INT'L. J. PSYCHIATRY IN MEDICINE, Vol. 26(1) 93-104,1996
SPLITTING ON A PEDIATRIC CONSULT
LIAISON SERVICE
JULIA M. ROBERTSON, M.D.
BRADLEY D. ROBISON, M.D.
BRYAN D. CARTER, PH.D.
School of Medicine
Univemity of Louisville, Kentucky
ABSTRACT
Objective: Although the concepts of splitting and projective identification
have been useful in explaining certain group phenomena on adult psychiatric
and medical wards, their application to pediatric settings has not been
addressed in the literature. The authors demonstrate that early identification,
staff conferencing. and fmilyhtaff conferencing can diffuse these dynamics
in an academic pediatric setting. Method: The existing literature on splitting
and projective identification is reviewed. Case vignettes are then used to
illustrate the manifestations of splitting and projective identification in a
pediatric setting and to demonstrate intervention strategies modified for
children and their families from the adult literature. Results: Splitting and
projective identification can be interrupted in pediatric settings with early
identification, staff conferencing.and family/staffconferencing. The cooperation of pediatric clinicians is critical in the implementation of these intervention strategies. Conclusions: The development of liaison support groups for
pediahic residents and interdisciplinary treatment teams will enlist their
cooperation in identifying splittingearly, and in employing staff conferencing
and familylstaff conferencing to diffuse this group dynamic which, if left
unchecked, can disrupt professional relationships and compromise the treatment of pediatric patients.
(/nf'/.J. Psychiatry in Medicine26:93-104, 1996)
Key Words: splitting, projective identification, consult liaison,pediatrics,group process,staff
conferencing, family/staff conferencing, liaison support groups
93
0 1996, Baywood Publishing Co.. Inc.
doi: 10.2190/FWVM-38C3-F4QN-XNHX
http://baywood.com
94 I ROBERTSON, ROBISON AND CARTER
INTRODUCTION
Splitting is a psychological construct described in a variety of contexts [l, 21
including early personality development [3-51, borderline personality disorder
[6-111, and in healthier individuals under the influence of either severe stress [12]
or the regressive pull of primitive group processes [l, 131. The term splitting is
often used pejoratively to explain the behaviors of patients who generate intense
conflicts among professional staff. However, it is a defense mechanism that
occurs automatically,out of the individual’s conscious awareness, when there is a
perceived threat to psychological survival [11.
Kernberg [1,6,7] popularized the use of the term splitting in his formulation of
the defensive style of borderline personality disorders, much of which is derived
from the theories of Melanie Klein [ 141. Psychoanalyticwriters disagree about the
source of the intense primitive transference feelings associated with splitting in
borderline patients [15]. Kernberg believes that the intense affects of borderline
characters are constitutional and that their primitive transference arises from
defensive distortions of early relationships with parents [6,7]. Others associate the
primitive transference and intense affects of borderline personalities with real
inadequacies, rather than fantasy distortions, of the early caretaking environment
[4,9-111. Van der KO&et al. [16] and Herman et al. [17] developed a Traumatic
Antecedent Questionnaire to obtain systematic information about childhood
traumatic experiences in adults diagnosed with personality disorders. They found
a significant correlation between a childhood history of severe abuse and neglect
and an adult diagnosis of borderline personality disorder. These authors conclude
that severe trauma in early childhood can interfere with the establishment of
object constancy, resulting in an inability to relinquish splitting as a mechanism to
ward off anxiety about ambivalent feelings.
In the latter years of his career, Freud came to believe that splitting was a
universal feature of human psychopathology throughout the life cycle in neurotic
as well as psychotic patients [ 11. Numerous authors have described the relationship between splitting and projective identification [l, 3, 6, 7, 12, 18-21]. The
latter defense involves the dissociation and projection of intolerable aspects of the
self onto another person. This person is then identified with because of the
attributes that are now perceived as belonging to himher. The projector elicits
feelings and behavior that conform to the projections, and the recipient owns these
attributes as part of himherself. Projective identification,like splitting, occurs out
of conscious awareness.
