To the Editor: Congratulations to Miles S. Quaytman, M.D., and Steven S. Sharfstein, M.D. R7515511CHDCIBHD, for a splendidly written case report illustrating the treatment of a severely impaired patient with borderline personality disorder. It vividly portrays the affective confusion and interpersonal complexity of these often treatment-resistant patients and hints at the familial components. The patient struggles with an experience of her dependency being intolerable. This is a familiar family dynamic in such cases, in which the child’s dependency is colored by negative family projections, despite the family’s competence in other areas, and is then experienced by both patient and family as hateful and devouring R7515511CHDBBGHC. Given their experience of the child’s dependency as unacceptable, the family inevitably distances her, in this case by literally putting her in the closet. These patients inevitably recreate this context in their lives and treatment settings R7515511CHDECGAD.

The authors address the institutional aspects of treatment, focusing on the problem of providing a secure space for the patient to begin to integrate her disavowed, unacceptable affects and her self-destructive response to them. In the successful long-term hospital treatment, this was first attempted through seclusion and wet packs, which led to a reenactment within the treatment staff of the family’s split around managing dependency. The staff learned to integrate their split, recognizing the meaning for the patient of their divisions. With this integrated interpersonal space for examined living, the patient could finally consider her own internal split about dependency. The outcome was excellent. We used to do very good work with these patients; fewer of us do now.

The question is how to construct such an interpretive environment outside of an inpatient setting. Quaytman and Sharfstein’s quarter-way house seems useful, but many institutions create a continuum of care with discontinuous staffing and therapy. With every change of program, patients also experience changes in nursing and other clinical staff, doctors, treatment teams, and peer groups. It is extraordinarily difficult to build and staff competently an interpretive community where the patient can find the integration she needs without providing concomitant continuity of the psychotherapy, marital treatment, and milieu intervention. Given the patient’s rapid shifts toward projection in all of these contexts, her inner and outer worlds must be worked with together—by clinicians trained in this specialized work and in communication with each other. In the hypothetical case, the crucial moment comes when the patient withdraws a negative projection from another patient. This follows her move from inpatient treatment to outpatient to quarter-way house. We wonder about the capacity of rapidly shifting settings to help patients use each other this way as well as how lasting such an internalization can be. In fact, even in the hypothetical case, there is ongoing evidence that the patient’s projections simply shift into her marriage, which falls apart as she considers supervised apartment living. This follows almost a year of treatment.

In this changing treatment world, many of us have learned—as these authors have—how important it is to recognize that the responsibility for the treatment must be in the patient’s hands R7515511CHDBCCDB. Particularly with borderline and other personality-disordered patients, it is not only possible but also essential to include resource management as part of the patient’s responsibility. "Limited resources" is both a reality and a metaphor for much of these patients’ experience R7515511CHDCJGGFR7515511CHDDHGID. Joining with patients and their families both to manage the limitations and interpret their meaning in a setting where the enactments of these issues can be grasped significantly deepens and expedites the treatment.

We support the message from Drs. Quaytman and Sharfstein. There is a great deal of learning to be derived from the excellent (although expensive) treatments of the past. We can develop new settings to maximize this learning, so that treatment-resistant borderline patients can grasp their experiences and allow themselves to have a life after treatment. This possibility requires managed care companies and their reviewers to recognize what we have learned about these patients, who are "outliers" compared with the less complicated, often first-episode, patients the behavioral health industry has in mind when it designs treatment algorithms. In the absence of this recognition, reviewers can unwittingly reenact the family system that attributes aggressive, unbearable, devouring dependency to these patients. In this repetition, these patients are at terrible risk of being thrown into the closet of chronic care.