[Dr. Conner is the Director for Planning and Program Development for Mentor Research Institute, a non-profit public health and safety organization (www.OregonCounseling.Org). Dr. Conner has worked in private practice, primary medical care, emergency psychiatric services, inpatient psychiatry, outpatient mental health services and health education. 

One of the most severe and challenging mental health problems to treat is a complicated problem found almost exclusively in females called Borderline Personality Disorder (BPD). It can be detected as early as middle to late adolescence, and may have genetic and endocrine related causes. 

The Diagnostic and Statistical Manual of Mental Disorder (DSM), and the American Psychiatric Association advise waiting until a teenager has reached 18 years of age before diagnosing BPD. Prior to that time the symptoms associated with this disorder are referred to as Borderline Personality Traits (BPT). Generally there is a better prognosis when BPT is detected in adolescence, rather than when the person has reached maturity and adulthood. 

(See “A Criticism of America’s Diagnostic Bible – The DSM” www.OregonCounseling.Org/Diagnosis/CriticismOfDSM.htm and Woodbury Reports July 99 #59) 

The behaviors associated with Borderline Personality Traits (BPT) can be a serious problem to address in a wilderness therapy program. In many cases, the “diagnosis” has not been made prior to admission, but the symptoms associated with BPT will become evident and more pronounced after admission. Failure to recognize and respond appropriately can exhaust field staff, diminish the benefits that other students might otherwise gain and can contribute to alarming and life threatening behavior. 

In early stages, the symptoms of BPT appear more like Depression, Conduct Disorder (CD) or Oppositional and Defiant Disorder (ODD). Efforts to address CD and ODD while not recognizing BPT can lead to a pattern of Decompensation and Failure to thrive for students admitted to a wilderness program. [Decompensation, as defined by Conner in his article in Woodbury Reports Sept # 61, can take many forms, normally involving the onset of childlike behavior, a complete lack of regard for hygiene, loss of bladder control while sleeping, increasingly disorganized behavior, a dramatic change in the level of energy, or a complete loss of interest in pleasurable activities.] 

(See www.OregonCounseling.Org/Wilderness/Decompensation.htm) 

Failure to recognize BPT in a wilderness program can lead to chronic problems and can have a destructive impact on a child’s life. Many young girls with the initial behavioral symptoms of this disorder will go undetected primarily because they can hide these behaviors from parents and family members, since such behavior is generally not evident until the child is stressed and is able to be continuously observed by therapists in a structured setting. In a wilderness program, a student may not demonstrate all of their symptoms until the third or fourth week. 

Students with Borderline Personality Traits are: very vulnerable, usually over-react to stress, characteristically form unstable and intense “love-hate” relationships, and are prone to view their caretakers as either “all-good”, or if problems occur, as “all-bad.” They may initially view their caregiver as a “rescuer” then suddenly switch and view them as the “villain.” It is crucial that caregivers avoid falling into the trap of being idealized and overvalued by the student, and then being pitted against other caregivers who the student hates. 

The psychological and emotional needs of children with BPT are rarely satisfied, except briefly, and their anger over this eventually alienates their friends and peers. The response toward caregivers who do not know how to respond is usually one of frustration and anger. At the same time, students with BPT will make frantic efforts to avoid real or imagined abandonment. The resulting message to a caregiver is “I hate you! Don’t leave me!” This mixed message creates further distress in their life and the life of others. 

Behavior That Will Be Encountered In The Field: 

1.)  Intense emotional pain (shame, guilt, fear, loneliness, emptiness, longing) 

2.)  Rapid mood swings (anger, sad, fearful to happy) Anyone’s failure to meet their needs is interpreted and reported to others as personal, intentional, neglectful or abusive. 

3.)  Interpreting their experience as either “good” or “bad” instead of accepting that which is actually “grey”, “mixed” or “good enough” 

4.)  Building and maintaining relationships with other students and staff by creating a common enemy or sharing their criticism of program activities 

5.)  Progress or improved emotional well being will trigger thoughts about how bad they have felt in the past and that their positive emotional state will not last. 

6.)  Reports to staff create the impression that the student is misunderstood, a victim, unloved, ignored or has been abused. Caregivers and peers will be drawn into and expected to rescue, take sides or take action to protect the student from “bad” people in their life. 

