Day Hospital Group Treatment of Primitive Character Pathology

Sarah Alonso, MEd
38 East First Street - Freeport, NY 11520

Treatment of borderline and other character pathology has been a source of frustration and dissatisfaction for both clinicians and patients. Restrictive trends in insurance coverage for both inpatient and outpatient care have heightened this dilemma; long-term, consistent psychodynamic treatment is considered the treatment of choice, but is rarely available in todayís changing treatment settings. This paper examines partial hospitalization as an alternate group therapy modality, focusing on examples from a day hospital program in Massachusetts. Through discussion of relevant theory, a description of the program, and selected case studies, a variety of clinical implications are presented for the treatment of this patient group.

Implications of Insurance Review.
Much of the literature written about psychodynamic treatment of borderline character pathology describes patients who have long term connections with an individual and/or group therapist, often meeting at least once a week. The majority of patients in this diagnostic category who are seen at the mental health center do not have benefit of such regular care: these patients typically have poor work histories and may have no insurance at all, or if they do, their coverage is sadly inadequate to their treatment needs. The increasing prevalence of Managed-Care policies and HMOs, with their low ceilings for outpatient benefits, makes long term, weekly contact with a therapist a virtual impossibility for those who cannot afford to pay out of pocket. Many chronically ill, character disordered patients receive treatment only when they present themselves in sufficient crisis to warrant an inpatient hospitalization. In addition, they frequently drop treatment or act out self-destructively, straining the resources of private practitioners and agency clinicians.
The relatively inexpensive price tag of partial hospitalization - about one-third that of an inpatient stay - makes it an appealing alternative to 3rd party payers. In addition, the requirement that patients maintain their outside responsibilities of home, family, etc., helps decrease the malignant regression typically encountered with inpatient hospitalization of this patient population. Day hospitalization offers an opportunity for borderline patients to struggle with both their wishes and fears of being totally cared for, and supports them in maintaining the integrity inherent in going home each day.
The increasing prevalence of insurance reviews and treatment teams made up in part by insurers has led to a multitude of complications in the treatment of any patient, and especially in the treatment of borderline patients. While the day hospital is less expensive than an inpatient setting, it is by no means immune to compromise by the interventions of an insurance reviewer. In these cases, care must be taken to avoid fostering or colluding with the borderline patient's bad object projections onto the insurer, however accurate they may seem. Such countertransferential responses serve only to reinforce the patient's already certain belief that she or he is the passive recipient of warring outside forces, and perpetuates the defensive splitting which is the hallmark of this population.

Definition of the population.
In describing this treatment option for a population of borderline patients, some clarification must be made regarding exactly who is meant by "Borderline patients". People with borderline defensive structures fall along a developmental continuum, with some functioning quite well by external standards - that is, job, home, spouse, family reasonably intact - and some virtually unable to survive off a locked unit, with frequent serious suicide/homicide attempts, no significant family connections, state hospitalizations, etc. Most of the patients we see fall somewhere between these poles. Because of the great variability in symptomatology and response to treatment which is seen in patients diagnosed with "borderline personality disorder", it seems clearer and more accurate to refer to these patients' defensive structures rather than personalities as being borderline. In considering personality organization not as a static entity but rather as made up of an assortment of self- and object-representations, we see that a given patient may exhibit defenses from many points along the developmental continuum. In addition, as patients change (whether through treatment or other means), the use of particular defenses may decrease as others are used in their place.
Many borderline patients do well in the Day Hospital, although some fare poorly, and for the majority the experience is mixed. Measurement of these patients' success or failure (or ours in their treatment) is a complicated matter, and beyond the scope of this paper. What will be undertaken is a discussion of the treatment, with explorations of selected clinical examples. In looking at these people's progress, it becomes apparent that positive results can be also have negative implications, and vice versa. An understanding of "two steps forward and one step back" is important as we look at the work these patients do; in this area, context is everything.

Course of Treatment.

