Psychotherapy for Borderline Personality Course Series

Chapter 1: THE NATURE OF BORDERLINE PERSONALITY ORGANIZATION
The model of personality disorder and its treatment that is the foundation of transference-focused psychotherapy (TFP) is based on contemporary psychoanalytic object relations theory as developed by Kernberg (1984, 1992) and amplified by findings from current developmental and neurobi ological research (Clarkin and Posner 2005; Depue and Lenzenweger 2001). In this first chapter we examine the nature of personality, and based on that foundation we describe a psychoanalytic understanding of person ality disorder and a related nosology of personality disorder that utilizes both dimensional and categorical constructs.

PSYCHOANALYTIC OBJECT RELATIONS THEORY
A PSYCHOANALYTIC MODEL OF NOSOLOGY
NEUROTIC PERSONALITY ORGANIZATION
THE PSYCHOPATHOLOGY OF HATRED: THE CHIEF OBSTACLE TO LIBIDINAL DEVELOPMENT

Chapter 2: TREATMENT OF BORDERLINE PATHOLOGY
The Strategies of Transference-Focused Psychotherapy The world is a looking-glass, and gives back to every man the re flection of his own face. Frown at it, and it will in turn look sour ly upon you; laugh at it and with it, and it is a jolly, kind companion; and so let all young persons take their choice.

Chapter 3: TECHNIQUES OF TREATMENT The Moment-to-Moment Interventions
The borderline patient’s experience of the therapist is determined by his or her fragmented internal world of partial, split-off, caricatured representa tions of self and other, and changes dramatically from one moment to the next. In this transference relationship with the therapist, the patient expe riences perceptions, attitudes, affects, and fantasies that are an unconscious repetition of internalized perceptions based on past experience and dis placed onto the therapist. As described in Chapter 1 (“The Nature of Bor derline Personality Organization”), transferences are repetitions in the present of object relations patterns based on early experiences that have been internalized (often in distorted form) in the individual’s psyche and have become the structures that determine the individual’s experience of the present reality and, in particular, of relationships. In the case of border line patients, these internalized relationship paradigms retain primitive characteristics derived from the unresolved conflicts between love and ha tred in infancy and childhood and result in pathological relations to self and others in the present. These primitive paradigms unfold in the patient’s re actions to the therapist and will become the principal means of understand ing and intervening in the patient’s internal world. Within an object relations point of view, the complexities of the trans ference regression at its deepest levels of psychopathology can be clarified and interpreted. It will be recalled that object relations theory emphasizes that the transference activation involves basic dyadic units of both a self and a related object representation, which are linked by a distinctive affect. These dyadic units play important roles in determining the expression of drives and the experience of affects in an individual. These dyads are the means through which a drive as well as the inhibition to the drive are expe rienced. The object relations dyads therefore are the vehicle for the expe rience of intrapsychic conflict. Here we introduce an important addition to the concept of activated dy ads in the transference. Insofar as the patient communicates this relation ship to the therapist, there is still a potential, implicit hope—mostly unconscious, at that point—that the therapist will not perpetuate the prob lems of the past but will introduce a new actor into the relationship. By the same token, the therapist’s role is both to experience his or her transitory identification with the self-representation or the object representation that the patient has projected onto him or her and also to take an observing dis tance from the part of himself or herself that is involved in the enactment of that emotional relationship. The therapist acts as a separate third party that disrupts the primitive object relationship by means of his or her coun tertransference analysis and interpretive interventions that incorporate the knowledge gained from listening to the patient’s verbal discourse, observ ing the patient’s nonverbal behavior, and analyzing the countertransfer ence. The dyadic relationships in the transference are thus continuously exposed to a potentially triadic one. At a symbolic level, that triadic rela tionship signifies the entrance into—or disruption of—the pre-oedipal re lationship by the oedipal one. The dyads that are activated in the transference may represent the ex pression of drives or defenses. It is typical in the patient’s transference re action to the therapist for the impulse-defense organization to be activated first in the form of an object relation that represents the defensive side of the conflict. For example, a patient whose initial response to the therapist consisted of angry depreciation of the therapist as a cold, uncaring person may be defending against a libidinal impulse rooted in a split-off dyad in which the therapist is imagined as the wished-for nurturing other. An alter native example would be that of a patient who initially idealized the thera pist in a way that defends against split-off paranoid and aggressive feelings. Later the object relation reflecting the impulsive side of the conflict emerges in the transference. An object relations point of view enables the therapist to have a framework to understand what at first looks like a chaotic relationship and to begin to perceive the pattern in the oscillations and al ternations of the relationship’s dyads as they are reenacted in the transfer ence. This understanding provides the basis from which the therapist intervenes with the techniques described in this chapter. Interpretations focus on the delineation of the patient’s internal object relations and the role they play in the expression of the patient’s internal conflicts. The object relations stimulated in borderline patients’ transfer ences are best conceived of as a combination of realistic and fantasized, dis torted representations of past relations with important others. Because of this, transference interpretation is different with borderline patients than with patients who are organized at a neurotic level. In neurotic patients, the more primitive, caricatured, split-off internal representations of early de velopmental stages have been integrated into more complex, coherent in trapsychic structures constituting the self and the internal object world (with a relatively clear sense of identity) and the superego (with a relatively consistent sense of moral values and internal prohibitions). In therapy with neurotic patients, the analysis of resistance activates in the transference rel atively global characteristics of these structures (e.g., superego prohibitions against id drives). These structures have a coherent quality because in a neurotic individ ual the self aspects are linked together and the object aspects are linked to gether. In other words, a self-representation “sticks” to the rest of the self, and the same is true for object representations. In the neurotic individual interchanges between mutually split-off representations of self and others occur only at times of extreme regression. In contrast, in borderline pa tients, primitive internal representations remain split off from other repre sentations of self and others, all of which are unintegrated into any larger, more coherent structure. The result is a more chaotic subjective experi ence, more erratic behavior, and more disturbed interpersonal relations. In ternal conflicts are not expressed in a consistent pattern with fixed impulsive and inhibiting forces but are expressed in dissociated ego states based on the primitive defense of splitting. These dissociated ego states may shift abruptly, with the patient identifying exclusively with one side of a conflict at one moment, only to shift to identifying exclusively with the other side of the conflict at the next moment. The discussion of tactic 6 in Chapter 4 (“Tactics of Treatment: Laying the Foundation for the Tech niques”) provides an example of this splitting. There are five basic tech niques in transference-focused psychotherapy (TFP) (Table 3–1). Before addressing these techniques in detail, a note of caution: transfer ence interpretations are still a controversial issue in the psychotherapy lit erature, including interpretation in the treatment of borderline patients (Bateman and Fonagy 2004; Gabbard and Weston 2003). The research data that suggest transference interpretations have the potential to do both good and harm (Piper, Azim, Joyce, and McCallum 1991). From our point of view, transference interpretations cannot be seen as isolated therapeutic events separated from the process of therapy, nor can they be judged in iso lation. As we make clear in this manual, therapists embed interpretations in the context of an interactional sequence between therapist and patient. This sequence includes the full extent of the patient’s understanding (aided by the therapist’s work toward clarification of the patient’s mental states), the emergence of contradictory elements in the patient’s presentation, which the therapist encourages the patient to reflect on (confrontation), and only then the formulation of a hypothesis by the therapist (interpreta tion) as to possible meanings and motivations of the behavior.

