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Milieu Concepts For Short Term Hospital Treatment Of Borderline Patients

Jesse Viner, MD
Founder and Executive Medical Director

Case Example

Ms. S, a 24-year-old homosexual woman was admitted to the hospital by her (female) outpatient therapist due to rageful outbursts and suicidal ideation. Once in the hospital, Ms. S began to break furniture after her sessions with her therapist. Consultation with the author as program director clarified the therapist's submission to and withdrawal from the patient's anger and led to an intervention by the program director in which the program's willingness and commitment to treat the patient were reaffirmed; but the patient was made aware of the inability to allow a situation in which the safety of others was compromised and there was willful destruction of hospital property. Her difficulty in managing her anger was acknowledged, the availability of the milieu's resources to cope with these tensions more successfully was offered, and the patient was informed that recurrence would lead to transfer to a state hospital. Ms. S not only did not repeat the behavior, but began to use her psychotherapy more effectively to discuss the origins of her anger.

While the milieu needs to undertake realistic precautions and restrictions to not undermine the borderline patient's capacity to struggle with regressive and impulsive impulses, it is vital to not assume ultimate responsibility for the control of these behaviors. Since these behaviors often are an attack or otherwise directed towards transference figures, it is necessary to develop an understanding and comfort with wishes for omnipotence, and feelings of anger and guilt towards the patient. With patients who insist on regressive behaviors in the milieu, it is vital, after realistic restrictions for the milieu are enforced, that the focus be not on behavioral control, but the dynamic context within which the symptom exists. This may at times require working with, and not being narcissistically injured by, the persistence of a disturbing and dangerous symptom, like self-mutilation. In situations such as these, there needs to be an ongoing assessment of whether the symptom is operating as a core resistance to further progress in treatment. If this (difficult) clinical judgment is made, then there needs to be an insistence on the part of the treatment team that the behavior stop or be significantly modified for continued treatment in the program.

Chronic suicidality and self-mutilation, which potentially threaten life, pose special problems in hospital treatment. Often the staff and physician feel obligated to continuously and indefinitely monitor the patient (1:1 observation). In my experience this most often leads to a stalemate or deterioration in the treatment process as the focus shifts towards behavioral control as the implicit goal of treatment. It often becomes a burden to both patient and staff and becomes a vehicle for sado-masochistic struggles and acting out of affects by patient and staff. A more effective course is to acknowledge with the patient that staff cannot fully protect the patient, and that meaningful treatment may involve serious suicidal risk, accidentally or intentionally. The patient, sometimes with the family, the physician, and the hospital, need to agree on pursuing meaningful treatment in the face of these risks. If it is decided, this decision should be documented in the chart. The patient is then taken off prescribed 1:1 staffing and allowed to participate fully in the milieu. The patient and staff then have as a plan that they will share a responsibility for helping the patient identify and experience affect states and their relationship to self-mutilation and suicidality, and adjust staff contact according to their ability to be successful in this task. It is acknowledged that both the patient and staff may make mistakes, perhaps serious, even lethal ones, but that this risk is necessary to create the conditions which allow the patient an opportunity to work on the identification and management of profound affect states.

Case Example

Ms. B was a 29 year-old woman admitted for suicidal ideation and self-mutilation by cutting and burning herself following tile announcement by her therapist that he was leaving the city in two months. Ms. B. had a history of serious suicide attempts in the past. She was admitted and placed on 1:1 with a treatment plan of focusing on her feelings about the termination and starting with a new therapist. Ms. B. continued suicidal and engaged in head banging and cutting herself, requiring restraints at several points. Staff felt provoked by the behaviors and unable to maintain an empathic or supportive response. The author intervened and suggested a change to the approach as above. This required additional support for the physician and a willingness to share medicological responsibility, and working with the staff to relieve them of feelings of guilt and helping them tolerate and work with the anxieties inherent in the alternative plan. Most importantly, it required repeated explanantion and clarification with the patient, as well as a discussion of her feelings of being abandoned and unprotected. The plan was introduced gradually over a period of a week. Following its introduction, the patient's self-mutilation and suicidality gradually subsided. Episodes of self-mutilation were less intense and were now the focus of psychotherapeutic inquiry. The physician and staff felt the patient made significant gains in working through her separation reaction such that she was able to be discharged and successfully transferred to another therapist.