Carl was a severely regressed patient who had initially made the transition to Day Hospital from the inpatient unit. He forged a powerful bond almost instantly with his Day Hospital therapist, but refused to talk in groups, glaring accusingly at anyone who dared approach him. He spent group time curled up in a corner, seemingly asleep. Any attempt to push him in the direction of increased group interaction was met with vague promises of suicide and increased hopelessness. As he pulled away from the group, however, Carl drew himself closer to the therapist by speaking more clearly in individual sessions, showing some capacity for insight, and including her in his humor. When the time came for discharge, Carl pleaded with the therapist to allow him to stay longer. He was told he could return at a later date, that the program would remain available to him, but that this particular round of treatment had come to an end. Carl became even more despondent, and his already minimal functioning suffered as he became too depressed to sell the skincare products which had previously been a source of pride and pleasure for him. On the day of his discharge, Carl rallied somewhat, and spoke up in his final group session to say goodbye.

The powerful transference reaction this patient formed is even more understandable in light of his history. This patient's mother, who had been emotionally quite distant, had died when the patient was in his early teens. The patient had been something of a pariah in his family, and felt his father blamed him for his mother's death. He was the youngest of three, and intensely competitive with his sister, who had had a child the year before.
Given this background, a dynamic understanding of Carl's experience of Day Hospital becomes more apparent. To him, the therapist/parent was at once all-understanding and loving and yet punitive and abandoning, leaving him at the mercy of his group members/siblings. He did not offer anyone an opportunity to join with him in his suffering, lest he be taken advantage of once again. Countertransference reactions elicited by Carl in the staff were also powerful and varied, with some feeling punitive and rageful and others sympathetic and encouraging. The milieu presented Carl with a catalyst for the recapitulation of his family of origin, but because of the limitations of the program framework he was not able to remain in the program long enough to benefit from any specific corrective emotional experiences within the group. He remained desperate to please his Day Hospital therapist, first by working harder in individual sessions, and then by decompensating into suicidal threats. Finally, when all else had failed, he ended treatment rather like a captain going down with the ship: valiant and well-behaved, presenting the therapist with a gift (an empty picture frame) and the group with smiles and banter.

In the months following discharge, Carl telephoned the therapist a number of times. Each time the therapist spoke with him briefly, then referred him back to his individual therapist whom he had begun seeing upon discharge from the Day Hospital. Carl was told that Day Hospital was an option for him. He was reminded of the difficulties he had encountered in engaging and then leaving treatment there, and encouraged to determine with his individual therapist when would be the best time for a readmission. Eventually Carl returned to the Day Hospital. Prior to beginning, he agreed upon a discharge date and a limited number of individual meetings with the therapist. Carl struggled at length over each negotiation, but made an effort to hold up his end and in fact used the groups more. Angry over the therapist's decreased availability, Carl turned to the other therapists who referred him to the group, and eventually he began forming friendships among the other patients. In individual sessions he was able to struggle with his conflicted feelings toward the therapist, who continued to support Carl while welcoming his anger and his confusion. Toward the end of his admission, Carl spontaneously began considering a volunteer job and began talking in groups about his fears and concerns about leaving treatment. Although he fought discharge when it arrived, he negotiated a planned readmission for several months in the future and terminated appropriately, if sadly. Not once in his stay had he mentioned suicide.

During his second admission, Carl's experience of the therapist began to more closely simulate that of a "good-enough" mother. He was disappointed by the therapist's unwillingness to offer more contact, and enraged each time she called attention to a mistake or failing on her own part. Gradually, Carl was able to see and acknowledge that the therapist did not abandon or punish him; he made small attempts at friendships with others, breaking the exclusivity of his bond with the therapist, and was not punished for this either. Carl's experience of the therapist as constant but fallible, and of the group and other therapists as nonjudgemental and accepting, helped make this therapeutic contact an emotionally corrective one. At the end of this treatment, Carl presented the group - rather than the therapist - with a gift (a poem about hope), and in his last individual session spoke for the first time of an attraction he held for a woman who lived in his apartment building.

Object Constancy.