MANAGEMENT OF TECHNICAL NEUTRALITY
ONGOING INTEGRATION OF COUNTERTRANSFERENCE DATA INTO THE INTERPRETIVE PROCESS
MAINTAINING THE FRAME OF TREATMENT
TRANSFERENCE ANALYSIS
THE INTERPRETIVE PROCESS: CLARIFICATION, CONFRONTATION, AND INTERPRETATION
COMPLICATIONS IN PROCEEDING FROM SURFACE TO DEPTH
FURTHER ELEMENTS IN THE PROCESS OF INTERPRETATION
THE ACTIVE ROLE OF THE THERAPIST
TECHNIQUES NOT UTILIZED IN TFP

chapter 4 : TACTICS OF TREATMENT
The tactics of transference-focused psychotherapy (TFP) are the maneuvers the therapist uses to set the stage for and to guide the proper use of techniques (described in Chapter 3, “Techniques of Treatment: The Moment-to-Moment Interventions”) in the sessions. For example, tactics inform the therapist when to apply an interpretation, at what depth, and with what priority. These maneuvers are in the service of the central strategy of defining and understanding the primitive relationship or relationships active in the patient that are affectively dominant in that session so that the part-self and part-object representations can be identified and eventually integrated. The tactics (Table 4–1) involve therapist activities that range from creating the framework for the therapy (contracting and limit setting), to guiding the therapist’s choice of what material to address (the hierarchy of priorities), to maintaining appropriate attitudes with regard to the patient and the material. We provide an overview of these tactics in this chapter, and we further elaborate on the key tactics of contract setting and choosing the priority material in subsequent chapters.

Chapter 5 : ASSESSMENT PHASE
Our psychodynamic nosology (see Chapter 1, “The Nature of Borderline Personality Organization”) is based on the patient’s subjective experience, observable behavior, and underlying psychological structures. Therefore, clinical assessment, which precedes treatment selection and its initiation, must include each of these three areas: 1) subjective experience (e.g., symptoms such as anxiety and depression); 2) observable behaviors (e.g., investments in relationships and work, deficit areas in functioning); and 3) psychological structures (e.g., identity and identity diffusion, defenses reality testing). This method of evaluation is not purely descriptive, as is sometimes seen in psychiatry, with the focus only on symptoms. Nor is this method of assessment a traditional psychoanalytic one with its focus on underlying dynamics related to the past. Rather, our orientation is that the nature of the treatment experience will be shaped by the level of personality organization (neurotic personality organization or high- or low-level borderline personality organization [BPO]), the symptoms the patient experiences, and the areas of functioning that are compromised. Personality (psychological structural) organization is central to the manner in which the patient integrates and organizes all his or her experiences and behavior. The specific symptom constellations (depression, anxiety, eating disorders, substance abuse, suicidal behavior) and areas of dysfunction (social relations, work) vary across the levels of personality organization (i.e., neurotic level, high-level borderline, and low-level borderline). The primary goal of patient assessment before initiating treatment, therefore, is to correctly identify the patient’s symptoms, areas of dysfunction, and personality organization, since they directly influence the focus, process, and outcome of treatment. After an assessment of these areas, the therapist forms his or her diagnostic impression and moves on to the discussion of the treatment contract (see Chapter 6, “Assessment Phase, II: Treatment Contracting”) before therapy per se begins. The patient with BPO often wants to “begin therapy” without attention to the preliminary details of history taking and setting of the treatment contract. In fact, many BPO patients come to us in self-defined crisis asking for immediate attention to details, such as a refill of medication, a sudden eruption of suicidal ideation, or a disruption in a previous course of psychotherapy that has lapsed or gone sour. Our approach is to tactfully acknowledge the patient’s situation but at the same time proceed with adequate assessment before committing to a treatment defined by the appropriate treatment contract. While respecting the patient’s felt need for immediate therapy and change, the therapist indicates that effective help depends on understanding the background of the problem and a clear agreement between the two participants as to how to proceed. If the patient’s situation constitutes a clinical crisis, the patient is referred to emergency services. Careful assessment and treatment contracting can be carried out later, after the emergency has been dealt with.,

chapter 6 : ASSESSMENT PHASE, II
One of the initial treatment tasks is setting the frame of treatment, introduced in Chapter 4 (“Tactics of Treatment: Laying the Foundation for the Techniques”) as the first tactic of transference-focused psychotherapy (TFP). This is the first task after the diagnostic assessment has been completed and is carried out by the negotiation of a treatment contract between the therapist and patient. A treatment contract establishes the frame of the treatment, defines the responsibilities of each of the participants, and assesses whether the patient is motivated to pursue this type of treatment . The contract details the least restrictive set of conditions necessary to ensure an environment in which the psychotherapeutic process can unfold. Because the patient’s ability and willingness to accept the contract cannot be known until it is presented to him or her, and because the contract defines the minimum conditions required for therapy to take place, the contract setting precedes the beginning of therapy. To schematize the progression of the initiation of therapy, the therapist proceeds according to the following sequence: evaluation and history taking (averages three sessions; see Chapter 5, “Assessment Phase, I: Clinical Evaluation and Treatment Selection”), then the setting of the treatment contract (averages two or three sessions but may require more in complicated cases), then the beginning of therapy (if patient and therapist agree on the contract). The first aim of the contract is to create conditions in which a psychodynamic exploration can take place. A guiding principle is that the therapist must feel comfortable and safe enough to remain neutral and think clearly. This is no small matter in the treatment of patients who often create a level of anxiety in the therapist that leads the therapist to abandon psychodynamic techniques in favor of whatever measures seem to meet the need of the moment. In so doing, therapists usually participate in acting out the primitive dynamics of the patient rather than helping the patient understand and resolve them. A second aim of setting the frame of treatment is to limit the patient’s secondary gain of illness—for example, using symptoms to elicit extra access to the therapist or as a reason to claim inability to function and therefore medical disability. In discussing the treatment contract, the therapist must address 1) universal and essential parameters of treatment that apply to all cases in psychodynamic therapy (Table 6–1); and 2) the specific threats to treatment that characterize the individual patient’s unique history and pathology and that are likely to endanger the treatment (see Table 4–2 in Chapter 4, “Tactics of Treatment: Laying the Foundation for the Techniques”). These threats require the establishment of specific parameters that go beyond the universal parameters of psychodynamic treatment and that vary according to the individual patient; an example is the need for the therapist to set up contingencies that clarify his or her position vis-à-vis a patient who got her previous therapist so involved in the emergency management of her suicide attempts that he was unable to carry out the work of exploratory therapy. To engage in treatment, the patient must make a meaningful commitment to try from the start to work within the parameters of treatment, but the therapist should understand that difficulty in adhering to the contract may constitute a primary topic in therapy before full adherence to it is achieved. The therapist should also understand that even though the contract is set up before the therapy begins, the work of therapy often involves referring back to the contract and sometimes involves revising it or adding to it during the course of treatment. We emphasize that the therapist should not feel an obligation to work with a particular patient if that patient does not accept fundamental aspects of the treatment. It is the therapist’s job to make sure that he or she is providing proper treatment. It is analogous to the situation of a surgeon who would not proceed with the operation unless essential conditions, such as a e operating field, were in place. If the patient does not accept the essential conditions of treatment, it is better that the patient seek another treatment than engage in a treatment he or she objects to. The contracting stage may include a meeting with the patient’s parents or spouse if the therapist deems it necessary to communicate to them the nature and limits of the therapy. This is generally done when the patient is very dependent on these others and when there is a risk that they do not understand either the nature of the patient’s illness or the fact that the treatment offers no guarantee that a self-destructive patient will not harm or kill himself or herself even in the context of treatment. The therapist who proceeds without such an understanding in place generally experiences a pressure to be a survior that is counterproductive and that leads to deviations from adhering to the role of exploratory therapist.

Chapter 7 : EARLY TREATMENT PHASE
The goals and related tasks of the early treatment phase (Table 7–1) reflect the nature of borderline pathology and the manner in which psychodynamic treatment begins to shape the interaction. A main goal is to diminish the patient’s level of acting out, both in his or her daily life and within the context of the therapy (acting out in sessions or in relation to the frame of treatment). Acting out in the first phase of therapy often takes the form of challenging or testing the frame of treatment that is set up in the contracting phase. Another early type of acting out comes in the form of the patient’s impulses to leave the therapy. In the successful early phase of treatment, the patient begins to demonstrate increased control over impulsive and self-destructive impulses. This occurs largely in response to the elimination of secondary gain from acting out resulting from the parameters set up in the treatment contract. Limit setting tends to shift acting out into the therapeutic relationship, in which the implicit object relationship is activated in the transference. Transference interpretation consolidates the effects of limit setting. As the patient’s impulse control is strengthened, chaotic and socially inappropriate behavior is reduced—although not necessarily eliminated—outside the treatment setting. Intense affects tend to become concentrated in the treatment situation, which has been defined as a space where all affects can be tolerated. The therapist has the opportunity to link impulsive action and symptoms such as anxiety, rage, emptiness, or depressed mood to vicissitudes in the relationship with the therapist and the dominant, underlying object relations in the patient’s inner life. As the patient becomes more confident in the possibility of expressing intense affects in the treatment setting, the therapeutic alliance increases. Even so, urges to drop out may come up again at times when the patient’s increasing attachment to the therapist is threatened by fears of abandonment or by the patient’s dissociated or projected aggressive impulses.