7.)  Idealization of select staff and students in order to form and benefit from that relationship 

8.)  Recurrent inability to tolerate their emotional state followed by escape and avoidance behaviors such as medication seeking, inflicting pain through scratching or picking, self-mutilation, acting immature, becoming quasi- psychotic, or “acting out of control” to create a physical altercation and “emotional release.” 

9.)  Decompensation in response to program structure, expectations and their inability to escape and avoid their “here and now” responsibility and emotional experience 

Program Therapeutics 

The program should focus on solving the student’s “here-and- now” problems, despite the student’s tendency to avoid reality-oriented problem-solving. Group counseling or therapy should be supportive and not exploratory, with arrangements for backup in place, should severe regression, dangerous or psychotic behavior surface. 

Regardless of the type of therapy used, two important issues in the program must be addressed: 

1.)  Setting appropriate limits 

2.)  Reality-oriented problem-solving 

Students with BPT must learn how to limit their behavior and they must learn how to respect the limits of what others can provide. It is essential that their caregivers set boundaries and not rescue students, as well as tolerate the student’s angry outbursts with patience, compassion and confidence. This will demonstrate to the student that the caregiver will not rescue or abandon the student (as the student angrily expects and fears). Children with BPT must slowly learn to overcome their overuse of fantasy and problem-avoidance. A high degree of repeated confrontation can lead to decompensation. In many cases, a student’s acting out can become so dangerous that treatment in a wilderness therapy program can become impossible. Program staff and caregivers must be able to tolerate repeated episodes of a student’s rage, distrust, and fear. Students with severe or advanced BPT can demand more attention than all of the students in a camp combined. 

The therapeutic community within a wilderness therapy program is a 24 hour living and learning experience, where daily interactions in the community are examined and unhealthy behavior is challenged. A wilderness program has many components where individual therapy, groups, active student participation in the maintenance of the community and constant monitoring of group processes can be used to confront and redirect the behavior associated with Borderline Personality Traits. 

Crisis Hospitalization

Children with BPT who exhibit regressive behavior, suicide attempts or brief psychotic episodes are frequently hospitalized. Most emergency departments that are medical and not psychiatric are unable to recognize or respond with appropriate understanding of the needs of student with BPT. Students with BPT are prone to sincerely fabricate and report abuse and neglect by caregivers, parents and program staff. The emergency room staff must be careful not to let borderline students pit the hospital staff against the student’s parents, counselors, therapists and staff in their treatment program. Brief admissions have been found to be more effective than long-term admission. 

Medications 

The use of medications, especially an initial trial of a medication in a wilderness program is very problematic, and should generally be considered for symptom relief, not “cure.” Starting a student on a medication while in a wilderness setting requires trained staff to monitor the student’s mental and medical status for side effects, and to avoid potentially life- threatening interactions with certain foods. 

Recommendations 

1.)  Prospective students for admission with Borderline Personality Traits should be carefully screened by a qualified mental health professional who is familiar with the stress and therapeutic structure of the particular wilderness program. It is essential that the program provide a therapeutic community and maintains the level of individual supervision appropriate to the student’s needs. 

2.)  Students with BPT considered most likely to benefit from wilderness therapy must demonstrate considerable motivation to address their problems and be willing and able to co-operate in the group life of the community. Students admitted to a program should be free of medication. This will restrict admission to those without acute problems or co-morbid chronic mental illness, thus severely limiting the number of students with BPT for whom the wilderness option may be considered. 

3.)  In the event that a student with BPT is admitted, or a diagnosis is made after admission, staff interactions should focus on the student’s “here-and-now” problems despite the student’s psychological “escape” behavior and their tendency to avoid reality-oriented problem-solving. Staff should avoid in- depth, exploratory or insight oriented interactions for students with BPT. Discharge without completion of the program will be necessary for some students. 

4.)  Program goals for students with BPT should be in terms of supporting gains toward more independent functioning, and not changing their personality. Graduation and placement in follow- up outpatient treatment, a residential treatment program or a therapeutic boarding school will be essential to maintain the gains provided by a wilderness therapy program.