Borderline Personality Disorder

Written by John M Rathbun M.D.

DEFINITION - a pervasive pattern of instability of interpersonal relationships, self-image, and affect, and marked impulsiveness, beginning by early adulthood and present in a variety of contexts

HISTORY:

EPIDEMIOLOGY

ETIOLOGY

DIAGNOSIS

DIFFERENTIAL

Compared to cyclothymic and bipolar patients, Borderline Personality Disorder more reactive, angry in reaction to frustration in dependent relationships, with chronic feelings of emptiness

compared to depressive disorders, Borderline Personality Disorder more manipulative in their suicidality and have poorer relationships

compared to psychotic disorders, Borderline Personality Disorder have brief, reactive psychotic symptoms, not chronic, persistent ones

COURSE

MEDICAL TREATMENT

PSYCHOTHERAPY

These are difficult psychotherapy patients. They have a lot of turbulent emotion in relation to the therapist, and they act out in ways that endanger them and irritate the therapist. Therapists are tempted to reject or indulge Borderline Personality Disorder.

It often takes five or more years of intensive individual psychotherapy to resolve Borderline Personality Disorder.

The therapist must be consistent and reliable, with excellent boundary management.

These patients routinely induce splitting in treatment teams.

They will not progress in therapy if currently being abused; they may under-report or over-report abuse.

These are not cases for the beginner, and student therapists should have intensive supervision when working with borderlines.

A DYNAMIC FORMULATION

Ego States Theory was developed to explain why some adults intermittently behave like children. According to Ego States Theory, we all start out life as a collection of unintegrated ego states, such as "Happy baby", "Hungry baby", "Scared baby", "Mad baby", and "Sleepy baby". We observe normal infants making abrupt switches between these ego states according to their current circumstances, and there seems to be little continuity of memory from one such ego state to the next. We observe normal parents sponsoring integration of ego states in normal youngsters. The preschooler who falls and hurts himself while playing undergoes a switch from the "Happy child" ego state to the "Scared and painful" ego state, and seems to have no idea that his suffering is a temporary condition. Mother provides reassurance along the following lines: "You're OK now, even though it hurts; you were happy a few moments ago, and you'll be happy again in another few minutes!" We can later observe the same child in grade school getting hurt, starting to switch ego states, and then reassuring himself that he'll feel better soon, thereby maintaining his own ego integration. In adulthood, the fabric of ego integration is usually so tightly woven that it takes a catastrophe to cause dissociation of ego states.

Some children, however, don't have a "normal" childhood with the support of well-integrated parents. Suppose father is alcoholic: he may come home drunk and rape the little girl, and the next day he may not remember what he did. Mother may be physically or psychologically absent from what's going on with her daughter, so father is her only source of comfort. The child may be unable to get help for a variety of reasons, including her fear of father, fear of losing her father, and a sense that what's happening is inevitable. She faces an endless series of irreconcilable realities.

Her best defense may be to maintain two distinct ego systems, one of which deals as best she can with father the rapist, the other with everyday living. The defense of dissociation permits the child to avoid thinking about the abuse so she can have as normal a life as possible.

When this sort of childhood starts early and goes on a long time, the ego states may accumulate very different memories, emotions, and behaviors. They may even have different names for themselves: one name representing the angry, hurt, sexually aware part, and the other designating the innocent child in her public persona.

A child growing up in a very sick family system faces a large number of insoluble problems, and dissociation may become the preferred way to deal with virtually every conflict the child faces. Thus, a system of dissociated ego states may arise, one of which does well in school, another is very athletic, a third feels a great deal of rage, a fourth can function sexually, and the fifth goes to church and prays a lot - thus fully expressing all the family values in one person without having to resolve any of the conflicts that divide the family.

Most borderlines report growing up in family environments that were

UNSAFE - abusive, threatening, unstable

DEPRIVING - rather than nurturing

HARSHLY PUNITIVE - often following inconsistent or invisible rules

SUBJUGATING - punishing child's normal expression of needs and feelings.

Therefore, the borderline patient may usefully be viewed as a collection of relatively unintegrated ego states, whose dysfunctional behaviors and emotions constitute the presenting signs and symptoms. They differ from DID in that complete amnesia between ego states is not seen in Borderline Personality Disorder as in DID. They differ from PTSD in that intrusive recollections are less prominent in BPD than in PTSD. However, there's considerable overlap in the origins, signs, symptoms, and effective treatment paradigms for DID, PTSD, and Borderline Personality Disorder; if you are successful with one of these groups, you'll likely do well with the others.

