Psychotherapy for Borderline Personality

Beginning in 1967 with the publication of “Borderline Personality Organization” (1), Otto Kernberg has been developing and teaching a psychoanalytically based treatment for the heterogeneous group of disorders lying between psychosis and neurosis. Expressive psychoanalytic psychotherapy, now renamed transference-focused psychotherapy, has affected almost every therapist who seriously treats patients with borderline personality disorder. The extensive impact has come in spite of the incredible complexity of Kernberg’s concepts and language. Psychotherapy for Borderline Personality makes Kernberg’s work more accessible than ever before. Explanations are clearer, detailed clinical examples are woven throughout, and in those examples we gain access to the therapist’s private considerations. The complexities, subtleties, and clinical pearls, which until now were available only to Kernberg’s supervisees and students, are presented here.

The book is divided into three segments—the Ingredients, the Phases, and Special Issues of the treatment—the latter including crisis management and medication management. The authors delineate the theory of transference-focused psychotherapy, the overarching goals, the targets of each phase, the “broad stroke” strategies that prevail over weeks and months of work, the session-by-session tactics, and the techniques used to effect the tactics, strategies, and goals. The creation of a clear contract between patient and therapist is outlined, step by detailed step. The treatment is a melding of big-picture psychoanalytic guidelines with dozens of “mini-protocols” that direct the therapist’s moment-to-moment thinking and intervention. The authors present this as a transference-focused psychotherapy manual but emphasize that it is not a rigid protocol.

The authors have taken the opportunity to address critiques and misunderstandings of their work. Let me summarize a few of these. On the one hand, transference-focused psychotherapy is used to treat a very broad and heterogeneous set of disorders. On the other hand, however, the patients for whom transference-focused psychotherapy is indicated represent a fairly narrow band within that spectrum: those who are not too isolated, not too much in need of external structuralization, those for whom secondary gain of symptoms is not too pronounced, and those with sufficient motivation and psychological-mindedness. The interpretations, of course, are based on inference and are always held tentatively at first, but they are often delivered with admittedly disproportionate force, in part to counter the patient’s substantial resistance. The therapist hews to a position of technical neutrality, equidistant from id, superego, and external reality, refraining from supportive techniques, but technical neutrality, which presumes an attempted alliance with the healthy part of the patient, is entirely compatible with frequent, extensive, and powerful interventions. Technical neutrality is neither bland nor detached.

Confrontation, although intended to be firm and clear, is to be done tactfully, often including reference to the patient’s healthier intentions. The authors are well aware that they have been criticized for having a negatively biased approach to patients with borderline disorder, especially as they “smoke out” the aggression that emerges early in the negative transference. They clarify that the aggression comes from the patient, that it is a destructive fact of borderline psychopathology, that it must be addressed early and relentlessly, that the libidinal transference is present (and usually more deeply defended), and that it too will have its day.

Beyond these clarifications, we are treated to some of Kernberg’s clinical pearls that have rightly affected psychotherapies well beyond the boundaries of transference-focused psychotherapy. Kernberg has shown the power of vivid, engaging, often elegant metaphors in getting the patient’s attention. He has provided a model of sitting with, staying with, and working with terribly chaotic and confusing situations that can prompt therapists to attack, run, or make mistakes. The comprehensive model of transference-focused psychotherapy, including rich use of countertransference, helps the therapist to preserve himself or herself and to persevere. The authors’ presentation of the contracting process is masterful, including an excellent clinical example. Clarifying the therapeutic frame can immediately bring intense transferences to light, where they can be clarified, confronted, and interpreted. At the same time, the authors emphasize that the therapist does not commit to the treatment until the contracting is successfully completed. The point is made repeatedly that regardless of the level of chaos in the therapy, the therapist maintains a vision and a goal of a mutual, authentic, mature interaction.

In psychoanalysis, where treatments are validated on the basis of their clarity, their elegance, their applicability, and a preponderance of convincing clinical anecdotes, transference-focused psychotherapy stands as a well-developed, if controversial, model. In the world of empirical treatments, where demonstrated effectiveness is the highest goal, transference-focused psychotherapy must be considered a pilot approach, not yet subject to even the first empirical trials. The authors are now in the process of empirically testing the treatment. As they describe it, the good news is that it has been relatively simple to train therapists up to adherence, which presumably means getting therapists to use clarifications, confrontations, and interpretations, while refraining from explicit supportive techniques. The difficulties come in teaching therapists to reliably identify the predominant object relation in the session; to determine which among various object relations is deeper; to identify and expose primitive defense mechanisms; to name the resistance and its source; to become aware of countertransference and convert it to an understanding of the patient; and to do this with tact and timing. All these and much more involve subtle judgments about invisible, inferred entities that often shift with the moment. Standardizing the measurement of this incredibly complex series of tasks, which the authors consider part and parcel of competent delivery of transference-focused psychotherapy, will be a challenge. Everyone knows that psychodynamic therapies have not typically been validated in the scientific sense. One hopes that the painful, often humiliating impact of leading patients to see the hypothesized hatefulness of their internal worlds will in the end be justified by positive outcomes.