Milieu Concepts For Short Term Hospital Treatment Of Borderline Patients
PSYCHIATRIC QUARTERLY, 57(2) Summer 1985
© Human Sciences Press
In contrast to the extensive literature on the outpatient treatment of the borderline patient, there exists only a handful of articles which address the complexities of hospital treatment.1-5 This paper will focus on aspects of the milieu for short term (less than three months) length of stay hospital treatment.
To begin, it is important to define the patient group referred to as borderline. As Gunderson (1982)6 has noted, the results of research give confidence to the conclusion that a borderline syndrome exists as a valid diagnosis, but that questions persist as to the particular criteria that define the syndrome. He asked to what extent the current definitions of borderline personality syndrome define a discrete personality disorder, and to what extent is the syndrome representative of a mid-level personality organization which encompasses a variety of more specific personality disorders, as suggested by Kernberg (1975). 7 Gunderson concludes that both conceptualizations look for validation primarily in terms of treatment issues and response. For this reason, I have chosen to have borderline refer to the more inclusive concept of borderline personality organization. As almost all authors have noted, this entire patient group, despite differentiating symptom clusters, shares a central aspect of psychopathology; the potential for precipitous, primitive, yet reversible regression. As I have described previously, Viner (1983),8 this potential rests on the underlying fragility of a self-organization which lacks irreversible unification. Since borderline patients often enter the hospital in the midst of a regressive crisis, the understanding and management of regression and associated impulsiveness is at the center of any milieu treatment efforts with these patients.
A MILIEU APPROACH TO REGRESSION
Given the centrality of regression, it is important to develop an understanding of this psychic process from which derives an attitude and approach to its manifestations. Acute regression in borderline patients results from the disruption of the patient's self-organization. It is a symptomatic expression of and a pathological, compensatory attempt at mastery of internal disorganization. As these patients are partially reliant on external objects and the environment for the integrity of their self-organization, assessment of the external and intrapsychic contributors to this breakdown, and their interrelationship, is of critical importance in treatment. Communication of acceptance of the patient as a person vulnerable to regression is critical, but it is no less essential that there be recognition and enforcement of the patient's accountability and responsibility for their behavior and for the consequences that their behavior may bring.
Each milieu needs to define a philosophy within which there is a specific and detailed outlining of the limits of the milieu's willingness or ability to tolerate certain types of regressed or impulsive behavior. Each milieu needs to identify and respect its limitations. Patients are less able to regulate themselves when their caretakers allow them to abuse them.