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An Overview of

With Borderline Patients

GLEN 0. GABBARD, M.D.

Successful management of countertransfer- I feel used, manipulated, abused, and at the same time I feel responsible for her ence is critical to the of border- feelings of rejection and threats of sui- line patients. The author discusses the most cide, or feel made to feel responsible for common countertransference reactions en- them because I don’t have time for her countered in such treatments. A theoretical and don’t choose to be/cannot be always framework is also proposed that conceptual- available as a good object, nor as a stand- by part object. izes countertransference as a joint creation be- She has hooked me into thinking tween therapist and patient. It follows from love and friendship will heal her, as if this conceptual framework that therapists there were nothing wrong with her but must constantly monitor their own contribu- rather it was all of the people in her life tions from past relationships as well as the who were the problem. Then I come up with fatherly friendship, and her control aspects of countertransference evoked by the begins. She tells me, in different ways, patient’s behavwr. Countertransference in that I am different from the others. And the psychotherapy of borderline patients must just when I’m basking in “good objectiv- be viewed as a source of valuable diagnostic ity,” she really begins to control me by and therapeutic information and not simply telling me that I’m just like the rest, that I don’t care: “I see you looking at your as interference with the therapeutic process. watch. I know you want to leave. I know you have a life out there. It will be a long night. You don’t care. Nobody cares.”

A s this quotation from a borderline pa- tient’s therapist vividly conveys, patients suffering from borderline disor- der tend to overwhelm the clinicians who treat them. A comprehensive treatment pro- gram for such patients often includes individ- ual psychotherapy or , adjunctive pharmacotherapy with any one of a number of agents, brief or extended hospi-

Received April 1, 1992; revised May 14, 1992; accepted May 15, 1992. From The Menninger Clinic and the Kansas University School of , Topeka, Kansas. Address reprint requests to Dr. Gabbard, The Menninger Clinic, P.O. Box 829, Topeka, KS 66601-0829. Copyright © 1993 American Psychiatric Press, Inc.

JOURNAL OF PSHOTHERAPY PRACTICE AND RESEARCH 8 COUNTERTRANSFERENCE AND BORDERLINE PATIENTS

talization, family or marital , and therapists suffer for them.5 They seem to de- . Regardless of the spe- mand that the therapist abandon the profes- cific form of treatment, however, counter- sional therapeutic role: anyone who attempts can be a major impediment to to treat them must share in their misery. successful therapeutic efforts.’ The treater’s Searles6 has cautioned that the traditional emotional reactions to the patient sweep analytic posture of evenly suspended atten- through the course of treatment like a tem- tion is neither viable nor appropriate in the pest with the potential to create havoc for psychotherapy of borderline patients. Thera- both patient and therapist. Although the pists who attempt to assume a detached, “ob- skillful management of countertransference jective” role vis-#{224}-visthe borderline patient is only one aspect of an overall treatment are at risk of projectively disavowing their own approach to borderline , conflicts and and using the patient it constitutes the foundation of the treatment as a container to receive them. The classical on which all other efforts will rise or fall. notion of the therapist as “blank screen” is The primitive defenses of borderline pa- simply not applicable to the psychotherapy of tients, particularly and projective borderline patients. identification, produce a kaleidoscopic array of and chaotic in the S i E C I F I C therapeutic setting. As these varying configu- COUNTERTRANSFERENCE rations of - and object-representations pa- R E A C T 1 0 N S rade before the therapist, they are further complicated by accompanying affective states Controversy over the diagnosis of borderline that are unusually intense and raw, often in- personality disorder persists despite the in- ducing in therapists a feeling that they are troduction of this category into DSM-III 12 trapped in a life-and-death struggle.2 Some years ago. The first systematic empirical study clinicians have even suggested that counter- of the disorder by Grinker et al.7 suggested transference reactions may be the most reli- that borderline personality disorder is a spec- able guide to making the diagnosis of bor- trum that ranges from the psychotic to the derline personality disorder.3 These patients neurotic. Kernberg8’9 argued that the border- make us “come alive” in a specific way that line is really a personality organiza- heightens our awareness much like the expe- tion rather than a specific nosological entity. rience of driving over a mountain pass on a A variety of different personality disorders, narrow two-lane road without a guard rail. including paranoid, antisocial, schizoid, in- Because they are so sensitive to the therapist’s fantile, narcissistic, and cyclothymic, all could choice of words and nonverbal nuances, they be subsumed under the overarching ego or- are able to evoke a sense of walking on egg- ganization. shells, as if our margin of error were very Gunderson,’#{176} on the other hand, sought narrow indeed. Yet, in spite of this untoward to identify discriminating criteria that would impact, they somehow become “special” to distinguish borderline personality disorder their therapists4 and inspire a surprising op- from other related Axis II conditions. Abend timism despite a host of pessimistic prognos- et al.” raised serious questions about tic signs.3 Therapeutic zeal rises like a Kernberg’s diagnostic of bor- phoenix from the ashes of previous failures. derline patients by documenting the success- Borderline patients seem to have the pe- ful psychoanalytic treatment of such patients culiar ability to inflict a specific form of “sweet with classic psychoanalytic technique based suffering” on their therapists. They them- on traditional conflict . Adler’2 pre- have suffered throughout their lives, sented yet another point of view. He pro- and it is important to them to have their posed that borderline patients could best be

