This report describes an intensive psychodynamic psychotherapy that the author conducted with a patient with borderline personality disorder named “Ellen.” Dr. Bateman, one of the founders of mentalization-based treatment
(1), and Dr. Kernberg, the founder of transference-based psychotherapy
(2), comment on the treatment, emphasizing the overlapping and distinctive aspects of the two forms of therapy. Each was asked to comment independently and then asked again to offer additional comments on issues that the other had brought up. As such, Ellen’s case illustrates alternative perspectives about psychotherapy with patients with borderline personality disorder.
This report offers vignettes derived from six time points in Ellen’s therapy: the time of referral, 3 months later, 11 months later, 4 years later (when the therapy effectively ended), and from follow-up at year 7.
Discussion
Ellen’s overall course of change reflected a generic sequence of what can be expected from long-term treatments: first alleviation of subjective distress, then behavioral change, then improved interpersonal relationships, and finally intrapsychic changes. Ellen was recurrently depressed for much of the first year, with gradual lessening of its severity. She did achieve behavioral change, but the most prototypic behavioral pathology, cutting, had ceased years before she began with me, a product, I think, of Dr. A’s support and of her aging. Six months after starting therapy, she had begun to work part-time; achieving stable community-based supports and vocational activity should be expected in the first year. She also had begun to depend on me as someone who she knew cared about her and was reliably attentive to her best interests without her expecting me to be a rescuer. Achieving a positive dependency is a nonspecific corrective attachment experience. The unexpectedly frequent remissions of borderline personality disorder observed in longitudinal studies
(7,
8) is a testimonial that this can be achieved—and usually is—with people other than therapists.
The most fundamental disagreements about techniques between the two discussants involved the importance assigned to interpretations in transference-based psychotherapy and to supportive interventions in mentalization-based treatment. This disagreement in turn was related to differences in how transference-based psychotherapy and mentalization-based treatment conceptualized borderline personality disorder psychopathology, and most specifically, the patient’s problems with anger. Transference-based psychotherapy sees unacknowledged or unintegrated anger as the core problem. The focus is on integrating this anger and the derivative hostile/punitive or helpless/victim part objects into a whole and stable self. To not do this, Dr. Kernberg suggests, perpetuates an identification as a victim. My inconsistent focus on anger accompanied by my readiness to be supportive was the reason why Dr. Kernberg felt the therapy was incomplete and that a return for a transference-based psychotherapy might still be in Ellen’s interest.
The mentalization-based treatment model considers anger a mental state that a therapist will identify to help the otherwise unknowing patients with borderline personality disorder label their experience and to help them learn about its role in causing behaviors, etc. But the mentalization-based treatment therapist would be wary of interpreting anger, especially in the therapy relationship (what transference-based psychotherapy would call transference), because even if accurate, such interpretations, unless “robust mentalizing” capacities are available, destabilize borderline patients rather than aid self-integration. Mentalization-based treatment would focus on the patient’s current mental state and mental functioning. By giving it attention and thereby underscoring the importance of these mental states while assuming a “not knowing” inquisitive stance, mentalization-based treatment therapists help patients become more introspective (“reflective”) and develop more of a sense of self and self-agency. Insight per se is eschewed. It seems notable that although both therapies aim to establish a more coherent and stable sense of self, their theories and techniques about how therapy facilitates this are radically different. To my mind, Ellen’s more stable sense of self and her improved ability to mentalize that allowed her to process the loss of her romantic partner were partly the result of a corrective relationship that made her become more accepting of herself and partly a result of my interpretations, although their traction depended upon the use of supportive interventions.
Ellen’s commitment to finding a love relationship at the expense of finding a vocation is not unusual for many people with borderline personality disorder. Although this led me to suggest she give primacy to work, neither of the consultants agreed with this. Ellen’s subsequent decision to give up on her hope for “love” is not an unusual adaptation for aging people with borderline personality disorder; usually this occurs in the 30s after concluding that such hopes have only brought heartache. For many, love gets replaced by broad and nonintensive sources of support that can come from churches, organizations, communal living, etc. Ellen will, I think, always be somewhat bitter and alone. If Ellen seeks psychiatric help, I think it will probably be resuming medications and not psychotherapy. Her life truly was unfair.
Beyond the interesting contrasts between mentalization-based therapy, transference-based psychotherapy, and my own perspectives, these alternatives all recognize that to be effective with patients with borderline personality disorder requires extensive modifications from the technical neutrality and lack of structure that characterize traditional psychoanalytic therapy. Much of the extensive early literature on psychoanalytic treatments for borderline personality disorder provides lessons in how inadequate structure, hostile or rescuing countertransferences, and a failure to be an active participant in here-and-now interactions led to rages, suicidal threats or gestures, therapeutic regressions, noncompliance, excessive intersession demands, and frequent dropouts. Patients such as Ellen should now be able to expect that the current generation of psychodynamic therapists will have learned these lessons.