I find ego states theory helpful in understanding dissociative disorders, PTSD, and Borderline Personality Disorder. Ideas about dissociation have become very controversial, however. Many psychologists are strongly opposed to the idea that traumatic memories can be lost and then reemerge. I find these criticisms ignorant, corrupt, and absurd.

They are ignorant in that they persistently confuse dissociation and repression in statements like, "There's no evidence for repressed memories!" DISSOCIATION is a theory introduced by Pierre Janet, who observed patients with various sorts of hysterical illness to be cured when they recalled traumatic events that were symbolically connected to their symptoms. Janet's work came before that of Sigmund Freud, who initially endorsed Janet's ideas, then proposed his own theory of REPRESSION. What is repressed in Freud's theory is a girl's unacceptable wish: to replace mother as father's love object. This wish is both denied and gratified in a SCREEN MEMORY: that father initiated sexual activity with the child. In other words, REPRESSION leads to remembering trauma that never happened, while DISSOCIATION is the forgetting of trauma that DID happen. Any so-called expert who confuses these two antithetical theories is not worthy of serious attention.

Many of the critics of dissociation are corrupt, in that they are associated with an organization that exists mainly to assist persons accused of sexually abusing their children to escape prosecution.

Finally, criticisms of dissociation are absurd, in that they allege that memory is fallible in only one direction. They claim that real trauma can never be forgotten, but that overzealous therapists often create memories of trauma that never happened through their suggestive techniques. These concerns are based on a small number of cases studied by one particular psychologist who observed contrived situations with little relevance to clinical reality.

The "recovered memories" controversy is heated and serious in its implications; it's well for therapists who treat trauma victims to be keenly aware of the major issues being debated, to avoid hypnotic and other suggestive techniques, and to steer clear of prosecutions based on recovered memories unsupported by other convincing evidence.

THERAPEUTIC TECHNIQUES

The basic techniques that have been found useful in dissociative psychopathology, whether PTSD, BPD, or DID, emphasize the following common therapeutic factors

1. development of continuity of memory across ego states, leading to improved integration of behavior, affect, sensation, and knowledge

2. a more thoughtful approach to decision making should replace dysfunctional behavior patterns which are impulsive and emotionally driven

3. appropriate expression of affect is facilitated in a therapeutic setting, with attention to parallel development of a repertoire of healthful self-soothing behaviors

4. the patient is encouraged to experiment with new patterns of behavior which will be more effective in getting the patient's legitimate needs met

5. the patient is given the opportunity to use the therapist as a role model for a more healthy adult lifestyle.

To assist the therapist in maintaining appropriate engagement with borderline patients, a psychologist at Columbia named Jeffrey Young has developed an interesting way of categorizing the ego states commonly seen in borderlines. In his experience, the borderline patient will normally present four ego states, which he calls MODES:

1. The patient normally presents for therapy in an ego state which Young calls The Vulnerable Child Mode - in this mode, the patient is compliant and seeking assistance. This is a continuation into adulthood of behavior patterns used by most children to secure caring and assistance from powerful adults. The therapist will be idealized by the patient in this mode, often leading to a breakdown in normal therapeutic boundaries if the therapist's grandiosity or guilt can be hooked by the patient. Since the borderline's need for emotional nurturance exceeds the capacity of even the most giving therapist to satisfy, the therapist who lacks good professional boundaries will often begin to experience anxiety and resentment about the patient's escalating demands. This will cause a failure of empathy on the therapist's part, leading to the emergence of

2. The Angry Child Mode - in which the therapist is harshly devalued by the patient. If the therapist reacts defensively, an even more dysfunctional ego state will emerge:

3. The Punitive Parent Mode - since the child was punished for expressing normal needs and emotions, the adult knows that she is wrong to have these needs and emotions, and deserves punishment for expressing her feelings. Because she has internalized her parents' dysfunctional attitudes and behaviors, she will begin to punish herself for having needed the therapist so much, and for having expressed her anger at the therapist for not satisfying those needs. In the punitive parent mode, the patient will derogate herself during internal dialogues, will experience herself as defective, worthless, and contemptible, and will often punish herself through self-mutilating or self-poisoning. Her attempt to regain a position of emotional equilibrium will often lead to the fourth and last of the common ego states seen in borderlines:

4. The Detached Protector Mode - in which feelings are disavowed, and the patient appears passively compliant and placid. This particular ego state is often overvalued by naive therapists whose personal insecurity leads them to prefer the appearance of calm to the turbulence of the patient's other ego states.

