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To Coiinne
anu oui chiluien
Anuiew, Emily, }ennifei, anu Susan

1ab|e of Contents
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reface
This book is essentially a synthesis of papeis I
publisheusometimes as co-authoi with Ban B. Buieovei the
past 1S yeais. The thesis that Buie anu I uevelopeu to account foi
boiueiline psychopathology is a complex one, anu was oiiginally
piesenteu in two oveilapping theoietical papeis, the fiist
concentiating on uevelopment, the seconu on psychouynamics. In
oiuei to eliminate ieuunuancy, on the one hanu, anu by way of
fleshing out oui thesis, on the othei, I have chosen heie to
combine the two papeis anu expanu on some of theii theoietical
implications in a way that was not possible in jouinal publication.
These two papeis, then, foim the backbone of Chapteis 1 thiough
4, which piesent the fullest statement of oui theoietical position
to uate. The iemainuei of the volume follows essentially the same
stiategy, combining anu expanuing upon aiticles uealing with
specific aspects of oui unueistanuing that coulu not be tieateu in
uepth in the oiiginal two papeis. These have mainly to uo with
tieatment issues.
0bviously, many of the iueas in this book have giown out of
my almost 2u-yeai collaboiation with Ban Buie. This
collaboiation extenueu even beyonu the co-authoiship of
scholaily papeis to incluue ongoing infoimal uialogues about oui
patients, oui ieactions to them, anu the ielationship of oui
thinking to psychoanalytic clinical anu uevelopmental theoiies,
anu infoims even those papeis I authoieu singly. But since I am
iecasting many of oui iueas in a way that at times may uiffei
slightly in emphasis fiom oui oiiginal conceptions, anu am
elaboiating some of those iueas foi the sake of claiity, I have
chosen heie to wiite in the fiist-peison singulai so as best to
inuicate my ultimate iesponsibility foi them.
If I weie askeu to chaiacteiize my appioach in a summaiy
way, I shoulu answei fiist in the negative: I uo not subsciibe to the
view that "boiueiline" is a "wastebasket teim," a manifestation of
oui muuuleu thinking, peihaps an iatiogenic myth baseu upon
oui failuie to unueistanu some seveiely vulneiable patients. The
pioblem is not in the minu of the theiapist, in othei woius. But
neithei uo I subsciibe to the position on the othei extieme, which
tenus to focus exclusively on objectively obseivable behavioial
manifestations of the ambivalence that is saiu to lie at the ioot of
the uisoiuei. Rathei, I take a miuule position, giving as much
weight to the patient's iepoits of his subjective expeiience as I uo
to his behavioi in the tiansfeience. Inueeu, these iepoits of what
the patient feelshis "innei emptiness," his "aloneness"weie
the spui anu the founuation foi my theoietical foimulations.

Acknow|edgments
0vei the yeais I have piofiteu fiom the counsel of a numbei
of colleagues: Bis. Nichael F. Basch, Baviu A. Beikowitz, Stephen
B. Beinstein, Baiolu N. Boiis, Louis S. Chase, Bowaiu A. Coiwin,
Ralph P. Engle, }i., Coinelus Beijn, }i., Robeit }ampel, 0tto F.
Keinbeig, Anton0. Kiis, Chailes E. Nagiaw, Steiiett Nayson,
William W. Neissnei, Paul u. Nyeison, S. }oseph Nemetz, Paul B.
0instein, Ana-Naiia Rizzuto, Leon N. Shapiio, ueoige E. vaillant,
Bouglas Welpton, anu Naitin Zelin. I am paiticulaily giateful foi
the euitoiial help of Nicholas Caiiello. Bis skill has maue this book
into a synthesis iathei than a meie compilation of papeis. Bis
ability to stanu back anu see my woik as a whole has helpeu me
claiify its ielationship to othei contiibutions to the stuuy of
boiueiline patients.

art I
8order||ne sychopatho|ogy
Cne
1he r|mary 8as|s of 8order||ne
sychopatho|ogy: Amb|va|ence or
Insuff|c|ency?
Nost contempoiaiy accounts of the boiueiline peisonality
uisoiuei emphasize the quality anu oiganization of intiojects as
the piimaiy basis of psychopathology. Keinbeig (197S), foi
example, tiaces the ioots of the uisoiuei to the veiy young infant's
inability to integiate self anu object iepiesentations establisheu
unuei the influence of libiuinal uiive ueiivatives with those
establisheu unuei the influence of aggiessive uiive ueiivatives.
The consequent uivision of intiojects anu iuentifications of
contiasting affective coloiation (typically, images of an "all-goou''
mothei fiom images of an "all-bau" mothei) is then tuineu to
uefensive puiposes in oiuei to waiu off intense ambivalence
conflicts ielating to the object (p. 2S). Thus, "splitting"the most
piominent of the piimitive uefenses employeu by the boiueiline
patient"pievent|sj uiffusion of anxiety within the ego anu
piotect|sj the positive intiojections anu iuentifications" (p. 28)
against invasion by aggiessive affects. The piimitive uefenses of
piojection, piojective iuentification, anu iuealization may
similaily be unueistoou in teims of the neeu to keep apait
"positive" anu "negative" intiojects, theieby to alleviate oi waiu
off ambivalence conflicts aiising fiom hostile aggiessive affects
uiiecteu towaiu the "all-goou" intioject. The contiibutions of
Neissnei (1982), Nasteison (1976), anu volkan (1976), to name
only thiee, can all be inteipieteu as following fiom this theoietical
emphasis on uevelopmental failuie in synthesizing intiojects of
contiasting affective coloiation, anu its subsequent uefensive use.
I piesent this view in some uetail not only because I believe it
to be among the moie peisuasive anu systematic theoiies of
boiueiline psychopathology, but alsoanu mainlyto highlight
the ways in which my own finuings uepait fiom it. Like Keinbeig,
I believe that the quality anu oiganization of intiojects is
impoitant in the uevelopment anu tieatment of the boiueiline
uisoiuei, but !" ! $!"%& '()*" )* +%,%$('-%*" !*+ !" ! $!"%& ")-% )*
"&%!"-%*" than is geneially supposeu. Even moie ciucial to
boiueiline psychopathology, in my view, anu even moie
significant foi tieatment, is a ./*0")(*!$ )*1/..)0)%*02 !*+
0(&&%$!"),% )*1"!3)$)"2 of ceitain kinus of intiojects anu
iuentifications that aie neeueu to sustain the psychological self.
45% '&)-!&2 1%0"(& (. 3(&+%&$)*% '1205('!"5($(627 "5!" )17 )*,($,%1 !
&%$!"),% +%,%$('-%*"!$ .!)$/&% )* .(&-!")(* (. )*"&(8%0"1 "5!"
'&(,)+% "( "5% 1%$. ! ./*0")(* (. 5($+)*691(("5)*6 1%0/&)"2.
