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An Understanding and Approach to Regression in the Borderline Patient

Jesse Viner, MD
Founder and Executive Medical Director

Hospital Treatment

What are the implications of this view for the conceptualization of brief and intermediate length of hospital treatment of the borderline patient?  Borderline patients most often enter acute regressions, and the hospital, when there is a disruption in a self object relationship. This occurs within social and therapeutic relationships, as well as within the hospital itself. The goal of hospitalization is to repair this disruption and enable such patients to organize and unify themselves through the renewed use of a self/object relationship. Besides providing a setting where this may occur, the role of the hospital serves to facilitate and reinforce the patient's integration around one or several self objects. Techniques such as assigning one worker per shift to the patient or rigid adherence to a policy of certain issues being discussed only with the therapist achieve their effectiveness primarily on this organizing basis, not because they interfere with defensive splitting. Daily visits with specific appointment times also help such patients organize themselves around the visit by their therapist. The principle of facilitating the patient's organization around self-objects has multiple applications for specific techniques. Adler17 has written on the function of the hospital in repairing disruptions in the patient therapist relationship for the borderline patient in outpatient psychotherapy. This is one very important example of the role of the hospital in repairing the disrupted self-object bonds for the patient. When the disruption occurs in extratherapeutic relationships, the hospital most make active efforts to include these significant others in the treatment plan.  An additional implication is that the establishment of extratherapeutic self-object relationships should not be interpreted as a defensive displacement from the transference but should frequently be encouraged as it provides stability on a broader basis.  It should also be explored because it demonstrates and is a manifestation of the patient's core psychopathology. Particularly for the more schizoid borderline patient, this self-object relationship may not exist with another person but only with inanimate objects or a specific talent or capacity, such as artistic creativity, which provides these same functions of tension and self-esteem regulation. In any case, the borderline patient cannot be discharged until there is a reestablishment of a self-object relationship that will sustain them beyond discharge. Because therapists so often become the central self-object relationship, no borderline patient should be treated by a therapist who is unable to continue with the patient after discharge.

Another important role of the hospital is as an institutional self-object. Reider18 described a group of patients who formed idealized transferences to clinics and hospitals which helped them regulate and sustain self-esteem and functioning. This is an example of how the hospital itself can serve as a self-object and perform psychic functions either in actuality or in conscious and unconscious fantasy within the patient. These transferences exist simultaneously with similar transferences organized around the therapist or other self-objects. The institutional transference is best understood not as displacement but as a further manifestation of the patient's specific psychic deficit.

For those patients who have been hospitalized but were also involved in intensive outpatient psychotherapy, the institutional self object transference often assumes the character and function of the transitional object. As described by Winnicott,19 the transitional object of infancy is provided by the environment but the illusion cast upon it by the child allows the child to experience it as neither me nor not me. It must never change unless changed by the infant who, while abrogating a measure of omnipotence, assumes rights over the object. It must soothe, give warmth and survive loving and hating. Borderline patients often describe their attitude about the hospital in these terms. Rage reactions and regressions may occur when the hospital is unable or unwilling to function within this characterization. This may help to explain why these patients may at times be unable to allow the hospital to comfort them but rather must either reject and hate it or be rejected and hated by it.

For Winnicott, the transitional object is not internalized or forgotten but loses meaning as development ensues. Marion Tolpin20 agrees that the transitional object is not internalized but adds that it serves as a transitional mental structure through which the infant is able to gradually internalize the tension regulating functions of the infant mother relationship. It is this author’s belief that for the borderline patient, the hospital serves this very same function of facilitating the processes of internalization which are occurring in the patient-therapist relationship. When the therapist frustrates, disappoints, or is not available in a minor way, the borderline patient often evokes the fantasy of hospitalization and is able to use this fantasy to comfort himself.  At times of major disruption and regression, the hospital itself must actually provide these self soothing functions. Gradually, as therapeutic progress occurs and the borderline patient internalizes tension regulating functions in psychotherapy, actual regressions to the hospital are replaced by the associated fantasy and then this fantasy becomes increasingly less meaningful. The patient is more able to comfort himself without the use of the transitional mental structure.