The Detached Protector Mode is actually the least workable of the four ego states commonly seen in borderline patients; the only appropriate therapeutic technique for this mode is to encourage the Vulnerable Child mode to reemerge. One can do this by reminding the patient how she felt in a previous session.

You may then have to work through eruptions of the Punitive Parent Mode by assuring the patient that her need for nurturance is normal and acceptable. In general, your goal is to extinguish the Punitive Parent Mode by presenting yourself as a more accepting and appropriate parent for the patient.

The Angry Child needs help learning how to express that emotion in nondestructive ways. A therapist who is personally secure will encourage the patient to verbalize even more anger at the therapist, but actual verbal abuse should be redirected into more authentic emotional expressions. In this regard, the patient can be helped to use "I" statements rather than "you" statements - "I felt abandoned by you" rather than "You're a cold, uncaring, heartless bastard". You may have to assist the patient to understand that "I think you're a cold, uncaring, heartless bastard" is really a "you" statement disguised as an "I" statement. The payoff for the patient in learning how to verbalize anger more appropriately is that the patient can then be angry without sacrificing connection with potential sources of emotional nurturance.

The Vulnerable Child Mode is the most workable ego state in borderline patients. Young suggests four basic techniques for this ego state:

1. Cognitive interventions - using journaling, you can teach the patient to examine her dysfunctional thoughts and decide for herself if they are valid. Some common dysfunctional assumptions in borderlines are

a. The world is dangerous and wants to hurt me

b. I am powerless in this world

c. I am hopelessly defective

d. Things are good or bad, choices are all or nothing

2. Experiential techniques - such as gestalt, imagery, and inner-child work

3. Therapeutic relationship - giving the patient a good example to imitate

4. Behavioral pattern breaking - finding new and more effective ways to get legitimate needs met

Some basic therapeutic techniques to use with borderlines:

1. validate needs and feelings; avoid problem-solving for the patient

2. be reliable and caring and real

3. strongly praise any improvement in behavior

4. re-attribute parental rejection to parental defects

5. teach the patient to recognize the various ego-states or modes of behavior as they emerge in the sessions, and to understand how their dysfunctional assumptions arose naturally from their suboptimal early experiences

6. attribute any patient failures to the patient's excusable misunderstandings and help the patient to analyze these

7. using the empty chair technique, teach the patient how to talk back to the punitive parent

8. acknowledge your mistakes and model forgiveness of yourself and others

Most therapists who write about treatment of post-traumatic syndromes emphasize that treatment must proceed in stages. The first stage is always focused on the development of a therapeutic relationship based on mutual understanding and respect. Young suggests this stage will be facilitated if the therapist can always think of the patient as a needy, primitive child rather than as a greedy, manipulative opportunist. Emergence of such negative attitudes in the therapist is associated with poor treatment outcomes, as the patient's original experience with a punitive parent is repeated in the therapy.

It is important that patient and therapist agree on goals for the treatment in language that makes sense to the patient. It will also be necessary for the therapist to make clear the limits of therapist availability. Most patients with Borderline Personality Disorder have daily and nightly emotional crises, and will need frequent reassurance by phone or in extra sessions, at least until they learn how to manage their emotions better. It's legitimate to tell the patient that daily phone calls are not OK, and that late night calls make you cranky the next day. You can also mention that learning self-soothing is one of the important goals of therapy.

If the patient is doing something that you can't tolerate, it's important to discuss this in session before you reach the point of resenting the patient. It's appropriate to tell the patient that frequent phone calls disrupt your personal time, and that you may begin to feel resentful if it continues. Borderline patients have usually grown up around people with poor conflict resolution skills and poor interpersonal boundaries, so you want to show the patient how two adults can discuss and resolve a conflict without becoming abusive or withdrawn from each other.