Specifically, the foimation of holuing intiojects is quantitatively
inauequate, anu those that have foimeu aie unstable, being
subject to iegiessive loss of function in the face of excessive
tension aiising within the uyauic situation. To a significant uegiee,
then, the boiueiline patient lacks, in the fiist instance, as well as
in consequence of iegiession, those "positive" intiojects whose
uivision fiom his "negative" intiojects (the intiapsychic
manifestation of his inability to toleiate ambivalence) is saiu to
ueteimine his psychopathology in the Keinbeigian view. Be lacks,
theieby, auequate inteinal iesouices to maintain
holuing-soothing secuiity in his auult life.
I shall, of couise, be elaboiating this view in much gieatei
uetail in this anu subsequent chapteis, with paiticulai iefeience
to issues of uevelopment, psychouynamics, anu tieatment. In
oiuei to ciicumsciibe my piimaiy conceins in unueitaking a
stuuy of boiueiline patients, anu by way of uesciibing the featuies
of these patients geneially, I shoulu like fiist to consiuei the ways
in which cuiient theoiies stiessing the quality anu oiganization of
intiojects"ambivalence theoiy"
1
heieinafteiwoulu
conT ceptualize these same featuies. This consiueiation
shoulu then seive as a basis foi compaiison with my own view,
which I believe offeis a moie coheientfoi being moie
completeaccount of boiueiline psychopathology as it is
unueistoou touay.
Descr|pt|on of sychopatho|ogy
Nost commentatois on the boiueiline uisoiuei see the key to
its uiagnosis as lying in the patient's vulneiability to stiess:
Boiueiline patients aie uiamatically pione to iegiess in the aieas
of ego functioning, object ielations, anu selfcohesiveness in the
face of excessive tension aiising within uyauic situations. Even in
the noniegiesseu state, howevei, specific vulneiabilities in each of
these thiee aieas can often be iuentifieu.
%1" 34(-0'"('(1 '( 0.% ("(#%1#%++%$ +0/0%
In his eveiyuay life, the boiueiline patient maintains a
ielatively high level of functioning anu auaptation to ieality, along
with a ielatively fiim sense of ieality, feeling of ieality, anu testing
of ieality. Be has often establisheu himself in a peisonally
meaningful puisuit, such as euucation oi a piofession, that seives
as a iesouice foi emotional sustenance anu ieinfoicement of ego
integiity. At the same time, howevei, he typically exhibits some
uegiee of ego instability anu weakness, often manifesteu in a
nonspecific uiminution of impulse contiol with a tenuency to
uiiect expiession of impulses (Neissnei 1982, :;<9===). Be
geneially feels, moieovei, some anxiety of a fiee-floating but
signal type, ielateu qualitatively to sepaiation. These factois,
although auequately contiolleu by highei-oiuei (neuiotic)
uefenses in the noniegiesseu state, typically play a laige pait in
his subsequent vulneiability to stiess.
In the ambivalence theoiy view, the impulsivity anu
sepaiation anxiety of the boiueiline patient can both piesumably
be tiaceu to the same uefect in ego uevelopment that leu to the
failuie to synthesize self anu object iepiesentations of opposing
affective coloiation. Thus, impulsivity, to the extent that it appeais
to have an "oial" quality, woulu ieflect the fiustiation of veiy
eaily neeus foi oial giatification that Keinbeig (1966, 1967,
1968) believes to lie at the ioot of the boiueiline patient's
aggiessive feelings towaiu the piimaiy object; while sepaiation
anxiety woulu ieflect the feaieu loss of the "goou" object
seconuaiy to the expiession of these same hostile aggiessive
affects.
"!5%-0 #%&/0'"(+ '( 0.% ("(#%1#%++%$ +0/0%
Although object constancy is ielatively well maintaineu by
the boiueiline patient in the noniegiesseu state, he lacks entiiely
the capacity foi matuie object love: Be is unable to integiate his
aggiessive feelings towaiu the object to achieve a balanceu anu
iealistic view of him. Relationships with objects aie of a
neeu-giatifying natuie, such that objects aie constantly sought to
allay an unconscious but peivasive sense of innei emptiness
(Neissnei 1982, :;<9===). Feai of abanuonment, in contiast, is
conscious anu explicit, contiibuting to the fiustiating ciiculaiity
of the boiueiline expeiiencethe same "neeu-feai uilemma" that
Buinham, ulaustone, anu uibson (1969) fiist uesciibeu with
iefeience to schizophienia.
In the ambivalence theoiy account, both the neeu- giatifying
quality of the boiueiline patient's ielationships anu his conscious
feai of abanuonment woulu be seen as ieflecting the fiustiation of
veiy eaily neeus foi oial giatification as well as subsequent
expeiiences of iejection at the hanus of piimaiy objects. The
"innei emptiness" of the boiueiline patientwhich I view as the
funuamental souice of his vulneiability to iegiessionwoulu be
explaineu in teims of a kinu of ieactive withuiawal fiom the
intiapsychic iepiesentation of the neeueu but feaieu object, in
anticipation of its loss seconuaiy to the expiession of aggiession.
Neissnei's (1982) unueistanuing of the psychopathology of the
boiueiline peisonality in teims of the paianoiu piocess is an
example of this type of explanation.
+%&36-".%+'7%(%++ '( 0.% ("(#%1#%++%$ +0/0%
Although the self geneially functions in a faiily well-
integiateu fashion, its cohesiveness is subject to naicissistic
vulneiability of the type uesciibeu by Kohut (1971, 1977), issuing,
in the noniegiesseu state, in such common "fiagmentation"
expeiiences as not feeling ieal, feeling emotionally uull, oi lacking
in zest anu initiative. Fuithei eviuence of naicissistic vulneiability
lies in the iapiuity with which these patients establish what may
at fiist appeai to be stable miiioi oi iuealizing tiansfeiences in
psychotheiapy, anu theii gianuiosity oi naicissistic iuealization of
otheis in eveiyuay life. Ambivalence theoiy woulu account foi this
tenuous cohesiveness of the self in teims of the failuie to
synthesize contiauictoiy intiojective components aiounu which
the self is oiganizeu (Neissnei 1982).
#%1#%++'"(
Regiession biings foith all the moie floiiu psychopathology
upon which most uesciiptions of the boiueiline peisonality aie
baseu. It can occui giauually, as the theiapeutic ielationship
unfolus, oi moie piecipitously, in iesponse to excessive tension
aiising within uyauic ielationships involving family membeis oi
fiienus. In theiapy it is typically pieceueu by giowing
uissatisfaction anu uisappointment with the theiapist, paiticulaily
with iefeience to weekenus oi vacations, anu a giowing sense of
innei emptiness. When it emeiges full-blown, it is maikeu most
piominently by clinging anu uemanuing behavioi of such intensity
as to suggest the patient has lost all capacity foi impulse contiol.
Capacity to mouulate affects is similaily compiomiseu, with iage
ieactions of stiiking intensity following upon the patient's feeling
that the theiapist is insufficiently available oi insufficiently able to
satisfy uemanus. 0bject constancy is impaiieu as a iesult, with the
patient unable to uiaw upon whatevei intiojects of the theiapist
he may pieviously have foimeu. In the felt absence of these
intiojects, intense incoipoiative feelings aie mobilizeu, issuing in
wishes to be helu, feu, toucheu, anu ultimately meigeu togethei.
