Psychotherapy of Borderline Personality

The preface to this volume begins: “This treatment book should be memorized, and then forgotten.” It is a just epigram, for that is precisely the role of theory: understood, in the background, accessible at the service of clinical experience. The therapist is always urged to look first to the experience of therapy, what the patient is feeling, what the therapist is feeling, what the patient is saying and not saying, doing or not doing. This is a book rich with guidance and insights for psychotherapists at many levels, from highly experienced clinicians to beginners. For readers who have struggled to read and understand Kernberg's powerful work over the years, this book is the clearest statement yet of his ideas as they apply to the actual performance of psychotherapy. The aim of this book is to provide a manual of transference-focused psychotherapy (TFP) for patients with borderline personality organization. To this end, the first section reviews relevant object relations theory and delineates the goals, strategies, tactics, and techniques of treatment. The overriding goal of TFP is to change the characteristics of the patient's internalized object relations that lead to repetitive maladaptive behaviors and chronic affective and cognitive disturbances. Such change involves the resolution of fixed primitive internalized object relations and the integration of split-off conceptions of self and significant others into integrated, more mature, and more flexible constructs. The authors approach these TFP goals with three treatment strategies: 1) the delineation of the patient's dominant object-relationship paradigms as experienced in the transference relationship between therapist and patient; 2) the analysis of role reversals by the patient—for example, unconsciously alternating between powerless victim and sadistic victimizer states; and 3) the integration of the positive and negative views of self and significant others. These strategies are reflected in the tactics of each session (choosing a priority theme in the session, protecting the frame of treatment, setting limits) and in the techniques of treatment—clarification, confrontation, and interpretation in the here-and-now transference interaction between therapist and patient. The first four chapters stand on their own as a statement of theory and its translation into practice, replete with examples of clinical dilemmas and of how a seasoned therapist might actually put a complex and emotionally loaded idea into words. The volume's second section, “Phases of Treatment,” offers guidance in assessing antisocial, narcissistic, and histrionic levels of borderline psychopathology and addresses treatment contracts in detail. It then provides an overview of treatment: the early stage, with its focus on impulse containment; midphase treatment, with its unfolding and deepening understanding and emergence of issues of love and sexuality as antisocial and paranoid transferences move toward tolerance of loss and sadness; and advanced treatment and termination. Many case examples illustrate clinical pitfalls and their resolutions, such as the hazards of neglecting to address hidden paranoid transferences at midphase, when much seems calm. The volume ends with two chapters addressing crisis management and a brief and somewhat controversial discussion of a controversial topic, the role of medication in the treatment of borderline psychopathology within a psychodynamic psychotherapy. This is a book by and for clinicians, and it serves many levels well. I have used it in teaching psychodynamic psychotherapy to residents; they respond eagerly to its clarity, its overall sense of priorities and structures, and its step-by-step exposition of what therapists actually do and why. How do you identify what is most important to talk about with a borderline patient living and thinking in chaos? How do you actually formulate a statement that confronts in a way that the patient can hear? This book abounds with examples. Expert clinicians will recognize their own clinical challenges in the examples and discussions of psychotherapeutic maneuvers. The clarity and elegance of the descriptions, informed by high sensitivity to the verbal and nonverbal productions of patients and a structural model that allows for movement and flexibility, will help even seasoned psychotherapists to refine their practice. In the rich examples and the discussions of them, many readers will be struck by the length and insistence of therapist interventions. While I wondered at times how attentive and emotionally connected a patient could be when receiving such lengthy interpretations, I always felt the therapist's tenacious commitment to the treatment in these comments. The TFP therapist is extraordinarily active compared with those using more traditional techniques, and I find the authors persuasive in their arguments for this level of activity, as well as their alarm at the risks of passivity or, worse, inattention. Another area that will surely provoke reflection is the authors' posture with regard to suicidal threats and self-destructive or suicidal behavior. In treating patients who have already experienced many years or episodes of supportive psychotherapy with little sustained benefit, the authors have come to a clear sense of what they can and cannot do and what will be of ultimate help to the patient. Their discussion of this important topic is thoughtful and sensitive, and their recommendations, although difficult to carry out, raise deep questions about physicianly behavior and the capacity for responsibility that we assume our patients—and ourselves—to have.