Chapter 8 : MIDPHASE OF TREATMENT
s the tasks of the beginning phase of treatment are accomplished, the work proceeds, often gradually, into the midphase. The patient enters the midphase of treatment when some equilibrium is established, characterized by increased acceptance of the treatment frame with a corresponding decrease in the chaos in the patient’s life and intensification of affects in the sessions. The overt behavioral manifestations of conflict and turmoil that may characterize the beginning phase are contained. Affects—both positive and negative, but usually extreme—become more concentrated in the sessions. The work of deepening the exploration of the transference themes can progress with a diminished threat of treatment dropout or suicidal behavior (although these may recur at times of regression). Time in the sessions alternates between reexperiencing intense conflicts in the relationship with the therapist and mutual exploration of these conflicts, with the goal of increasing the patient’s capacity to reflect on his or her internal experience and on its impact on the patient’s relationship with others outside the session The intensification of affects in the session may not occur if the treatment and therapist are idealized and the patient’s internal split is stabilized with the bad object chronically projected outside the treatment setting. Another stable, but static, scenario that may occur as treatment enters the midphase is that low-grade acting out may continue, creating a situation in which the patient experiences secondary gain (i.e., rewards) from being in treatment and wishes to perpetuate it rather than work toward changing. The primary tasks in the midphase (Table 8–1) are to deepen the understanding of the split-off representations of self and other that are present in the dominant transference themes that are enacted and projected, respectively, in alternating cycles of interchange of the roles of self and other with the therapist, and to help the patient observe, reflect on, and eventually integrate them. These split-off representations of self and other are imbued with primitive aggressive and libidinal affects. Their integration helps increase affect regulation as the extreme and discontinuous parts of the self that contribute to ongoing conflict become modulated in a more complex whole.

