Issues involved in combining drugs with psychotherapy for the borderline inpatient

The hospitalized psychiatric patient is commonly treated with both pharmacotherapy and psychotherapy. This is definitely true of borderline patients whose pathology is contributed to by both biologic and psychodynamic factors. For several reasons, it is particularly difficult to provide these patients the ideal conditions for both approaches within the same inpatient program. First, even the best assessment of a borderline patient may leave the clinical team uncertain as to what degree biologically based pathology plays a part. Second, the current state of research on borderline conditions leaves a clinician very unsure whether to use drugs, what drugs to use, and what form of psychotherapy would be most useful. These two basic sets of uncertainty provide fertile soil for polarization, reductionism, and fuzzy eclecticism. Third, the borderline patient's clinical condition can change rapidly and unpredictably, especially in response to new interventions. The pathology can therefore change before the clinician's eyes. It can be difficult to know whether the dramatic responses reflect efficacy or manifestations of primitive transference reactions. Fourth, the staff members working with the borderline patient commonly have strong emotional reactions, often unconscious ones. The urges to hold, love, rescue, attack and destroy, or the desire to keep a distance can easily influence decisions about whether to prescribe a drug or whether to change the nature of the psychotherapy. These third and fourth factors make it very difficult, once treatments are underway, to evaluate efficacy objectively and to stay the steady course that borderline patients often need above all. Fifth, the case illustration nicely demonstrates that arguments in a team based on philosophical differences, diagnostic disagreements, and fueled by the splitting maneuvers of borderline patients can lead to intrastaff devaluation and mistrust. A number of recommendations have been offered to help with the management of combined inpatient drug-psychotherapy treatment.