The example of Carl is one in which some of the failings of the Day Hospital treatment modality can also be put to therapeutic use. The brevity of treatment in this setting precludes much in the way of long-term learning, especially for this fragile group of patients who require so much and are so draining to work with. Using the program over time as a containing environment which, like a true "good-enough" family, one can enter, leave, and then re-enter offers the patient an opportunity to begin working on issues of separation and individuation. The freedom exists to "practice" endings, to leave the nest and yet return at will for a community lunch or perhaps another round of treatment. The program as a whole remains stable, although the faces of the other patients and occasionally the staff will change. In individual therapy with this patient population, there are far fewer opportunities for this kind of work, and the potential threat to the patient is much greater. By experiencing the comings and goings of treatment over time, the patient learns to tolerate changes that occur within the hospital and not be devastated. The program may move to a new space in the hospital; staff may change positions or leave altogether, to be replaced by a new staff person; a new group or a new rule may be instituted. Gradually, the establishment of object constancy begins, as the patient assimilates each change while still relating to the Day Hospital as a whole entity.
The Day Hospital setting provides a rich opportunity for the observation and interpretation of transference in its many forms. This setting is in many ways a theater, with its players depicting a microcosm of the outside world of the patient. On this stage one may find the therapist representing the parent, the other patients in the roles of siblings or peers, and staff playing the parts of other relatives or authority figures. These roles are not consciously undertaken; however, the flexible boundaries and shifting roles of staff and patients inherent in the milieu setting provide fertile ground for transference/countertransference relationships to emerge in the course of treatment.
Membership in a therapeutic group promotes swift regression, as in the course of daily functioning there patients begin having their problems rather than simply talking about them (as would be the case in individual therapy).

Anne had been attending Day Hospital for about two weeks, during which time she frequently questioned in individual sessions the validity of group treatment for her problems. She was often concerned that other group members were too sick, their problems too enormous for her to feel comfortable in using the group for her own needs. During one session, the group was focused on a male member's having been accused by a relative of sexually molesting a child, an action which that member firmly denied. As the discussion ensued, Anne grew pale and began quivering silently, tears coursing down her face. She was unable to answer when the group inquired about her reaction, and continued to cry soundlessly throughout the group session. In a subsequent individual meeting with her therapist, who had been leading the group, Anne was able to identify her reaction as stemming from her own history with her father, who had been physically intrusive to her in her childhood and whom she had idealized all her life. Her mother had done nothing to stop this behavior, and Anne grudgingly acknowledged her anger at the therapist for not intervening during the group. Throughout this meeting, Anne had difficulty differentiating between past and present events, and cried that "when I looked at his face, all I could see was my father's face. Suddenly, I was five years old and I couldn't stop anything from happening".

For these patients with brittle boundaries and little capacity for self-soothing, the passions in a group can often stimulate intense and dramatic transference reactions. Anne's experience during the group, while initially quite frightening for her, became an event from which to learn about ways to protect herself and gain support from others. Anne was able to identify ways in which she could "ground" herself in reality during a frightening group: in this instance, she wrote on a sheet of paper, "look at the clock", "look at the chairs", and "this is not happening now, this is only a memory. I am 28 years old, and this is a group". This paper Anne folded up and kept in her purse, and throughout the remainder of her treatment often took it out and examined it at times of extreme agitation. Such an opportunity to sustain injury, survive, recover, and protect oneself from future harm within the containing environment of the milieu is a hallmark of the Day Hospital's usefulness in the treatment of borderline patients.

Countertransference.
A large proportion of this population is severely developmentally compromised; it is no surprise, then, that the attachments these clients form often feel like a whirlwind love affair with a tragic ending. Sorting out transferential and countertransferential responses becomes a critical means of understanding these patients. At the same time, the clinician gains a deeper understanding of his or her self when countertransference emerges and can be analyzed and understood.

Laura, a woman of 30, was out of work over a year due to injuries sustained while working for the medical carrier who now cared for her. She was overweight, with long, unkempt, stringy hair, and walked with a marked stoop which varied according to her mental status. Laura's mother had died ten years previously, and her father had been dating a series of women around Laura's age. Laura frequently stated her feelings of hopelessness and futility, and in meetings with her therapist would often announce her suicidal intent. Laura was bright, with a keen, maudlin sense of humor, and the ability to enrage everyone with whom she came into contact.