Chapter 9 : ADVANCED PHASE OF TREATMENT AND TERMINATION
ADVANCED STAGE OF TREATMENT The advanced stage of transference-focused psychotherapy (TFP) commences when a sufficient working through and integration of mutually split-off persecutory and idealized transference development has taken place. By the advanced phase, the patient has come to understand emotionally that he or she tends to identify both with a self-representation and also with an object representation of the corresponding object relations dyad. The patient can now tolerate the awareness of interchange of roles with the therapist, so that an interpretive integration of the mutually split-off idealized and persecutory segments of the experience may proceed as the centralfocus of the treatment. The advanced phase does not start all at once but emerges when the patient begins to accept the awareness that his or her identity includes parts that he or she had attempted to reject by the use of primitive defense mechanisms such as splitting and projective identification. As described in Chapter 8 (“Midphase of Treatment: Movement Toward Integration With Episodes of Regression”), even after the advanced phase of treatment begins, the process of integration can alternate with periods of regression as the patient’s primitive defense mechanisms diminish but then briefly reassert themselves. The time it takes to enter the advanced phase of therapy varies from one case to another; it can come as early as 6 months into treatment, or it could take years to emerge. Patients who are less antisocial, paranoid, or narcissistic generally reach the advanced phase more quickly. A patient came to understand that his paranoid fear that the therapist despised him (and that the therapist was trying to get rid of him and thought that he was a boring imposition and that his statements were stupid) corresponded to how he thought about the therapist at times when he saw himself as intellectually superior (and above the therapist’s understanding and bored with the therapist’s “repetitive” statements to him) and considered changing therapists. The patient also came to understand that he could judge himself, criticize himself, and put himself down in equally harsh terms. In other words, an arrogant object and a devalued self (actually an arrogant, pathological, grandiose self that incorporated idealized aspects of powerful parents in contrast to a split off, more conscious, devalued self) were the elements of a hate-infiltrated relationship that was completely split-off from his need to establish a dependent relationship with the therapist as a loving father. The conflict included the fear that his self-devaluing sense of inferiority and humiliation would contaminate and spoil his only positive possibility for a dependent relationship with the therapist. The advanced phase of therapy begins when the patient has sufficiently experienced both the idealized (dependent) and persecutory (aggressive and arrogant) segments of his or her internal experience to be able to tolerate them in emotional continuity without having to reenact them in a split-off way, with a temporary loss of reality testing in the transference and massive manifestations of primitive projective mechanisms. In the above example, this development permitted the therapist to interpret the mutual splitting off of these two kinds of relationships. The therapist could then interpret the patient’s fear that a more integrated view of the therapist as both ideal and yet also potentially frustrating, and an idea of the patient as having serious conflicts around hatred and yet a good self-core, would make him undeserving of a gratifying or dependent relationship with the therapist. The patient and therapist were able to achieve the integration of these opposite segments by pointing to the defensive mutual splitting off of them. In simple terms, the patient was beginning to tolerate an ambivalent relationship toward the therapist as both an ideal father and a potentially critical one, and an ambivalent view of himself as having loving feelings and feelings of hatred toward the therapist because of his resentment of the therapist’s assumed attitude of superiority over the patient. The integration of love and hate under the dominance of love, fleetingly at first, and more consistently later on, marked the beginning of the advanced stage of treatment in this case. These integrations do not occur continuously even in the advanced stage of treatment. Regression to what seems to be an exact repetition of the earliest sessions of the treatment, with splitting, projective mechanisms, omnipotent control, and denial of experiences contrary to those that momentarily dominate the transference, may still occur. However, these regressive episodes no longer last for days or weeks before they can be worked through again or before they shift into the split-off, opposite segment. They now may be worked through in several sessions, and eventually during the course of a single session, during which the patient shifts rapidly from states of activation of primitive, split-off, part object relations in the transference to an integrated object relation. Eventually the shifts from 1) recognition of the dominant object relation, to 2) the definition of selfand object representations and their mutual interchange in the transference, to 3) the integration of mutually split-off dyads with corresponding integration of self-representations into an integrated self and the integration of object representations into an integrated concept of significant others may be condensed into a single or a few sessions. This process continues repetitively throughout the advanced stages of the treatment, with a gradual decrease in the regressive tendencies (Table 9–1). Under optimal circumstances, a shift occurs from the dominance of primitive, particularly psychopathic and paranoid transferences into advanced or depressive transferences that begin to resemble the transference in patients with neurotic personality organization and signal the resolution of identity diffusion. Depressive transferences are more advanced than psychopathic and paranoid transferences because these latter are based on primitive, split-off representations of self and other (e.g., the dyad of the evil other menacing the helpless self, which coexists with the opposite, though often submerged, dyad of the perfect provider caring for the beloved self). Depressive transferences, in contrast, are based on the beginning integration of primitive good and bad object representations into a more complex and realistic representation of others. This movement toward integration involves a depressive affect associated with the loss and mourning of the ideal object whose continuation in the psyche was protected by the primitive, fragmented state. CLINICAL CHARACTERISTICS OF THE ADVANCED STAGE Resolution of Psychopathic Transferences Throughout successful treatment a shift evolves from predominantly psychopathic and paranoid into depressive transference patterns (see Chapter 2, “Treatment of Borderline Pathology: The Strategies of Transference-Focused Psychotherapy”). The psychopathic transference—involving the patient’s consciously deceptive behavior as a major characteristic in his or her relationship with the therapist, or the patient’s consistent wariness and suspiciousness of the therapist—should be sufficiently resolved in the advanced phase of treatment for completely honest communication with the therapist to be possible. Honest communication does not mean that the patient may not have occasional secrets that the patient feels he or she has to keep from the therapist, or does not temporarily suppress important material out of paranoid fears or feelings of shame or guilt, but means that in general the therapist can rely on the patient’s honest communication to resolve such transitory breakdowns of communication in the course of their psychotherapeutic work. One cannot really speak of an advanced stage of the treatment before full resolution of psychopathic transferences. These transferences resolve when the patient is able to question and doubt his or her initial assumption that the therapist is totally exploitative and incapable of empathy and that the relationship is based exclusively on who can get what from the other, or who can use the other for some purpose. Transient Paranoid Transferences In contrast, paranoid transferences may still be strongly present during the advanced treatment stage, with the particular characteristic that they can be resolved within the session or in days rather than in weeks of psychotherapeutic work, and that there is a sufficiently strong therapeutic alliance available (that is, a sufficiently strong relationship between the therapist in role and the observing part of the patient’s ego) to tolerate paranoid regressions without a threat to the continuity of the treatment. It is in the context of those still-present (but no longer chronically festering) paranoid transferences that moments of the patient’s tolerance of guilt over his or her aggression and the acknowledgment of ambivalence and reparatory strivings in the transference signal continuing integration. Controlled Acting Out Outside of Sessions When the treatment progresses effectively, severe acting out outside the treatment sessions should be under control even during the early stages of the treatment, so that the patient’s life outside the sessions may have already normalized to a significant extent, while, to the contrary, intense transference regression is reflected in affect storms and general turbulence in the sessions. In the advanced stages of the treatment, the patient has become aware of the therapist’s tolerance of his or her regressive behavior during session in order to understand it, and yet realizes the need to control his or her behavior outside in order to bring his or her difficulties into the therapy for exploration rather than expressing them in action outside the sessions. Therefore, the highest priorities of intervention of the earlier stages— namely, 1) threat to the patient’s or other people’s lives, 2) threat to the continuity of the treatment, and 3) threat of severe destructive or self-destructive acting out outside the sessions—should have decreased significantly to permit the therapist to focus increasingly on the transference itself. At this point the therapist is more able to rely on the patient’s communication of his or her experiences outside the session. This is in contrast to the patient’s tendency earlier in treatment to split the external reality from the sessions. Because of the intense turmoil in the sessions, the therapist may not be aware of the patient’s improvement outside the sessions and of significant changes that may have already taken place. Particularly when the transference is intensely negative, the improvement outside the sessions may be so dissociated from them that the therapist may be unaware or may neglect to acknowledge the patient’s changes in significant areas of his or her relationship Patients whose tendency toward acting out is matched by tendencies to somatize intrapsychic conflict may increase their capacity to experience their emotional difficulties within themselves, with significant others, and in the transference rather than automatically transforming these affect states into somatic complaints. Typically, when experiencing somatic complaints, patients at this point may search for emotional issues that they are trying to avoid, and somatization itself becomes a natural element of transference exploration. For example, one patient with infantile personality and bulimia nervosa and obesity in the advanced phase of treatment acquired an awareness of the relationship between bingeing episodes and transference developments, spontaneously brought the temptations to binge into context with the conflicts in the transference, and was able to reduce her bingeing behavior more easily. This can be a very gratifying development for both patient and therapist. In summary, the developments in advanced stages of the treatment are reflected in increasing tolerance of ambivalence on the patient’s part and in reductions of splitting and related mechanisms (particularly projective identification) and of acting out and somatization. Tolerance for selfreflectiveness increases, and the patient’s communication of subjective experience now predominates over communication through nonverbal behavior and through the activation of the therapist’s countertransference. Integration of internalized object relations is reflected in greater complexity and continuity of the experience of the self and of significant others. The patient may describe a desired action or a fantasy instead of carrying it out. The patient’s capacity to predict his or her own behavior as well as to reflect on it is increased. Deepened Relationship With the Therapist There will be growing evidence of the capacity to internalize the therapist in the form of fantasizing more realistically about his or her actions. In addition, other relationships in the patient’s life will acquire a sharper, more realistic, more alive quality in the sessions. More subtle contradictions in the patient’s behavior may emerge that were previously ignored by the patient and the therapist. The relationship with the therapist now deepens; the patient appreciates more appropriately the therapist’s contribution to the therapy; and the patient evinces a more empathic, realistic observation of the therapist as a person. The patient’s capacity to recall the shared history of the relationship with the therapist increases. Mutually contradictory transference dispositions tend to get mixed up, to be resolved in the same session, and to acquire a new emotional depth and complexity. The patient is able to work more autonomously in the sessions. New information may be forthcoming—for example, regarding secrets previously kept from the therapist over an extended period of time. Regarding shifts in the interpretive approach in advanced stages of the treatment, the therapist may be able to increase the linkage of present transference developments to unconscious, past pathogenic object relations. In other words, the therapist can increasingly include psychogenic interpretations along with the here-and-now interpretations that predominated in the early and middle phases of treatment. There may be an increase in the patient’s capacity to use free association and dream interpretation, and the therapist may rely more on the observing part of the patient’s ego in his or her formulations of transference interpretations. The relationship between the sessions and the patient’s external life may become more fluid and natural, in contrast to earlier sharp dissociation between these two areas of the patient’s experience. In terms of the analysis of the content of the patient’s conflicts, the focus may be on more normal and pathological mourning reactions—characteristic of the depressive position—in contrast to a predominant focus on paranoid transferences. The atmosphere of the individual sessions gradually shifts during the advanced stage of the treatment. There tends to be a reduction in the pervasive, dominant, primitive, defense mechanisms that earlier distorted the transference, and the patient’s relationship with the therapist seems closer to that of a therapy session with a neurotic patient. Having incorporated the general therapeutic instructions, the patient begins to talk freely at the beginning of the sessions without consistently presenting a challenge to the boundaries of the psychotherapeutic relationship. The patient’s greater availability of fantasy and sharper awareness of his or her psychosocial reality may facilitate longer stretches of a narrative in which significant subjective experiences are verbally communicated, in contrast to the previous dominance of nonverbal communication. The patient’s observations of his or her own behavior and that of important people surrounding him or her have a more balanced and less chaotic or rigidly restrictive quality. In the relationship with the therapist, the patient may anticipate the therapist’s comments, thus signaling his or her internalization of aspects of the therapist’s attitudes toward the patient and a sharper awareness of realistic aspects of the therapist’s personality. This more realistic awareness of the therapist’s personality begins to strengthen the patient’s observing ego when, under the domination of an intense regression in the transference, the patient begins to return to an unrealistically idealized, devalued, or persecutory view of the therapist. For example, the patient might say, “What you’re saying, it’s making me upset. It makes me think you’re disgusted with me and want to get rid of me...though I know that’s not true.” The therapist, at the same time, may feel more at ease in being direct with the patient, such as in presenting the patient with more direct reflections about his or her difficulties that may be painful for the patient to experience, without leading to the patient’s transformation of the interpretation into a perceived attack or devaluation. The therapist may become more direct and open, in the sense of being less cautious or tentative in formulating interpretations, with the assurance that the patient is now able to understand interpretation in the context of the history of the exploration of a certain problem in the treatment. If the therapist has consistently confronted the patient with his or her difficulties without giving in to the patient’s unconscious efforts at omnipotent control, and if the patient has learned that to be confronted with the previously unacceptable or intolerable aspects of his or her personality does not mean that he or she is being attacked or devalued, the patient will now be much more able to listen and will be less afraid of his or her own negative transferences, including hatred in the transference, with a concomitant decrease in his or her needs to project aggressive impulses onto the therapist. In general, the decrease in the use of primitive mechanisms implies a greater awareness of and tolerance for internal contradictions and conflicts on the patient’s part and a strengthening of the patient’s ego in terms of impulse control and anxiety tolerance. In other words, nonspecific manifestations of ego weakness decrease as higher-level defensive operations start to become predominant. Independent work by the patient in some areas of conflict now begins to emerge, and there are times when the therapist may become more passive, more receptive to the patient’s autonomous work in the sessions. INDICATORS OF STRUCTURAL INTRAPSYCHIC CHANGE There are a number of indicators of structural change manifested by the patient that can be used as markers of the advanced stage of TFP. Exploration of Therapist Comments The patient’s statements now demonstrate either an expansion or further exploration of the therapist’s comments, in contrast to an earlier pattern of systematic disagreement without any indication of reflection on the therapist’s comments. The issue here is not whether or not the patient agrees with an interpretation or goes along with the suggested subject for exploration, but the extent to which the patient gives himself or herself the chance to reflect on what the therapist has said versus an immediate automatic rejection or denial of the therapist’s comments. It also needs to be underlined that the issue is not whether the transference is positive or negative but whether there is some degree of cooperation in clarifying what is going on, in contrast to a categorical rejection of exploration or a thoughtless acceptance, submission, or lip service to the therapist’s suggestions. This is a category of particular importance in the treatment of patients with severe narcissistic personalities and of patients who use primitive defenses against acknowledging aggression. Containment and Tolerance of the Awareness of Hatred Insofar as borderline personality organization (BPO) is linked with the inability to integrate extremes of primitive aggression and primitive libidinal longings—regardless of whether they are derived from genetic, constitutional, or temperamental factors or are secondary to severe and chronic traumatization, physical or sexual abuse, or witnessing such abuse—the dominant unconscious conflict of such severe primitive structures involves the affect of hatred. The patient’s psyche is marked by a characterologically structured hateful relationship between a traumatized self and a sadistically perceived object (with a fundamental motivation of destroying the object, making it suffer, or controlling it) and, by projection, corresponding fears of the object’s hatred toward the self. The process of overcoming the internal split and bringing affects of aggression and hatred into an integrated self includes the patient’s becoming aware that these affects are part of the human experience and that, if integrated and mastered, they do not destroy any possibility of experiencing oneself as a decent human being and experiencing gratifying relationships. In this context, the patient’s desperate desire and need for an ideal, loving, and dependent relationship may emerge and gradually become integrated with the experience of a gratifying realistic love relation that also incorporates erotic freedom. Containment and tolerance of the awareness of hatred—in contrast to its expression by acting out, somatization, or destruction of the communication with the therapist—is a sign of an advanced stage of treatment. We explore the manifestations of primitive hatred in Chapter 1 (“The Nature of Borderline Personality Organization”). What is of interest here is the decrease in its manifestations (such as the direct expression of violence in sessions or the aggressive dismissal of whatever comes from the therapist); the resolution of the triad of arrogance, curiosity, and pseudostupidity found in a type of aggressively narcissistic patient; and the reduction in sadomasochistic transferences. In addition, negative therapeutic reactions (Table 9–2) such as the expression of unconscious envy of the therapist decrease, as do characterologically anchored self-directed manifestations of hatred such as suicidal, parasuicidal, and self-injurious behavior; substance abuse; eating disorders; or severe self-destructive sexual behaviors. We refer to the decrease in psychopathic transferences earlier in this chapter (see “Resolution of Psychopathic Transferences”), and in this connection, antisocial behavior outside the treatment situation should also be markedly decreased or have disappeared. At this stage of the treatment, the most destructive aspects of the patient’s sexual behavior should be under control. In the early stages of the treatment, the dominance within the patient’s sexual behavior of severe aggressive and self-aggressive trends often interferes with all intimate love relationships, and in many cases these patients present with an absence of all sexual engagements. Although an active (even if self-destructive) sexual life is prognostically more favorable than a severe primary inhibition of all capacity for sensual engagement, a general increase in the concern of the patient for his or her love life in the content of the sessions may indicate an improvement in the patient’s functioning, in the sense that sexuality and love are no longer totally under the control of aggression and are experienced more freely in the counterdeveloping object relations that are becoming stronger and becoming integrated. However, a potential problem in advanced stages of the treatment is that in cases of severe primary inhibition of the sexual response, such inhibition may increase as the patient’s general functioning improves and repressive mechanisms replace more primitive dissociative or splitting mechanisms. This is a complication that may require modification of the psychotherapeutic approach, such as combination with sex therapy once the patient’s severe inhibition of sexual desire has been sufficiently reduced to make the unconscious dynamics of this primary sexual inhibition clarified enough to permit an integration of psychodynamic psychotherapy