances in interpersonal relations and limitations in their abilities to form working alliances (Edward et al, 1981). Mahler (1972) highlights the similarity between commonly associated features of BPD and phenomena associated with deviant negotiation of separation-individuation. These features include increased separation anxiety or failure to unite good and bad aspects of the self and the object representations.

A continued striving for missed symbiotic supplies exaggerates the need for closeness, leading to increased coerciveness and heightened fear of engulfment. Some children may cling, demanding closeness, while others withdraw, resulting in a loss of vitally neeàeà partnering. Ambitendency is heightened to the point that the child appears to be anxiously coming and going simultaneously. Mahler et al. (1975) further explicate the similarity between borderline features, emphasizing the rapproachment subphase as significant in possible development of borderline psychopathology. Failure at this subphase to negotiate the rapproachment crisis may reflect deficits so profound they are irreparable, constituting a significant pathogenic condition leading to BPD.

If rapproachment crisis is overly intense, the child may use splitting excessively as a defense mechanism. This may remain as a fixation, leading to borderline organization (Mahler, 1975). The over-reliance on splitting, oscillating between fear of separateness and fear of merger, the propensity for blurring of the self-object distinctions, and pathological internalized relationships with bad introjected objects are among those factors impeding development of more mature levels of object relatedness (Edward et al., 1981). Mahler et al. (1975) allege that both splitting of good and bad representations of the mother, and the coercion of her that characterize rapproachment crises, typify the later transference reactions of individuals with BPD.

Borderline Personality Disorder in the Adult

This disorder is a distinct diagnostic entity reflecting a maladaptive lifestyle. Adults with BPD are "dissatisfied with life, lack any sense of self, and feel empty and depressed" (Gallop, 1985, p. 7). They experience short-lived relationships and lack satisfying interpersonal qualities. The defensive array of BPD centers on splitting. External objects are perceived as all good or all bad, and perceptions may alter rapidly. In a hospital setting, the patient with BPD presents particular difficulties to immediate caregivers. Splitting environments, including caregivers, into good and bad precipitates countertransference reactions in hospital staff (Gallop, 1985).

Countertransierence reactions are subconscious; therefore, nursing staff may experience them as normal reactions to patients exhibiting challenging behaviors. Gallop (1985) suggests that a facilitator with considerable interpersonal skill can assist staff in recognizing countertransierence reactions, thus engaging staff in a way that assists them in working with and helping patients with BPD.

Application to Older Adults with BPD in Long-Term Care

Little attention has been given to BPD in the elderly population, as evidenced in a review of the literature. The Diagnostic and Statistical Manual of Mental Disorders (DSM) (American Psychiatric Association, 1987) declares that manifestations of personality disorder, although often recognized at adolescence, continue throughout adult life. However, symptoms often become less obvious in middle or old age.

Long-term studies have demonstrated that by middle age, the majority of individuals with BPD no longer exhibit acute symptoms that meet the diagnostic criteria as outlined in the DSM (McGlashen, 1986; Paris, 1993; Paris, Brown, & Nowlis, 1987; Plakun, Burkhardt, & MuIIer, 1986; Stone, Stone, & Hurt, 1987). The DSM-IV (American Psychiatric Association, 2000) states the majority of individuals with BPD attain greater stability in their relationships and vocational function in their 30s and 40s, thereby no longer meeting the full criteria for diagnosis. Snyder, Pitts, and Gusting (1983) contend it is uncommon to find patients older than 40 who fulfill me diagnostic criteria of BPD as they did at a younger age. Thus, these patients receive other diagnoses at an older age. This may be more reflective of a "lack of fit of our existing diagnostic yardsticks than the lack of borderline personality disorder in old age" (Rosowsky & Gurian, 1991, p. 39).

A person's character is generally stable throughout life (McCrae & Costa, 1984). Rosowsky and Gurian (1992) say that characterological difficulties are life-long, molded by interactions of individuals with their environments. Such traits pervade all aspects of the individuals' lives (Koenig, Siegler, & George, 1990). Personality disorders are purported to be life-long, continuing to be shaped by the interaction of individuals with their environment. Clinicians are aware that elderly individuals with BPD exist. Therefore, the diagnostic tools should, perhaps, be adapted to identify these individuals, because diagnoses currently are made by clinical expertise (Rosowsky & Gurian, 1991).

Benchmark symptoms of BPD in the younger patient (i.e., risk-taking, substance abuse) do not appear to define the disorder in later life. Environmental changes or social context of elderly individuals can cause exacerbation of core symptoms. One study of individuals with BPD in late life suggests anorexia or self-prescribed polypharmacy might be symptom substitutes for self-mutilation as a geriatric variant (Rosowsky & Gurian, 1991).

Sadavoy (1987) proposes that severe character disorder, a less specific term than BPD, derives from five core vulnerabilities evoked in the early development, and remains fairly consistent throughout the life span. The following five issues are proposed as central aspects of character pathology:

* Fear or experience of abandonment or empty aloneness.