Laura's therapist approached working with Laura with some apprehension; on a tired or slow day it would take only a few seconds with the patient before she felt "like tearing {her} hair out". She felt frantic, inadequate, and underqualified, and prone to such thoughts as, "What's the use of treatment anyway, what can I possibly do to help this woman; nothing will ever be enough". Any attempt to help Laura seemed but an insult to her pain. At other times, and sometimes simultaneously, she felt a great wave of warmth toward Laura. She agonized over developing a suitable treatment plan for this patient, and in sessions with her was often reminded of dramatic sequences in old Bette Davis movies.
Attempts to understand Laura on a cognitive level proved frustrating. The therapist's own responses to Laura were a cluster of extremes, ranging from irritation and abhorrence to genuine caring and warmth. When she was feeling benevolent toward Laura, she tended to feel more hopeless and frustrated herself; when she felt more competent and assured about her own work during a session, Laura would likely be in the depths of despair. In this way, the borderline split was complete in the relationship, with one or the other of them containing all of the bad or the good attributes in the room at any given time.
Through projective identification, the therapist was fusing with Laura and risked creating a borderline state in the therapy, which would ultimately be antitherapeutic (at best) for the patient. The absoluteness of Laura's self-hatred, with the feeble struggles of her ego coming through in her humor and her intellectualizations, were quickly shot down if the therapist did something skilled or said something intelligent. The therapist's impulse to say something bright, or to make some thoughtful interpretation in her meetings with Laura, in part were an effort to prove her own self-worth as she felt engulfed by the patient's despair. In a struggle such as this, however, the clinician's being one-up could only result in the patient being one-down, and this woman could ill afford such a status. Other staff felt enraged with Laura, and at times with her therapist, whom staff members sometimes thought should have set limits more aggressively to counteract some of Laura's unpleasant behaviors in group. Laura's therapist consciously struggled with the secret wish to be Laura's savior, the only one who fully understood her and wanted to help. Again, good supervision and a norm of open communication about cases among the staff ensured a healthy resolution of staff conflicts, and remain the most effective means of preventing serious staff splitting and the "burnout" so often associated with work with this population.
Countertransferential responses among Day Hospital staff run fast and furious, as the quick pace and intensive nature of the group treatment have a profound effect on therapists as well as on patients. In this work with a community of characterologically disordered patients, frequent supervision and open communication among the staff are essential. Each staff member may have a different - and powerful - reaction to a given patient, and an understanding of an individual's effect on a staff as a whole can enhance the planning and implementation of treatment for that patient. In addition, borderline character pathology in a patient will draw for the most primitive affective responses in a therapist, and a staff working closely together can both diffuse the intensity of such reactions and lend fresh perspective to a therapist in the midst of a difficult and confusing case. Given such a functional staff arrangement, the treatment team is free to use the countertransference to heighten clinical understanding and therapeutic effectiveness within the milieu, rather than do their work "in spite of" this affective response.

Suicidality
Helping patients struggle with their pull toward self-destruction is arguably the most draining aspect of work with this population. Much of the appeal of partial hospitalization in the treatment of borderline character pathology is the encouragement of autonomy which is intrinsic in this model (as opposed to inpatient hospitalization, which by its nature fosters severe regression). However, the price paid for this is the potential for greatly increased anxiety in the clinician, as her patient goes home each day to fend for himself and do what he will, far beyond the control of clinician or agency.
Patients with borderline defensive structures are, by definition, ambivalent about the value of their existence. Within this group, there exist varying degrees of ability to tolerate this ambivalence, and to control suicidal impulses. Maltsberger (1991) describes variations in the fragmenting of self-representation which occurs in these fragile patients as they struggle with the wish to consume and destroy themselves and/or others. In order to be appropriate for the day hospital, patients must be willing and capable of "contracting for safety", or entering into an agreement not to act on feelings of wanting to self-destruct. To this end, each patient signs a treatment contract prior to entering Day Hospital. In addition to outlining other behavioral expectations of the program, this contract states that "...I understand that if I act on these {suicidal} feelings, I will be discharged without the possibility of readmission".
For many borderline patients, suicidal acting-out becomes a means of expressing feelings of rage or ambivalence. Often, it is difficult for these patients to imagine the impact of their behavior on others around them. The reality is that a suicidal gesture by one member of a treatment community is enormously distressing to others in the group, and always threatens the integrity and safety of the group as a whole, whether the attempt is successful or not. Careful screening and evaluation is necessary to determine a given patient's capacity to resist impulse in this area, as well as to assess overall risk. The patient's history of past attempts (including level of severity), engagement in treatment, access to support structures (such as family, friends, work), family history of suicide and capacity for self-soothing must all be evaluated in order to determine appropriateness for the program. Naturally, in no instance is it possible to be absolutely sure, particularly when dealing with someone new to the system. In some cases, several interviews may be necessary before making a determination. Experience at the Day Hospital shows that for many patients, feeling invested in their treatment here enables them to resist acting on self-destructive impulses, at least throughout the period of their admission.