When your practice situation permits, it's appropriate to inform the patient that you charge for after hours phone contacts as well as for extended phone contacts during office hours. These are professional services which the patient should expect to pay for, just as you would expect to pay for the furnace man to come and relight your burner on a cold winter's night. Offering unlimited free support at all hours of the day or night is a recipe for therapist burnout and for a major betrayal of the patient's trust, because you will not be able to keep it up, and a burned-out therapist is both unhappy and dangerous.

Since many of you work for not-for-profit agencies, let me take a moment here to disparage certain dysfunctional attitudes that seem to pervade such organizations. You probably went into this sort of work because you enjoy helping people, and you feel real compassion for those less fortunate. These traits make you willing to work long hours for low pay, and your professional reputation depends on your willingness to go the extra mile for your clients. When an entire organization is staffed from top to bottom with professionals who share the value of self-sacrifice, there's an opportunity for the best intentions to lead to the worst outcomes.

Not only does your borderline patient need to see that relationships can have limits and still be rewarding, she also needs to believe that she can survive on her own adult resources in this world. The therapist who can't limit the patient in her quest for constant reassurance is saying, "Yes, you really are just as incompetent as you feel!"

The most challenging aspect of therapy with Borderline Personality Disorder is knowing how to set and enforce limits. This is a matter of therapeutic art, and cannot be taught in a lecture or manual. We all make errors in judgement when it comes to enforcing limits and providing optimal levels of support in therapy. More experienced therapists are less likely to make these errors, and should be sought as mentors by less experienced therapists. Therapeutic technique is not perfectible, only subject to endless improvement. Borderlines are those patients who show us where we have room to grow in our technical skills.

Important areas for limit setting in Borderline Personality Disorder:

1. rules for outside contacts

2. abusive behavior in sessions

3. client must agree to attend one more session before quitting (implies no impulsive suicide)

4. missed sessions must be planned (charging for no-shows and late cancels, except in extraordinary circumstances, is good for the patient)

5. patient must contact therapist before destructive acting out

6. "If you make me hospitalize you involuntarily, I won't work with
you after discharge"

Note that the threatened loss of the therapeutic relationship, once established, is the most potent adverse consequence available.

Dealing with the borderline in crisis:

a. find out what mode they're in and respond appropriately

b. increase visits, even a few minutes every other day can help

c. assess suicidality: plan, intent, timetable, available means, any steps taken, past history, substance abuse

d. get permission to talk to significant others and arrange increased support

e. consult with another professional and document it

f. consider referral for medical therapy

g. consider day hospital or support group\h. consider brief hospitalization

If you're interested in a more complete protocol for the treatment of Borderline Personality Disorder, and one with some actual outcome research to recommend it, you should look at two books published in 1993 by Guilford Press, both written by Marsha M Linehan: Cognitive-Behavioral Treatment of Borderline Personality Disorder, and Skills Training Manual for Treating Borderline Personality Disorder. Linehan's method is briefly outlined in Guilford's Clinical Handbook of Psychological Disorders.

Linehan calls her method Dialectical Behavior Therapy, because she emphasizes training the patient to abandon simplistic ways of thinking. She correctly points out that reality is complex and multifaceted, and that we all have to deal with situations involving conflicting and ambiguous data. An overall therapeutic goal of Linehan is to teach the patient to avoid rigid thinking and extreme behavior.

Linehan emphasizes that the therapist must respond hierarchically to the many challenges presented by borderlines. Suicidal behaviors have the highest priority for therapist attention, followed by therapy-interfering behaviors, then quality-of-life interfering behaviors. Important behavioral skills taught in Linehan's method:

1. distress tolerance (desensitization, using the therapist to reduce anxiety

2. emotion regulation (including affect identification and management)

3. interpersonal effectiveness (conflict resolution and empathy)

4. self-management (learning how to increase chances of success in meeting ones goals)

5. mindfulness (non-judgmental awareness)

These skills can be taught in individual sessions, but it's more cost-effective to offer weekly didactic groups to teach basic skills while the individual therapy focuses on the problem areas most relevant to the particular patient.

Both Linehan and Young, in common with most therapists who work with trauma survivors, delay dealing with traumatic memories until the patient has sufficient trust in herself and in the therapist to withstand the high levels of emotional arousal that commonly accompany a focus on past trauma. It may require many months of preparation before a patient can reliably resist self-destructive impulses, maintain a stable lifestyle, and show significant progress in the basic skills addressed in Linehan's Stage I.

