Time-limited treatment of hospitalized borderline patients: Considerations

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.     

Time-limited thematic group with post-mastectomy patients

Twenty-four post-mastectomy women participated in thematic time-limited groups. About half of the women reported that the groups helped them a lot, and in these women a significant decrease in psychological distress, especially anxiety and depression, was found. In the few who reported they were not helped, an increase in psychological distress was found, especially in hostility. The main concerns of the post-mastectomy women are described, as well as the need to develop predictors about who can benefit from time-limited groups. The preliminary data seems to indicate that patients became less prone to improvement with time (after the operation) and that patients who have the wish to share their experience with others do especially well in groups.     

Long-term changes in borderline symptoms of patients after client-centered group psychotherapy

In a follow-up study the long-term changes of borderline symptomatic of 14 patients with the diagnosis borderline personality disorder (criteria by Kernberg and Rorschach test) are compared with 13 patients with diagnosis schizophrenia and 16 patients with diagnosis depression (each case according to ICD-9 criteria). The Diagnostic Interview for Borderline Patients (DIB) is evaluated to comprehend the structure and kinds of borderline symptoms before and 4 years after treatment. Borderline patients are treated in a setting of client-centred group psychotherapy (twice a week, approximately 100 sessions). The treatment of the patients joining the control group is based on clinical standard. As a result all patients reduced the borderline-like symptoms. However, the most significant changes can be seen in the borderline group. 2 out of 14 borderline patients still fulfill the DIB Criteria of borderline personality disorder. Nevertheless, there are differences in the reduction of specific categories of borderline symptoms. The greatest changes are in the categories "loss of impulse control" and "psychotic episodes", whereas there are only slight improvements in the category "interpersonal relationships".     

Time-limited psychotherapy with university students.

A report of the developments that stemmed from initial observations in time-limited psychotherapy with University student patients. These led to the conceptualization of the process not in terms of focal conflict but in the development of the relationship itself. Autonomy came to be seen as the central issue and a similarity was noted between the pattern of the relationship in therapy and a proposed developmental model of the growth of autonomy. Within this framework reciprocity became the focus of the relationship dimension. A case illustration is given the significance of time and separation discussed and some therapeutic and theoretical implications considered.     

Early discontinuance of borderline patients from psychotherapy

Sixty newly hospitalized patients with borderline personality disorder who began psychotherapy were followed for 6 months. Thirty-six discontinued their therapy--most often (N = 26) this was due to covert opposition, familial resistance, or angry dissatisfaction with treatment. The dropouts were healthier on some baseline measures than those who continued in therapy. Clinical implications that may diminish dropouts are discussed.     

Prognostic indicators in the psychotherapy of borderline patients

Although diagnostic and therapeutic difficulties, including countertransference problems, in borderline patients make prognostic estimates hazardous, practical necessity often requires a prognostic judgment regarding treatability. This paper proposes a list of prognostic indicators in borderline patients which may be useful to the psychotherapist in the evaluation of treatability. Unfavorable prognostic indicators include history of brutalized early environment, severe behavior problems in childhood, antisocial behavior, addictions, egosyntonicity, superficial or highly disturbed relationships, marked narcissistic features, injurious social environment; and, in the course of therapy, strong negative reaction of the therapist toward the patient, and antisocial acting out. Suggesting a more favorable prognosis for psychotherapy are: nonspecific personality traits which may promote the therapeutic relationship (likeableness, warmth, reliability, or interest in people), and intact sublimatory outlets (talents, skills). In general, the quality of object relations, especially the therapist-patient relationship, including the countertransference, is crucial to prognosis. The unfavorable prognostic implications of certain atypical forms of anxiety, depression, and dependency, as well as anhedonia and abulia, are discussed. Borderline patients with infantile features probably have better prognosis than is generally recognized; with narcissistic features, a worse prognosis than generally recognized.     

An outcome study of psychotherapy for patients with borderline personality disorder.