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understood as suffering from a deficit-based describing aspects of the psychothera- condition rather than intrapsychic conflict. peutic process, attempts to hold rigidly Specifically, this condition involved the ab- to a dichotomous view that prescribes a given form of therapeutic modality to sence of a holding-soothing introject that specific diagnostic entities is neither the- could sustain them emotionally in the ab- oretically sustainable nor clinically prac- sence of their psychotherapists. Other clini- tical. .. . the therapist needs to maintain cians influenced by ’3’4 a position of flexibility and adaptability, maintained that borderline symptomatology allowing the selection of available tech- results from breakdowns in the empathic re- niques from the range of psychothera- latedness between therapist and patient and peutic interventions to deal with the should therefore be reconceptualized as an problems presented. (p. 121) entity that is definable only in the context of a relationship. The concept of a spectrum is important This controversy about diagnosis is mir- because, in discussions of countertransfer- rored in a corresponding controversy regard- ence, one must keep in that the ing the optimal treatment. Many (though not therapist’s reactions may vary considerably all) of the differences of opinion can be ac- depending upon where on this continuum a commodated by embracing Meissner’s’5 no- particular patient stands. ob- tion that the borderline diagnosis is serves: “Countertransference in relation to essentially a spectrum of conditions that are borderline conditions is therefore not an psychodynamically related. At the high end univocal phenomenon but rather involves a of the spectrum are patients who have nota- spectrum of levels and intensities of transfer- ble ego strengths and can undergo psychoan- ence/countertransference interactions that alytic treatment with little modification. At can vary considerably in both quality and the low end of the spectrum are patients who quantity” (p. 211). With this caveat in mind, are prone to psychotic disorganization be- I will consider several common countertrans- cause of prominent ego weaknesses and who ference reactions to borderline patients. require more supportive approaches. From a clinical perspective, however, the Guilt Feelings spectrum must be regarded as a metaphorical construct. Borderline patients are known for Borderline patients have an wide fluctuations in their clinical presenta- ability to tune in to the therapist’s vulnerabil- tion. One can see normal, neurotic, and psy- ities and exploit them in a manner that in- chotic transferences in the same patient in duces feelings of guilt. A common the course of one therapeutic hour.’6 A cor- development is that a patient will behave in ollary of this observation is that therapists such a way as to infuriate and exasperate the must assume a flexible approach to the psy- therapist. At the very moment when the ther- chotherapy, wherein their interventions shift apist is wishing the patient would disappear, to and fro along the expressive-supportive the patient may accuse the therapist of not continuum according to the patient’s needs caring and of disliking the patient. Such ac- at a particular moment. Meissner’5 shares this cusations may create feelings in therapists point of view and has offered the following that they have been “found out.” Under such observation: conditions therapists may reproach them- selves for their of professionalism and

My own view is that, while the theoretical attempt to make amends to their patients by discrimination between supportive and professing undying devotion. The patient’s expressive modalities has a certain utility accusatory charges may strike to the very mar- from the point of view of articulating and row of the therapist’s professional

JOURNAL OF PSHOTHERAPY PRACTICE AND RESEARCH 10 COUNTERTRANSFERENCE AND BORDERLINE PATIENTS

and create a form of “physiological counter- The origins of this proneness to primitive transference”4 that involves manifestations of expressions of aggression may be constitu- sympathetic discharge, such as a pounding tional9 or secondary to trauma,2#{176}but the end heart, a dry mouth, and trembling limbs. result is that therapists often feel threatened Another common scenario is that the or intimidated by the patient’s volatility and therapist begins to feel responsible for appar- potential to explode. ent clinical deterioration in the course of To ward off the patient’s anger, the ther- psychotherapy. Many borderline patients ap- apist may extend the session, engage in self- pear relatively intact at the beginning of treat- disclosure, defer payment or not charge any ment and seem to unravel as therapy fee whatsoever, or engage in physical or sex- progresses. Searles6 has suggested that such ual behavior with the patient. In some cases, guilt feelings by therapists may be related to this violation of professional boundaries is unconscious with the patient’s child rationalized because of the perception of the self-representation, who felt guilty about driv- patient as a victim who is entitled to compen- ing a parental figure to the point of madness. sation in the form of extraordinary measures He has noted also that some therapists will because of the suffering he or she has en- feel guilty that the patient’s more psychotic dured. Suicide threats may also lead thera- aspects provide greater fascination than the pists to justify various boundary healthier or more neurotic areas of the ego. transgressions, often with the claim that if they had not deviated from their usual prac- Rescue Fantasies tices, the patient would have committed sui-