Skillful treatment of PTSD is a complex, challenging, and contentious area. The basic goals are:

1. remembering and accepting the facts of earlier traumatic events, or learning to live with perpetual uncertainty about what actually happened; and

2. reducing stigmatization and self-blame

Arthur Freeman chairs the psychology department at the Philadelphia College of Osteopathic Medicine and also directs the Cognitive Therapy Training Program at the Adler School of Professional Psychology in Chicago. Among his many relevant publications is a book called Cognitive Therapy of Borderline Personality Disorder.

At a recent symposium on Borderline Personality Disorder, Dr. Freeman gave some pointers on here-and-now focus in the treatment of PTSD. In his view, "The preferred intervention is the least intensive, least extensive, least intrusive, and least costly alternative that will provide what the patient requires at that time."

Focusing on Cognitive treatment of intrusive recollections and flashbacks, Freeman suggests the therapist's initial focus should be on assisting the patient to precisely characterize the experience so as to make it more concrete and less eerie for the patient. He asks for

1. A complete description of the thoughts or perceptions which constitute the episode;

2. Identification of anything in the current life situation which may have triggered the episode, with specificity as to the particular aspect of the current situation which was a trigger;

3. A description of emotions, thoughts, sensations, and behaviors which followed the episode.

Dr. Freeman's approach shares with the majority of therapists working in this area the basic technique of converting emotions into words, which seems to assist the patient in gaining a sense of mastery over the strong emotions involved. He also encourages journaling for this purpose, and teaches relaxation and imagery as tools for self-soothing.

Traumatic nightmares are handled similarly to flashbacks; writing down the nightmare upon arousal is useful because some of the most important images will not be remembered the next day. Freeman emphasizes reinforcing the patient for gaining control over the intrusive recollections.

With reference to the specific problem of flashbacks which occur during sexual activity, Dr. Freeman suggests that sexual activity be interrupted until both partners are comfortable with its resumption; to close one's eyes and wait for him to finish would tend to reinforce dissociation through reenactment of the trauma. Communication with the partner about what's happening is encouraged, as is asking for the partner's support. The patient can also train herself to pay attention to important differences between the current partner and the original perpetrator, including both differences in appearance and differences in the quality of the relationship. In some cases, the partner may need professional assistance to become more comfortable with the patient's special needs; in others, the problem in need of attention may be the patient's inappropriate choice of partner.

Linehan's third stage puts appropriate focus on the patient learning how to maintain improvement without so much help from the therapist. Goals of this stage are:

1. non-defensive self-appraisal that will resist unreasonable attacks on one's self-esteem; and,

2. trust in one's ability to cope with stress.

In her discussion of telephone contacts between sessions, Linehan emphasizes the need to repair the relationship. Borderline patients often experience delayed emotional reactions to something the therapist said or did during a session. Often, the next call after a session relates in some way to such a delayed reaction. The therapists's ability to accurately hear the underlying concern and to respond with empathy can substantially improve the chances for the patient to stay in therapy. Arthur Freeman suggests that each session end with an invitation for the patient to give the therapist some feedback, thus reducing the probability of rumination and after hours phone calls.

Linehan characterizes the skillful therapist as "able to balance a high degree of nurturing with benevolent demanding." This is one of a number of paradoxical elements of the therapy situation to which she refers in her writing. Others are

a. Clients are free to choose their own behavior, but they cannot stay in therapy if they do not work at changing their behavior.

b. Clients are taught to achieve greater independence by becoming more skilled at asking for help from others.

c. Clients have a right to kill themselves, but if they ever convince the therapist that suicide is imminent they may be locked up

d. Clients are not responsible for being the way they are, but they are responsible for what they become

Such paradoxical elements can be presented to a patient at the appropriate time and in an appropriate manner, to stimulate reflection and to help the patient move beyond simplistic thinking. Linehan also recommends skillful use of metaphor, stories, parables, and myth in therapy. These techniques require a certain literary bent and much skill to apply; their strength is that they circumvent the patient's logical resistance to new ways of thinking about the world.

Another advanced therapeutic technique recommended by Linehan, and applicable in any therapy, is to take the patient's absurd position and logically extend it until even the patient sees the absurdity. This has to be done with exquisite sensitivity or the patient will feel mocked. Two examples cited by Linehan are:

1. The patient would rather die than gain weight; if being dead is preferable to being overweight, the overweight therapist is within reason to offer to join the patient in a suicide pact.