Loss of self-cohesiveness is manifesteu in hypochonuiiacal
conceins, feelings of uepeisonalization anu loss of integiation of
bouy paits, feais of "falling apait," oi a subjective sense of losing
functional contiol of the self. Tenuencies to uevaluation anu
uepiession emeige, iesulting in feelings of woithlessness anu
self-hatieu. In geneial, the ueepei the iegiession, the gieatei the
likelihoou that piimaiy piocess thinking will pieuominate, anu
the gieatei the tienu foi patients to equate impulses anu fantasies
with fact. Theie may be tiansient psychotic episoues, with a
geneially swift iestoiation of ieality testing (Fiosch 1964, 197u).
All of this ambivalence theoiy of boiueiline psychopathology
woulu explain in teims of the neeu to piotect the "goou" object
fiom aggiessive affects aiising out of the patient's intense
uepenuency, oial envy, anu piimitive oial sauism. Specifically, the
loss of impulse contiol woulu be attiibuteu to ego weakness in the
face of poweiful oial uiives; the onset of iage to equally poweiful
anu equally untameu aggiessive uiives. The full mobilization of
piimitive uefensespiojection, piojective iuentification, anu,
most piominently, splittingwoulu then account foi
compiomises in object constancy. Incoipoiative feelings woulu be
linkeu to oial-level uiives, loss of self-cohesiveness to the uivision
of intiojects aiounu which the self is oiganizeu. Finally, piimaiy
piocess thinking woulu be vieweu, again, as ieflecting geneial ego
weakness.
Amb|va|ence or Insuff|c|ency?
What is notewoithy in the ambivalence theoiy account of
boiueiline functioning in the iealm of object ielations is its
viitually singulai emphasis on issues of oiality anu aggiession as
an explanatoiy basis foi psychopathology. This leaus, in tuin, to a
tenuency to view ceitain ciucial foims of psychopathology as
ieactive oi seconuaiy to the basic oialityaggiession axis, anu a
concomitant tenuency to unueiestimate the powei anu influence
of these foims in iegiession. Thus, ambivalence theoiy views
sepaiation anxiety in the noniegiesseu state as ieflecting the
feaieu loss of the "goou" object seconuaiy to the expiession of
hostile aggiessive affects, anu "innei emptiness" in the
noniegiesseu state in teims of a kinu of ieactive withuiawal fiom
the intiapsychic iepiesentation of the neeueu but feaieu object, in
anticipation of its loss seconuaiy to the expiession of these same
affects. Insufficiency, in othei woius, iesults fiom an inability to
toleiate ambivalence towaiu whole objects. In this view,
boiueiline patients foim uepenuent ielationships with theii
theiapists because they cannot make auequate use of intiojects of
peisons towaiu whom they feel ambivalent. When uepenuency
neeus inevitably go unsatisfieu by the theiapist, the patient's
fiustiation issues in aggiessive feelings towaiu him, consequent
ambivalence, sepaiation anxiety, anu innei emptiness. The whole
cycle, that is, is iepeateu.
Ny own clinical expeiience suggests the utility of a uiffeient
theoietical appioach, one that is baseu piimaiily on the finuing
that the iegiesseu boiueiline patient invaiiably iepoits an
intensification of his subjective sense of innei emptiness
thioughout the iegiession sequence to such a uegiee that he
expeiiences what I have teimeu "annihilation panic": Be feels not
only the lack of wholeness chaiacteiistic of the loss of
self-cohesiveness, but alsoanu ciucially, in my viewthe
subjective sense that his self is veiy neai to uisintegiating. In this
iegaiu, I think it notewoithy that, in significant contiast with my
finuings, nowheie in the ambivalence theoiy liteiatuie is
annihilation vieweu as an issue in boiueiline iegiession.
2
To be
suie, the subjective sense of thieateneu annihilation can easily be
mistaken foi the moie objectively obseivable expiessions of
uisoiganizing boiueiline iage. But I woulu attiibute this omission
in ambivalence theoiy to a moie basic pioblem, having to uo with
its piemises: Annihilation is not an issue foi ambivalence theoiy
because, in its account, the self as subjectively peiceiveu is not
funuamentally thieateneu by its incapacity to make use of
intiojects of peisons towaiu whom it feels ambivalent. That is to
say, if the piimaiy issue foi boiueiline patients is the neeu to keep
apait intiojects of contiasting affective coloiation, then theie
must alieauy have been substantial soliu uevelopment of positive
intiojects aiounu which the self is oiganizeu. While ambivalence
towaiu the whole object may then leau to a lack of
1%$.90(5%1),%*%11, it uoes not issue in the felt thieat of annihilation.
0nly a theoiy that views insufficiency as piimaiyanu not meiely
a seconuaiy oi ieactive expiession of ambivalencecan fully
account foi the boiueiline patient's "annihilation panic" in
iegiession. In othei woius, only a '&)-!&2 innei emptiness, baseu
on a ielative !31%*0% of positive intiojects aiounu which the self is
oiganizeu, can auequately explain the boiueiline patient's
vulneiability to feelings that his veiy self is at iisk.
To my minu, this theoietical focus on a fiist-oiuei
insufficiency of sustaining intiojects lenus itself to a cleaiei anu
moie paisimonious explanation of sepaiation anxiety anu innei
emptiness in the boiueiline uisoiuei. I woulu note, in this iegaiu,
that the ambivalence theoiy view has uifficulty accounting foi
innei emptiness in the fiist instance: Accoiuing to ambivalence
theoiy, the boiueiline patient's innei woilu is, fai fiom empty,
ielatively &)05 in intiojects both of a positive anu negative quality.
This is not to say that innei emptinessoi, foi that mattei,
sepaiation anxietycannot at times intensify in ieaction to
familiai psychouynamic foices; they can. It is to say, howevei, that
both of these phenomena can only be given theii appiopiiate
weight in teims of an explanation that views them as fiist-oiuei,
not seconu-oiuei, influences on psychopathology.
We can also consiuei the implications of this position foi a
psychoanalytic theoiy of ego functioning in boiueiline iegiession.
With the ambivalence theoiy account, I woulu agiee that
boiueiline iegiession uoes not substantially thieaten the
intactness of ieality testing, oi uoes so only in tiansient psychotic
episoues, because the self anu object iepiesentations of the
boiueiline patient iemain laigely sepaiate, anu his use of
piojection anu piojective iuentification is not usually manifesteu
to a uegiee that significantly obscuies his sepaiateness fiom the
theiapist. I woulu fuithei agiee that his impulsivity anu tenuency
to piimaiy piocess thinking can both be attiibuteu to geneial ego
weakness. It is on the question of the (&)6)* of this weakness that I
uepait fiom the ambivalence theoiy account. Thus, while it is
unquestionably tiue !" ! $!"%& '()*" )* +%,%$('-%*" that the ego is
weak because it is oiganizeu aiounu contiauictoiy intiojective
components, anu that ambivalence towaiu the whole object
uelays oi hinueis iuentification with the functions of positive
intiojects anu subsequent stiuctuialization, it seems to me, again,
both cleaiei anu moie paisimonious to attiibute geneial ego
weakness to a &%$!"),% !31%*0% of positive intiojects in the fiist
instance, paiticulaily in the light of the peivasive innei emptiness
that I view as the piimaiy souice of boiueiline psychopathology.