The clinical manifestations of splitting on adult psychiatric inpatient units
[l, 18, 22-24] and inpatient medical wards [25-291 have received considerable
attention. Management of the adult borderline on a medical service is facilitated
by the early involvement of the psychiatric consultant, primarily, in liaison meetings with the medical team, rather than face-to-face contact with the patient. A
behavioral management plan [25-271 developed with the medical team, includes
PEDIATRIC CONSULT LIAISON SERVICE I 95
frequent staff conferencing [25, 26, 281 centralization of care to as few staff as
possible [25,26,28], avoidance of direct confrontation of the patient’s entitlement
[25-27, 291 while providing f m but empathic limits when hidher demands are
interfering with the provision of medical care [25-291.
By contrast, there is little recognition in the child psychiatric literature of the
role splitting can play in the treatment of children and their families in pediatric
hospital settings.
METHOD
We will describe two vignettes in which splitting generated staff conflicts in an
academic pediatric hospital setting. We will also show how the steps of early
identification, staff conferencing, and familylstaff conferencing were successful
in diffusing this dynamic.
CASE 1.
P.P. EARLY IDENTIFICATION AND
STAFF CONFERENCING
P.P. is a fourteen-year-old white girl who was admitted to the pediatric
intensive care unit after an overdose of amitriptyline. The patient had been
assisting her mother with babysitting for three small children. Her two older
siblings were unwilling to help with the mother’s child-care commitment.
When P.P. asked for assistance with one of the crying children, her mother
stormed out of the house and over to her sister’s (P.P.’s aunt’s) house, uttering
that she was “fed up.” P.P. swallowed some amitriptyline pills in the medicine
cabinet, changed into a nightgown and placed herself dramatically on the bed
in a “corpse position.” Her aunt quickly found her while checking on the now
unsupervised children and, after direct questioning. P.P. acknowledged the
amitriptyline overdose and was brought by her aunt to the hospital. Of note,
P.P.’s mother had a history of childhood sexual abuse and referred to her
daughter, in the psychiatric interviews, as “Mom.”
The psychiatric consult team was asked to determine the disposition once
P.P. was medically stable. The psychology intern consultant interviewed her
and determined that P.P. was no longer suicidal, had no past history of suicide
attempts or psychiatric treatment, and was willing to participate in outpatient
follow-up. He came to his supervisor for assistance, however, as her mother
insisted that P.P. be hospitalized.
When the psychiatric consult team approached the intensive care unit for a
second assessment, they were informed by ICU nursing staff that the chaplain
would like to be present for any consultations with the family. The chaplain
informed the consult supervisor that the mother had enlisted him with the
following statement: “Maybe you can explain to those doctors what we really
need.” He went on to say that he felt his role was to speak for the mother, who
was having difficulty getting through to the physicians about her fears for her
daughter should she come home. He also informed the consult team that,
regardless of what the daughter said, the mother was convinced that P.P.
96 / ROBERTSON, ROBISON AND CARTER
would not participate in outpatient psychiatric treatment and, therefore,
needed to be psychiatrically hospitalized for her own safety.
In this vignette, the mother is enlisting the chaplain as her spokesman in her
quest to get her daughter psychiatrically hospitalized. She has informed him that
the doctors are not listening to her concerns about her daughter and that he is the
only one who can be counted on to make sure the right decision (her decision) is
made. The first step in interrupting the destructive potential of splitting is early
identification of the process before the splitter’s need to idealize some caretakers
and devalue others has polarized the medical team. Strong disagreements among
clinicians regarding the medical and/or psychological management of a difficult
patient or parent are early indications of splitting [l]. A conference between the
staff members directly involved in the split can interrupt its development before
other members of the treatment team are enlisted through projective identification.
Anticipating a potential split, the consultation supervisor met with the
chaplain privately and thanked him for his input. She requested that he not
attend the ongoing psychiatric assessment. While the chaplain was taken
aback by this request, he was able, with gentle encouragement, to recognize
that his actual presence was not required. The psychiatric consult team met
first with P.P., then with her mother and aunt, and finally with P.P., her
mother, and her aunt together. P.P. was consistent in reporting that she was
scared by what she had done, had no plans for further self-destructive
behavior, and was willing to attend outpatient treatment. The mother and aunt
stated that P.P.’s overdose was a highly lethal attempt and that, despite her
stated intent to cooperate with outpatient treatment, she would not follow
through. However, when P.P., her aunt, and her mother met together with the
consult team, a discharge plan was negotiated that involved the aunt’s commitment to take P.P. and her mother to the appointment at an acute crisis
intervention outpatient program the following morning. Information about the
observed family dynamics were shared with the phone intake worker at the
outpatient agency to assist in treatment planning. P.P. and her family attended
the scheduled appointment at the crisis program and were provided with an
array of intensive outpatient services, including individual and family
therapy. The psychiatric consultant supervisor shared the outcome of her
intervention and a brief review of her formulation with the chaplain and
thanked him for his cooperation. He was receptive to her feedback.
