Supportive psychoanalytic psychotherapy for borderline patients: an empirical approach

The author describes a reformulation for research purposes of a supportive psychoanalytic therapy for patients with borderline personality disorder. The major influences on the thinking that led to the modification of prior formulations and the historical background of treatment manuals are described. Supportive treatment is contrasted with transference-focused psychotherapy and dialectic behavior therapy in the interest of creating a clear comparison that lends itself to empirical study.     

Strategies for Securing Commitment to Treatment from Individuals Diagnosed with Borderline Personality Disorder

Individuals diagnosed with borderline personality disorder (BPD) are notoriously difficult to engage in treatment. The purpose of this paper is to highlight therapeutic strategies that are likely to facilitate early alliance in therapy with individuals diagnosed with BPD. The seven strategies include, collaborative assessment, the use of contracts, motivational interviewing, linking treatment targets to client goals, commitment strategies, validation, and the use of metaphors. Clinical vignettes are presented to elucidate the concepts described and demonstrate their use in clinical practice.     

Psychoanalytic inpatient psychotherapy of depression – Two naturalistic samples throughout the course of a decade

Background: While the general effectiveness of psychodynamic inpatient psychotherapy has been established, very few studies have specifically investigated the effectiveness of psychodynamic inpatient treatment of depression, though depressed patients represent the largest group of inpatients.

Method : This study investigated two naturalistic samples of depressed patients regarding treatment outcome as well as clinical and treatment characteristics. Patients were treated in a psychoanalytical psychosomatic hospital unit. Data was collected from 2000 to 2002 (N=234) and from 2008 to 2010 (N=514). Data was acquired at admission and discharge.

Results: The findings reveal high pre-post effect sizes for symptom reduction (SCL-90-R), general functioning (GAF) and medium changes of interpersonal problems (IIP). The improvement on the IIP was significantly higher for patients with comorbid personality disorder. Based on therapist ratings, the sample treated from 2008-2010 showed higher levels of impairment on several levels: chronic, complex, functional (GAF) and structural (OPD).

Conclusion: Findings indicate that patients show substantial short-term benefit following psychoanalytic inpatient psychotherapy, as practiced under naturalistic conditions. Open questions remain regarding the long-term nature of these benefits and the possible influence of placebo-effects.     

对边缘性人格障碍亚型的研究

边缘性人格障碍是一种最常见的人格障碍。描述性精神病学、心理测验和精神分析的研究发现,边缘性人格障碍可能是由若干个异质性的亚群体组成,不同的亚群在症状表现、病因、心理病理机制、对治疗干预的反应和预后等方面可能都存在着很大的差异,可以根据不同的维度将其进行亚型分类,而使同一个亚群中的个体差异小于不同亚群之间的个体差异。     

Integrating Individual and Family Systems Psychotherapy to Treat Borderline Personality Disorder

This paper focuses on two areas. The first is the framework for psychotherapy integration used by Unified Therapy, a psychotherapy approach that is an integration of psychodynamic, cognitive–behavioral, and family systems therapy. The second is the use of this treatment paradigm in the psychotherapy of adults with borderline personality disorder. The theory posits that continuing and recurrent interpersonal behavior patterns within the patient's family of origin serve as behavioral triggers to typical acting-out behaviors. Therapy is geared toward planning strategies to alter these destructive patterns. A case example is presented to demonstrate the use of the therapy's theories and techniques.     

"Without being in psychoanalysis I would never have dared to become pregnant": psychoanalytical observations in a multidisciplinary study concerning a woman undergoing prenatal diagnostics

