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Milieu Concepts For Short Term Hospital Treatment Of Borderline Patients

Jesse Viner, MD
Founder and Executive Medical Director

Treatment Planning

The treatment plan has three stages: first is the pretreatment contract, followed by the initial treatment plan as performed by staff, and finally by the formal treatment plan.

Sederer and Thorbeck (1983)10 have outlined the usefulness of a preadmission contract for borderline patients. As many hospitals may not have the opportunity to arrange for this prior to admission, I have revised the concept to that of a pretreatment contract, recognizing that admission may have already occurred. They note that it is useful in defusing primitive idealization which might subsequently lead to disappointment and regression that could disrupt the treatment. They encourage a discussion with the patient regarding the goals for hospitalization, the length of stay, and the philosophy and policies of the milieu. This discussion mobilizes the potential for a therapeutic alliance with the patient.

Hospital goals in most cases should be focal, modest, in the here and now, and should be limited to the indications for hospitalization. The indications for hospitalization should be clearly and explicitly identified for the patient and staff. Koenigberg11 has recently described these for short and longer term hospitalizations. As Gordon and Beresin (1983)12 have noted, the establishment of a goal of internal change for the patient has implications for the milieu's approach to regression and acting out. The more a milieu seeks to achieve goals associated with internal changes, the greater the likelihood of regression and therefore the necessity for flexibility regarding acting out. If the milieu is encouraging the patient to become immersed in their internal world, it must be prepared to respond both supportively and psychotherapeutically when the patient predictably has brief periods of being overwhelmed. There needs to be a vigilance towards attempts to change the goals once they have been achieved. Failure to achieve the goals should include an honest assessment of the limitations of the milieu's ability to help the patient.

Because borderline patients often enter the hospital in the midst of an acute regression, the first few hours and days can be critical in determining the potentials for the success or failure of the treatment efforts. The first goal of the initial plan is to help the patient develop an attachment to the treatment team which will interrupt and not stimulate further regression. This allows the patient to begin to utilize the staff to work on the problems that required hospitalization. A beginning focus on the specific indications for the hospitalization often provides a useful starting point.

Other aspects of the initial treatment plan to be performed by staff include:

  • Immediate, in-depth, collaborative assessment with the patients of their need for protection from self-destructive impulses or for protection from aggressive outbursts.
  • Immediate and in-depth orientation to the unit and as to what is going to happen.
  • Assessment of the patient's ability and willingness to collaborate and accept responsibility within his own treatment.
  • Assessment of the patient's actual level of coping and social skills functioning; self-care, task completion, cognitive functioning and interpersonal relations so as to define an appropriately supportive environment.
  • Assessment of the patterns of interaction with staff and patients that are being established.
  • Early identification of issues that might disrupt treatment so that they may be addressed collaboratively by staff, therapist, patient, and family.

The formal treatment plan is the result of an in-depth diagnostic process among the staff and the individual therapist, utilizing an understanding of the patient from a variety of frames of reference including, but not limited to, medical, intra- psychic, behavioral, family, and milieu perspectives. The emphasis of the formal treatment plan will be determined by the specific indications for and goals of the hospitalization. However, there should be an assessment and consideration of treatment possibilities in each of the areas of a biopsychosocial perspective.

It is essential that the role of the milieu be defined in the formal treatment plan. As discussed previously, the milieu has an important role in the assessment of the patient. The attention by the milieu to regression, realistic autonomy, limits and consequences, and the patient's involvement and responsibility offers the patient a form of containment in an attempt to create the conditions which will stabilize the patient, create conditions of security, and allow the pursuit of additional specific treatment goals. Where these goals include psychotherapeutic interactions, the milieu can serve additional roles of supporting the psychotherapy and/or supportive psychotherapy proper.  Supporting the psychotherapy might include providing observations, encouraging trust in the therapist, hopefulness about therapy, and by providing support for the capacities required for psychotherapy such as reality testing, verbalization of affects, self-observation, etc.  Supportive psychotherapy by the milieu might include an active involvement by the staff, usually in task oriented groups, in exploring and changing the patient's coping and problem solving skills, tension reduction exercises, social skills training, etc.In summary, this paper has attempted to outline a milieu approach to short term hospital treatment of the borderline patient. Due to the incompleteness of the self-organization, these patients are especially reliant on the external object and environment for psychic stability. This incompleteness creates a vulnerability to precipitous, but reversible regression and impulsivity. An understanding and approach to regression has been discussed. Treatment planning has been conceptualized as a three-stage process of pretreatment contract, initial treatment plan by staff, and the formal treatment plan.