This mother presented a different side of herself to the chaplain than to the
psychiatric consult team who had more information about the events surrounding
her daughter’s suicide attempt. She appeared to the chaplain to be a competent
parent who was deeply concerned that the psychiatric consultants were underestimating her daughter’s potential to kill herself. Her mother portrayed P.P. as
irresponsible and unreliable, i.e., as someone who could not be trusted to follow
through with commitments.
PEDIATRIC CONSULT LIAISON SERVICE I 97
The psychiatric consult team was struck by the mother’s history of early sexual
abuse and her joking reference to her daughter as “Mom.” Her expectation that
P.P. care for three young children (that the mother was being paid to look after)
and her angry impulsive abandonment of her daughter and the three children were
not the behaviors of a competent caring mother. On the contrary, P.P.’s mother
appeared to have unrealistic expectations that her youngest daughter should provide child care which she, not P.P., had agreed to provide. When P.P. betrayed her
assigned role as adult caretaker by asking for assistance, her mother angrily
abandoned her, precipitating the suicide attempt. The mother’s insistence that P.P.
be hospitalized appeared to the psychiatric consultants to be a punitive retaliation
for P.P.’s failure to meet her mother’s dependency needs. Mother’s request to the
chaplain to intervene in the decision regarding her daughter’s disposition was the
first indication that a split was forming.
It is understandable that the chaplain would want to assist this mother, who
appeared genuinely distressed by her daughter’s suicide attempt. Had the chaplain
attended the ongoing evaluation and accepted his assigned role as the mother’s
spokesman, this early split would have progressed to include projective identification. The chaplain, by his identification with the mother’s distress and by his
designated role of “keeping her daughter safe,” would have lost sight of the
delineation of responsibilities among different professional staff in the hospital.
The psychiatric consult team would likely have met a worthy adversary in the
team of chaplain and mother. Efforts to determine an appropriate disposition could
have been greatly complicated and the consult team would probably have felt
frustrated and devalued. A calm thorough evaluation of the clinical situation
would have been very difficult under these circumstances, and it is possible that
the level of conflict generated between the chaplain and the consult team might
have made it impossible to avoid hospitalization.
The chaplain’s willingness to extricate himself from the emerging split was
critical to the successful resolution of this consultation. From the behaviors
surrounding the suicide attempt, the consult team deduced that the mother’s sister
was the most reliable participant in this family drama. She had acted responsibly
in checking on her niece and the young children when her sister came storming
over to her house. The aunt had intervened rapidly when she found P.P. lying in a
corpse position with a bottle of amitriptyline nearby. The aunt initially supported
the mother’s position that P.P. would not attend outpatient therapy. However,
when she met with both the mother and daughter, in the presence of the psychiatric
consultants, the aunt recognized that her sister had not behaved responsibly in the
events surrounding P.P.’s suicide attempt and could not be counted on to assure
that P.P. received outpatient treatment. The aunt stepped in, with the encouragement of the consult team, and agreed to take P.P. and her mother to the outpatient
appointment. An unnecessary hospitalization was avoided and the chaplain and
the psychiatric consult team remained on good terms.
98 / ROBERTSON, ROBISONAND CARTER
Unfortunately, the psychiatric consultant does not always have the opportunity
to interrupt the process of splitting before additional members of the milieu have
been recruited and projective identificationhas polarized the treatment team. The
dynamics of splitting and projective identification,if not identified and interrupted
quickly, can lead to the crystallized perception, by the family and members of the
professional staff, that certain clinicians are caring and competent while others are
uninterested and incompetent. A psychiatric consultant will often be asked to
address this situation after it has progressed to the point of significantly interfering
with the provision of medical services on the unit.
Case II.