17 Intimately related to guilt feelings are the Still another source of boundary trans- evocation of rescue fantasies in the therapist. gressions relates to the issue of abandon- This aspect of the countertransference in- ment. Many borderline patients feel that they volves more than simply therapeutic zeal. It are always on the verge of being abandoned also reflects a perception that the patient is by significant sources of nurturance and sup- essentially helpless. Therapists often feel that port, typically their parents, lovers, or thera- they must do things for the patient. Border- pists.2122 Some patients interpret any line patients often present themselves as communication from the therapist-except Dickensian orphaned waifs4 who need the unconditional love-as having an implicit therapist to serve as a “good” mother or fa- threat of rejection.’2 These patients’ de- ther to make up for the “bad” or absent mands for reassurance that one really cares parent responsible for victimizing the child. and is not simply a prostitute who receives a fee in return for time and attention may lead Transgressions of therapists to go to extraordinary lengths to Professional Boundaries demonstrate their sincere concern. Because these demands may escalate to late-night The third form of specific countertrans- phone calls, a rendezvous outside the ther- ference reaction follows naturally from the apy, and sexual liaisons, therapists who treat first two. Borderline patients are notorious borderline patients have an ethical as well as for evoking deviations from the therapeutic a clinical need to understand countertrans- frame that lead to ill-advised boundary cross- ference pitfalls thoroughly.23 ing.’7’9 These patients may feel a specific form of resulting in demands to Rage and Hatred be treated as exceptions to the usual proce- dures. They are known to have a “short fuse” A common phenomenon in the psycho- that leads to frequent expressions of rage. therapy of borderline patients is their alley-

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ating tension by evacuating or “dumping” primitive level, the borderline patient’s con- feelings into the therapist’: what Rosenfeld24 fusion about boundaries may lead therapists has termed a “lavoratoric transference.” to feel a primal terror related to the concern Whereas neurotic patients tend to project that they will be swallowed up by their patient superego constellations into the therapist, and annihilated. In psychotic transferences, borderline patients project the “sick” or patients may misidentify feelings belonging “bad” self in a primitive split-off form.9’25’26 to them as residing in the therapist instead. Volkan26 has described the feeling of being A feeling of merger or fusion may be ex- “choked” by the externalization of such prim- tremely unsettling to the therapist in such itive and negatively charged affects and intro- situations. A common response is to distance jects. One can hardly avoid feeling rage, oneself from the patient and become aloof.27 hatred, and resentment when being used in The that the patient will commit this way by the patient. Being held hostage to suicide is ever present in many treatment suicide threats or driven to distraction by processes, and the sense of guilt and respon- late-night phone calls and unceasing de- sibility induced by the borderline patient mands for extraordinary treatment can also amplifies such worries. The previously men- lead to profound feelings of seething resent- tioned concern that one will say the wrong ment. thing and cause the patient to explode, frag- ment, or abruptly walk out of the office also Helplessness and Worthlessness creates countertransference anxiety. Finally, an overriding anxiety that runs throughout Borderline patients tend to devalue their the treatment arises from the feeling that therapists’ efforts.’2 Also, when their de- therapists often have that they are simply not mands are frustrated rather than gratified, up to the clinical task or are failing in their these patients can shift from idealizing to efforts. contemptuous transferences in the twinkling of an eye. They tend to indulge in pars pro toto THE OF thinking in which one becomes “all bad” for COUNTERTRANSFERENCES even a minor transgression. The result is that therapists often feel unskilled, incompetent, As the concept of countertransference has and helpless to do anything about it. This moved to center stage in contemporary psy- form of countertransference is further en- choanalytic discourse, it has undergone a hanced by the expertise of borderline pa- transformation in meaning. Countertransfer- tients at identifying vulnerable areas and ence as a disruptive obstacle has been re- exploiting that awareness by constantly point- placed by a view of countertransference as a ing out weaknesses to the therapist. Defen- valuable, if not essential, source of under- siveness and withdrawal are often overt standing. Accompanying this shift is height- postures of the therapist in the throes of such ened interest in how the patient-therapist devaluing attacks, but underneath the sur- relationship serves as a forum for re- face the feelings of helplessness and incom- enactments of past experiences. The archae- petence are prominent. ological search for the buried past has been replaced by careful attention to the moment- Anxiety and Terror by-moment reverberations between therapist and patient.28 Regardless of what else is going on in the ’s original definition of counter- treatment, borderline patients almost always transference was narrowly focused on the make the therapist anxious. The sources of analyst’s transference to the patient. In other this anxiety are many and varied. At the most words, countertransference involved feelings