* Failure of interpersonal relationships that sustain the self - self object relationship stemming from age-associated narcissistic assaults.

* Impaired affect tolerance producing dysphoric feelings.

* Ineffective modulation of rage leading to an over-reliance on the defense mechanism of splitting.

* Vulnerability to loss of selfcohesion with accompanying temporary impairment of reality perception and loss of ego boundaries that may lead to mini-psychotic states.

Sadavoy (1996) alleges that individuals vulnerable in these five areas fit in Kernberg 's (1975) Borderline Personality Organization. According to Sadavoy (1996), aging imposes inevitable assaults that attack the points of greatest psychological vulnerability in BPD. Examples of these factors include:

interpersonal losses of previously sustaining relationships; decrease in physical beauty, energy, and capability which were sources of external admiration; similar loss of role-functioning - occupational, parental, or societal; restriction in outlets for management of intolerable anxiety such as sexual or aggressive acting out, increased reliance on forced intimate relationships with caregivers leading to mobilization of rage, primitive dependency conflicts, fantasies of rescue, abandonment anxiety, and fear of engulf ment (Sadavoy, 1996, p. 25).

Losses are a normal part of aging, and the capacity to grieve is essential to free energies that can be rallied to other endeavors. Failure to grieve is a central deficit of individuals with primitively organized personalities such as BPD. These elderly individuals are forced into depressive withdrawal, over-reliance on narcissistic defenses, somatic preoccupations, and intense interpersonal chaos (Sadavoy, 1996). Elderly individuals with BPD can excessively disrupt the long-term care environment. When in a therapeutic helping relationship, they foster splitting, and evoke negative countertransference reactions in caregivers (Rosowsky & Gurian, 1992). Naturally occurring stressors in late life induce transient regressions. Older adults with BPD may undergo comparable changes, yet remain clinically recognizable. The evolution of BPD in elderly life in a long-term care environment is demonstrated in the following case study.

Mary's Story

Mary was 85 years old when she was transferred to a complex continuing care unit in a long-term care facility. Mary had spent the previous 5 years in the nursing home portion of the facility. However, deteriorating health had increased her care requirements, resulting in her subsequent transfer. Mary's medical diagnosis was congestive heart failure resulting from several previous myocardial infarctions. Although Mary was under the care of a psychiatrist and being treated with various antidepressant medications, she suffered from long standing depression.

Mary was born and grew up in a small town in eastern Canada, where she met and married her husband. She had married in her early 20s, and had two children, a son and daughter. Mary claimed her husband was physically abusive to her. They finally separated, but prior to this he had several liaisons with women, leaving Mary angry and embarrassed because she was well known in the town. She divorced in her early thirties, and claimed to have raised her children with little assistance from their father. Mary never remarried. Her son and daughter had moved to the United States, and were living in different states.

Shortly after her arrival on the continuing care unit, Mary began "acting out." Her relationships with the nursing staff were filled with constant confrontation. She vacillated between demeaning and overvaluing them, depending on the strength of needs for merger and individuation. She belittled and demeaned staff at every opportunity, pointing out their lack of status. She would ridicule them, make derogatory remarks about their ethnicity, and consistently berate them. Only a few nurses were considered "good." When relief staff were assigned to care for Mary, she became particularly insulting, throwing food items at them and on the floor.

Elderly individuals who are frail impose increasing levels of interdependence on caregivers. Dependency is central to lifelong conflicts inherent in BPD. These individuals demand because they fear the power of the other to overwhelm and destroy them (Sadavoy, 1996). The internal unconscious conflict can be expressed as splitting, projection, or denial, and is a stimulus to their need to control all relationships. Mary, therefore, moves away from relationships with staff when necessary, only to be forced to move back when needs overcome her.

Splitting by individuals with BPD, as previously discussed, involves keeping apart self-representations that contradict each other into good and bad (Brown, 1980). Object representations are also divided along contradictory affective lines. Thus, Mary's experience of herself and others is divided along polar opposites. People, for example, are perceived as being weak or strong, good or bad, dependent or independent Protective identification, closely related to splitting, occurs when Mary splits off unacceptable self, and object representations are imagined as residing in another. Seeking to control what is denied and rejected in herself, individuals like Mary employ others as pawns that play out her internal struggles. This behavior roused countertransference reactions in caregivers, where some staff actually experienced themselves as "stupid nurses." Some members of the health care team, including some nurses, actually protected Mary. This splitting of staff and sabotaging treatment plans challenged staff collaboration and cohesion.