and sex therapy. Tolerance of Fantasy The tolerance of fantasy and the opening of the transitional space is particularly relevant in the treatment of BPO patients with narcissistic personalities. Here the issue is the extent to which the patient may open himself or herself to free associations that are not under his or her control, with the implicit danger that the therapist may gain understanding about what is going on in the patient’s mind before the patient is fully aware of it. Narcissistic patients’ need for omnipotent control tends to inhibit free association and reduce the availability of fantasy material. With BPO patients in general, the increase in the ability to symbolize increases patients’ capacity to experience affects in fantasy rather than having to discharge them in action. Capacity to Use Interpretation of Defense Mechanisms During the early stages of the treatment, interpretations are often effective despite apparent dismissal of them or a premature acceptance on the patient’s part. In the advanced stages of the treatment, the effect of interpretations includes an increase in the patient’s capacity for self-awareness and self-exploration as a consequence of interpretation. John Steiner (1993) recommended that during the early stages of treatment with patients with severe personality disorders, the patient’s image of the therapist that emerges as a consequence of projective identification should be interpreted without directly rejecting or accepting it—examining, as it were, the patient’s internal images as they are projected onto the therapist. The gradual tolerance on the patient’s part of that projected representation may facilitate the eventual acknowledgment by the patient of an intrapsychic experience of it. This increased capacity to take back what has been projected is precisely what may be expected in the advanced stages of psychodynamic psychotherapy with borderline patients and is one indicator of structural intrapsychic change. In one session with a patient who alternated her view of the therapist as someone who was sometimes friendly and at other times (through a projection of an internal image of a sadistic stepmother) hostile, the therapist commented, “This raises the question of whether I am indeed two different persons or you see in me something you are struggling with inside of you. Part of this person is friendly and nice, trustworthy. The other part is a hostile, sadistic person who enjoys provoking and acts innocent and is totally blind to this aspect of his personality.” The patient commented, ironically, “Does that sound like somebody we know?” When asked whom she had in mind, she wondered whether it was herself or her stepmother, and the therapist responded that this image referred to both of them and to her colluding with the image of her stepmother inside of her. The patient returned to this interpretation later on, using it to help gain mastery over aggressive and controlling tendencies she was now more aware of. Shift in Predominant Transference Paradigms A shift in predominant transference paradigms, an indicator of structural change, can be considered the most fundamental marker of the patient’s entrance into advanced stages of the psychotherapy. Each patient has only a limited number of predominant transference patterns that repeat themselves over many months and even years of treatment. In each of these transference paradigms, there are three steps of interpretation: 1) defining the predominant relationship in the transference; 2) identifying self- and object representation and their interchange; and 3) integrating the mutually split-off idealized and persecutory self-representations and respective object representations. In the advanced stages of the treatment, a significant shift occurs in the relationship of the patient to his or her internalized object relations in connection with the overcoming of splitting operations and the development of normal ego identity. In practice, this shift is illustrated by the appearance of new, more complex and differentiated aspects of self and objects and the emergence of new relationships that transcend the rigid patterns of the repetitive early ones. A patient—who oscillated between experiencing her therapist as a warm but weak and asexual father image and a powerful and sadistic stepmother image—began to experience the therapist as a friendly yet strong and sexually seductive father image, a totally new constellation that emerged as a consequence of the integration of the previously split-off primitive transference mentioned. In this context, new aspects of the relationship with her father emerged that had a markedly oedipal quality, in contrast to the pre-oedipal denial of all sexuality in the image of the (idealized yet weak) warm and giving father. Another patient, with severe antisocial features—who for a long period had perceived her therapist as a persecutory, sadistic moralizer against whom she had to protect herself through a combination of secrets and manipulation—gradually began to acknowledge and feel guilty about her dishonesty and also felt guilty about mistreating her therapist, whom she now perceived as reassuringly maintaining their relationship despite her indirect attacks on him. She now began to perceive him as a strict but concerned father figure—very different from what she now, probably realistically, became aware of as the manipulative and dishonest father in her past. She became depressed and developed a profound conviction that she did not deserve to be loved and taken care of by the therapist. She also developed a quiet remorse that coincided with an effort to repair relationships with former friends whom she had treated badly and whose friendships she was now trying to recover. This case illustrates a clear shift into a depressive type of transference in the advanced stage of the treatment. Perhaps the most dramatic shift in transference dispositions in advanced stages of the treatment is the case of the breakup and working through of the pathological grandiose self in the transference of patients with narcissistic personality disorder, and particularly patients with the syndrome of malignant narcissism (i.e., a narcissistic personality with severe paranoid features, antisocial behavior, and ego-syntonic aggression, either self-directed or externally directed). However, this dramatic, positive development in the treatment situation does not occur consistently. On the contrary, in our experience, some patients with narcissistic personality disorders—particularly the syndrome of malignant narcissism—improve to the extent that ego strength develops in the context of all the various indicators mentioned so far, but with a simultaneous consolidation of the pathological grandiose self at a higher, more adaptive level and the utilization of this better-functioning pathological grandiose self as a defense against further change in the treatment. In these latter cases, significant changes in symptoms evolve outside the sessions, and there is a decrease in severe turmoil inside the sessions as well. Yet there is also a subtle yet stubborn resistance to further change that, matched with an often impressive improvement in the patient’s total functioning, may lead the therapist to conclude that this is as far as the patient can get in his or her treatment. In such cases the therapist may move toward termination, with the potential recommendation that the patient obtain further treatment (possibly even standard psychoanalysis) later on if the remaining narcissistic personality structure predisposes him or her to difficulties in sustaining intimate relationships. MAJOR IMPEDIMENTS TO ENTERING ADVANCED STAGES OF THE TREATMENT Narcissistic Features As mentioned earlier (see “Shift in Predominant Transference Paradigms”), patients with narcissistic personality disorder who function on an overt borderline level—typically presenting at the beginning of the treatment fulfilling DSM-IV-TR criteria (American Psychiatric Association 2000) for both borderline personality disorder and narcissistic personality disorder, or even more likely fulfilling the criteria for the syndrome of malignant narcissism— may improve dramatically in their functioning outside the treatment hours, and may even significantly reduce the intensity of violent, paranoid, or dishonest behavior in the sessions, while consolidating in a subtle yet rigid way their pathological grandiose self. They may utilize their very improvement to indicate that they are doing well; in some cases they may even insist that their improvement is due entirely to their own work and that they do not owe anything to the therapist. They may either be willing to stay in a treatment situation without any further change over extended periods of time, or they may wish to end the treatment, with the rationale that they are functioning well and do not have any major problems left. Of course, insofar as they are symptom free and are functioning well in their social lives, at work, and in their studies—and perhaps even are able to establish some intimate relations—there are good reasons to go along with the patient’s assessment of the situation. However, given the poor prognosis for the capacity for intimate love relations and the consolidation within a couple that these patients present, or even the danger of the lack of a sufficient investment in work or study to guarantee gratification and effectiveness in them in the future, it is worthwhile to carry on the treatment as long as further change can be observed and terminate it with a strong recommendation that if any of these problems present themselves in the future, the patient should seek further treatment. In the climate of managed healthcare, such an attitude by the therapist might appear as a luxury, if it were not that patients with unresolved narcissistic pathology may ruin their lives in the long run in undramatic ways and that a psychoanalytic treatment may make a difference between a gratifying and successful life and one with repeated failures in work and intimacy. Depressive Transference and Unconscious Guilt Another complication in advanced stages of the treatment may be linked to the improvement itself: the move from a predominantly paranoid into a dominantly depressive transference constellation, with the development of unconscious guilt over being helped (“I am not worthy of this”) and an unconscious tendency to avoid further improvement as a price to pay for the improvement obtained thus far. Following are two examples: After years of treatment in which she was chronically confined to her home or in a psychiatric hospital, a patient with severe self-mutilating tendencies, total incapacity to study or to work, and extreme sexual inhibition was able to resume her studies, successfully follow a professional career, get married, and have children. She nevertheless continued to have severe sexual inhibition that she now felt she had no desire to explore further, reflecting unconscious guilt over the triumph over her siblings, because she was doing so much better than the rest of them. Another patient, who in the course of treatment had resolved her severe antisocial tendencies, in the middle of the development of strong depressive transferences decided to marry a man with a chronic physical illness. This decision would force her to undertake major nursing functions, thus restricting her life while at the same time also significantly limiting the possibilities of a safe social and economic situation. This patient had systematically avoided establishing relationships with men who might have presented a much more gratifying choice, and she felt herself irresistibly attracted to men with significant handicaps. This type of negative therapeutic reaction out of unconscious guilt (Table 9–2) needs to be differentiated from negative therapeutic reactions out of unconscious envy of the therapist that are typical for narcissistic pathology, and this differential diagnosis can usually be resolved in the early stages of psychotherapeutic treatment along the lines we have proposed. Paradoxically, the development of normal superego functions in advanced stages of the treatment may bring about an important complication that requires alertness and the interpretation of what often emerges in the transference as significant masochistic tendencies. It is a special form of negative therapeutic reaction and of unconscious guilt that takes the form of masochistic transferences. The predominant dynamics of these developments in the transference may include both intense guilt over pre-oedipal aggression to the maternal object and oedipal guilt over success and improvement related to now-emerging oedipal conflicts and rivalry. Clinically, such masochistic acting out in the sessions or the patient’s external life, geared to prevent the patient from obtaining further improvement, may take the form of a sense of boredom, a loss of motivation for further learning, or an unconscious effort to empty out the sessions to induce the therapist to lose interest in the patient and in the treatment. If this occurs in the context of significant therapeutic change and a relatively long duration of treatment, it may lead to an erroneous assumption that maximum benefit has been attained, and the therapist may miss the self-defeating implications of the patient’s unconscious efforts to empty out the relationship because of feeling unworthy of the gratification the relationship is beginning to provide. Intensification of Paranoid Transferences There are some developments that—although they are essentially positive in terms of overall treatment goals—may temporarily appear as regressions and require particular attention from the therapist. In patients with significant antisocial personality features, these developments include the intensification of paranoid transferences. These may be previously expressed psychopathic transferences that have been worked through and have transformed into paranoid tendencies in the sessions. This is generally perceived as a positive development by the therapist because the previous distancing and emptiness of the emotional contact between the patient and therapist has now been replaced by intense, primitive paranoid enactments. However, the paranoid developments in the transference may regress to a point where delusional developments in the transference take place in an advanced stage of the treatment, requiring the utilization at this point of the method of incompatible realities, spelled out elsewhere (see “Tactic 3” in Chapter 4, “Tactics of Treatment: Laying the Foundation for the Techniques”). This method requires carefully exploring whether the patient has developed what amounts to a delusional conviction in the transference, or whether he or she is still aware that his or her paranoid fantasies are in fact fantasies. If the former is the case, the therapist may then let the patient know that he or she has completely opposite convictions regarding this particular transference issue (the therapist should emphasize that he or she is not trying to convince the patient to adopt a different position but is only interested in analyzing the emotional relationship that evolves when incompatible interpretations of reality clash as if there were a normal and a totally irrational person in the room). The analysis of incompatible realities in the transference leads to the analysis of a psychotic nucleus or a psychotic object relationship that may be explored while leaving actual reality open or in suspension. This method is very effective in reducing paranoid regressions and also severe sadomasochistic transferences, which may reach a similar point of delusion formation in the transference. Intense, eroticized transferences are discussed in Chapter 8 (“Midphase of Treatment: Movement Toward Integration With Episodes of Regression”) TECHNICAL APPROACHES DURING THE ADVANCED STAGE OF TREATMENT The need to analyze the dominant transference developments systematically (i.e., the gradual, stepwise interpretive integration of split-off transferences with their opposing counterparts) continues to be a major technical strategy during the advanced phase. The attention to every opportunity for integrating mutually split-off idealized and paranoid transferences is the major concern at this stage of treatment. The effectiveness of this approach will be signaled by the strengthening of depressive transferences along with the related deepening of the affective relationship between the patient and the therapist, the integration and maturation of affective responses, the tolerance of continuity in the relationship, and reduction in the abrupt shifting between mutually split-off object relations. At this point, more extensive evidence of the impact of the split internal psychological structure may be seen in the patient’s life. Beyond the splitting seen in the relation with the therapist, discussions in therapy may lead to the emergence of entire segments of the patient’s life that have been neglected or have not been integrated as the patient increasingly elaborates his or her past and present life. For example, the patient may demonstrate important self-destructive patterns in studies, work, or career; interpersonal relationships with colleagues, subordinates, and bosses may have become infiltrated by general masochistic patterns of defeating the patient’s own interests. In addition, new areas of lasting interests and commitments that were previously impossible because of the syndrome of identity diffusion may now be explored fully. The patient’s relationship to his or her broader social and cultural background—his or her link with cultural, religious, artistic, and intellectual interests and pursuits—and, in particular, the more complex relationships with the patient’s intimate partners may begin to absorb the attention in sessions. A patient developed an interest in becoming an art therapist in the course of her therapy, carried out the corresponding studies, and became employed in psychiatric treatment centers. However, this interest, based in part on an identification with positive qualities the patient perceived in the therapist, was happening before the patient had adequately integrated idealized and persecutory internal representations. Unconsciously, the patient also invested this interest with a destructive meaning of imitating what she considered the “phony” interest she believed most mental health professionals had toward their patients, based on the projection of a persecutory representation. A lack of true commitment to her work led to the patient’s losing her positions in psychiatric hospitals because of inappropriate interactions with patients, including sharing illicit drugs with them. In the course of the psychotherapy, the acting out of the negative transference, a particular psychopathic type of transference involving the expectation of exploitation, was explored and resolved. The patient’s interest in art therapy evolved into an authentic commitment to an area not reflecting only narcissistic gratification, and she returned to this field at a later stage of her treatment. At this point her effectiveness in working with individual patients as well as with groups drew the attention of the authorities of the institution where she worked, who sponsored further specialized training in related therapeutic activities. She eventually became a highly respected therapist in her area of specialization, now with a very different attitude from the one that had initially moved her in that direction. Moving from the acting out of a specific psychopathic object relation to the development of a general new area of concern or expertise represented a broadening of her psychological space, and her adjustment to this new field of activities occupied an important part of the sessions during advanced stages of her treatment. It is important that the therapist continually reexamine in his or her mind whether the routine ongoing contact with any particular patient has led to a narrowing of his or her perspective regarding this patient’s overall conflicts, life situation, and potential. In other words, it is important for the therapist to resist being lulled into accepting the patient as he or she is, with a consequent subtle restriction of the treatment goals. The therapist should rather continue to reexplore the patient’s present and potential future functioning. In relation to this, the connection between learning in the sessions and the patient’s utilization of this learning outside the sessions becomes very important. A general attitude of impatience (vs. complacency) in each session, combined with great patience in terms of long-term working through of dominant problems, becomes important. Impatience in each session leads to maintaining the momentum of work in opposition to the patient’s subtly learning how to maintain the equilibrium in the sessions and serves as a protection against a natural tendency of the therapist to relax because things seem to be going well. We mentioned above the possibility of more direct and less cautious interpretive statements (see “Deepened Relationship With the Therapist”). This goes along with increased attention to the patient’s work both in the sessions and between the sessions. At a certain point more complex, advanced neurotic transferences may emerge, such as typical oedipal fears and fantasies, or rivalries regarding other patients, reflecting such oedipal structuring. The therapist needs to be alert to the fact that attention to such advanced neurotic transferences may need to be temporarily put aside in order to pay attention to regressions to primitive transferences that usually take priority over the more elaborate transferences that now evolve. The general principle that psychopathic transferences need to be interpreted before paranoid ones and paranoid ones before depressive ones holds particularly true at this advanced stage of the treatment. In addition, new aspects of the patient’s material may acquire relatively more importance. Genetic interpretations may link the unconscious present with the unconscious past and contribute to integrating the patient’s life history in the context of an increased capacity for self-reflectiveness about present and past experiences. The patient’s increased capacity for reflectiveness should become evident in his or her increasingly in-depth evaluation of others, particularly in the context of relations with sexual partners and intimate friends in general. Dream analysis may now take the more classic forms of inviting the patient to free-associate regarding the components of the manifest content of the dream and of connecting these associations with the patient’s style in communicating the dream and with the dominant transference at that point—that is, a fully developed dream analysis, in contrast to the partial dream analysis used in the early stages of the treatment, in which aspects of the manifest dream are selected as elements to be integrated with transference interpretations (Koenigsberg et al. 2000). The patient’s reactions to separations from the therapist on weekends, during vacations, and in the case of illness or unexpected disruptions of the treatment need to be explored very carefully, because they will also illustrate the advance into the predominance of depressive transference reactions. Reactions to separations in the earlier stages of the treatment may take the form of severe separation anxiety, panic, and regressive behavior. Alternatively, in the case of narcissistic pathology, they may involve complete denial of dependency on the therapist and, to the contrary, a tendency by the patient to leave the therapist as a counter move to feeling left behind. If there has been movement toward internal integration, there tend to be more depressively tinged separation reactions, with mourning processes and feelings of sadness and loneliness rather than panic over being abandoned and mistreated. In turn, the systematic analysis of these separation reactions further helps to integrate split-off primitive transferences and helps the patient advance in the integration of ego identity. It also helps the patient to prepare for the reactions to termination.