As is well known, Freud described the clinical practice of psychoanalysis as the 'loam' of his cultural-theoretical work, an assessment which is shared by many psychoanalysts up to the present, including the authors of this paper. The complex interplay between unconscious phantasies on the one hand, and the real experiences arising from the new possibilities opened up by prenatal diagnostics on the other, is described with reference to a report of an intensive, long psychoanalysis with an analysand from a family burdened with a genetically transmitted illness (haemophilia). The holding and containing function of the analyst enabled this analysand, despite traumatic experiences with the miscarriage of a healthy child triggered by a prenatal diagnosis and the later abortion of a haemophiliac baby, nevertheless to have the courage to go through another pregnancy and give birth to a healthy girl. The intensive clinical investigation of the unconscious phantasies, conflicts and traumas around the prenatal diagnostics proved to be not only therapeutically fruitful for the analysand, Ms F. It also facilitated insights into those individual chances and risks which appear to be an integral part of the opportunities presented by todays prenatal diagnostics and, through them, it lead to a cultural-critical look at the ambivalence of medical-technical progress. These insights, which are only attainable through psychoanalysis, can represent a distinctive contribution of psychoanalysis to a multi-disciplinary dialogue with medical practitioners, geneticists, ethicists and health policy-makers. By referring to a large EU study on 'Ethical Dilemmas due to Prenatal and Genetic Diagnostics', this paper gives a practical example of such a discussion. Ms F. was psychoanalytically interviewed as part of this study, 16 years after the conclusion of her analysis. The summary of these interviews, which is set against the account of the treatment, offers an impressive insight not only into the long-term effects of a psychoanalysis under very particular personal circumstances, but also into the lasting consequences of decisions made in the context of prenatal diagnostics. Finally, the results of the individual case study are brought together with the clinical outcomes of the EU study, and some considerations are formulated concerning the protective and risk factors facing women during and after prenatal diagnostics. The paper is an appeal to psychoanalysts, with their specific competence in dealing with unconscious phantasies and conflicts and their high level of professionalism in dealing with traumatised patients, to get involved in fresh dialogue with prenatal diagnosticians and their patients.     

Lines of Advance in Treating People of Color with Borderline Personality Disorder: Alloying the “gold” of Vocational Rehabilitation with the “Copper” of Psychodynamic Psychotherapy

People of color with borderline personality disorder (PoCwBPD), in particular African-Americans and Latinxs in the inner city, present a special population at risk for unemployment and long-term impairment in psychiatric and psychosocial recovery. A growing literature points to the need for comprehensive care that addresses the symptoms of the borderline syndrome alongside social, vocational, and educational achievement. This article paints a picture of the individual, communal, and systemic complexities involved in aiding PoCwBPD achieve psychosocial recovery. After contextualizing the historical and systemic forces that impact recovery for PoCwBPD, I discuss principles of intervention to assist clinicians tailor treatment to this population. Drawing on insights from Transference-Focused Psychotherapy, an evidence-based psychodynamic therapy for BPD, I offer a theoretical cultural adaptation for people of color. This article provides clinical vignettes to illustrate the resulting model, and shows that helping the patient engage in productive activity provides the foundation for exploratory work, which in turn addresses intrapsychic obstacles to psychosocial success.     

克恩伯格边缘性人格组织理论述评

边缘性人格组织是人格障碍的内在结构。克恩伯格主要从非特异性自我虚弱性、现实检验、原始防御机制、病理性的内在客体关系以及身份认同紊乱五个方面阐述了边缘性人格组织理论。该理论弥补了DSM-Ⅳ中人格障碍诊断标准的无理论化倾向的缺陷,并为深入理解人格障碍的心理病理学提供了一个系统框架。     

Self-esteem in patients with borderline and avoidant personality disorders

This study compared self-esteem in patients with avoidant personality disorder (APD) and borderline personality disorder (BPD). Patients diagnosed with one or more personality disorders answered the questionnaire Index of Self Esteem as part of a comprehensive evaluation within the setting of a treatment trial. Our hypotheses were that (1) both patients with APD and patients with BPD would report low levels of self-esteem, (2) patients with APD would report lower self-esteem than patients with BPD. We further expected that (3) patients with higher levels of depression would report lower levels of self-esteem, but that (4) both borderline and avoidant personality pathology would contribute to explained variance in self-esteem beyond what would be accounted for by depression. All of our hypotheses were supported. The results from our study showed a significant difference in self-esteem level between the two personality disorders, patients with APD reporting lower self-esteem than patients with BPD. Subjects with both disorders were measured to have self-esteem levels within the range that presumes clinical problems. Self-esteem represents an important quality of subjective experience of the self, and the study of self-esteem in PDs can offer new and important knowledge of PDs as self-pathology.     

Borderline personality disorder and laboratory-induced cold pressor pain: Evidence of stress-induced analgesia

Behavioral neuroscience findings regarding stress-induced analgesia may be an appropriate model for the paradoxical effects of self-mutilative pain of patients with borderline personality disorder (BPD). We hypothesized that BPD patients would show an exaggerated antinociceptive effect from an uncontrollable cold pressor stress, compared to persons with other personality disorders or to a nonpsychiatric control group. This hypothesis was supported. Limitations of the study and directions for future research are discussed.     