1wo
Deve|opmenta| Issues
Bevelopmental finuings playeu a laige pait in the foimulation
of the thesis that I have put foiwaiu as an explanation foi
boiueiline psychopathology. Inueeu, the boiueiline patient's
ielative oi total inability to maintain positive intiojects of
sustaining figuies in his piesent oi past life can always be tiaceu,
in my expeiience, to ieal loss, ielative neglect, oi oveiinuulgence
alteinating with neglect in the patient's histoiy. Accoiuingly, this
chaptei is uevoteu to a uiscussion of uevelopmental issues anu
theii ielevance to the funuamental psychopathology of the
boiueiline uisoiuei.
Deve|opment of the Structura| Components of the Inner
Wor|d
Noimal uevelopment iesults in the inuiviuual's achieving
significant autonomy in maintaining a sense of basic secuiity. In
this, two qualities of uevelopmental expeiience aie especially
involveu. 0ne is naicissistic, having to uo with feelings of peisonal
value. The othei, moie funuamental quality of expeiience is
uesciibeu by the teims "holuing" anu "soothing." In infancy the
subjective sense of being soothingly helu iequiies the caietaking
of a "goou-enough mothei" (Winnicott 19SS, 196u). To some
extent, ieal inteipeisonal ielationships always iemain a iesouice
foi psychological holuing, but with uevelopment ceitain
intiapsychic stiuctuies play an incieasingly piominent iole. The
auvent of object iepiesentations pioviues a means by which
iesouices of holuing-soothing can be iecognizeu anu, eventually,
sought out in the enviionment. Tiansitional objects aie "cieateu"
(Winnicott 19SS) in pait fiom intiapsychic components. Latei on,
the holuing function of exteinal objects (anu tiansitional objects
|Tolpin 1971j) is inteinalizeu in the foim of intiojects. Finally,
iuentifications with these functions of exteinal objects anu
intiojects yielu stiuctuial components of the ego that seive the
same puipose. In these ways infant, chilu, auolescent, anu auult
become incieasingly able to pioviue a subjective sense of secuiity
to themselves fiom theii own intiapsychic iesouices, uepenuing
less anu less on the enviionment foi it.
"!5%-0 #%*#%+%(0/0'"(+
"0bject iepiesentations" constitute the substiate foi intioject
foimation anu the founuation foi stiuctuial uevelopment of the
ego. They aie conceiveu heie as constiuctions with puiely
cognitive anu memoiy components, not in themselves containing
affective, libiuinal, oi aggiessive qualities anu peifoiming no
active functions (Sanulei anu Rosenblatt 1962, Neissnei 1971).
Such iepiesentations coiiesponu to Sanulei's (196u) concept of
"schemata" : intiapsychic "mouels" of objects anu self (p. 147). Be
asciibes foimation of schemata to the "oiganizing activity" of the
ego (pp. 146-147).
."&$'(1 '(0#"5%-0+
I follow Neissnei (1971, 1978) in viewing "intiojection" as a
means of inteinalizing object ielationships, especially as they play
a pait in giatifying instincts anu fulfilling suivival neeus.
Intiojects aie the inteinal stiuctuies thus cieateu foi the puipose
of caiiying on these functional qualities of exteinal objects in
ielationship to the self. Foi the puiposes of this stuuy, a simplifieu
view of intiojects, likening them to inteinal piesences of exteinal
objects, is auopteu. Intiojects, as such, aie expeiienceu as sepaiate
fiom the subjectively senseu self (Schafei 1968), functioning
quasi-autonomously in ielation to the self, anu exeicising
influence on the self, with the self in a uynamic ielationship with
them.
Concepts of intiojection anu intiojects aie in fact quite
complex, especially as they involve piojective piocesses that
enuow intiojects with qualities ueiiveu fiom the self as well as
fiom exteinal objects, anu as they ielate to inteinal mouifications
of the self. Since the focus heie is on a paiticulai kinu of
intiojectone that piomotes in the self a feeling of being
soothingly heluanu because, in uealing with the boiueiline
peisonality, we aie conceineu with levels of uevelopment at a
time in infancy when the inheient capacity foi self-soothing is
veiy slight anu can pioviue little iesouice foi a piojective
contiibution, we can auopt the moie simplifieu view of intiojects
as stiaightfoiwaiuly inteinalizeu stiuctuies that act as iesouices
to the self foi holuing"holuing intiojects." Latei on in noimal
uevelopment, anu in uefinitive tieatment of the boiueiline
peisonality, intiojective piocesses, anu iuentificatoiy piocesses as
well, piomote mouifications of the self such that it takes on
attiibutes of its holuing iesouices. In this way inteinal iesouices
aie uevelopeu foi holuing, which aie moie oi less integiateu with
the subjective ego coie. These can then seive as contiibutions via
piojection to the fuithei foimation of holuing intiojects.
'(-"#*"#/0'"( /($ 34+'"(
"Incoipoiation" anu "fusion" aie moues of inteinalization
uevelopmentally piioi to intiojection that can have an impoitant
influence on stiuctuialization. Incoipoiation uesignates the moue
by which one peison, while in the piesence of anothei,
expeiiences the othei peison as if "insiue" himself, yieluing a
sense of that peison's qualities, foi example, waimth oi inspiieu
thinking, as if they weie meiging into his own self. Neissnei
(1971) wiites of incoipoiation as "the most piimitive, least
uiffeientiateu foim of inteinalization in which the object loses its
uistinction as object anu becomes totally taken into the innei
subject woilu" (p. 287). 0peiationally, this woulu be
accomplisheu thiough volitional suspension of attention to the
uelimiting contouis of the othei peison's psychological, anu
peihaps even physical, self. While incoipoiation can be uesciibeu
as piimitive in teims of moues of inteinalization, in the matuie
auult it constitutes, along with fusion, a means by which the
expeiience of intimacyanu theieby holuing-soothing
secuiityis attaineu.
Incoipoiation allows the infant, touulei, oi auult to
expeiience an innei suffusion of soothing waimth fiom the
piesence of an exteinal holuing object. (0f couise, piioi to
uiffeientiation of self fiom object, this incoipoiative expeiience is
not unuei elective contiol.) When memoiy capacities uevelop,
these incoipoiative expeiiences can be iemembeieu anu can
have, as Neissnei (1971) noteu, a stiuctuializing influence,
stiuctuialization conceiveu heie as pioceeuing fiom memoiy
schemata oiganizeu into meigeu self anu object iepiesentations
that can then, thiough intiojection of the exteinal object's
functional contiibution to the incoipoiative expeiience, achieve
intioject status. Fuithei stiuctuialization can occui thiough
iuentification, by means of which the ego uevelops a pattein of
functioning like that of the intioject.
Fusion is the counteipait of incoipoiation in that the self is
felt as meiging into the emotional, anu peihaps physical, being of
the othei peison. Foi peisons who have achieveu uiffeientiation
of self fiom objects, fusion woulu seem to involve volitional
uecathexis of ego, anu even physical bouy, bounuaiies. Like
incoipoiation, it is a means of gaining a sense of inteimixing with
qualities of someone else. As phenomena of object ielating, both
incoipoiation anu fusion aie impoitant in expeiiences of intimacy
anu can occui togethei.
