Problems Of Borderline Patients In Therapeutic And Work Settings

IN THIS ARTICLE I EXAMINE the borderline patient in three types of group settings: inpatient hospitalization, outpatient group psychotherapy, and work-related contexts. I will describe those aspects of character pathology that are the most salient, i.e., those borderline traits that cause the most trouble in these settings. I will also suggest how to organize these settings, not only to minimize difficulties, but also to capitalize on these borderline qualities in ways that enrich both patient and system functioning. The following case material will set the stage for this examination.

When Nancy presented herself in my office nine years ago she described a series of "horrifying" treatments, which included several psychotherapies, two extended hospitalizations, and a night hospital treatment program. Her descriptions were uniform only to the degree that the health professionals were presented as insensitive, stupid, and quite often, cruel. There were a few exceptions, a nurse here, a psychiatric aide there, mostly those not responsible for her primary care—those willing to "buck the system, " as she put it. She had an uncanny recall of the details in her alleged abuse by the members of the mental health system, and seemed to argue, at times, that their callousness was more to blame for her suicide attempts than her own intense depressions. She used this same exquisiteness of recall in our work together to catalogue a volume of my mistakes and empathic failures. In fact, over the course of the