2. The patient will kill herself if the therapist won't see her immediately; the therapist expresses great anxiety and offers to call an ambulance so the patient can be hospitalized for her own protection.

These are tricky techniques, in which the therapist both joins with the patient and proposes a therapeutic ordeal.

Linehan's method, like Young's, emphasizes the therapeutic relationship as the ultimate reinforcer of patient behavior. It is essential that the therapist pay a lot of attention to the patient's progress and minimize attention to negative behaviors. The therapist may find herself in a dilemma when it comes to responding adequately to the patient's self-destructive behaviors without reinforcing them. It may be helpful to frankly share this dilemma with the patient.

In her discussion of limit-setting, Linehan stresses that the therapist must understand the limits of his or her own tolerance for the patient's bad behavior, and clearly communicate this information to the patient. "Therapists who do not do this will eventually burn out, terminate therapy, or otherwise harm the client." She suggests the therapist be frank and unapologetic about some limits being for the good of the therapist.

Linehan chooses to instruct her patients that cognitive distortions are frequently a consequence of emotional arousal. This is a departure from a purely cognitive framework, in which dysfunctional cognitions are seen as the cause of turbulent emotion. None the less, Linehan shares with therapists all the way back to Sigmund Freud the basic idea that pausing for rational analysis is better than allowing one's rawest emotions to govern one's behavior. She also shares with most mainstream therapists a preference for techniques which encourage the patient to desensitize herself to the fear of emotion by repeatedly experiencing these emotions in the therapy sessions while the therapist assists her to delay any behavioral response.

In her discussion of therapist style, Linehan suggests that the therapist's negative emotional reactions to the patient can be used to educate the patient about her impact on others. For example, "When you demand warmth from me, it pushes me away and makes it harder to be warm." I'm a bit uncomfortable with this intervention because it contains embedded YOU statements: "you demand... you push me away...." A more authentic statement might be, "Sometimes I feel more distant from you at the very times when I sense you wanting me to show warmth to you. I wonder if others around you sometimes have the same response, and if there's anything you could do differently to increase the chances of getting the response you want."

Linehan also recommends the therapist try to stay in a consultant-to-the-client role, except when the patient is clearly overwhelmed. This helps to avoid infantilizing the patient, and also helps the therapist to avoid being sucked into confrontation with others over what's "best" for the patient.

It's important to remember that you can't save every patient, especially the chronically suicidal ones, without locking them up for several years at a time. This means that if you don't have the strength to bear the loss of an occasional patient to suicide, even the ones you really care about, you shouldn't be in this business.

When you do lose one, it should be a learning opportunity. You as therapist should insist on case consultations from consultants chosen for their expertise rather than for friendship. This process is scary, but also uniquely growth promoting.

CONCLUDING REMARKS

In summary, Borderline Personality Disorder is one of the most challenging entities for today's therapist; in fact, this category originated as a repository for patients who fail to improve with ordinary treatment methods and whose particular pathology is most likely to provoke a negative emotional reaction in the therapist. Comfort and effectiveness in the treatment of BPD implies mastery both of one's own emotions and of therapeutic techniques in general. It is not realistic to expect success in every case, and successful treatments are usually long and stormy.

Borderlines ARE treatable. Linehan's study of 44 severely affected women, treated over one year with either Dialectical Behavior Therapy or "treatment as usual", showed an attrition rate of only 17%, with reductions in frequency and severity of self-injury, and fewer hospital days for the patients treated with DBT. A second study showed improvements in anger management, social adjustment, work performance, and anxiety with DBT. These results were maintained at 6 and 12 month follow-ups. The original study was published in the Archives of General Psychiatry, vol 48(1991) pp 1060 ff.

The major open question is whether current restrictions on payment for psychotherapy will permit many borderlines to have effective treatment. No satisfactory brief therapy for Borderline Personality Disorder has been reported. In many settings, the best we can hope for is to deal with a series of crises in ways that may have a favorable cumulative impact on the patient. We must assist borderline patients to get their emotional needs met without their having to resort to grossly self-destructive behavior. The current tendency to provide acute medical treatment and outpatient referral rather than inpatient admission, and to keep inpatient stays very short, may actually be helpful in this regard, because it avoids reinforcing the patient's dysfunctional behavior.