D.B. Staff Conferencing and
FamilyEtaff Conferencing
D.B. was a five-month-old black male admitted to the hospital with increasing respiratory distress, edema, and a low-grade fever. He had been diagnosed
at age three months with Wiscott-Aldrich syndrome, a fatal immunodeficiency disorder treatable only by bone marrow transplantation. D.B. was the
only child of parents in their late thirties who had been trying to have a child
for thirteen years. Both extended families had strong religious roots and both
grandfathers were fundamentalist ministers. Despite several early infections,
D.B. had been developing normally up until the age of seven weeks. He was
described, at an earlier admission for Klebsiella bacteremia, as physically
active, tracking well, smiling, eating heartily, and appearing his developmental age in all respects. However, a day after that admission, D.B. became
unresponsive and stopped breathing. He was intubated and a CT scan
revealed a static encephalopathy with increased ventricular size, multicystic
encephalomalacia, and multiple septic infarcts. He was now unresponsive
to anything but deep pain and had difficulty maintaining his body temperature due to extensive damage to his cerebral cortices, hypothalamus, and
brain stem. For these reasons, he was not a candidate for bone marrow
transplantation.
At the time of the current admission, D.B. required reverse isolation. Both
parents were intensely involved in his care and knowledgable about his
treatment, as was his maternal aunt, a nurse working at another local hospital.
During the first four weeks of his hospitalization, nursing staff noticed that
D.B.’s mother almost never left the isolation unit. She interrogated all medical
personnel about their contacts with D.B. and took detailed notes of their
actions and answers. On several occasions she refused to allow staff to draw
D.B.’s blood, and on one occasion became very upset when a pediatric
resident took several hours one evening to evaluate D.B.’s loose stools. The
mother indicated that this was a life-threatening situation and required immediate attention. After the resident evaluated D.B.’s stools, the mother
demanded that the infectious disease attending physician be called at home, as
the mother did not trust the resident’s judgment and felt her son was receiving
“second-class care.”
PEDIATRIC CONSULT LIAISON SERVICE / 99
This pediatric infectious disease attending had been spending at least an
hour daily with D.B.’s mother patiently answering all her questions. However, nursing staff and residents-in-training were becoming sharply divided
about how much attention to give this family. Some were sympathetic to the
family’s tragedy and, like the pediatric attending, were willing to put in extra
time to support the parents. Others felt that the care of other patients on the
ward was being compromised by the mother’s unreasonable demands on their
time. Most nursing staff, residents, and infectious disease attendings were
intimidated by the mother’s interrogations and note-taking, and were at a loss
for how to reassure her of their competence. Moreover, some staff were
concerned that both parents appeared to be in psychological denial about
D.B.’s prognosis, as they had repeatedly made comments about what activities they would include D.B. in “after he’s all better.” Mother, in particular,
seemed to believe that if she did everything humanly possible for D.B., and if
she and her family prayed fervently, he would recover fully.
These staff disagreements approached a crisis level as the current pediatric
infectious disease attending prepared to sign over her service to her colleague
at the end of the month. All four infectious disease attendings were aware of
the clinical situation. The oncoming attending had indicated to the treatment
team that he would be unable to spend as much time with this mother as his
predecessor. He indicated that, when he took over the child’s care, the family
would need to decrease their demands on medical and nursing staff. As the
turnover in service chief approached, the psychiatric consult team was asked
to intervene by a third infectious disease attending, as the “ward was being
tom apart.”
In this vignette, the psychiatric consultant did not have the opportunity to
identify splitting early. A consult was not requested until the level of conflict
among the pediatric treatment team had reached crisis proportions. The parents’
denial of their child’s fatal prognosis was a clue regarding the source of the intense
staff polarization. The pediatric treatment team appeared, to the psychiatric consultant, to be aligned into two diametrically opposed camps. One group of
clinicians, led by the departing infectious disease attending, was extremely sympathetic to this family’s tragedy. They felt they should do everything possible to
respond to the mother’s requests. Another group of clinicians, led by the incoming
infectious disease attending, found the expectations placed on them by this family
unreasonable. These clinicians felt that it was impossible to reassure D.B.’s
mother of their competence and concern. Moreover, other pediatric patients’ care
was being compromised by the time spent on this child, who was already severely
neurologically compromised and for whom there was no expectation of recovery.
