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. 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