An Intensive Outpatient Program for Patients With Borderline Personality Disorder

Intensive outpatient programs are a type of clinical service that was developed in the early 1990s as a response to managed care organizations. They attempt to offer a cost-effective alternative to hospitalization and day treatment by facilitating the transition from more intensive levels of care. They can also be an alternative to hospitalization and day treatment for outpatients in crisis (1).

Intensive outpatient programs promote a patient's functioning in the community by offering a more intensive level of structure and support than was previously available for outpatients. The programs provide psychotherapy and integrated group treatment, usually for five to ten hours a week. At their best, they offer a therapeutic milieu where patients feel heard and understood and provide containment with minimal intervention by clinicians. This paper describes an intensive outpatient program developed at McLean Hospital in Belmont, Massachusetts, specifically for patients with borderline personality disorder.

In keeping with Winnicott's (2) concept of a "holding environment," a critical function of a treatment program for patients with borderline personality disorder is to provide an environment where the patient feels sufficiently safe and contained. Traditional outpatient care may not provide this type of environment (3). To offer sufficient "holding," an intensive outpatient program must embody the structure, support, and coordination normally associated with milieu therapy.

An intensive outpatient program for patients with borderline personality disorder should contain the four main elements of effective treatment for this population—reliance on structure, the expectation that each patient will be an active participant in the development and implementation of his or her treatment plan, ongoing identification of maladaptive interpersonal functioning, and a focus on adaptation to community life and a longitudinal perspective on the patient's life (4).

Components and procedures

The intensive outpatient program provides individual psychotherapy—with or without pharmacotherapy—in conjunction with integrated group therapy. Component groups include self-assessment, dialectical behavior therapy skills training (5), and parenting skills training (6). Other groups focus on common problems of persons with borderline personality disorder, such as eating disorders, difficulties in interpersonal relations, substance abuse, trauma recovery, and vocational development. The program operates Monday through Friday, with most sessions scheduled early in the morning or late in the afternoon to minimize interference with work or school.

The program's role within the larger system of care requires that it receive patients deemed ready for immediate step-down or accept outpatients in crisis who urgently require more intensive intervention. The program uses the self-assessment group to determine a patient's commitment to treatment and motivation for change, and how he or she relates to others. The patient is then triaged to other components of the program. Patients usually spend four to eight weeks in the program, after which they are expected to make a transition to less intensive outpatient services.

The fee-for-service reimbursement has been evenly distributed between Medicare, Medicaid, managed care, and self-payers. About 140 patients participated in the program between March 1996 and February 2000. Feedback from patients and referring clinicians has been consistently positive.

The self-assessment group

This group emphasizes the patients' roles in assessing themselves, that is, how they are managing, both emotionally and functionally. Patients attend the self-assessment group two to five times a week, usually in conjunction with one or more of the topical therapy groups. The group usually includes six to eight patients. The frequency of participation is negotiable, but we expect patients to attend on days they have designated for themselves. A phone call from group leaders to patients who miss a session conveys the message that their absence was noticed and gently holds them accountable for returning.

Patients attend meetings frequently and become familiar with the details of each other's lives. They value the group as a place where they feel heard and understood. The group is highly structured. Each patient has a ten-minute turn, which is followed by group feedback. Regular topics include concerns about safety, difficulties in relationships, substance abuse, feelings of inadequacy, interactions with families, intolerance of dependency, and fear of abandonment.

The group discussion attempts to identify stressors or unrecognized emotions that may underlie symptomatic behavior. Group members can be astute at recognizing subtle forms of manipulation, and patients seem more receptive to feedback and confrontation from each other than from clinicians. The group works best when patients hold each other accountable for maladaptive behaviors. This peer pressure is often an effective deterrent to destructive behavior.

The goal of the self-assessment group is to shift the locus of responsibility from the group leaders to the group members, that is, to the patients themselves. For example, a group leader might respond to a concern about self-harm by asking, "How are you going to manage your impulsivity?" rather than, "Are you safe?" In rare instances, a leader may have to arrange hospitalization for a patient with acute suicidality, but responsibility for maintaining safety is usually left to the patient. Group members are encouraged to think through the practical steps necessary to manage a crisis, which may include when to contact a therapist and what to do if the therapist is not immediately available.

Discussion

The intensive outpatient program works optimally when the leaders resist the temptation to actively intervene and instead encourage patients to take responsibility for managing their own problems. A leader's judgment about when to intervene and his or her confidence and familiarity with the overall objectives of each patient's treatment are critical. Patients with borderline personality disorder often feel that they are not "getting enough." They are extremely difficult to treat when the clinician agrees with this perception or has misgivings about the adequacy of the treatment being offered.

To contribute to the patient's sense of being "held," the clinicians themselves may need support in feeling confident about the treatment they are providing. Working with these patients requires taking acceptable risks to avoid overprotecting and overmanaging. Collaboration with other clinicians helps diffuse the intensity, confirm treatment decisions, and clarify roles and responsibilities (7,8). Coordination between clinicians in a program minimizes splits, alleviates fragmentation, and helps maintain focus. The empirically documented effectiveness of individual psychotherapy (5,9) and of psychiatric day hospitals (10) underscores the importance of coordination and communication.

Conclusions

Intensive outpatient programs offer a clinically sound and cost-effective alternative to both traditional outpatient services and more intensive levels of care. These programs can be the treatment of choice for patients with borderline personality disorder who may regress in more controlling situations but who also require sufficient structure and support. The principles of milieu therapy promote a sense of involvement, containment, and validation that allows patients to feel heard and understood as they proceed with their lives in the community. With these patients, there is a tendency for clinicians to overmanage clinical situations that are better left for the patient to handle. Active collaboration with colleagues helps clinicians evaluate the need for direct intervention and find support for handling high-risk situations. The program's support, structure, and emphasis on self-reliance can help patients stabilize their lives and grow in the community.

Acknowledgments

Dr. Ruiz-Sancho was supported in part by a fellowship from the Academic Council of the Real Colegio Complutense. The authors thank James Chu, M.D., James Hudson, M.D., Elsa Ronningstam, Ph.D., and Lloyd Sederer, M.D., for their comments on the manuscript.

Mr. Smith is director of the intensive outpatient program, director of outpatient group psychotherapy services, and associate director of outpatient personality disorders service at McLean Hospital, 115 Mill Street, Belmont, Massachusetts 02478. He is also a teaching associate at Harvard Medical School, where Dr. Gunderson is professor of psychiatry. Dr. Gunderson is also chief of the psychosocial and personality research program and director of the outpatient personality disorders service at McLean Hospital. Dr. Ruiz-Sancho has a private practice in Cadiz, Spain.