The concepts of the good enough mother and holding environment have often been used to describe the optimal, posture of the therapist and hospital milieu for the borderline patient. The basis for this recommendation has been that this leads to internalization of the holding functions. For brief hospitalizations, the aim of providing a holding environment is attachment, not internalization. The holding environment allows the patient to securely attach and form a self/object relationship to the milieu. The patient cannot attach and form a sustaining self object transference to a person or milieu that is in disequilibrium. Avoiding such disruptions requires an awareness of the factors which can produce disequilibrium in individuals and the milieu. Disruptions stem from sources capable of inducing regression: (1) the balance of frustration vs. gratification, (2) the degree of structure and maintenance of task functioning, and (3) the quality of the object relationship.

Frustration and regression are concepts linked together since Freud's early writings. In deficit disorders the transference is comprised of legitimate developmental needs and not primarily drive needs (Tolpin).13  Demands for drive gratification result from the frustration of developmental needs. Assessment of the specific developmental needs of a patient must be made and provided in reality as a legitimate treatment intervention. Particularly with the borderline it must be remembered that stimulation of regressive needs can be overwhelming for the patient and lead to intense overstimulation and subsequent disappointment, frustration and rage attacks. Borderline patients need to be realistically supported while also challenged to develop their internal capacities to function autonomously. The most important developmental need of the borderline patient is a stable and secure self-object relationship which provides tension regulating functions and protects against the dangers of separation and overstimulation. Patients will fail to attach to treatment milieu or systems that do not respect those particular vulnerabilities. Requirements include but are not limited to therapists who can continue with the patient following discharge and the provision for a stable and predictable staffing pattern, especially for primary workers with the patient. The equilibrium of the milieu must be protected from a multitude of severely disturbing patients or the disruptive effects of large numbers of simultaneous admissions and discharges. Beginning on the day of admission, the issue of discharge and the anxieties around separation must be attended to and discussed in depth.

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, tasks, plans and expectations, limits of the milieu and rational, predictable consequences for violations of these limits. It is vitally important that there is a discrete maintenance of specific task functioning among treatment personnel of various disciplines. This not only helps the patient, who functions on a need satisfying, function related manner, but also helps stabilize the staff as a work group against the regressive processes activated by borderline patients. While providing needed structuring functions, this approach also helps to give patients a sense that their problems and the solutions to them are real, that the staff, therapist, and the patient are not helpless, and that they can change if they choose to do so. The structure provides the opportunity for the hospitalization to be experienced as a success and an accomplishment, thereby building a foundation of hope.

The quality of the therapeutic object relationship exerts a major influence on the patient's potential for regression. These patients require relationships which provide just that much real support, availability, presence, consistency, structure, flexibility, etc. which meets the patient's actual needs while continuing to also respect their vulnerabilities, limitations and capacities.

Kernberg21 has described the regressive processes in organizations which are influenced by the quality of the object relationships among its members. His dealings have enormous implications for the psychiatric hospital milieu and treatment of the borderline patient. Regression within the milieu will stimulate regression in the patient and vice versa. Effective leadership is necessary at all levels of the treatment team but especially at the level of clinical administrator to stabilize the milieu against regressive processes. The functional leader is defined as one who is accountable and responsible for his constituency, exercising only as much authority as is necessary for the task and is appropriate for his role. It is essential that the clinical administrator demonstrates and provides a model of this type of leadership in his relationships with staff. He also needs to create a structure within which specific roles and tasks are defined with appropriate support for autonomous functioning within the structure. The clinical administrator is responsible for establishing himself or herself as a model committed to staff cooperation and mutual respect, understanding of individual and group regressive processes, quality of care, ethical integrity, and a genuine and appropriate concern for the institution, and the people that work and are treated within it.