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that belonged to the analyst’s past but were pouring of interest in the Kleinian concept of displaced onto the patient in the same way projective identification.”6’9’25’3 Although that the patient displaced feelings from the the original concept as used by Klein in- past onto the analyst. This view conceptual- volved an intrapsychic rather than an ized countertransference as an interference interpersonal coercion, the modern usage or obstacle that needed to be removed by has focused to a great extent on changes in rigorous of the analyst. the recipient of the patient’s projective iden- Paula Heimann3#{176} altered the landscape tification. Whereas the concept remains of psychoanalytic thinking. In her view, coun- highly controversial, there is a general con- tertransference needed to be construed in a sensus that the split-off self-representation, much broader form as all the feelings that the object-representation, or affect that the pa- analyst experiences toward the patient. Im- tient projects into the therapist produces plicit in Heimann’s understanding of coun- changes in the therapist to conform to the tertransference was the notion that some of nature of that projection. These changes are the feelings the analyst experiences are in- effected largely through powerfully coercive duced by the patient’s behavior. interpersonal pressure exerted by the pa- Racker3’ divided such patient-induced tient. Projective identification, as one of the reactions into concordant and complemen- central defense mechanisms used by border- tary countertransferences. Concordant line patients, takes on crucial importance for countertransferences are those involving an this discussion, and I will elaborate on it empathic link between therapist and patient below. (i.e., the therapist identifies with the patient’s One implication of this shift in thinking subjective affective state or self-representa- about countertransference is that the tions). Complementary countertransfer- analyst’s response to the patient provides a ences involve identifications with an internal great deal of information about the patient’s object-representation of the patient that has internal object world. Moreover, counter- been projectively disavowed and attributed to transference entails first serving as a con- the therapist. Racker viewed this complemen- tainer to receive projected aspects of the tary reaction as an instance in which the patient and then studying the contents of analyst’s own conflicts were activated by the those projections. Sandler45 suggested that patient’s projections. Grinberg32 took this no- the analyst’s free-floating attention must be tion one step further with the concept of supplemented by a free-floating responsive- projective coun teridentification, in which ness involving a form of that the analyst introjects a reaction, feeling, or determines what complementary role is object-representation that comes entirely being coerced by the patient’s words and from the patient. behavior. Winnicott,33 in his classic paper on coun- This influence from the British school of tertransference hate, spoke of an “objective” has traveled across the form of countertransference in which the Atlantic and has had a significant impact on analyst reacted to the patient in a specific the classical or ego-psychological school, cre- manner evoked by the patient that was con- ating considerable interest in such sistent across all people who interacted with as interaction and enactment.4#{176} In a recent the patient. According to this , certain overview of countertransference and tech- patients might consistently induce feelings of nique, Abend5’ acknowledged that the no- hate in other people that reflect more about tion originating with Klein that the analyst’s the patient than about the analyst’s or other countertransference can be a crucial source person’s past. of understanding the patient’s inner world This shift in thinking led to an out- has now become universally accepted. As part

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of this , the self-analytic activities and patient vary according to the severity of of the analyst have come to be regarded as a the psychopathology. In general, projective systematic effort at collecting data about identification or “objective” countertransfer- one’s analysand. The analyst must be partic- ences occur with sicker patients, such as those ularly attuned to subtle or not-so-subtle forms suffering from borderline personality disor- of “,” whereby the patient’s internal der, whereas the narrow or “subjective” coun- object relationships are enacted in the clini- tertransferences are more prominent with cal setting between patient and analyst. In healthier or neurotic patients. Although speaking of enactments, Chused notes: many coun tertransference reactions with borderline patients are overwhelming in An analyst reacts to his patient-but intensity, we must not neglect more elusive catches himself in the act, so to speak, forms of enactment that also occur through- regains his analytic stance, and in observ- out the spectrum of psychopathology. ing himself and the patient, increases his Jacobs49 has pointed out that even aspects of understanding of the unconscious fanta- the standard analytic or therapeutic posture, sies and conflicts in the patient and - such as neutrality or silence, can become self which have prompted him to action. involved in subtle enactments that are uncon- (p. 616) sciously determined by issues in both patient and therapist. Borderline patients, in particular, evoke This modernization of the concept of enactments through the sheer power of the countertransference has led some to believe affect and the primitive self- and object-rep- that the term has been so greatly expanded resentations that are projected into the ther- as to lose its specificity. Natterson,53 for ex- apist. However, it would be erroneous to ample, makes a differentiation between assume that all of a therapist’s countertrans- countertransference and the therapist’s own ference reactions are simply aspects of the subjectivity. He prefers the language of inter- patient. In my view, countertransference subjectivity because the therapist initiates as must be thought of as a joint creation, in well as reacts. It is my view, however, that in which both the therapist’s past conflicts and actual practice the interactions between ther- the patient’s projected aspects create specific apist and patient are so inextricably bound up patterns of interaction within the therapeutic with one another that what is initiative and process. Indeed, a central feature of the what is reactive may be next to impossible to therapist’s role with such patients is to engage dissect. in an introspective process that attempts to Meissner’5 has also argued for a narrower differentiate one’s own contributions from or more limited definition of countertrans- those of the patient.2’M Bollas52 notes: “In ference. In his view, not all reactions that the order to find the patient we must look for him therapist experiences toward the patient within ourselves. This process inevitably should be construed as countertransference. points to the fact that there are ‘two patients’ He proposed that only the analyst’s transfer- within the session and therefore two comple- ence to the patient and the analyst’s reaction mentary sources of free ” (p. 202). to the role assigned by the patient should be The therapist, then, must maintain both an regarded as countertransference. In this con- intrapsychic focus and an interpersonal focus ceptualization, reactions that involve the in an effort to sort out what is going on within therapeutic alliance and the “real” relation- the patient and bear it within himself.47 ship (outside of technique) between thera- If one accepts the premise that counter- pist and patient are not necessarily transference is ajoint creation, it also follows countertransferential. Again, this distinction that the relative contributions of therapist may be extremely difficult to tease out in the

