The Borderline Patient

Emerging Concepts in Diagnosis, Psychodynamics, and Treatment

James S. Grotstein, Marion F. Solomon, Joan A. Lang, James S. Grotstein, Marion F. Solomon, Joan A. Lang

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317771708
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

This volume focuses on treatment issues pertaining to patients with borderline psychopathology. A section on psychoanalysis and psychoanalytic psychotherapy (with contributors by V. Volkan, H. Searles, O. Kernberg, L. B. Boyer, and J. Oremland, among others) is followed by a section exploring a variety of alternative approaches. The latter include psychopharmacology, family therapy, milieu treatment, and hospitalization. The editors' concluding essay discusses the controversies and convergences among the different treatment approaches.

Part IV

Issues in Treatment: Psychoanalysis and Psychoanalytic Psychotherapy

THE CONTRIBUTORS TO this section offer a rich harvest of extensive and in-depth treatment guidelines for borderline disorders. Volkan, a classical analyst who has also been influenced by Winnicott, offers a valuable distillation of his extensive analytic work with borderlines. He defines six sequential stages in their treatment. The first is the “establishment of a reality base,” by which he means the initial face-to-face sessions, the setting of the limits of the treatment (four times a week), later use of the couch, and an exclusive use of interpretations. Gradually, the couch is introduced, and phase two begins, where a split-transference can be observed. During this phase, the holding environment seems to be more important than interpretations, whereas in phase three, where he finds the development of a “focalized psychotic transference leading to reactivated and transference-related transitional phenomena,” interpretations become of more importance as a state of therapeutic symbiosis begins to develop. In phase four, a second split-transference, a more organized one than the first, begins to emerge, followed by phase five where there is the development of a transference neurosis, including the development of the Oedipus complex. Finally, in phase six, a third split-transference takes place, a final surge of the more primitive split-transference, but one which the therapist does not interpret but rather allows to emerge.

Searles was one of the first to introduce the concept of transitional relatedness in the treatment of primitive mental disorders and is also a pioneer in the advocacy of the positive importance of countertransference phenomena. Reading his work, one can readily see the therapist who is talking from an “open systems” point of view; that is, the patient is not the only object of scrutiny but also an active member of the “therapeutic team.” Searles states, for instance, “The more ill the patient is, the more does he tend to identify, earliest, with the analyst’s own sickest, least fully conscious introjects.” Searles also highlights the difficulty these patients have with mourning: “The borderline individual’s inability (without therapy) to accomplish grief-work is both one of the major diagnostic criteria for the borderline state and is, necessarily, one of the major tasks of therapy.” In addition to their inability to grieve, Searles cites their striking loss of memory for their childhood, and a vengefulness for the ill treatment they received by their primary objects. Searles emphasizes especially the intensity of countertransference phenomena and the importance of symbiotic relatedness when treating these patients.

Boyer is well known for his long experience in the treatment of psychotic and borderline patients. His forte is his intuitive understanding of primary process mechanisms in the associations of these patients. His contribution is a case presentation emphasizing primary process mechanisms throughout. It is interesting to note that his patient seems to have sought aspects of herself in her tentative objective attachments, reminding one not only of the Kleinian concept of projective identification, but also of Kohut’s newly revived concept of twinship or alter ego selfobject transferences.

Giovacchini’s contribution emphasizes the difficulties in the treatment of the “unreasonable patient.” In this situation, he reminds us, the therapist is drawn into a psychotic transference situation that seems absolute and concrete. The patient seems to be beyond understanding the phenomenon of illusion or distortion and refutes the analyst’s attempts at interpretation. Gioacchini also makes the important point that many borderline patients are victims of what Winnicott has called privation, in contradistinction to deprivation. He therefore emphasizes the ego defect aspects (developmental arrests) in these patients.

Kernberg, who has been associated with the borderline disorder more than most other authors, speaks here from the vantage point of a practicing psychoanalyst and psychiatric training hospital administrator. In his contribution, he deals with the importance of the suicidal potential in borderline patients, how to anticipate it beforehand, and how to manage it during and afterwards. Kernberg emphasizes the importance of making a diagnosis in borderline patients at risk of suicide. This diagnosis is made in terms of the clinical severity of the depression, especially if there is a major affective component superimposed on their borderline personality disorder as well as a tendency toward self-mutilating behavior and suicide as a “way of life.” Further, he discusses the management of suicide-risk patients.

Oremland offers clinical vignettes from the treatment of borderline patients where the dreams were of critical importance in helping him to gauge significant shifts in regression and progression, phenomena which are very important in the treatment of borderlines. Using patient dream material, Oremland distinguishes neurotic, borderline, and psychotic disorders in reference to the nature and structure of transferences. He points out that classical analysis has hitherto emphasized “contents within transferences,” whereas, thanks to our knowledge of narcissistic disorders, we can now study the structure of transferences and elicit the very nature of “being” and “relatedness,” which are at issue with borderline and psychotic disorders.