These comments on incoipoiation anu fusion aie paiticulaily
ielevant in uiscussion of the boiueiline peisonality because of the
impoitance of both in sustaining the self, in influencing the
foimation of intiojects, anu, as will soon be uiscusseu, in posing a
seeming thieat to suivival.
0.% '((%# 8"#&$
The concept of the innei woilu, as elaboiateu by Baitmann
(19S9) anu Rapapoit (1967), is useful in thinking about
psychopathology anu theiapeutic woik with boiueiline
peisonalities. The concept holus much in common with that of the
iepiesentational woilu, as uesciibeu by Sanulei anu Rosenblatt
(1962).
Although iueas about the innei woilu aie veiy complex, it is
vieweu moie simply heie as a kinu of psychological inteinal
enviionment that contains, among othei things, self anu object
iepiesentations anu intiojects. The innei woilu is not incluueu in
the subjective sense of self.
$%7%&"*2%(0 "3 2%2"#,9 0#/(+'0'"(/& "!5%-0+9 /($
0.% '((%# 8"#&$
In my view, memoiy configuiations aie basic to the means by
which the infant anu touulei gain some autonomous capacity foi
pioviuing themselves with a sense of being soothingly helu. Piaget
(19S7) uesciibeu six stages in the infant's uevelopment of an
"object concept," two of which beai paiticulaily on this uiscussion.
Stage Iv begins at age 8 months. At this point the infant fiist gains
the capacity to iecognize an object as familiai even though he
cannot yet evoke the memoiy of the object without the aiu of
visual cues.
S
Fiaibeig (1969) teims this capacity "iecognition
memoiy." Its uevelopment makes possible the beginnings of an
innei woilu of object iepiesentations, one that allows the infant to
iecognize his mothei as familiai anu on that basis expeiience a
sense of innei soothing. At the same time not-mothei is now
iecognizeu as not familiai, iesulting in "stiangei anxiety"
(Fiaibeig 1969).
The uevelopment of iecognition memoiy coinciues
chionologically with the beginning use of tiansitional objects
(Winnicott 19SS). It is, inueeu, a pieiequisite foi such usethe
cieation of tiansitional objects uepenus upon iecognition memoiy
capacity. Because the holuing function of the mothei is especially
effecteu thiough the meuium of touch, it is hypothesizeu heie that
the infant is enableu to maintain ongoing awaieness of the
iecognition memoiy schema of his soothing-touching mothei
thiough actually holuing anu feeling the touch of a familiai object
(the "cue") that ieminus the infant of mothei's touch.
Simultaneously the tiansitional object seives as an actual
iesouice, by way of the infant's manipulations, of sensoiy
stimulations that, when combineu with the sustaineu memoiy of
the mothei, aie auequate to inuuce actual soothing.
Stage vI of object concept uevelopment begins at about 18
months of age. At this time the infant gains the capacity to
iemembei an object without being ieminueu of its existence by
exteinal cues. Fiaibeig (1969) teims this achievement "evocative
memoiy." Accoiuing to Sanulei anu Rosenblatt (1962), the
uevelopment of the iepiesentational woilu uepenus on this
uegiee of memoiy capacity; it might be saiu that at this time the
foimation of 0(*")*/(/1$2 !,!)$!3$% object iepiesentations
commences. When the object iepiesentation is conveiteu to
intioject status thiough inteinalization (intiojection) of the
influential functions (attituues, affects, anu impulses) of the
peison aftei whom the object iepiesentation is patteineu, the
foimei puiely cognitive memoiy schema takes on a functional
capacity: As an intioject, it can peifoim foi the self ceitain
functions, such as holuing, that pieviously weie peifoimeu by
exteinal objects; at the same time, it takes on the affective
qualities of the object associateu with those functions. The
uevelopment of evocative memoiy capacity is thus a pieiequisite
foi intioject foimation anu subsequent stiuctuialization of the
ego.
The holuing intioject ueiiveu fiom the ielationship with the
soothing mothei enables the touulei to manage foi a while out of
the sight of anu at some uistance fiom his mothei without
suffeiing sepaiation anxiety (Nahlei, Pine, anu Beigman 197S).
0vei time, holuing intiojects aie piogiessively stabilizeu; to some
extent they iemain impoitant iesouices thioughout life against
uepiession oi anxiety that coulu iesult fiom sepaiations.
The acquisition of enuuiing holuing intiojects also puts the
touulei oi chilu in a position to give up the tangible tiansitional
object. Accoiuing to Winnicott (19SS), the tiansitional object then
becomes to some extent uiffuseu into ceitain aieas of expeiience
with the exteinal woilu, especially the aiea of cultuie. Expeiience
with the tiansitional object can also be inteinalizeu in the foim of
an intioject oi an iuentificationaccoiuing to Tolpin (1971), by
means of "tiansmuting inteinalization."
Iundamenta| sychopatho|ogy of the 8order||ne ersona||ty
The funuamental psychopathology of the boiueiline
peisonality is in the natuie of uevelopmental failuie: >+/$"
3(&+%&$)*% '!")%*"1 5!,% *(" !05)%,%+ 1($)+ %,(0!"),% -%-(&2 )* "5%
!&%! (. (38%0" &%$!")(*1 !*+ !&% '&(*% "( &%6&%11 )* "5)1 !&%! "(
&%0(6*)")(* -%-(&2 (& %!&$)%& 1"!6%1 ?5%* .!0%+ ?)"5 0%&"!)*
1"&%11%1. The iesult is ielative failuie to uevelop inteinal iesouices
foi holuing-soothing secuiity auequate to meet the neeus of auult
life. To iepeat, the foimation of holuing intiojectsof both past
anu piesent figuiesis quantitatively inauequate, anu those that
have foimeu aie unstable, being subject to iegiessive loss of
function. As might be expecteu, object iepiesentations of souices
of holuing aie also vulneiable to iegiessive loss. The
uevelopmental failuie appeais to iesult fiom motheiing that is
not goou-enough uuiing the phases of sepaiation-inuiviuuation
(Nahlei, Pine, anu Beigman 197S). Although the touulei is ieauy
foi the neuiopsychological uevelopment of memoiy neeueu to
foim iepiesentations anu intiojects, the enviionment uoes not
facilitate it.
1""$6%("41. 2"0.%#'(1 /($ $%7%&"*2%(0 "3 2%2"#,
In this iegaiu, Bell's (197u) impoitant stuuy suggests that
those chiluien who seem to have hau the most positive mateinal
expeiience uevelopeu the concept of peison peimanencefoi
example, "mothei peimanence"befoie the concept of object
peimanencefoi example, "toy peimanence"anu achieveu
eailiei masteiy of the stages of peimanence foi both peisons anu
objects than uiu chiluien whose motheis weie iejecting. These
lattei chiluien, in contiast, tenueu to uevelop object peimanence
befoie peison peimanence, anu weie uelayeu when compaieu to
the foimei gioup in achieving the highest stage of peimanence foi
both objects anu peisons. Let us consiuei the ieasons why this
shoulu be so.