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heat of the affective storms generated by bor- to a reintrojection of them by the derline patients in psychotherapy. patient in modified form. The conceptualization of countertrans- ference that I have been advocating here Ogden also stressed that the projector feels a places great responsibility on therapists to see sense of oneness or union with the recipient themselves as both clinicians and “patients” of the projection. whose own issues enter into the therapeutic This model transcends the simple pur- arena.6’25’52’53 Self-analysis, then, is of para- pose of defense. As Scharff42 has eloquently mount importance in effectively managing summarized, four distinct purposes can be countertransference. Indeed, Bollas54 o b- delineated for projective identification: served, “My view. . . is that contemplation of the countertransference is a systematic rein- 1) Defense: to distance oneself from the tegration into the psychoanalytical move- unwanted part or to keep it alive in some- ment of an exiled function: that of one else, 2) Communication: to make self-analysis” (p. 339). oneself understood by pressing the re- cipient to experience a set of feelings like one’s own, 3) Object-relatedness: to in- T H E R 0 L E 0 F teract with a recipient separate enough P R 0 J E C T I V E to receive the projection yet undifferen- IDENTIFICATION tiated enough to allow some mispercep- tion to occur to foster the sense of In light of the central importance of projec- oneness, and 4) Pathway for psychologi- tive identification in the psychotherapy of cal change: to be transformed by borderline patients and in the conceptualiza- reintrojecting the projection after its tion of countertransference as I have defined modification by the recipient, as occurs it, a more careful consideration may be help- in the mother-infant relationship, in ful in clarifying my use of this term. Despite marriage, or the patient-therapist rela- the controversy over confusing usages of the tionship. (p. 29) term, I view the concept of projective identi- fication as essential for understanding the This model of projective identification car- transference-countertransference develop- ries with it a spirit of therapeutic optimism. If ments in the psychotherapy of patients with therapists can bear the projections of their borderline personality disorder. patients, they offer the of helping pa- To begin with, projective identification tients transform their internal world through should be regarded as more than simply a containment and modification of those pro- defense mechanism of borderline patients. jections and affects in the crucible of the OgdenTM has defined it as a three-step proce- therapist’s countertransference. dure in which the following events occur: Some critics of this model37’4’ have ob- jected, arguing that Ogden38 has broadened 1.An aspect of the self is projectively dis- the definition beyond Klein’s original intent avowed by unconsciously placing it in by including the third step involving someone else. reintrojection. Kernberg8 preferred to re- 2. The projector exerts interpersonal gard projective identification as a primitive pressure that coerces the other person defense mechanism involving projecting in- to experience or unconsciously identify tolerable aspects of the self, maintaining em- with what has been projected. pathy with the projected contents, 3. The recipient of the projection (in the attempting to control the object, and uncon- therapeutic situation) processes and sciously inducing the object to play the role contains the projected contents leading of what is projected in the actual interaction

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between the projector and the recipient. ment process. Boyer believed that an import- Sandler4’ also objected to extending the ant therapeutic element of projective identi- projective identification concept to include fication is the patient’s observation that the therapeutic actions of containment, de- neither therapist nor patient is destroyed by toxification, and modification as described by the projection and reintrojection of negative Ogden.TM However, Sandler’s45 notion of role affects. responsiveness is very much in keeping with Although Scharff42 shares the broadened the first two steps of Ogden’s concept and view of projective identification that I am with my view of countertransference as joint endorsing, she stresses that the patient and creation of patient and therapist. He said: therapist engage in a mutual process. More- over, she places greater emphasis on the in-

