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Psychotherapy for Borderline Personality: Focusing on Object Relations
Reviewed by MARDI J. HOROWITZ
Am J Psychiatry 2006;163:944-944. doi:10.1176/appi.ajp.163.5.944

by John F. Clarkin, Ph.D., Frank E. Yeomans, M.D., Ph.D., Otto F. Kernberg, M.D. Washington, DC, American Psychiatric Publishing, 2006, 397 pp, $55.00.

The science of psychotherapy is supported by public funding in large measure. In the NIMH study sections that guide, and also limit, psychotherapy research it has been a virtual requirement that all investigators who submit applications provide treatments manuals for the specific population to be studied. The concept is that these pamphlets or little books have enough specific detail that clinicians can conform to the set of techniques provided if and when the investigators’ demonstrate that a treatment is efficacious.

Most clinicians not involved in psychotherapy research dislike these manuals because the details provided, although concrete, do not well fit their own inferences about their patients. The authors have labored in this vineyard, and here provide more than a treatment manual with concrete and specific techniques. Lucid examples allow a clinician to imagine actual situations. Their book will therefore be of greater use to many clinicians.

The longer the psychotherapeutic treatment is needed, the less the treatment manuals seem to fit individual cases. What works better for clinicians is to know enough relevant theory of explanation and processes of change that they can infer how an individual case might work out. With objective theory they can make better subjective judgments and individualize phase-specific treatment plans. That is, they can make inferences about what to do at any phase of the individual treatment.

Such theory can be linked to practice using systems of case formulation. The authors provide such theory of etiology and formulation. Starting with the first chapter, they define what they mean by “borderline” by outlining the context of both normal personality and the range of other, related, and sometimes overlapping personality disorders. Their system of formulation is both like and unlike other systems such as configurational analysis (Horowitz, 2005). Their principles of treatment are both like and unlike those advocated in cognitive-behavioral approaches for borderline personality disorder, such as dialectical behavior therapy.

The big difference is in the therapist’s attitude toward the utility of activation of the patient’s irrational schemas of self and other, including scenarios for intense feelings, within the relationship of the therapy itself (patient with therapist). In their transference-based approach, communications in the session area are used to analyze and clarify irrational projections. A firm structure of boundaries and transactions within the therapy is established to keep negative emotions such as rage from destroying a working alliance. Within this structure, and once it is established, the authors advocate close observation for transferences and countertransferences with interpretation of transferences as a vehicle for insight. The newly emerging therapeutic-alliance relationship between therapist and patient becomes a key opportunity for schematic change in operative role-relationship models, as a kind of corrective relational experience.

In contrast, cognitive-behavioral approaches use educative means to both contain and ward off this potential for transferences. As one might expect, a related difference with cognitive-behavioral techniques for psychotherapy of borderline personality disorder concerns active analysis of a patient’s defenses. Transference-based therapy tunes into analysis of defense mechanisms such as splitting self-other schemas into all-good and all-bad segregations of self and other person schemas, what I like to call role relationship models. This analysis can lead to interpretation of emotional beliefs that are projected onto others, and why for example blame is dislocated from self to others. In comparison, cognitive and behavior therapies tend to tune in on obstacles and resistances without as much specific work on pathogenic defenses, without clarifying what is projected, what is dissociated, and why.

In cognitive behavioral approaches as in this transference-based approach there is attention to hatred as a way of feeling strong, and revenge as a way of controlling a person who might otherwise make the self feel so weak that loss of identity coherence would be a feared result. More than in cognitive behavior therapy, the transference-based approach in this book regards activation of such hate as a defense to be interpreted as such. Usually the rage is a defense against fear of personality disintegration.

As one might expect, this kind of approach takes years of continuous therapy sessions to achieve maximum positive effects. As some may not realize, some cognitive behavior therapy approaches also assume the necessity of such durations of psychotherapy. Unfortunately, NIMH has been reluctant to fund long-term treatment research although the nature of severe psychopathologies requires centers for such empirical work.

Step one, in both this transference-based approach and cognitive behavior therapy approaches involves work on experiencing and tolerating confused states and explosive state cycles. The goal in the first phase of both approaches is to increase state stability, and this is a first step in supportive therapy and pharmacologic approaches as well. The authors have a good understanding of this and take a step toward where we have to go (psychotherapy integration) by a capable comparison of their transference focused psychotherapy with three other current therapy brand names: cognitive therapy, dialectical behavior therapy, and mentalization-based treatment.

Using case examples, the authors tell readers how to understand and intervene in short segments, considering the “here-and-now” few minutes, the present moments in a therapy session. This will help therapists to understand on the spot their otherwise often confusing or glossed-over moment-by-moment countertransferences.

Is this perhaps too psychoanalytically deep for the non-analytically trained clinician? I think not. First of all, the book is written in lucid prose without much jargon. Second, the depth is warranted by the complexity and nonhomogeneity of borderline personality disorder. Third, the authors give special care to informing clinicians how to protect the boundaries that establish a sense of the safety of therapy sessions. This includes establishing clear contracts, choosing current topics of concern that have priority and sage advice on how to handle the many specific threats to the treatment.

These threats are seen as both symptoms and signs of psychopathology and as tests of the integrity and skill of the therapist made by the patient to see if he or she can safely go on. I refer to such signs and symptoms (and tests) as suicidality, homicidal impulses, substance abuse, dishonesty, and excessive and provocative passivity.

There are too many worthy scientific articles and books for every clinician to read everything. Even in the area of borderline personality disorder, these authors do not quote all the relevant literature, and if they did, the book might have become unreadable. So who is the ideal reader of this work other than a borderline personality disorder psychotherapy research specialist? I think it would be the psychotherapist who has completed his basic training and is perhaps 3–4 years after graduation. He or she will find many epiphanies and gain the acumen of the highly experienced authors.

1.Horowitz M: Understanding Psychotherapy Change. Washington, DC, American Psychological Association, 2005.
 
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References

1.Horowitz M: Understanding Psychotherapy Change. Washington, DC, American Psychological Association, 2005.
 
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