Brandchaft and Stolorow offer both theoretical and clinical formulations about the treatment of borderline patients from the Self Psychology point of view. In particular, they offer the concept of intersubjectivity as a guiding thread running through the treatment of these disorders. As Self Psychologists, they tend to veer away from considerations of psychopathology which emphasize drive derivatives and emphasize instead that the borderline condition, like other psychopathological conditions, results from developmental empathic failures resulting in the emergence of a self without cohesion. These developmental failures are recapitulated in the transference situation, they believe, in frequent situations that should not technically be called transference but which actually constitute the therapist’s failure to attune to the patient’s experiences, thereby continuing the original psychopathological setting.

Lichtenberg engages the issue of the similarities and distinctions between narcissistic and borderline patients experientially, giving two detailed case examples to demonstrate these experiential constants. He addresses not only some of the countertransference difficulties, but also the variety of listening stances necessary to maintain optimum contact with these patients – listening stances that include the therapist as “outside the patient’s mind,” “an interested, sympathetic companion-listener,” and “within the patient’s state of mind.”

Paul is a psychoanalyst with considerable experience in analyzing primitive mental disorders. The case he presents here fits into the category of the borderline organization but seems to display more schizotypal-withdrawal characteristics than the more flagrantly unstable cyclothymic with which most therapists are more familiar.

This patient demonstrates many of the difficulties addressed by virtually all our contributors, however. She primarily manifests separation anxiety and individuation anxiety (fear of impingement and engulfment), difficulty in regulating her emotions, and fear of regression, as well as disorganization and fragmentation, fear of strangers, deficits in selfobject functions, particularly safety and soothing, difficulty in performing at work, manipulative suicidal gestures, and the like. She also demonstrates what might be termed deficits in instinctual functions insofar as her capacity for phantasy formation seems to have been limited. She also demonstrates another factor not emphasized by any of our contributors: she was molested on several occasions as a child. Molestation (which is now being reported more often among other patients) must have been an important factor in her becoming borderline. At the same time, it demonstrates the possible importance of post-traumatic stress disorder as a component of the borderline syndrome.

Chapter 20

Six Constellations of Psychoanalytic Psychotherapy of Borderline Patients

Vamık D. Volkan

Nine Patients

AN ATTEMPT TO systematize my observations on my psychoanalytic outpatient psychotherapy with low-level borderline patients has led me to conclude that such therapy moves through six constellations.

After Kernberg (1966) systematized the evolution of internalized object relations and described the borderline personality organization both phenomenologically and metapsychologically (Kernberg, 1975), I began a series of analytic treatments with patients who lacked an integrated identity, who had object relations conflicts rather than structural conflicts, and whose treatment was necessarily designed initially to mend the splitting of their self- and object representations. I tried to examine the course of treatment with these patients systematically and offered nine of them an undiluted version of psychoanalytic psychotherapy on the couch that was designed to effect lasting structural change. This process used the maximum potential of both patient and therapist.

Each of these patients was in treatment with me for an average of six years, and all except one, who came five times a week, had four weekly sessions. Each knew where his sense of self ended and where others began; they all had psychic boundaries, but these were not intact, although they remained distinct when close to the psychic boundaries of other people. Whenever the patient was on drugs or affected by some other regressing influence, the representations of others would sometimes flow into his self-system through boundary flaws. Thus I recognized in making my diagnosis that they would develop transference psychoses when further regressed in the course of treatment.

I feel strongly that not every analyst or therapist should feel an obligation to work intensively with severely regressed or undeveloped persons as outpatients; his own ability to regress in the service of the other, his own personality makeup (Little, 1981), and the degree of his training are crucial factors. Some therapists and analysts simply do not feel comfortable working with patients who are extremely regressed or undeveloped and who will inevitably require in treatment a corresponding but controlled regression from the analyst or therapist.

Intensive treatment approaches in such cases can be divided into two opposing styles for the purpose of discussion, although such division cannot be observed altogether in practice: (1) The first supports keeping the patient at a level where it is possible for him to function without further regression, while at the same time providing in the therapeutic setting new ego experiences calculated to help him integrate what he experiences in a fragmented way – opposing self-representations and the object representations that correspond to them. Therapists endorsing this style believe that if regressed further, such already regressed patients will become psychotic and beyond the reach of “the talking cure”; (2) the second view holds that such a patient needs the experience of further regression, in this instance controlled regression and, accordingly, that the therapist should not interfere with the patient’s regression to a level lower than the chaotic one already exhibited. This theory holds that after regressing so far in a therapeutic setting, the patient will progress through healthier developmental avenues toward psychic growth, much as a child does when in a suitable environment. Those advocating this approach know that already regressed or undeveloped patients may exhibit transference psychosis when regressing further, so the therapists embark on the treatment, expecting to continue working through the patient’s psychotic transference with the goal of his becoming able to reorganize a new and healthier psychic structure.

