Advances in psychotherapy of the borderline patient

Abstract

This book consists of 13 papers from 1 1 sources, some of which are well known. The editors have contributed lengthy introductory articles. LeBoit’s is an effort to integrate the rather disparate contributions by summarizing each briefly and clearly, albeit uncritically, and Capponi’s discusses the history of the borderline concept. The book is misleadingly titled because substantial segments are devoted to the theory of borderline personality and because most of the psychotherapeutic contributions focus on a single issue: the analyst’s countertransference. The belief that patients with borderline personality form transferences is the unstated rationale for the book, and the fact that this places most of its authors at odds with Kohut is never even mentioned. The other pervasive bias of the book is toward a Kleinian view of development and pathology. Unfortunately, Kleinians tend to use concepts impressionistically and imprecisely, they seem to adhere to an unwritten code that forbids criticism of one another, and they do not acknowledge that significant criticisms of their position have been made by analysts of other theoretical persuasions. As a result the book has a parochial quality. The best parts of the book are two articles by Searles, which include fine clinical descriptions of the analyst’s often bizarre experiences with primitive patients. Searles describes a ‘ ‘ symbiotic’ ‘ transference, using concepts of dissociation of introjects, projective identification, and introjection, and he demonstrates how the analyst’s countertransference often represents nonintegrated aspects of the patient’s experiential world. In addition to presenting clear examples from his impressive therapeutic work, Searles provides the only intrabook criticism I could find when he cornments on Kemnbemg’s ‘ ‘Olympian” stance with borderline patients in contrast to the maelstrom of intense and confusing feelings, self-doubts, and loneliness Searles experiences in his own work. Searles also suggests that there may be an explanation for the maintenance of dissociations other than that of defense against rage, which Kemnberg and other Kleinians postulate. Kemnberg contributes a previously published but useful and articulate exposition of the therapy of borderline patients. Capponi’s lengthy historical review is both interesting and misleading. His exposition on Wilhelm Reich brings to light an important and little-known early contribution to the borderline problem. On the other hand, his intense and uncritical Kleinian bias causes his article to resemble a partyline document. The critical portions of some of the work he reviews are omitted or distorted. For example, Mack (1) is cited repeatedly, but his central thesis that the term “borderline’ ‘ may represent current fashion rather than diagnostic precision is ignored. Fairbairn (2), who differed fundamentally from Klein, is revisionistically described as though he were merely amplifying her viewpoint. Although Fairbairn abandoned Kleinian dual instinct theory in favor of a selfpsychology more like Kohut’s, he is said to have ‘ ‘created postulates . . . based on . . . a basic primary object seeking instinct” (p. 90). Capponi ignores many critical reviews of the borderline concept, including my own (3), and excellent articles by ShapirO (4) and Meissner (5) that, although recent, are no more so than others included in his bibliography. Some of the other articles in the book are more seriously flawed. Grotstein makes such assertions as, ‘ ‘The psychotic personality’s envy of its more successful twin is pathognomonic for the borderline and psychotic disorders’ ‘ (p. 175). In so doing he tends to confuse fantasy with metapsychology. Thirty pages of Giovacchini’s article consist of a repetitious and poorly written case history, illustrating the problem of inadequate editing that plagues the book. Finally, Spotnitz presents an interesting description of his therapeutic technique with primitive patients, which includes sessions as infrequent as every other week and such interventions as communication of his feelings, instruction of the patient, and approving and critical responses, but he asserts that it represents ‘ ‘ modern psychoanalysis.” In conclusion, therapists who are learning to work with primitive patients may benefit from the good clinical material and sound suggestions about technique that parts of this book have to offer, but they must beware the book’s tendency toward imprecision, polemicism, and theoretical unidimensionality.