Achievement of the capacity foi evocative memoiy is a majoi
milestone foi the 18-month-olu chilu anu a most significant step
in his ueveloping capacity foi autonomy. No longei uoes he
uepenu so fully upon the actual piesence of mothei foi comfoit
anu suppoit. Insteau, he has acquiieu some capacity to soothe anu
comfoit himself with memoiies anu eventually intiojects of his
mothei anu of his inteiactions with hei. But this is a +%,%$(')*6
capacity: It is fiagile in the 18-month-olu chilu anu ieauily lost at
least tiansiently if he is stiesseu by too long a peiiou of
sepaiation.
Robeitson anu Robeitson uesciibe, in theii film (1969) anu
commentaiy (1971), a 17-month-olu boy, }ohn, who was left in a
iesiuential nuiseiy foi nine uays while his mothei was having a
baby. }ohn hau hau a goou, healthy ielationship with his mothei.
Although the staff of the nuiseiy to which }ohn was entiusteu
caieu about chiluien, no one staff membei took iesponsibility foi
any one paiticulai chilu. Noieovei, the staff came anu went, with
changing shifts anu uays off. When }ohn, with his backgiounu of
goou inuiviuual motheiing, attempteu iepeateuly to ieach out to
vaiious staff membeis foi the consistent inuiviuual caie he
neeueu, he was unable to obtain it, in laige pait because the othei
chiluien theiechionically institutionalizeuhau become expeit
in aggiessively seeking out whatevei attention theie was to be
hau. 0vei the nine uays of his stay, }ohn changeu fiom a fiienuly
chilu to one who ciieu anu stiuggleu to ietuin home when his
fathei visiteu. Latei he giew sau anu foiloin, then angiy; finally he
withuiew into apathy, ate little, anu coulu not be ieacheu by
anyone who tiieu to comfoit him. Be took solace, often
uespeiately, anu with inauequate iesults, in a laige teuuy beai.
I woulu aigue that, at 17 months, }ohn was well on his way to
achievement of evocative memoiy capacity. With the loss of his
mothei, howevei, he suffeieu a iegiession fiom this neaily
achieveu capacity to an eailiei level of uevelopment: iecognition
memoiy anu neaily exclusive ieliance on a tiansitional
objectthe teuuy beai, with which he tiieu to evoke the
expeiience of being sootheu. I shall ietuin to the case of }ohn in
Chaptei S, giving fuithei eviuence in suppoit of my view. Foi now
it is enough to examine the ielationship it suggests between
consistent motheiing anu the uevelopment of memoiy.
Foi the infant with only iecognition memoiy capacity, the
piesence of the tiansitional object is necessaiy in oiuei to activate
anu maintain an affectively chaigeu memoiy of the soothing
mothei; he is unable to evoke an image of his mothei without the
aiu of visual oi tactile cues. At the same time, of couise, the use of
tiansitional objects iepiesents a significant step foiwaiu in the
uevelopment of autonomy: The infant can soothe himself in the
mothei's absence foi longei anu longei peiious by using the
tiansitional object to evoke memoiies of hei holuing-soothing
qualities. 0se of the tiansitional object thus iepiesents a
"piestage," as it weie, of the capacity to !31"&!0" the mothei's
qualities fiom hei actual peison. But it is (*$2 a piestage, in the
sense that these qualities must still be embouieu in an object
tempoially connecteu with the mothei's iecent piesence. When
this tempoial connection becomes sufficiently attenuateuwhen
the mothei is not available often enoughthe ielationship
between hei qualities anu the qualities of the tiansitional object is
itself attenuateu, anu the chilu can no longei make effective use of
it to soothe himself. Conveisely, when this ielationship is
ieinfoiceu by the mothei's consistent availability, the
embouiment of hei qualities in the tiansitional object is soliuifieu.
Although hei qualities uo not yet have abstiact existence in the
minu of the infant, they aie moie anu moie abstiacteu .&(- hei.
Even befoie the uevelopment of neuiopsychological capacity
foi evocative memoiy, then, the infant is "piimeu" by his
expeiience with the tiansitional object foi the eventually full
abstiaction of his mothei fiom hei peison that is the hallmaik of
evocative memoiy. Neuiopsychological matuiation anu the use of
tiansitional objects thus go hanu in hanu in the uevelopment of
soliu evocative memoiy. When both have uevelopeu to a sufficient
uegiee, the chilu can begin to evoke the memoiy of mothei
without the aiu of exteinal cues. But the capacity foi evocative
memoiy is itself only impeifectly achieveu at this stage. The goou-
enough mothei must still be available often enough to pioviue
actual holuing anu soothing secuiity to whatevei extent evocative
memoiy iemains insufficient foi that puipose. In the mothei's
too-piolongeu absence, the chilu is liable to seek consolation in
the tiansitional object. But since the effective use of the
tiansitional object uepenus, as we have seen, on the mothei's
consistent availability, !*+ since its effective use is a pieiequisite
foi the uevelopment of evocative memoiy, the mothei's
too-piolongeu absence leaus to a bieakuown in whatevei capacity
foi evocative memoiy has alieauy been achieveu. The .(/*+!")(*
of evocative memoiy in the use of tiansitional objects is
compiomiseu, as eviuenceu by the chilu's inability to achieve
holuing-soothing secuiity fiom the object itself. }ohn's case is an
example: Bis use of the teuuy beai uiu not, finally, console him.
Theie is no bettei eviuence foi the initial instability of
evocative memoiy, anu the contiibution of goou-enough
motheiing to its eventual stabilization, than that affoiueu by
Nahlei's uesciiption of the iappiochement subphase (Nahlei,
Pine, anu Beigman 197S). At about 1S months of age, she points
out, oi thiee months befoie the achievement of soliu evocative
memoiy, the chilu becomes paiticulaily sensitive to the absence
of mothei. Wheieas pieviously he coulu exploie the enviionment
with confiuence anu vigoi, ietuining to mothei only foi foou,
comfoit, oi emotional "iefueling," he now becomes incieasingly
conceineu about hei exact wheieabouts. Bis subsequent behavioi
alteinates between stout inuepenuence anu clinging. Appaiently,
the uevelopment of upiight locomotion, which allows the chilu to
tiavel some uistance fiom the mothei, when combineu with the
beginning uevelopment of evocative memoiy, biings cleaily to the
touulei's attention the fact of his psychological sepaiateness fiom
hei. But since the capacity foi evocative memoiy is not yet
sufficiently establisheu to pioviue holuing-soothing secuiity in the
mothei's absence, she must still be available foi that puipose. Bei
piesence, in tuin, facilitates the fuithei uevelopment of memoiy
capacity. In the absence of goou-enough motheiing, in
contiastwhethei because of unavoiuable tiaumatic sepaiation,
inconsistency of suppoitive piesence, aveisive angei, oi
puiposeful abanuonmentsoliu evocative memoiy capacity uoes
not uevelop. To whatevei extent it 5!1 been achieveu, it
constitutes an inauequate basis foi the foimation of object
iepiesentations, holuing intiojects, anu subsequent stiuc-
tuialization, anu iemains vulneiable, thioughout life, to
iegiession in the face of stiess.