OBJECTIVE: This study evaluated the effectiveness of well-defined outpatient psychotherapy for patients with borderline personality disorder. METHOD: Thirty patients with borderline personality disorder diagnosed according to the DSM-III criteria were given twice weekly outpatient psychotherapy for 12 months by trainee therapists who were closely supervised. The treatment approach was based on a psychology of self (this term being used in its broad sense), and strong efforts were made to ensure that all therapists adhered to the treatment model. Outcome measures included frequency of use of drugs (both prescribed and illegal), number of visits to medical professionals, number of episodes of violence and self-harm, time away from work, number of hospital admissions, time spent as an inpatient, score on a self-report index of symptoms, and number of DSM-III criteria (weighted for frequency, severity, and duration) fulfilled. RESULTS: The subjects showed statistically significant improvement from the initial assessment to the end of the year of follow-up on every measure. Moreover, 30% of the subjects no longer fulfilled the DSM-III criteria for borderline personality disorder. This improvement had persisted 1 year after the cessation of therapy. CONCLUSIONS: The results suggest that a specific form of psychotherapy is of benefit for patients with borderline personality disorder.     

Development of a scale for measuring techniques in the psychotherapy of borderline patients

Studies of psychodynamic psychotherapy require an instrument to measure the application of the prescribed therapeutic techniques during ongoing treatment. The authors describe the development of such an instrument, the Therapist Verbal Intervention Inventory (TVII), designed specifically for use in the study of the treatment of patients with borderline personality disorders. The TVII was designed, in addition, to test the hypothesis that psychodynamic techniques defined at a middle level of inference could be reliably rated by trained clinicians. The authors present data on the inter-rater reliabilities and inter-rater agreements obtainable with the TVII in the hands of highly experienced clinicians and in the hands of an independent group of junior clinicians trained in its use. The TVII appears to be a potentially useful tool for monitoring psychotherapy techniques in ongoing studies of the treatment of patients with severe personality disorders. Psychiatrists at the advanced resident level or immediate postresidency level have been trained to use the TVII to rate videotaped therapy sessions reliably.     

Standardized approaches to individual psychotherapy of patients with borderline personality disorder

Recent developments in individual psychotherapy for patients with borderline personality disorder include psychodynamic, interpersonal, behavioral, and cognitive treatments. The author provides an overview of standardized treatment approaches--that is, modes of treatment that have a clear theoretical rationale and specific strategies and techniques--for borderline personality disorder. Evaluations of the efficacy of these approaches are discussed. Although there is little empirically based knowledge about the effectiveness of these treatments, their adaptation for the specific treatment of borderline personality disorder represents an important step for treatment and research in this area.     

Time-limited psychotherapy for posttraumatic stress disorder: the traumatized ego and its self-reparative function

The course of time-limited psychotherapy of a case of an acute posttraumatic stress disorder is presented in detail and the material is analyzed in structural-theory and self-psychological terms. Theoretical and technical issues concerning the self-reparative function of the ego, a critically important but relatively neglected ego function, are discussed.     

Out-patient group psychotherapy with paranoid schizophrenic patients

Summary The treatment of two groups of paranoid schizophrenic patients with group psychotherapy was approached with the following goals in mind: (1) to maintain a group in treatment on an out-patient basis by means of ego supportive psychotherapy and drugs as necessary; (2) to help patients within the group to achieve more successful or healthy adjustments to social, family, and employment relationships by means of the group process.The theoretical and practical considerations in the use of group therapy in the treatment of schizophrenic patients are presented in this paper. Members of a spontaneously-formed patient subgroup obtain more beneficial and therapeutic results in group psychotherapy than non-subgroup members.It is felt that group therapy can be successfully used to provide adequate and intensive treatment for an out-patient schizophrenic population. For some schizophrenic patients in a general hospital psychiatric clinic setting such as the one described here, group therapy appears to be a feasible and probably more effective means of treatment than the routine individual follow-up care.From the Institute of the Pennsylvania Hospital, 111 N. 49th Street, Philadelphia 39, Pa. This study was supported in part by the Hall-Mercer Hospital, Pennsylvania Hospital Division and the Nathan Haward, Jr. Memorial Fund.The author wishes to express his appreciation to Drs. Samuel B. Hadden, Joseph J. Peters, and John C. Sonne for their supervision and guidance in the preparation of this paper and to Dr. Louise Osness for her assistance in the group.