Chapter 10 : COMMON TREATMENT COMPLICATIONS
Treatment complications occur when the acting out of primitive underlying conflict threatens to overwhelm the treatment and derail or end the therapeutic process. Although these moments in treatment have the potential of rendering the therapist so anxious that it is difficult to pursue exploratory therapy, when skillfully managed they offer important opportunities to advance the work of therapy. In managing complications the therapist may, on a practical level, become more proactive in the sense of calling the patient at home or communicating with a family member and, on a technical level, increase the speed of interpretations or make deeper interpretations. Dealing with crises may involve reinforcing adherence to the treatment frame or may involve temporarily deviating from technical neutrality. Especially in the early phases of treatment, a patient’s conflicts are more frequently communicated through actions rather than through words. In addition, in the early phase, splitting and projection are particularly intense, creating a situation where the therapist is likely to be viewed at times as a dangerous, exploitative person, with no integration of other characteristics to soften this perception. In this setting, the patient’s participation in therapy—his or her discussion of problem areas (interpersonal conflict, selfdestructive behavior, depression, etc.)—is generally limited in its scope to thoughts of which the patient is already aware. The character pathology— in particular, the internal splitting—so fundamentally underlies and determines the patient’s experience in the world that he or she has no awareness of it; the structure of the pathology is the structure of his or her subjective reality. This deeper level of disturbance—the disorder of psychic structure—is initially most evident in the patient’s actions, creating the need to pay special attention to actions and the therapeutic interaction. When the patient’s actions threaten to derail or end the treatment, the opportunity for deeper understanding goes hand in hand with the threat because it is a sign that intense affects have been activated in the treatment, usually at a time when the patient’s internal splitting is less effective in keeping a disturbing self- or other representation from consciousness. To a large extent, it is in dealing with treatment crises that the patient’s inner world becomes available for observation and exploration. A key to effective therapist intervention in times of crisis is an increased level of therapist activity, which surprises many therapists who are not familiar with transference-focused psychotherapy (TFP). Crises may occur early in the treatment, before the patient has significantly decreased his or her initial level of acting out. Such crises may include a component of challenging the treatment frame to see whether the therapist will adhere to or abandon the parameters set up in the treatment contract. Adherence to the parameters by the therapist can be reassuring to patients. Crises may also occur after the patient has settled into the treatment frame. Crises may correspond to moments when therapy has disrupted the precarious balance of primitive defense mechanisms (e.g., when the splitting off and projection of aggressive affects begins to fail) or when the chaos of the patient’s life has calmed down enough for the patient to consciously experience the identity diffusion that leaves him or her feeling empty and lost in the world. The patient may feel less anxious in the storm of crises than in the awareness that he or she has no clear sense of direction in life. Crises often represent enactments of feelings aroused in the transference, so a first question to ask when a crisis develops is, “What is going on right now in the patient’s experience of me and the therapy that would lead him or her to x (threat of dropping out, noncompliance with contract, psychotic regression, etc.)?” As stated above, one often discovers that a crisis in treatment is motivated by the patient’s beginning to consciously experience a self- or other representation that is intolerable to him or her. A variant of this is that in order to avoid a painful self-awareness, the projection of an un- desired internal representation becomes so intense that the patient’s experience of the therapist is overwhelmed by the negative projection. Because these moments in treatment tend to elicit strong reactions in the therapist (e.g., anxiety, frustration, despair, hatred), the exploration of these episodes requires careful management lest the therapist get drawn into a pathological mutual enactment with the patient, leading to abandonment of the exploratory effort or the therapy altogether. The therapist’s acting out in the countertransference generally takes one of two forms. The first commonly seen countertransference pattern is that of a superficially supportive response to a patient’s demands that—although it may appear to save the therapy—aborts the opportunity to understand the object relations dyad being enacted. The second pattern consists of a superficially neutral (structured), but essentially rigid and rejecting, response to the patient that is unconsciously geared to precipitating the end of the therapy to put an end to the therapist’s increasing anxiety. The management of treatment crises also challenges the adequacy of the frame established by the treatment contract (see Chapter 6, “Assessment Phase, II: Treatment Contracting,” and Chapter 7, “Early Treatment Phase: Tests to the Frame and Impulse Containment”) and the therapist’s ability to work within it as the treatment evolves. Exploratory therapy requires maintaining the effort to understand the dynamic meaning of the challenge to the frame rather than letting the crisis overwhelm the frame and distort the treatment.

