Patients with BPD constitute approximately 23% of inpatient admissions and 11% of the outpatient population. BPD is easily the most common form of personality disorder found in psychiatric hospitals.
The overall role of the hospital in the treatment of BPD usually involves management of regression or safety crises. Hospitals offer opportunities to complete diagnostic, pharmacotherapeutic, or family evaluations and to initiate or coordinate outpatient therapies.
The need for occasional readmission should be accepted as part of the usual course of patients with BPD and should not be viewed as a therapeutic failure or as an inappropriate submission to the patient’s manipulation. Misuse of hospitalizations occurs when clinicians fail to question, confront, or interpret the manipulative purposes behind suicidal gestures or threats or issues of secondary gain related to being hospitalized. Even with such interventions, hospitalizations often will be needed but are likely to be less contaminated by unrecognized agendas.
Even though use of a hospital may not be necessary for all borderline patients, access to a hospital and the readiness to use this approach are essential before outpatient treatment is undertaken. The mere presence of a hospital helps to diminish the countertransference feelings of helplessness or anger.
The option of long-term hospitalization is now extremely rare. Most stays are 4-10 days, which is generally adequate for evaluation and crisis interventions. Longer-term hospitalization often entails the danger of nontherapeutic regressions (e.g., angry, negativistic behaviors vis-a-vis the controls imposed by the hospital or childlike behaviors and demands). The three common causes for these regressions are 1) failure to sustain a focus on the situation that precipitated the admission, 2) failure to address the extra therapeutic context from which the patient seeks asylum, and 3) the unwitting reinforcement of dysfunction rather than function.
Evidence indicates that longer-term hospitalizations can be helpful if they involve special services. England’s Henderson Hospital offers a therapeutic community for selected voluntary, mostly borderline patients to stay in for up to a year. Patients who entered the program stayed an average of 7 months and showed significantly greater improvements on self-reported borderline symptoms a year after leaving than did patients who did not enter the program.
In the absence of the option for long-term hospitalizations for those borderline patients who need long-term intensive treatment, partial hospital programs usually suffice. Partial hospital programs (day hospital and/or night care, halfway houses) provide stabilizing and social rehabilitative functions for borderline patients while using less intensive staffing than hospitalization. The potential for regression within these programs is also greatly reduced. Day hospital programs offer therapeutic supports and structures along with the opportunity for focused time-limited group therapies. Good day treatment programs offer active vocational rehabilitation programs that are of value to the many borderline patients with histories of academic or vocational failures.
Bateman and Fonagy tested the efficacy of an 18-month psychodynamically oriented day hospital program. This day program featured a tightly integrated psychodynamically based group (three times a week) and individual (once a week) therapy along with once-weekly expressive therapy oriented toward psychodrama techniques and medications. Borderline patients in this program were compared with those who were randomly assigned to treatment as usual (e.g., intermittent hospitalization, with medication and outpatient follow-ups). Significant advantages for the day programs were already evident at 6 months and grew at 12 months and 18 months in the areas of depression, self-destructiveness, and social and interpersonal functioning.
Similarly, Hoge et al. showed that a day treatment program in which dynamically oriented group therapy was primarily used for patients with personality disorders was effective compared with a wait-list control in terms of symptom patterns, life satisfaction, and functioning. Community models of care, such as assertive community treatment (ACT) programs, have been used with borderline patients, and the effectiveness with this group parallels that of patients with chronic psychotic disorders.
Halfway houses offer a valuable way to add structure and support to borderline patients in outpatient psychotherapy. Halfway houses offer distance from toxic family or other social situations. They also offer social relationships with peers without the potential for regressive functioning that is common in inpatient settings.
Staff conflicts (“splits”) can complicate partial hospital treatments for borderline patients. There is general agreement about the content of these conflicts - namely, the contrast between viewing borderline patients as helpless waifs in need of nurturance and as angry manipulators in need of limits. Those whose views of borderline psychopathology emphasize the latter characteristics (e.g., aggressiveness) see the borderline patient’s projections as a cause for disagreements (e.g., they “split” the staff). More important may be the degree to which staff with more nurturing countertransference reactions are bound to disagree with staff with more angry countertransferences. Here, the staff members are “split” by what they themselves bring to their interactions with the borderline patient.
A useful perspective is offered by the concept of projective identification. Via projective identification, the patient externalizes his or her internal good and bad objects onto staff members in the milieu. The process is a joint creation in that the bad object is projected onto a staff member who tends to be rigid or harsh, whereas the good object is projected onto a more nurturing staff member.
Four General Guidelines for Effective Hospital or Partial Hospital Service
1. Strong reliance on structure. Borderline patients need a full schedule of activities that organize their time and place, that is, where they are to be and what they are to do.
2. Expectation that patient will act as a responsible adult and be an active participant in the development of the treatment plan. Patients are expected to be collaborators in their own treatment, and failure to do so could be used as a reason for “therapeutic discharge.” In other words, patients who consistently regress within hospitals are informed of the program’s failure to be helpful and are discharged on this account, with a stipulation that they may return when they feel more ready to work in a self-directed way with the treatment staff. Often admissions can be treated as a continuum, with patients making gradual progress with each subsequent admission. In defining the goals of the current admission, staff should keep in mind the progress made during the last admission.
3. Identification of maladaptive interpersonal patterns and functioning on a routine basis. The program should provide new strategies for managing the frustrations inherent in interpersonal involvement.
4. A focus on adaptation to life in the community and maintenance of a longitudinal perspective of the patient’s life. It is much more helpful for patients to focus on their functioning rather than the symptom pattern. Groups focusing on family problems, abuse experiences, vocation, and transitions that start within inpatient units can diminish regressions, structure patient time, maintain community connections, and serve the value of confronting maladaptive interpersonal behaviors to make them more dystonic. It is very desirable to sustain such groups through gradually reduced levels of care into outpatient settings.
Many of these characteristics are compatible with a psychiatric rehabilitation model that has been proposed to increase our understanding of BPD and to improve the success of services developed for borderline patients.
The literature indicates that, regardless of modality, treatment of BPD is difficult, severe countertransference problems are common, and the results are uneven. Individual psychotherapy remains the backbone of most treatment strategies for borderline patients. The importance of the supportive elements is increasingly recognized. Medications, especially SSRIs, have taken their place as a second standard component of treatment. Both of these standard treatments are in need of far more research.
The need for hospitalization to manage crises is variable, but this is a resource that should always be available in the overall treatment program. The use of coordinated partial hospital and outpatient behavioral therapy programs has been empirically established. Their empirical validation offers hope for more empirically based treatments in the future. The role of family and group therapies can be critical, but these therapies need to be deployed selectively, often with preparatory sessions. They too have received some empirical support.
The overriding trends combine an ongoing recognition that ambitious goals for change are realistic in the treatment of BPD with the understanding that achieving such goals requires multiple modalities, skilled experienced treaters, and many years.
Revision date: July 6, 2011
Last revised: by Jorge P. Ribeiro, MD