Maria had been in treatment at the Day Hospital for three weeks, and had become close to many of the other patients. Easily overwhelmed, Maria often disintegrated into tears both in groups and in free time. She had recently suffered the death of her fiancÈ, and leaned heavily on other group members for support. One day during group, she appeared sedated and wobbly, slurring her words. She denied having used any drugs or alcohol; staff, suspecting an overdose, decided to have her evaluated at the emergency room. While waiting for the doctor, Maria emptied the contents of all the prescription bottles in her purse and swallowed them. Her stomach was pumped, and she was placed on a locked unit. The referring agency subsequently re-referred Maria to the Day Hospital; however, the program's policy regarding readmission in the case of a suicidal gesture was explained, and the referral declined. Meanwhile, other patients in the program began to express their alarm and fear about Maria's overdose, and many reported feeling more shaky themselves since the incident. Gradually, the community strengthened, and several spontaneous discussions about death and responsibility ensued in the following weeks.
In this case, the treatment contract was not sufficient to prevent Maria from acting out suicidally. However, the effect of her overdose on other patients and its consequence to her in terms of the Day Hospital was considerable. Many of the other community members also struggled with suicidal thoughts and impulses, and the open discussions which followed Maria's overdose allowed them to consider the impact of such an action on others around them. In addition, while the thought of death can be nebulous and easily romanticized, being kicked out of a program is a concrete entity with negative implications which may be simpler for some to grasp. Had Maria returned to the Day Hospital, it is doubtful these discussions would have occurred, as the community may have been overly protective and fearful of the possibility of another attempt. Unreasonable as such a contractual stipulation may seem to the patient being refused readmission, its purpose is to protect the group as a whole. If any one member is to be safe within this group, then the whole group must be served when that safety is threatened, or none will benefit. For many character disordered patients at the Day Hospital, coming to understand this concept has been a first step toward comprehending their own function as agent in the events of their lives and the lives of others.
Conclusion
Theorists differ as to which is the treatment of choice for patients with severe character disorders. Virtually all successful treatment of these patients has occurred over substantial periods of time. However, the vast majority of such severely disturbed patients are not financially capable of undertaking such a treatment path, as many are unemployed (and unemployable) and do not have families who can support their considerable treatment expenses. Finances notwithstanding, these patients frequently cannot tolerate the limitations of and strong transferences within an individual therapy. This is especially true when the therapist cannot guarantee his or her availability for an extended period of time (often several years), as is frequently the case in outpatient clinics and training institutions. Yet these kinds of agencies are precisely where these patients wind up, where they bounce from clinician to clinician. Those borderline and other primitively functioning patients who are motivated to remain in therapy are all too often thwarted by the vicissitudes of clinic life, and even those lucky enough to have a long-term group frequently find themselves in need of more intensive containment.
A partial hospitalization group can provide an alternative to or a bridge from an inpatient hospitalization. Because patients are granted considerably greater autonomy than on an inpatient unit, regressive impulses can be countered with the pull to maintain ego integrity. Patients' transferences are diffused throughout the group, which can help them to tolerate both beginnings and endings more easily. This group model allows greater access to altruistic leanings, as well; patients become supports to one another outside of treatment hours, frequently introducing new members to the local support meetings and community activities.
It is in the area of helping patients develop some object constancy that a day hospital appears most valuable in the group treatment of patients with primitive character pathology. This modality provides the unique opportunity for patients to both succeed and fail, to leave and return (either to visit or stay a while), and to maintain a sense of a treatment "home". In this way, the mega-group of the day hospital atmosphere most closely resembles a true family, and patients who use the program over time seem to develop and maintain some evocative memory, and eventually the beginnings of object constancy as well.
Sadly, the days of extended, quality treatment are gone for all but the most privileged. A day hospital, though, is accessible to a large group of patients who are generally referred to by clinicians and insurers as "treatment refractory", who tend to use up their insurance benefits quickly, and who are not adequately contained in a weekly outpatient therapy group. Ideally, the group of the day hospital functions in concert with patients' individual or long-term group therapists to provide containment, structure, and support during times of decreased functioning. Because destructive regression is discouraged through the maintenance of patients' autonomy, a partial hospitalization group may be the treatment of choice for many primitively functioning patients, especially during times of stress or change in their lives. As an alternative to inpatient hospitalization, which so quickly stimulates infantile wishes and rage, this group modality exists as a truly heterogeneous community, a microcosm of the "real world" in which patients may practice their roles as functioning members of the world outside.

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