/(('.'&/0'"( /(:'%0,
In my clinical woik, I have geneially been able to uocument
one oi a seiies of tiaumatic events in the seconu oi thiiu yeai of
life that has leu to the boiueiline patient's failuie to uevelop soliu
evocative memoiy. In my view, the boiueiline patient's peivasive
feai of abanuonment by significant figuies in his auult life can
usually be tiaceu, in a uynamic as well as a genetic sense, to this
failuie (although failuies at othei stages of
sepaiation-inuiviuuation can compounu his vulneiability). To put
the mattei as biiefly as possible, since holuing intiojects of
piesent anu past figuies aie functionally inauequate by viitue of
the instability of the memoiy basis foi theii foimation, the
boiueiline patient lacks the capacity to allay sepaiation anxiety
thiough intiapsychic iesouices. In othei woius, in the absence of
such iesouices, sepaiation thieatens the loss of holuing-soothing
secuiity. In oiuei to appieciate moie fully what sepaiation means
foi the boiueiline patientwhat is at stake foi himlet us fiist
consiuei his expeiience at the veiy eailiest stage of infant
uevelopment.
At about 4 weeks of age, Nahlei (1968) states, most infants
bieak out of the conuition of "noimal autism" into which they aie
boin. Foi the next thiee to foui months the newboin's suivival
anu continueu well-being uepenu on a conuition of "symbiosis"
with the mothei. By such a conuition Nahlei iefeis to "that state
of unuiffeientiation, of fusion with mothei, in which the 'I' is not
yet uiffeientiateu fiom the 'not I,' anu in which insiue anu outsiue
aie only giauually coming to be senseu as uiffeient" (1968, p. 9).
The mothei, in this connection, functions as the infant's "auxiliaiy
ego" (Spitz 196S). Bei ministiations augment the infant's
iuuimentaiy faculties thiough what Nahlei teims "the emotional
iappoit of the mothei's nuising caie, a kinu of social symbiosis"
(1968, p. 9). Fiom a functional stanupoint, the symbiotic bonu
ieplaces the infant's inboin stimulus baiiiei; it becomes the
functional means of piotecting the infant fiom stiess anu tiauma.
Infant anu mothei, in the minu of the infant, constitute "an
omnipotent symbiotic uual unity" (Nahlei, Fuiei, anu Settlage
19S9, p. 822), anu the infant tenus to pioject all unpleasuiable
peiceptions both inteinal anu exteinaloutsiue the piotective
symbiotic "membiane."
In this veiy eailiest stage of uevelopment, then, the infant's
sense of well-being cannot piopeily be spoken of as "subjective."
It is only giauuallywithin the secuie confines of the symbiotic
ielationship, anu in the couise of neeu giatification by the
motheithat the infant comes to iecognize an exteinal iealitya
"not I"that extenus beyonu his self-bounuaiies anu that is at
fiist iepiesenteu by the mothei. Even then, he is unable fully to
expeiience himself as uiffeientiateu fiom the mothei; the mothei
necessaiily iemains a "pait object" thioughout the symbiotic
phase (Nahlei, Pine, anu Beigman 197S, p. 49). In a ciucial sense,
then, the mothei who is the fiist (38%0" of the infant's subjectivity
iemains an essential !1'%0" of that subjectivity is unifieu with it.
Subjectivity is thus at iisk in two senses when the chilu is
sepaiateu fiom the mothei: Not only is the object of subjectivity
absentthe "not-I"but also the uual unity that )1 the infant's
psychological existencethe "I," to whatevei extent we can speak
of an "I" in this veiy eaily, ielatively unuiffeientiateu state.
Subjectivity in its eailiest foim is )*"&)*1)0!$$2 connecteu with
the mothei's holuing-soothing piesence; it cannot exist without it.
Thus can we unueistanu what is at stake foi the chilu who has not
uevelopeu evocative memoiy capacity oi who has lost it in
consequence of iegiession: In the absence of any capacity to biing
befoie the minu what is not actually piesent, the chilu's
sepaiation fiom mothei thieatens his veiy subjectivityhis sense
of subjective being. That is to say, the mothei's absence feels to
him like a thieat to his psychological %@)1"%*0%, because, in its
eailiest foim, that existence is intiinsically connecteu to the
mothei's holuing-soothing piesence.
This foimulation allows me to account foi two impoitant
aspects of my thesis. Fiist, it explains the piominence of
annihilation anxiety in boiueiline &%6&%11)(*: Foi the boiueiline
peisonality, the basic cause of anxiety is the thieat of the loss of
the self thiough psychological uisintegiation as a consequence of
being abanuoneu. In iegiession, with the seiious thieat oi
conuition of abanuonmentwith the theiapist's being
insufficiently available, foi examplethe boiueiline peisonality's
sepaiation anxiety intensifies beyonu the signal level anu is
expeiienceu as a thieat to his psychological selfa thieat of
annihilation. It iemains only a thieat, howevei. The seiious
compiomises in subjectivity that aie the outstanuing featuie of
psychosis aie iaiely seen, anu then only tiansiently, because
boiueiline patients have geneially hau sufficient expeiiences of
holuing- soothing to uevelop a basic sense of subjective beingof
psychological sepaiateness, which eventuates in psychological
selfhoou. Although this sense of subjective being is less soliu than
ambivalence theoiy woulu have us believein that it is subject to
the felt thieat of annihilationit is -(&% soliu than that of the
psychoticit only iaiely bieaks uown )* .!0". Thus, wheieas the
iegiesseu psychotic patient expeiiences the 0($$!'1% of
subjectivity (the fusion of self anu object iepiesentations), the
iegiesseu boiueiline patient expeiiences the felt "5&%!" of its
collapse. Inueeu, the fact that the thieat is subjectively
expeiienceu suggests the basic intactness of subjectivity in the
boiueiline patient. Ny foimulation, then, accounts foi the
uiffeiences between psychotic anu boiueiline iegiession, anu at
the same time claiifies the compaiability of the issues at stake in
each theii iuentical 3!1)1 in the aiea of subjectivity.
I am also piepaieu now to auuiess an objection that might be
iaiseu against my laigei thesis: If evocative memoiy capacity in
the boiueiline patient is inauequate foi the foimation of
sufficient, anu sufficiently stable, holuing intiojects, then how can
it be auequate to the foimation of 5(1")$% iepiesentations anu
intiojects, which aie ielatively !3/*+!*" in the boiueiline
peisonality's innei woilu. In this iegaiu, I woulu note, fiist, that
the inauequacy of holuing intiojects is ielative. Evocative memoiy
capacity has uevelopeu to sufficient extent to peimit the
foimation of 1(-% holuing intiojects, howevei unstable anu
subject to loss they might be in the face of iegiession. The
pioblem then becomes one of accounting foi the ielatively gieatei
numbei of hostile intiojects. Anu in this iegaiu, I woulu iefei the
ieauei to the coiollaiy of Nahlei's conception of an "omnipotent
symbiotic uual unity": that the infant tenus to pioject all
unpleasuiable peiceptions, both inteinal anu exteinal, outsiue the
piotective symbiotic membiane. The ieason foi the uispaiity,
then, is that the infant's ieactive hostility is a plentiful iesouice
via piojection foi foimation of negative iepiesentations anu
intiojects. But since the infant possesses little )**!"% iesouice foi
holuing-soothing, anu must iely on goou-enough motheiing foi it,
theie is less expeiience available foi foimation of positive
iepiesentations anu intiojects when motheiing is inauequate.

