Time-limited treatment of hospitalized borderline patients: Considerations

Abstract

Patients with a diagnosis in the spectrum of “borderline personality organization” represent a significant proportion of inpatient hospital admissions. An intensive, psychodynamically-oriented treatment environment may induce further behavioral disturbances and regressions in such patients. 1,2 Among iatrogenic elements in the therapeutic milieu, which promote ego dedifferentiation and regression, are overgratification of pathologic dependency needs by a permissive supportive staff or inexperienced trainee therapists enmeshed in a quagmire of transference-countertransference difficulties. Borderline patients are often unable to keep a part of their ego available for observation in a therapeutic or working alliance, show marked senses of entitlement, and, by primitive projective mechanisms, protect themselves from seeing the implications of their actions on others. On admission and during a hospitalization, they often present difficult diagnostic and management problems, precipitate endemic psychotic regressions among other patients, or provoke critical staff conflicts. The literature on the “borderline patient”, though clarifying dynamic issues, has tended to emphasize chronicity of the condition and the need for intensive long-term psychotherapy by highly experienced analytically oriented therapists. 3,4 However, limited hospitalization funds and an unavailability of the prescribed outpatient treatment are often issues which generate an atmosphere of therapeutic nihilism. This atmosphere should be metabolized by treatment designs that integrate theory with reality constraints, and allow borderline patients to return to the community in a more functional mode than when they entered the hospital. It is the purpose of this article to identify features important for time-limited hospital treatment of patients with borderline character pathology.