Drs. Gunderson and Wheelis Reply

To the Editor: The letter from Linda S. Godleski, M.D., addresses issues related to working with Ms. A’s mother indirectly.

Dr. Godleski suggests that the therapist should have been more resistant to Ms. A’s wish to terminate their relationship, more active in helping her tolerate her fear of losing her mother, and more concerned with the prospect of Ms. A’s self-destructive responses. As Ms. A struggled with her conflict of being connected with her mother and her therapist, much effort went into helping her recognize that she could and would benefit by trying to resolve her dilemma in therapy without having to sacrifice one for the other. She was frightened by the thought of her mother dying and could not, in that context, bear her newfound and valued experience of separation from her mother. Ms. A could not keep her conflict on a symbolic level, and she felt she must choose literally. In fact, we worried that we may have erred by attempting too vehemently to keep Ms. A in treatment. We hoped Ms. A could tolerate her struggles around her fear of loss (to accept her ambivalence about mother), but she could not comfortably do so within the transference. To be able to do this without acting out requires that a borderline patient have improved much more than Ms. A had. With respect to the “danger,” we felt confident that Ms. A would return to therapy if she became self-destructive again.

Often errors are made, we believe, in overestimating the ability of a borderline patient to successfully navigate his or her psychopathology in the realm of the symbolic. We think that behavioral and psychoeducational techniques are successful because concrete interventions may facilitate less regressive treatments as well as develop skills that permit later structural change.