An Understanding and Approach to Regression in the Borderline Patient
From the Northwestern University Medical School and the Northwestern Memorial Hospital Institute of Psychiatry,
Chicago, Illinois
©1983 by Grune & Stratton, Inc.
THIS PAPER will attempt to synthesize clinical observations and the contributions of investigators in psychoanalysis and developmental psychology to work towards a conceptualization of borderline psychopathology? This understanding will be used to consider a conceptual approach towards treatment. In contrast to the extensive literature on the outpatient treatment of the borderline patient, there exist only a small handful of articles which address the complex issues of hospital treatment. As a result, specific focus on the implications for brief and intermediate length of stay hospital treatment will be discussed.
To begin, it is important to attempt to define the patient group we will call borderline. The work of several investigators notwithstanding, precise definition remains an area of confusion and controversy. Gunderson1 proposed a set of definitions that are operationally useful to follow. Borderline personality organization is a level of psychic organization and functioning. It represents a stable, albeit volatile and fluctuating, level of psychic organization which is distinguishable from the psychotic and psychoneurotic disorders. Within this level of psychic organization, there are multiple discrete diagnoses of a variety of personality disorders, one of which is the borderline personality disorder as defined in DSM III (1980).2 Borderline, for this discussion, refers to the more inclusive concept of borderline personality organization.
Why choose this broad definition as most useful? It is because this entire patient group, despite differentiating symptom clusters, shares a central aspect of psychopathology that will provide an organizing conceptual framework. Unlike metapsychological psychostructural diagnostic criteria, such as are proposed by Kernberg3 this feature is directly clinically observable. All of the patients within this level of psychic organization possess the potential for severe, primitive, precipitous yet reversible regression. More than any other feature, this potential for reversible regression within and outside the therapeutic situation helps define not only who these patients are, but also what their problem is. How one might understand this and attempt to treat it are the primary questions being addressed.