The treatment process for elderly patients such as Mary is complex. Characterological difficulties are dramatically exacerbated when relationships become intense and intrusive (Sadavoy, 1987). The institutional setting, therefore, becomes a fundamental forum for the full display of behavioral pathology in elderly individuals such as Mary. All the major précipitants of regressive symptoms can be exhibited, such as

abandonment, aloneness, loss of identity and sense of self-worth, absence outlets for action and control, intense intrusive relationships (staff and patients), noxious mirroring of aging by the old patients, proximity to true illness and death, and frequently inappropriate, unsophisticated staff responses to patient behavior (Sadavoy, 1987, p. 209).

This ambivalent pattern accounts for the interpersonal instability characteristic of individuals with BPD, and the emergence of stable-unstable intimate relationships, which resemble symbiosis, and characteristics of rage, depression, frequent separations, and temporary reconciliations. Sadavoy (1996) maintains that families of these individuals often have been highly stressed for years while adapting, albeit maladaptive, forms of coping. It is not unusual for children to place distance and geography between them and their parent, as occurred in Mary's case. This assists children in escaping demands and forming independent units.

The emotional counterpart of Mary's desire to control the nursing staff started to result in angry withdrawal by staff who felt they were being treated like refuse. Eventually, no one wanted to care for her. Nursing staff interchanged the assignment of caring for Mary, and she generally gave each of them a difficult time, some more than others. The nurse manager of the unit, seeing the expanding challenges presented by Mary toward the nursing team, arranged for the clinical nurse specialist to work in conjunction with a psychologist to assist the staff in ways of coping with Mary and handling their own countertransierence reactions.

The goals of treatment for Mary were to contain and limit the pathological behavior and establish a working alliance with staff. Developing a cohesive team approach might reduce inner tension levels and alter interpersonal stresses. Containing and limiting the pathological behavior involved a coordinated staff approach.

The psychologist interviewed both Mary and the staff, eliciting expectations of behavior that emphasized limits. This contract took into account Mary's needs for some sense of control as being distinct from the requirement that her behavior become tolerable and respectful to staff. For example, Mary was hearing impaired and claimed to become frightened if nursing staff "sneaked up from behind" and touched her. She also had little tolerance for anybody new, and did not want to be cared for by student nurses, which she referred to as "learners." Mary felt nurses did not answer the call bell quickly enough. She insisted that her needs for the nurses' attention were greater than other patients on the unit, whom she often referred to as "vegetables."

The terms and conditions of the contract were written down to reduce confusion, both for Mary and the staff. This limited the potential for Mary to defensively control the environment by splitting the staff. The goal was for all staff members who cared for Mary to be clear about the contract and be consistent in their approach with Mary. For example, both nurses and Mary agreed on a reasonable time frame for Mary to wait for the nurse after putting on her nurse call bell. A small core group of regular nurses were assigned to care for Mary. Relief staff and nursing students were never assigned. Both Mary and nursing staff agreed, if Mary was verbally or physically abusive, nurses would inform Mary that they were leaving the room and would return in 5 minutes. If Mary continued to be abusive, the nurse would again leave and return in 10 minutes.

The contract was signed by the nursing staff and Mary, and was posted in Mary's room and in her health record. The nurse manager was assigned as the mediator to make certain the contract was adhered to by both Mary and the nurses. This guaranteed a unified approach that ensured Mary received a single, harmonious, clear message that would reduce her anxiety by containing and restricting the sense of internal chaos enacted in her environment (Sadavoy, 1987). This approach was successful. Although not without some minor problems, Mary and her caregivers eventually formed a tolerable relationship. Mary was a client on the unit for 3 years before passing away.

CONCLUSION

Borderline personality disorder has a powerful effect on the outcome of aging, and data is lacking in this area. Sadavoy (1996) asserts it is intuitively attractive to reason that, in its more "malignant" (p. 32) forms, individuals with BPD are at increased risk of mortality and morbidity secondary to neglect in the community, increased risk of suicide and drug abuse, and premature institutionalization, as appeared to have been in Mary's case. Research on individuals with BPD in late life is confounded by a complexity of many factors, and must focus on developing treatments and interventions appropriate for elderly individuals with BPD.

Elderly individuals with BPD can severely disrupt a long-term care environment. The challenge for nursing staff is immense, and staff working with these individuals should receive special training and support. Highly individualized contracts setting clearly defined limits, as described in Mary's case study, can be effective in caring for individuals with BPD (Piccinino, 1990). Increasing understanding and employing a more sophisticated approach can provide more effective treatment and strategies, ensuring improved health care for the elderly individual with BPD.

Borderline personality disorder can be viewed in terms of Mahler's (1975) separation-individuation theory as a possible outcome of failure of the toddler to adequately resolve the rapproachment crisis. Understanding personality development of individuals with BPD in late life requires an understanding of early development. With failure to achieve psychological birth, the individual remains dependent on others to provide the continuity of identity - however, satisfying these needs can threaten engulfment. The dilemma of too much separation is overwhelming. When the object (i.e., nurse) is out of touch, it is lost - and when too close, it is also lost.

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