Very often the irrational response of the trojective identification component of the analyst, which his professional con- therapist who receives aspects of the patient. leads him to see entirely as a The therapist may respond in a concordant blind spot of his own, may sometimes be or complementary manner, according to usefully regarded as a compromise for- Racker’s3’ distinction, but Scharff also notes mation between his own tendencies and that introjective identification is determined his reflexive acceptance of the role which in part by the therapist’s own propensity to the patient is forcing on him. (p. 46) respond in an identificatory manner with what is projected by the patient. In other Of those who write about projective iden- words, some projections may represent a tification, most agree that control is a central “good fit,” whereas others may be experi- feature of the process. Patients may experi- enced as alien and discarded. Finally, Scharff ence the depositing of aspects of themselves observes that the reintrojective process by the in the therapist as forging a powerful link patient/projector may promote change if the between the two members of the dyad, giving containment by the therapist/recipient has them the illusion of influence over the ther- made slight modifications that can be ac- apist. Often the power of this control is cepted within the limits of the patient’s capac- recognized only after the therapist has re- ity to change. sponded in the specific manner that has been This can also be pathological, however, if unconsciously programmed by the patient’s the projection is returned in a completely projective identification. Therapists of bor- distorted form that does not modify the derline patients must accept that counter- patient’s anxiety or lead to psychological transference enactments are inevitable. By change. Certainly in nontherapeutic settings rigorously monitoring internal responses, the aspects that are projected are routinely therapists can at least regroup and process “crammed back down the patient’s throat” what has happened with the patient following rather than contained or modified, often such enactments. with considerably intensified affect. The ex- Boyer55 has also construed projective panded model of projective identification as- identification broadly in the manner of sumes a therapeutic context in which Ogden.TM In fact, he has written that the containment and modification are . (It patient’s reintrojection of what has been pro- should be noted that close friends, parents, jected into the therapist is a neglected aspect lovers, spouses, and the like may also be “ther- of the process. For example, when they proj- apeutic” in the way they contain what has ect hostility into their therapists, these pa- been projected into them even though a for- tients may benefit from the “detoxification” mal psychotherapy process is not involved.) of the affect and associated self- or object-rep- The joint-creation model of counter- resentation through the therapist’s contain- transference that I believe is most apposite

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for the psychotherapy of borderline patients jective identification, other theoretical mod- depends heavily on the expanded model of els have been used to explain the same clini- projective identification as described by cal phenomena. Porder4#{176} shares Ogden’sTM Ogden,TM Boyer,’ Scharff,42 and others. It is of view that projective identification is not sim- crucial importance, however, that therapists ply a defense mechanism. However, he ex- keep in mind the metaphorical nature of the plains it from a traditional ego-psychological exchange of mental contents. There is noth- perspective. Projective identification, in ing mystical about projective identification. Porder’s view, is an identification with the When patients coerce us into specific behav- aggressor that is a chronic repetition of an iors or feelings that correspond with what entrenched pattern of relatedness between they have projected into us, they have simply child and parent. The patient achieves active stimulated repressed or split-off aspects of mastery over a passively experienced trauma ourselvesjust as troops far from the front may by unconsciously casting the analyst in the be called into service when specific forms of role of the child while the patient assumes the battle need to be fought. We all possess myr- parental role. In Porder’s model the affect is iad self-representations that are integrated not projected into the analyst; it is simply into a more or less continuously experienced induced by the patient. sense of self. We all have sadists and murder- Adler and Rhine57 approached projective ers lurking in our depths as well as saints and identification from a self psychological per- heroes. Considerable is gained in con- spective. Kohut5#{176} stressed the need for the ceptualizing the psychotherapeutic process therapist to serve as a selfobject to the pa- as involving two patients rather than one, tient. In other words, therapists must allow understanding that the most bizarre aspect of themselves to be used by the patient for psy- the patient has some parallel counterpart in chological growth. The therapist’s selfobject ourselves.6 functions include allowing mirroring, ideal- ization, and twinship in the patient’s transfer- THE ROLE OF THEORY ences. Adler and Rhine described a case of a patient who insisted that her therapist func- Francis Bacon once said that even wrong the- tion as a selfobject by accepting her provoca- ories are better than chaos. My attention here tions and projections. They pointed out that to theory emphasizes that theoretical models the containing and modifying aspect of pro- are perhaps most useful when one is strug- jective identification converges with self- gling with intense countertransference feel- object functioning in situations where the ings. They bring order to the chaos of therapist understands and tolerates the need overwhelming affect and intense transfer- to be used by the patient and helps the pa- ence distortions. Friedman56 has noted that tient verbalize feelings rather than acting on the practice of psychotherapy involves con- them. Different , the authors sug- siderable discomfort for the psychotherapist gested, are essentially struggling with the a good deal of the time. One dimension of same clinical issues. the application of theory to the clinical situa- Most therapists use multiple mod- tion is that it also is applying balm to soothe els.M6162 Rigid adherence to only one theo- the therapist’s anxiety. retical frame when the clinical data do not fit Nevertheless, one must never regard the- the theory is an unfortunate phenomenon in ory as absolute or allow it to become reified. contemporary practice that privileges theory Theories are only as valuable as their clinical over clinical observation. Theory can also be utility. Although I have borrowed from object misused to rationalize countertransference relations theory in my conceptualization of .23 One can use self psychology to countertransference, and specifically of pro- rationalize enjoyment of idealization by a pa-

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tient. Similarly, one can misuse Kernberg’s9 schools: “The psychoanalyst is an object per- encouragement to confront and interpret forming multiple functions, each analyst- the early on in the ther- object being significantly more present than apy to justify expressions of anger at the pa- another analyst-object according to the clini- tient. Bollas63 has stressed that modern cal requirements of the analysand” (p. 100). analysts must understand a variety of analytic

