PSYCHOANALYTIC PSYCHOTHERAPY OF The Borderline Patient Arlene Robbins Wolberg Copyright © 1982 Arlene Robbins Wolberg e-Book Copyright © 2014 International Psychotherapy Institute All Rights Reserved This e-book contains material protected under International and Federal Copyright Laws and Treaties. This e-book is intended for personal use only. Any unauthorized reprint or use of this material is prohibited. No part of this book may be used in any commercial manner without express permission of the author. Scholarly use of quotations must have proper attribution to the published work. This work may not be deconstructed, reverse engineered or reproduced in any other format. Created in the United States of America For information regarding this book, contact the publisher: International Psychotherapy Institute E-Books 301-215-7377 6612 Kennedy Drive Chevy Chase, MD 20815-6504 www.freepsychotherapybooks.org [email protected] To Michael Lisa David Michael Preface Although borderline conditions have been with us for as long as any other emotional ailment, it is only recently that attention has been concen­ trated on this syndrome. Reasons for this focus are sundry. More and more psychotherapists have become aware of the vast multitudes of pa­ tients seeking help who possess a diversity of complaints but who cannot be pigeonholed in any distinctive diagnostic category. Symptoms come and go, fluctuating from evanescent paranoidal projections to obsessive-com­ pulsive maneuvers, to anxiety manifestations, to depression, to conversion phenomena, to distortion phenomena (fantasy defenses), and to temporary psychotic episodes. Moreover, the sadomasochistic relationships established by these patients have made therapy arduous and frequently unsuccessful. The challenge posed by the borderline malady that disables such great numbers of our population has promoted increasing empirical studies and has yielded a vast literature with craftily fabricated theories that espouse many contradictory themes. What is necessary, apart from a critical evalu­ ation of this work, is that systematic and coordinated research in the area of the therapeutic process, difficult as this may be, will hopefully come to pass in the future. In this volume I have attempted to disctiss some of the common elements found in working with a sizable group of borderline patients at the Post­ graduate Center for Mental Health in New York City. These studies deal with diagnostic impressions and therapeutic techniques that have proven helpful with many patients, even those who have resisted conventional therapies. I have focused on work with borderline patients over a period of thirty-five years, my first paper on this subject having been written twenty- eight years ago. The thirty-three patients with borderline diagnosis listed in Chapter 9 are those whom I have studied most intensely. Most of these pa­ tients have been very successful in their fields. Once they became truly in­ terested in working through their problems, they concentrated on their therapeutic tasks. Their struggles gave me many insights into the dynamics of the borderline personality. vi THERAPY OF THE BORDERLINE PATIENT This book is mainly about the treatment process. It is a companion piece to my first book The Borderline Patient (1973), in which I primarily considered one technique—the projective therapeutic technique. In this book I shall (1) describe the various theories current in the literature regarding the dynamics of the borderline patient, (2) trace the historical roots of some of these ideas, and (3) show how these theories are applied in the therapeutic endeavor. I shall then elaborate on how I utilize my theory in treatment. I do not employ the id, ego and superego concepts in the sense that Freud defined them, using the traditional developmental theory. Instead I emphasize the defenses of the patient, recognizing that in current theory de­ fenses are defined as functions of the ego. My contention is that all patients operate on two levels—a reality level and a neurotic level, the latter being associated with identification with neurotic parents who have imposed roles upon the patient that are functions of the parents ’ projections. It is the identification with severely neurotic, and sometimes psychotic, parents and the anxiety that this creates that evokes the organization of defenses and the repressions that are the essence of the borderline patient’s “unconscious.” Due to intense anxiety, the patient has many denial and projective mechanisms, which with his defensive identification, fantasies, and the acting out of the identification role constitute the main focus around which the treatment process is organized. I employ no psychoanalytic theory of development, believing that psy­ choanalysis is not the preferred area where developmental data can best be described and authenticated through research. Psychoanalysis is a theory of neurotic and psychotic behavior as well as a technique for the alleviation of neurotic and psychotic disorders. It seems quite possible to me that the structural theory will have to be augmented, enriched, and reorganized as the continuous flow of information comes from the developmental field. A much more rational theory of interpersonal relations within the field of psychopathology will have to emerge. I predict that Freud’s simplification of the instinct theory and his nebulous concepts about the id, describing the representation of instincts in the mind, will undergo even more revision in the future due to the infor­ mation we now have and will undoubtedly continue to acquire through the efforts of the many investigators in the behavioral sciences. In this book I have described some early papers that never before have been reported in modern literature as well as the various theories that have more recently been suggested to account for borderline conditions and the ways these theories have influenced present-day treatment methods. Throughout the book I contrast my ideas with the ideas of others and have attempted to illustrate through summary and illustrative sessions some of the techniques I use in relating therapeutically to the borderline patient. PREFACE vii Psychoanalysis is basically involved with how neuroses and psychoses develop as well as with the treatment of these disorders. We are interested in the dynamics of learned responses of a neurotic nature and particularly the dynamics of identification. We cannot as psychoanalysts and therapists encompass all that is “internalized” in our explorations; we thus must be content with understanding how and why identifications with the neurotic parents occur and how the “internalizations” that have to do with these identifications affect the life pattern of the individual. We have available to us data concerning these identifications from the patient’s dreams, symptoms, and fantasies. Both the patient’s “conscious” and his repressed ideas and feelings (“unconscious”) are represented in the dreams and fan­ tasies since the patient operates simultaneously by (1) attending to reality and (2) denying and distorting reality in selective ways as a means of defense. We have much to learn about the treatment of the borderline case. I have presented a four-part treatment outline that I believe will help to organize and integrate the material one hears and observes in sessions. It is my hope that this book will stimulate more thinking and work on the treatment of the borderline, this interesting yet elusive patient. I wish to acknowledge with gratitude the grant from the Postgraduate Center for Mental Health in support of this work. I must also thank several staff members at the Postgraduate Center for their help in collecting data in regard to borderline patients. I am especially indebted to Ellen Baumwoll for conducting the study of the personality characteristics of the sample of patients as seen by the therapists. Lee Mackler, our librarian, was of inestimable help in compiling the bibliog­ raphy. Typing and editing could never have been done without the assist­ ance of several experts, particularly Ann Kochanske and Frances Guss. I appreciate the opportunity to work at the Postgraduate Center and the cooperation of the many colleagues who have made my studies of the traits of borderline patients possible. I should like to name a few who have been especially helpful. In a 1958 study, Max Geller, Ph.D.; Oskar Guttmann, M.D.; Benjamin Fielding, Ed.D.; Thomas Aiello who was then M.S. but is now Ph.D. During the last four years I have worked with Leah Tolpin, M.S.S.; Eileen Toban, Ph.D.; Michael Glazer, Ph.D.; Marsha Wineburgh, M.S.W.; and Barry Weiner, Ph.D. Arlene R. Wolberg Contents Preface........................................................................................................... vii Part I: Historical Background 1. Early Papers: Present-Day Implications............................................. 2 2. Early Psychoanalytic Concepts Concerning Borderline C onditions.................................................................................................. 30 Part II: Current Theories and Their Implications for Treatment 3. Comments on Current Theories........................................................... 66 4. Special Problem s...................................................................................... 110 Part III: Understanding the Borderline Personality 5. Infant Development and Antithetic Diameters................................. 170 6. The Problem of Identification..............................................................