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Milieu Concepts For Short Term Hospital Treatment Of Borderline Patients

Jesse Viner, MD
Founder and Executive Medical Director

Creating The Conditions For Attachment

The milieu must be constructed in such a way as to support the integrity of the patient's self-organization and to minimize the vulnerability of the patient to regression. Thus the milieu attempts to create the conditions of security necessary for therapeutic attachment. Three aspects of the milieu which can contribute to a condition of security include:

  1. The levels of frustration and stimulation.
  2. The degree of structure and maintenance of task functioning.
  3. The quality of the object relationships.

Frustration and regression are concepts linked together since Freud's9 early writings. It must be remembered that stimulation of regressive needs can be overwhelming for the borderline patient and lead to intense overstimulation and subsequent disappointment, frustration, and rage attacks. Borderline patients need to he realistically supported while also challenged to take responsibility for their lives and develop their internal capacities to function autonomously, while recognizing and working with the knowledge that this level is fragile in the face of certain internal and external stresses.

An important developmental need of the borderline patient is a stable and secure relationship which provides tension regulating functions and protects against the dangers of separation and over-stimulation. Patients will fail to attach to individuals, treatment milieu, or systems that do not address these needs and do not respect these particular vulnerabilities. Beginning on the day of admission, the issue of discharge and the anxieties around separation must be attended to and discussed in-depth.

The inpatient milieu is often hesitant, if not outright frightened and conflicted, about engaging the newly admitted borderline patient in an appropriately nurturing and supportive manner. This ambivalence can itself often create the feared complications of intensification of hostile dependency. Many borderline patients respond positively to the appropriately nurturing milieu and use it to stabilize themselves. This is especially true when the hospitalization was precipitated by a situational crisis.

Patients who respond to the support of hospitalization with intensification of profound dependency needs and rageful reactions to frustration, disappointment, and narcissistic injury are often involved in intense, sometimes chronic, transference regressions, including psychotic transferences. For these patients, the appropriately nurturing milieu is over stimulating. They often require, as Friedman suggests, therapeutic transfer to an understimulating environment like a state hospital.

Environments in which there is a lack of structure promote regression. The borderline patient's vulnerabilities and lack of ego development become exposed when the milieu or specific treatment relationships lack structure and role definition. Treatment plans need to be collaboratively formulated among staff with the patient and must include specific indications for hospitalization, treatment goals, plans, and limit setting. The milieu program, while allowing for unstructured time "to be" with themselves and other patients informally, should be organized with a variety of task oriented structured groups (e.g. goals, discharge, tension reduction groups, etc.) which address the patient's difficulties making an adequate adjustment to reality stressors. It is vitally important that there is a discrete maintenance of specific task functioning among treatment personnel of various disciplines. This helps the patient, who is functioning in a need satisfying, function related, manner and whose boundaries are unstable. It also helps stabilize the staff as a work group against the regressive processes activated by borderline patients.

The quality of the therapeutic object relationships will exert a major influence on the patient's potential for regression. These patients require relationships which provide needed support without overstimulation, along with a level of structure, boundaries, and expectations which meet the patient's actual needs while continuing to also respect their vulnerabilities, limitations, and capacities. The therapeutic attitude should accept, but not encourage regression, while providing support for appropriate autonomous functioning, not pseudo-independence. Tile patient may stimulate and provoke the staff, through projection identifications, to participate in relationships which are experienced as either magically and mutually satisfying, or exploitive, controlling and depriving. Because of this, it is essential that staff develop a maturity about their own feelings regarding omnipotence, dependency, and aggression. Staff can help each other with these difficult tasks by developing a basic knowledge and trust in the people you work with and participating in an atmosphere which allows frank discussion of how patients may involve us in their intrapsychic process due to their perceptions of our character traits. Weekly meetings which allow for discussion of staff's experience in relation to their work tasks can be helpful towards the goal of developing staff.

More often than not, the most important object relationship is to the individual psychotherapist. The goal of creating conditions of security in the milieu is often in the service of fostering attachment to the psychotherapist. In most cases, this is not enough as the potential of a relationship to the therapist is often a serious threat to the patient. The relationship threatens to expose the patient's deficits and his need of the object, thereby creating a humiliation for the patient. In addition, the mobilization of longings for the therapist usually stimulates the potential for rage over deprivation and disappointment with associate primitive anxieties, guilts, and defenses. The milieu needs to reinforce the efforts of the individual psychotherapy by mobilizing and supporting the patient's capacity for hope, trust, and the ego functions necessary for psyhotherapeutic work.