TYPICAL TREATMENT COMPLICATIONS
MANAGING SUICIDE THREATS AND ATTEMPTS DURING TREATMENT
THREATENED AGGRESSION AND INTRUSIONS
THREATS OF DISCONTINUING TREATMENT
NONCOMPLIANCE WITH ADJUNCTIVE TREATMENTS
TREATMENT OF PATIENTS WITH BORDERLINE PERSONALITY ORGANIZATION AND A HISTORY OF SEXUAL ABUSE
PSYCHOTIC EPISODES
DISSOCIATIVE REACTIONS
DEPRESSIVE EPISODE
EMERGENCY ROOM VISITS
HOSPITALIZATION
PATIENT TELEPHONE CALLS
THERAPIST’S ABSENCE AND COVERAGE MANAGEMENT
PATIENT’S SILENCE
SOMATIZATION Severe somatization, such

Chapter 11 : CHANGE PROCESSES IN TRANSFERENCE-FOCUSED PSYCHOTHERAPY
Every treatment approach has an explicit or implicit theory of patient change. In this chapter we focus on the patient change processes and the activities of the therapist that are related to these changes in transference-focused psychotherapy (TFP). This places an emphasis not just on whether or not change occurs and in what domains, but also on the mechanisms of change— that is, what the therapist and patient do together in TFP in some predictable sequence that results in significant patient improvement not only in symptoms but also in personality organization (see Table 2–2 in Chapter 2, “Treatment of Borderline Pathology: The Strategies of Transference-Focused Psychotherapy”). There are a number of elements involved: therapists’ tech-