A staffconference was scheduled by the psychiatric consultant and infectious disease attendings. All four attending physicians, representatives from
the nursing staff, a social worker, the head chaplain, several pediatric residents, and the psychiatric consultant attended this two-hour meeting. The
infectious disease attending who had requested the psychiatric consult began
100 I ROBERTSON, ROBISON AND CARTER
this meeting by reviewing D.B.’s past medical history, current medical status,
and fatal prognosis. Discussion then moved to a review of the parents’ recent
behavior and the sense, shared by most clinicians, that the family was not
coping well with D.B.’s illness. Both parents’ references to “when D.B. will
eat real food . . . and be just fine” were reviewed and the treatment team
surmised that they were denying their son’s prognosis. The psychiatric
consultant suggested that the most effective intervention to address these
concerns would be a second meeting the following day with the treatment team and the family. Although the oncoming infectious disease attending was skeptical that such a meeting could change the current level of
conflict, he and all other clinicians present agreed to attend this stuflfumily
conference.
This conference also lasted almost two hours. D.B.’s parents and both
extended families were present, including mother’s sister who was a nurse.
The departing infectious disease attending began by reviewing the past medical history, current medical status, and prognosis with the family and treatment team. She told the family how sorry she was that nothing could be done
to reverse the fatal outcome. She then gently pointed out to the mother that her
note taking and intense scrutiny of D.B.’s treatment were intimidating the
health care team and making it harder for them to keep her son as comfortable
as possible. The mother, who had been quietly taking notes, expressed
surprise at this and let her sister, the nurse, speak for her. Her sister told the
treatment team how appreciative the family was of the care D.B. was receiving and informed them that her sister had always had an abrasive style and
meant no offense. The extended family then raised many questions about his
care, most involving the hope that there was another, as yet untried, treatment
available for him. These questions slowed down as the entire family realized
his prognosis was hopeless. At this point, many members of the treatment
team spoke of how sorry they were that there was nothing more to be done to
avert D.B.’s death and of their deep sympathy for the family’s tragedy. These
expressions of sympathy were genuine and heartfelt and were met with
appreciation from the entire family. As the conference drew to an end, a plan
was developed to provide the family with adequate input about D.B.’s care
and help them deal with his prognosis. The oncoming infectious disease
attending agreed to be available daily for forty-five minutes after rounds to
field questions about D.B.’s medical status, and his parents agreed to meet at
least weekly with the psychiatric consultant for assistance in coping with their
impending loss.
After this conference, the mother stopped taking notes. The following day
she was observed crying at length in her son’s room. She began to take breaks
from the reverse isolation room and even left the hospital for brief periods to
get some fresh air. The family never required the entire forty-five minutes
available to them with the new infectious disease attending. D.B. was discharged seven days later without further incident. His parents were informed
that he could be brought back to the hospital, but chose to allow him to die at
home several weeks later.
PEDIATRIC CONSULT LIAISON SERVICE I 101
In this case, while early intervention was not possible, staff conferencing and
stafgamily conferencing were effective in addressing and diffusing the splitting
and projective identification that had polarized the treatment team. Neither of
D.B.’s parents could accept their son’s fatal prognosis, after having waited so long
for a child. Their strong religious background led them to hope that another
miracle might occur, much like his birth. But miracles don’t happen without
unwavering faith. Any thought of resigning themselves to D.B.’s fatal prognosis
had to be resisted with fervor.
Yet D.B. had changed, over a twenty-four-hour period at age seven weeks, from
a thriving baby boy to an infant in an essentially vegetative state. Denying the
inevitable implications of his current mental status was difficult, and the numerous
discussions with doctors about his fatal prognosis tested the parents’ faith even
more. In order to tolerate the level of anxiety these two opposing perspectives
generated, the mother focused inordinate amounts of energy and attention into
assuring that he received the highest quality of care. Her self-imposed isolation
in his mom and copious note taking and interrogation were not meant to
intimidate the treatment team, but to protect her from confronting her son’s
impending death. Acknowledging the fatal prognosis would preclude the possibility of a miracle.
This conflict became externalized into the treatment team. Those willing to do
everything possible for her son, such as the departing infectious disease attending,
supported the possibility of a miracle. The pediatric clinicians who were unable or
unwilling to spend extra time and energy were giving her son “second-class care.”