As Jacobson (1964) and Kernberg (1975) have demonstrated, there is a “normal” developmental split between the libidinally and aggressively invested self- and object representations until the child becomes able to tolerate ambivalence. In a sense, this “normal” splitting persists in those with borderline personality organization, but it changes function and becomes the dominant defense mechanism. By using this defensive splitting, the patient with borderline personality organization retains his contradictory ego states and their affective investments separate from each other. Anxiety arising from object relations conflict is controlled at the expense of splitting (and related defense mechanisms), leaving the ego weak.

Therapeutic regression in such patients would, at least, involve regression to the level where they experience their self- and object representations in an undifferentiated (fused) way, as they would experience a transference psychosis. This would in turn be followed by progressive development in which self- and object representations would be differentiated, and the patient would experience developmental splitting in the transference instead of the previous defensive splitting. This in turn would give him a chance to mend his splitting as a normal child would do.

In my work with the nine patients I sought to test my theory. My experience with them showed that a focal, controlled therapeutic regression in such patients in undiluted psychoanalytic psychotherapy is indeed possible, and that once it is accomplished, patients progress toward health. Our technique, then, should focus on ways of controlling this regression and minimizing the danger of global disintegration.

The Concept of the Therapeutic Regression

“Getting well” does not always require regression. Boyer (1983) tells of a catatonically excited man who “got well” when he presented his therapist with two thick notebooks filled with his handwritten account of his aggressively colored hallucinatory and delusional experience. Boyer explains how this patient used his therapist as a repository for his madness. Boyer also would agree, however, that in our daily work with severely regressed patients, there is the start of lasting structural change if regression to earlier levels takes place, and if that change in turn initiates an experience that has a restorative function.

As Loewald (1982) states, “It is not regression per se which is therapeutic, but the resumption of progressive development made possible by regression to an earlier stage or to a ‘fixation point’” (p. 114). Loewald goes on to say that we notice and analyze defense that interferes with this resumption. But, as he emphasizes, the analyst also validates the patient’s regressive experience as a genuine one having its own weight, claim, and title “despite its incompatibility with the accepted normal organization of external reality, object relations, etc.” (p. 118). To accomplish this validation, the analyst must have a corresponding “therapeutic” regression of his own, so that his patient is “not left alone” with his own (p. 118). Loewald (1960) spoke earlier about the child-parent relationship that develops in the therapeutic process of borderline and psychotic patients on levels relatively like those of the early child-parent relationship. It is the regressive immersion of the analyst in the service of the other that creates a dyad analogous in intensity and extended influence to that of the early mother-child unit, and establishes a setting for a turn toward the resumption of ego development and maturation (Olinick, 1980).

Progress after therapeutic regression depends on the patient’s ability to gain new identifications with the analyst’s integrative functions. Analysis of defenses that interfere with the resumption of progressive development and validation of his regressive experience are not enough by themselves. Regressed or undeveloped patients relate to others with an excessive use of introjective-projective relatedness, as our clinical observations indicate, but this way of relating assumes the dominance of defending against anxiety. It is for such patients a stale way of dealing with object relations and conflicts. The inevitable inclusion of the therapist’s representation in this stale introjective-projective relatedness does not promote ego-building activity. However, the therapeutic regression in such patients also opens the way to new vigor and a change of function in their introjective-projective relatedness. Now certain introjections of the therapist’s representation may be retained as identifications. Cameron wrote in 1961 about finding therapeutically hopeful aspects in patients operating on archaic levels. He noted that operation at such levels involves the equivalence of early partial identifications in ways unattainable by a more maturely developed psychic system. He added that these patients could even internalize and assimilate new introjects (identifications) like an infant in spite of being chronologically adults. But hopeful processes do not occur massively without further controlled regression. Indeed, new identifications are possible without further regression; but unless regressive disorganization takes place first, such identifications seem only to cover up object relations conflicts that, in turn, may reemerge to continue to exert a pathological influence.

The Concept of the Fixation Point

At any given time all levels of regression may be taking place in the patient, but we can refer in theory to a fixation point in regression that is followed by progressive development, although the existence of such a fixation point has been widely debated (Lindon, 1967). I am not speaking of those fixation points that might occur in response to the need to adapt to some specific trauma; my notion of a fixation point is more general, involving a global response through the use of defensive (mal)adaptation to the accumulation of problems in the developmental process. Thus such points refer to the developmental level on which there remains some unfinished developmental tasks. Atkins (reported in Lindon, 1967) held a similar view, that although we sometimes look for some traumatic event to which a patient has regressed, such a search is unrealistic: “It is not necessarily a question of regressing to a trauma or a traumatic situation but could be a response to an earlier ego state or psychosexual orientation and it may not necessarily be to a traumatic experience. Also it...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Contributors
• Acknowledgments
• Preface
• Perspectives on Borderlines and on This Book
• Key Questions Regarding the Borderline Patient
• Part IV: Issues in Treatment: Psychoanalysis and Psychoanalytic Psychotherapy
• Part V: Issues in Treatment: Alternative Approaches
• Author Index
• Subject Index