R E F E R E N C E S

1. Boyer LB: Countertransference and technique, in line Spectrum. Northvale, NJ,Jason Aronson, 1988 Master Clinicians on Treating the Regressed Patient, 16. Little M: On delusional transference (transference edited by Boyer LB, Giovacchini PL Northvale, NJ, ). IntJ Psychoanal 1958; 47:476-485 Jason Aronson, 1990, pp 303-32’! 17. Eyman JR. Gabbard GO: Will therapist-patient sex 2. Kernberg OF, Seizer MA, Koenigsberg HW, et al: prevent suicide? Psychiatric Annals 1991; 21:651-655 Psychodynamic Psychotherapy of Borderline Pa- 18. Gutheil TG: Borderline personality disorder, bound- tients. New York, , 1989 ary violations, and patient-therapist sex: medicolegal 3. Solomon MF, Lang JA, Grotstein JS: Clinical im- pitfalls. AmJ 1989; 146:597-602 pressions of the borderline patient, in The Border- 19. Gutheil TG: Patients involved in sexual misconduct line Patient: Emerging Concepts in Diagnosis, with therapists: isavictim profile possible? Psychiatric , and Treatment, vol 1, edited by Annals 199!; 21:661-667 Grotstein JS, Solomon MF, Lang JA. Hillsdale, NJ, 20. Herman JL, Perry JC, van der Kolk Bk Childhood Analytic Press, 1987, pp 3-12 trauma in borderline personality disorder. AmJ Psy- 4. Gabbard GO: The treatment of the “special” patient chiatry 1989; 146:490-495 in a psychoanalytic hospital. International Review of 21. MastersonJF, Rinsley DB: The borderline syndrome: Psychoanalysis 1986; 13:333-347 the role of the mother in the genesis and psychic 5. Giovacchini PL: Tactics and Techniques in Psychoan- structure of the borderline personality. IntJ Psycho- alytic Therapy II: Countertransference. New York, anal 1975; 56:163-177 Jason Aronson, 1975 22. Rinsley DB: Developmental Pathogenesis and Psy- 6. Searles HF: My Work Wah Borderline Patients. choanalytic Treatment of Borderline and Narcissistic Northvale, NJ,Jason Aronson, 1986 . Northvale, NJ,Jason Aronson, 1989 7. Grinker RRJr, Werble B, Drye RC: The Borderline 23. Chessick RD: Intensive Psychotherapy of the Border- Syndrome:A Behavioral StudyofEgo-Functions. New line Patient. New York,Jason Aronson, 1977 York, Basic Books, 1968 24. Rosenfeld H: Impasse and Interpretation: Therapeu- 8. Kernberg OF: Borderline personality organization. tic and Anti-therapeutic Factors in the Psychoanalytic JAm Psychoanal Assoc 1967; 15:641-685 Treatment of Psychotic, Borderline, and Neurotic 9. Kernberg OF: Borderline Conditions and Pathologi- Patients. London, Tavistock, 1987 cal . New York,Jason Aronson, 1975 25. Boyer LB: and countertransference in the 10. Gunderson JG: Borderline Personality Disorder. treatment of a borderline patient, in The Borderline Washington, DC, American Psychiatric Press, 1984 Patient: Emerging Concepts in Diagnosis, Psychody- 11. Abend SM, Porder MS, Willick MS: Borderline Pa- namics, and Treatment, vol 2, edited by GrotsteinJS, tients: Psychoanalytic Perspectives. New York, Inter- Solomon MF, LangJA. Hillsdale, NJ, Analytic Press, national Universities Press, 1983 1987, pp 41-47 12. Adler G: Borderline Psychopathology and Its Treat- 26. Volkan VD: Six Steps in the Treatment of Borderline ment. New York,Jason Aronson, 1985 Personality Organization. Northvale, NJ,Jason Aron- 13. Brandchaft B, Stolorow RD: The borderline concept: son, 1987 an intersubjective viewpoint, in The Borderline Pa- 27. Lewin PA, Schulz CG: Losing and Fusing: Borderline tient: Emerging Concepts in Diagnosis, Psychody- Transitional Object and Self-Relations. Northvale, namics, and Treatment, vol 2, edited by GrotsteinJS, NJ,Jason Aronson, 1992 Solomon MF, LangJA. Hillsdale, NJ, Analytic Press, 28. Lester EP: Gender and identity issues in the analytic 1987, pp 103-1 25 process. IntJ Psychoanal 1990; 71:435-444 14. Terman DM: The borderline concept: a critical ap- 29. Freud S: The future prospects of psycho-analytic ther- praisal and some alternative suggestions, in The Bor- apy (1910), in The Standard Edition of the Complete derline Patient: Emerging Concepts in Diagnosis, Psychological Works of , vol 1!, trans- Psychodynamics, and Treatment, vol 1, edited by lated and edited by Strachey J. London, Hogarth Grotstein JS, Solomon MF, Lang JA. Hillsdale, NJ, Press, 1957, pp 139-151 Analytic Press, 1987, pp 61-71 30. Heimann P: On counter-transference. IntJ Psycho- 15. Meissner WW: Treatment of Patients in the Border- anal 1950; 31:81-84