Freedom and Borderline Experience

In–depth interviews with 52 diverse informants about their experience of freedom reveal a devaluation of freedom relative to money and power. The way in which many of these informants conceptualize freedom has a borderline quality to it—a term that refers to borderline personality disorder, but which is conceptualized here as a cultural construct similar to that of the culture of narcissism, as Christopher Lasch called it. The conclusion speculates about why informants see the world in this way.     

From I: A/M to “Who am I?”—Aggregation/Massification and Trauma-Based Affects and Object Relations in Groups: A Response to Earl Hopper

Hopper's portrayal of the fourth basic assumption of Incohesion: Aggregation/Massification has two components: (1) a revision of Turquet's theory of BA Oneness to incorporate the polarity of aggregation and massification stemming from annihilation anxiety; and (2) a conception of the difficult patient as having an encapsulated psychosis. Hopper's theory of the encapsulated psychosis offers an important but incomplete perspective in explaining borderline and narcissistic pathology, as well as psychological trauma. In this response to Hopper, I suggest that the fourth assumption is in fact a still more primitive state of boundary opening and closing. I also see a need to differentiate trauma as such from borderline pathology, and further hold that the relationship between Hopper's British Independent theory and trauma theories based on dissociation needs to be clarified.     

Prevalence of personality disorders among bulimics,nonbulimic binge eaters,and normal controls

We examined the comorbidity of bulimia and personality pathology among college women. Subjects included women (n=23) meeting DSM-III-R criteria for bulimia nervosa (bulimics), women (n=23) who reported binge eating but did not fulfill the criteria for bulimia nervosa (binge eaters), and women (n=23) who did not binge eat (normals). The subjects completed an assessment battery consisting of the Personality Disorders Examination and the SCID as well as the Beck Depression Inventory, the Rosenberg Self-Esteem Index, and measures of impulsivity and self-defeating tendencies. Fourteen of 23 bulimics (61%) met criterion for a personality disorder using DSM-III-R Axis II criteria. In comparison, 3 of 23 (13%) binge eaters and 1 of 23 (4%) normal subjects received an Axis II diagnosis. Borderline and self-defeating diagnoses were the predominant personality disorders in 96% of the bulimics exhibiting clinically significant personality pathology. Bulimics also exhibited significantly more depression, impulsivity, and self-defeating behavior and lower self-esteem than binge eaters and normals. The findings are discussed within a conceptual framework that posits an interaction between personality pathology and restrained eating.     

DSM-IV criteria for borderline personality disorder: A critical evaluation

The present article critically examines the diagnostic criteria for borderline personality disorder (BPD) recently proposed by the DSM-IV Axis II work group (Gunderson, J. G., et al., Journal of Personality Disorders, 5, 340–352, 1991). It is concluded that some of the revisions are trivial and there is insufficient justification for others. The revisions are likely to increase the overlap between BPD and other disorders and represent an attempt to retain a categorical classification in the face of evidence that a dimensional model is more appropriate. Evidence suggests that many borderline traits are manifestations of extreme neuroticism.     

Treating the Lesbian Batterer

Summary

The phenomenon of lesbian battering challenges mainstream assumptions about battering and defies traditional ways of defining and understanding domestic violence. This article identifies and illuminates variables critical to understanding and treating lesbian batterers. In particular, intrapsychic factors in the treatment of lesbian batterers are considered via an integration of the theoretical constructs of personality development with attachment theory, state and affect regulation, shame, pathological vindictiveness, and variables specific to lesbian domestic violence. Finally, two case examples and treatment considerations are discussed.     

Cognitive-Behavioral Treatment of Depression with Comorbid Borderline Personality Traits

Personality dysfunction can influence the onset and maintenance of depressive symptoms. When both depression and personality dysfunction are present, it is important to develop an integrated treatment plan that addresses both conditions. A case example is used to illustrate how features of borderline personality disorder can influence the assessment and treatment of major depression. Specific challenges encountered by the therapist include: 1) differentiating borderline personality from depressive symptoms, 2) maintaining the therapeutic alliance, 3) managing impulsivity and self-destructive tendencies, 4) staying focused on long-term therapeutic goals, and 5) coping with noncompliance. Over the course of 27 sessions, the client was able to make positive changes in mood, self-image, and impulsive tendencies. Although the client's borderline personality traits complicated the course of treatment for depression, neglecting these personality problems would have left the client vulnerable to depressive relapse.