Members of the treatment team had identified, through projective identification,
with the diametrically opposed sides of the mother’s ambivalence. By maintaining
this conflict in the interpersonal sphere, D.B.’s mother was able to avoid abandoning hope for the recovery of her moribund son.
The effectiveness of staff conferencing and familyhtaff conferencing was due
to the psychological mindedness of the pediatric attending physicians and the
strength of the previous liaison relationships. The infectious disease attending
who requested the psychiatric consult and started the staff conference collaborates
in clinical research with the psychiatric consultant. His support of the consultant’s
recommendations was critical to the success of the intervention. The staff conference began with a review of the medical management of the patient as a prelude
to encouraging the pediatric treatment team to consider what might be motivating
the family to idealize certain staff and devalue others. This discussion led to
increased empathy for the family and decreased conflict among the treatment
team. The familyhtaff conference interrupted the splitting and projective identification by bringing the mother and her extended family together with both
the “devalued” and the “idealized” health professionals [l]. While this initially
raised everyone’s anxiety, it eliminated the “separateness” necessary to maintain
splitting. The family/staff conference allowed the mother to face her son’s
102 I ROBERTSON. ROBISON AND CARTER
fatal prognosis. She was able, with the support of the entire pediatric treatment
team and her extended family, to relinquish splitting as a defense mechanism and
to begin the process of mourning her son.
DISCUSSION
Effective management of splitting in both these vignettes was facilitated by the
receptiveness of the involved pediatric clinicians to the consultants’ recommendations. Interrupting the process of splitting can be difficult, if not impossible,
without the cooperation of the treatment team. The dynamics of splitting and
projective identification are generally not familiar to nonpsychiatric medical,
nursing, and affiliated staff who can be resistant to psychological interpretations
of their or their patients’ behavior [30].
The management of splitting by the families of hospitalized pediatric patients
has not been addressed in the psychiatric literature. However, several authors have
discussed the use of liaison support groups to promote the exploration of emotional reactions of medical, nursing, and ancillary staff to adult medical patients
under their care [30,311. Stem et al. discuss the development of “autognosis”
rounds with the medical house staff in the ICU at the Massachusetts General
Hospital (MGH) [31].Attendance at these rounds, run by a psychiatric consultant,
is expected of all interns and residents rotating through the ICU. Membership is
restricted to physicians-in-training to foster a safe atmosphere for self-disclosure.
Humor and metaphor are utilized to assist interns and residents in identifying and
sharing their reactions to difficult patients. The psychiatric facilitator limits group
exploration to conscious feelings reported by individual physicians as interpretations of unconscious material would inhibit self-disclosure. Since some individuals express themselves better in writing, a “Red Book” is kept in the ICU at
MGH as well. A running narrative of comments about the ICU rotation is contained in this log, which is described by the authors as humorous, irreverent, and
illuminating.
Stem et al. emphasize the importance of administrative support from the
Department of Medicine at MGH in the success of these meetings [31].They
suggest that training directors arrange such liaison support groups for house staff
in all medical specialities, as research has demonstrated that interventions which
promote increased psychological mindedness among physicians avert resident
impairment and compromised patient care. Eisendrath describes the use of similar
liaison groups with interdisciplinary medical teams caring for adults [30].The
parameters for these groups also preclude interpretation of unconscious material
by the psychiatric facilitator or group members. Eisendrath addresses some of the
“resistances” psychiatric consultants may encounter in starting liaison support
groups, including hostility directed toward the facilitator, pessimism about the
group’s effectiveness, apathy, lack of communication, and participants’ fear of
becoming dependent on the group.
PEDIATRIC CONSULT LIAISON SERVICE / 103
The development of similar liaison support groups for pediatric house staff and
interdisciplinary treatment teams could assist pediatric caregivers in coping with
the emotional demands of treating sick children and their families. Such liaison
groups would also be likely to increase the early identification of splitting and
could facilitate its interruption before projective identification polarizes the
clinical team.
Splitting may not always be avoidable in pediatric inpatient settings where the
anxieties of sick children and their families can become overwhelming. However,
its early identification and management through staff conferencing and family/
staff conferencing can curtail its interference with medical treatment and limit
damage to professional relationships. We cannot allow the constraints of managed
care to obscure a fundamental wisdom that medical education is incomplete if it
emphasizes only the patient’s needs and discounts the feelings of those caring for
patients and their families [31].
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