JOURNAL OF PStHOTHERAPY PRACTICE AND RESEARCH 18 COUNTERTRANSFERENCE AND BORDERLINE PATIENTS

3!. Racker H: Transference and Countertransference. ical Dependency. Hillsdale, NJ, Analytic Press, 1992 New York, International Universities Press, 1968 48.Jacobs TJ: On countertransference enactments.J Am 32. Grinberg L: Countertransference and projective Psychoanal Assoc 1986; 34:289-307 counteridentification, in Countertransference, ed- 49.Jacobs TJ: The Use of the Self Countertransference ited by Epstein L, Feiner AH. New York,Jason Aron- in the Analytic Situation. Madison, Cl’, International son, 1979, pp 169-191 Universities Press, 1991 33. Winnicott DW: Hate in the counter-transference, 50. McLaughlin JT: Clinical and theoretical aspects of IntJ Psychoanal 1949; 30:69-74 enactment.J Am Psychoanal Assoc 1991; 39:595-614 34. Gabbard GO: Psychodynamic Psychiatry in Clinical 51. Abend SM: Countertransference and technique. Psy- Practice. Washington, DC, American Psychiatric choanal Q 1989; 48:374-395 Press, 1990 52. Bollas C: The of the Object: Psychoanalysis 35. Goldstein WN: Clarification of projective identifica- of the Unthought Known. New York, Columbia Uni- tion. AmJ Psychiatry 1991; 148:153-161 versity Press, 1987 36. Grotstein JS: Splitting and Projective Identification. 53. Natterson J: Beyond Countertransference: The New York,Jason Aronson, 1981 Therapist’s Subjectivity in the Therapeutic Process. 37. Kernberg OF: Projection and projective identifica- Northvale, NJ,Jason Aronson, 199! tion: developmental and clinical aspects, in Projec- 54. Bollas C: Regression in the countertransference, in tion, Identification, Projective Identification, edited Master Clinicians on Treating the Regressed Patient, by SandlerJ. Madison, CT, International Universities edited by Boyer LB, Giovacchini PL. Northvale, NJ, Press, !987,pp93-!!5 Jason Aronson, 1990, pp 339-352 38. Ogden TH: On projective identification. Int J Psy- 55. Boyer LB: Analytic experiences in work with re- choanal 1979; 60:357-373 gressed patients, in Technical Factors in the Treat- 39. Ogden TH: Projective Identification and Psychother- ment of the Severely Disturbed Patient, edited by apeutic Technique. New York,Jason Aronson, 1982 Giovacchini PL, Boyer LB. New York,Jason Aronson, 40. Porder MS: Projective identification: an alternative 1982, pp 65-106 hypothesis. Psychoanal Q 1987; 56:431-451 56. Friedman L: The Anatomy of Psychotherapy. 41. SandlerJ (ed): Projection, Identification, Projective Hillsdale, NJ, Analytic Press, 1988 Identification. Madison, CT, International Universi- 57. Adler G, Rhine MW: The selfobject function of pro- ties Press, 1987 jective identification: curative factors in psychother- 42. ScharffJS: Projective and Introjective Identification apy. Bull Menninger Clin 1988; 52:473-491 and the Use of the Therapist’s Self. Northvale, NJ, 58. Kohut H: The Analysis of the Self: A Systematic Ap- Jason Aronson, 1992 proach to the Psychoanalytic Treatment of Narcissis- 43. Tansey MJ, Burke WF: Understanding Countertrans- tic Personality Disorders. New York, International ference: From Projective Identification to Empathy. Universities Press, 1971 Hillsdale, NJ, Analytic Press, 1989 59. Kohut H: The Restoration of the Self. New York, 44. Klein M: Notes on some schizoid mechanisms (1946), International Universities Press, 1977 in Envy and Gratitude and Other Works, 1946-1963. 60. Kohut H: How Does Analysis Cure? edited by Gold- New York, Delacorte Press/Seymour Laurence, 1975 berg A. Press, 1984 45. SandlerJ: Countertransference and role-responsive- 61. Pine F: Drive, Ego, Object, and Se11 A Synthesis for ness. International Review of Psychoanalysis 1976; Clinical Work. New York, Basic Books, 1990 3:43-47 62. SandlerJ: On internal object relations.J Am Psychoa- 46. ChusedJF: The evocative power of enactments.J Am nal Assoc 1990; 38:859-880 Psychoanal Assoc 1991; 39:615-639 63. Bollas C: Forces of Destiny: Psychoanalysis and 47. Coen SJ: The Misuse of Persons: Analyzing Patholog- Human Idiom. Northvale, NJ,Jason Aronson, 1989

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