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behaviors. For example, the spouse of a patient who has thoughts of shooting himself will be asked to remove guns from the house. Personal and environmental strengths are identified and bolstered. Important treatment issues are uncovered or reevaluated, and modifications of psychotherapy approaches and medications may be recommended. Deeper exploration of these issues is limited on a short-term, inpatient unit, and is more thoroughly pursued on an outpatient basis or in a less intensive program, such as partial hospitalization (see page 174). Since the overriding concern is to return the patient to the outside world as quickly as possible and avoid regression or dependence on the hospital, plans for discharge and aftercare commence immediately upon admission.

Long-Term Hospitalization

Today, extensive hospitalization has become quite rare and is reserved for the very wealthy or for those with exceptional insurance coverage for psychiatric illness. In many cases where continued, longer-term care is indicated, but confinement in a twenty-four-hour residence is not necessary, therapy can continue in a less restrictive milieu, such as partial hospitalization. Proponents of long-term hospitalization recognize the dangers of regression to a more helpless role, but argue that true personality change requires extensive and intensive treatment in a controlled environment. Indications for long-term confinement include chronically low motivation, inadequate or harmful social supports (such as enmeshment in a pathological family system), severe impairments in functioning that preclude holding a job or being self-sufficient, and repeated failures at outpatient therapy and short hospitalizations. Such features make early return to the outside environment unlikely.

During longer hospitalizations, the milieu may be less highly structured. The patient is encouraged to assume more shared responsibility for treatment. In addition to current, practical concerns, the staff and patient explore past, archetypal patterns of behavior and transference issues. The hospital can function like a laboratory, in which the borderline identifies specific problems and experiments with solutions in his interactions with staff and other patients.

Eventually, Jennifer (see chapter 1) entered a long-term hospital. She spent the first few months in the closet—literally and figuratively. She would often sit in her bedroom closet, hiding from the staff. After a while she became more involved with her therapist, getting angry at him and attempting to provoke his rage. She alternately demanded and begged to leave. As the staff held firm, she talked more about her father, how he was like her husband, how he was like all men. Jennifer began to share her feelings with the female staff, something that had always been difficult because of her distrust of and disrespect for women. Later during the hospitalization, she decided to divorce her husband and give up custody of her son. Although these actions hurt her, she considered them “unselfish selfishness”—trying to take care of herself was the most self-sacrificing and caring thing she could do for those she loved. She eventually returned to school and obtained a professional degree.

The goals of longer hospitalization extend those of short-term care—not only to identify dysfunctional areas but also to modify these characteristics. Increased control of impulses, fewer mood swings, greater ability to trust and relate to others, a more defined sense of identity, and better tolerance of frustration are the clearest signs of a successful hospital treatment. Educational and vocational objectives may be achieved during an extensive hospitalization. Many patients are able to begin a work or school commitment while transitioning from the hospital. Changes in unhealthy living arrangements—moving out of the home, divorce, etc.—may be completed.

The greatest potential hazard of long-term hospitalization is regression. If staff do not actively confront and motivate the patient, the borderline can become mired in an even more