About Course

Course Content

PSYCHOANALYTIC OBJECT RELATIONS THEORY

A PSYCHOANALYTIC MODEL OF NOSOLOGY

NEUROTIC PERSONALITY ORGANIZATION

THE PSYCHOPATHOLOGY OF HATRED: THE CHIEF OBSTACLE TO LIBIDINAL DEVELOPMENT

CONTRASTING MODELS OF TREATMENT

THE TFP TREATMENT MODEL

THE STRATEGIES OF TFP

STRATEGY 2: OBSERVING AND INTERPRETING PATIENT ROLE REVERSALS

INTEGRATING SPLIT-OFF PART REPRESENTATIONS

REPETITIVE NATURE OF THE WORK

MANAGEMENT OF TECHNICAL NEUTRALITY

ONGOING INTEGRATION OF COUNTERTRANSFERENCE DATA INTO THE INTERPRETIVE PROCESS

MAINTAINING THE FRAME OF TREATMENT

TRANSFERENCE ANALYSIS

THE INTERPRETIVE PROCESS: CLARIFICATION, CONFRONTATION, AND INTERPRETATION

COMPLICATIONS IN PROCEEDING FROM SURFACE TO DEPTH

FURTHER ELEMENTS IN THE PROCESS OF INTERPRETATION

THE ACTIVE ROLE OF THE THERAPIST

TECHNIQUES NOT UTILIZED IN TFP

TACTIC 1: ESTABLISHING THE TREATMENT CONTRACT

TACTIC 2: CHOOSING AND PURSUING THE PRIORITY THEME

TACTIC 3: MAINTAINING A BALANCE BETWEEN EXPANDING THE INCOMPATIBLE VIEWS OF REALITY BETWEEN PATIENT AND THERAPIST AND ESTABLISHING COMMON ELEMENTS OF SHARED REALITY

TACTIC 4: REGULATING THE INTENSITY OF AFFECTIVE INVOLVEMENT

More subtle forms of acting out between sessions.

THERAPIST FLEXIBILITY IN USING THE TACTICS

CLINICAL ASSESSMENT

TREATMENT INDICATIONS

COMBINATIONS OF TFP AND OTHER INTERVENTIONS

THE PROCESS OF NEGOTIATING THE CONTRACT

PATIENT RESPONSIBILITIES

THERAPIST RESPONSIBILITIES

THE THERAPIST-PATIENT DIALOGUE IN THE CONTRACT PROCESS

INDIVIDUALIZED ASPECTS OF TREATMENT CONTRACTING

COMMON THERAPIST PROBLEMS IN CONTRACT SETTING

SHIFTING FROM THE CONTRACT TO THERAPY AND RETURNING TO CONTRACTING ISSUES

CAPACITY TO MAINTAIN THE RELATIONSHIP WITH THE THERAPIST

BRINGING IMPULSIVE AND SELF-DESTRUCTIVE BEHAVIOR UNDER CONTROL

AFFECT STORMS AND THEIR TRANSFORMATION INTO DOMINANT OBJECT RELATIONS

LIFE OUTSIDE THE THERAPY HOURS

CLINICAL ILLUSTRATION OF AN EARLY SESSION

DEEPENING UNDERSTANDING OF THE MAJOR TRANSFERENCE PATTERNS

DEEPENING THE UNDERSTANDING OF SPLITTING AND STRIVING TOWARD INTEGRATION

AGGRESSIVE INFILTRATION OF SEXUAL BEHAVIOR

EXPANDING THE FOCUS OF THERAPY IN THE MIDPHASE

TERMINATION

TIMING OF TREATMENT TERMINATION

TYPICAL TREATMENT COMPLICATIONS

MANAGING SUICIDE THREATS AND ATTEMPTS DURING TREATMENT

THREATENED AGGRESSION AND INTRUSIONS

THREATS OF DISCONTINUING TREATMENT

NONCOMPLIANCE WITH ADJUNCTIVE TREATMENTS

TREATMENT OF PATIENTS WITH BORDERLINE PERSONALITY ORGANIZATION AND A HISTORY OF SEXUAL ABUSE

PSYCHOTIC EPISODES

DISSOCIATIVE REACTIONS

DEPRESSIVE EPISODE

EMERGENCY ROOM VISITS

HOSPITALIZATION

PATIENT TELEPHONE CALLS

THERAPIST’S ABSENCE AND COVERAGE MANAGEMENT

PATIENT’S SILENCE

SOMATIZATION Severe somatization, such

OUR WORKING MODEL OF BORDERLINE PATHOLOGY

HETEROGENEITY OF PATIENTS WITH BPD: TREATMENT-RELEVANT SUBGROUPS

PATIENT CHANGES IN TREATMENT

Change in reflective functioning and patients’ conception of the therapist.

PRINCIPLES OF TFP APPLIED IN OTHER SETTINGS

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