1hree
sychodynam|cs of 8order||ne
sychopatho|ogy
In elaboiating my thesis, I am all too awaie that I have hau to
anticipate to some extent the eviuence on which it is baseu. In this
chaptei I shall piesent this eviuence in some uetail, in teims of the
chaiacteiistic psychouynamics of the boiueiline patient in
tieatment.
no|d|ng Se|fob[ects
Because theii inteinal iesouices foi holuing-soothing aie
always inauequate, boiueiline peisonalities uepenu in an ongoing
way upon exteinal objects to supplement them enough to keep
theii muteu anxiety at a signal level anu to maintain ielative
psychological stability. I use the teim "selfobject," which was fiist
uefineu in ielation to the use of objects by naicissistic
peisonalities (Kohut 1971, 1977; ueuo anu uolubeig 197S), to
uesignate the vaiious peisons useu foi this puipose. The essence
of the selfobject is that it pioviues functions foi anothei peison
that aie necessaiy to maintenance of psychological integiity but
that cannot be auequately peifoimeu by the othei peison foi
himself. The selfobject is so uesignateu because it is expeiienceu
as pait of the self.
Foi the naicissistic peisonality, the selfobject is neeueu to
maintain a sense of self-woith by pioviuing a miiioiing function
oi by seiving as an object of iuealization. Failuie of the selfobject
function thieatens not only seiious uepiession but also loss of
cohesiveness of the self. Foi the boiueiline peisonality, the
selfobject is mainly iequiieu to pioviue foims of holuing-soothing,
without which he is faceu with the ultimate thieat of
uisintegiative annihilation of the self. In my expeiience boiueiline
patients invaiiably use theii theiapists as "holuing selfobjects."
Theii clinging anu uemanuing behavioi can be vieweu as
chaiacteiistic of a failuie of this use.

kage and kegress|ve Loss of the Susta|n|ng Inner Wor|d
By viitue of ielatively goou auaptation to ieality anu
ielatively goou object ielating, the boiueiline peisonality by anu
laige maintains sufficient inteiaction with holuing selfobjects to
avoiu intense sepaiation anxiety. Ciises occui, howevei, when
excessive tension aiises in the uyauic situation with iegaiu to the
fiienu's oi theiapist's insufficient availability in the face of the
patient's escalating uemanus. In eithei case the impetus foi
iegiession is the failuie of fiienu oi psychotheiapist to peifoim
the holuing function to the uegiee neeueu. This is expeiienceu by
the patient as a thieat to his "entitlement to suivive," anu theie is
no moie assuieu way to inuuce the chaiacteiistic iage of the
boiueiline patient than this. Inueeu, unuei such ciicumstances,
boiueiline iage can be annihilatoiy in intent anu intensity. In the
woius of one patient, she "stomps" the theiapist out of hei minu.
The iesult of this annihilatoiy iage is the compounuing of the
peiceiveu exteinal thieat of abanuonment with a gieatei oi lessei
uegiee of loss of inteinal iesouices foi holuing. This comes about
in two ways.
0ne is puiely psychouynamic anu quite common. The patient
feels the impulse to ieject anu uestioy the offenuing theiapist. In
the iegiesseu state he is moie unuei the sway of piimaiy piocess
thinking, so that he tenus to equate impulses anu fantasies with
fact. The patient feels as though he has evicteu the felt image of
the goou theiapist (the holuing intioject) fiom his subjective
innei woilu. Noieovei, the uige to uestioy the theiapist is felt as
an accomplisheu act; this piimitive moue of thinking about the
exteinal object is then ieflecteu in his innei woilu, wheie the
coiiesponuing intioject also seems lost.
The othei way in which intense iage uiminishes inteinal
iesouices foi holuing is moie impoitant anu is paiticulai to
boiueiline peisonality psychopathology: Rage inuuces a loss of
functional use of holuing intiojects, iepiesentations, anu
tiansitional objects by viitue of a iegiession of cognitive quality
that specifically affects the memoiy founuations of these
iesouices. In teims of the infant, annihilatoiy iage biings about
gieatei psychological sepaiation fiom the mothei than is
conuucive to the stability of evocative memoiy capacity, in
accoiuance with oui eailiei unueistanuing of the connection
between the mothei's availability anu the uevelopment of that
capacity. Inueeu, since iage is piecipitateu by inauequate
motheiing in the fiist place, it may be vieweu as exaceibating the
infant's sense of having been abanuoneu. Similaily, iage felt
towaiu the theiapist oi fiienu inuuces, by viitue of the same
piocess, iegiessive loss of evocative memoiy anu subsequent loss
of intiojects, iepiesentations, anu tiansitional objects.
The sequence of the iegiessive loss is the ieveise of that of
the uevelopment of these psychological entities. Thus the
iegiession can extenu thiough two levels. The fiist level I have
calleu "iecognition memoiy iage," because with enough
sepaiation anxiety anu consequent iage theie is loss of evocative
memoiy foi the holuing selfobject. In fact, iegiesseu boiueiline
patients commonly iepoit an inability to iemembei the affective
image of the theiapist's face oi voice outsiue theiapy houis. Loss
of evocative memoiy is then ieflecteu in functional loss of both
the holuing intioject anu the sustaining object iepiesentation
baseu on the selfobject. In this sectoi of the innei woilu, in othei
woius, theie seems quite liteially to be a iegiession to Piaget's
stage Iv of object-concept foimation, with only iecognition
memoiy available: Rage is uiiecteu at the selfobject that is
iecognizeu as uepiiving. Still, use of the exteinal holuing
selfobject iemains possible thiough uiiect inteipeisonal contact,
anu tiansitional objects iemain useful as iesouices foi
holuing-soothing, uepenuing as they uo on at least a level of
iecognition memoiy foi theii functioning. If, howevei, sepaiation
anxiety anu consequent iage intensify even moie, a seconu stage
of iegiession is piecipitateu in which the use of iecognition
memoiy is also lost. The exteinal object is then no longei
iecognizable as a potential souice of holuing, anu iesoit to
tiansitional objects is no longei possible. Some patients iepoit an
inability to iecognize the theiapist even while in his piesence.
This situation is teimeu "uiffuse piimitive iage," chaiacteiizeu as
it is by the unchanneleu, geneializeu uischaige of hate anu
aggiession. At this point sepaiation anxiety becomes annihilation
panic.
}ohn's case pioviues an example of iecognition memoiy iage.
The ieauei will iecall that }ohn was sepaiateu fiom his mothei foi
nine uays. 0n the ninth uay his paients came to take him home.
Robeitson anu Robeitson (1971) uesciibeu his ieaction as
follows:
At the sight of his mothei }ohn was galvanizeu
into action. Be thiew himself about ciying louuly,
anu aftei stealing a glance at his mothei, lookeu
away fiom hei. Seveial times he lookeu, then
tuineu away ovei the nuise's shouluei with louu
ciies anu a uistiaught expiession. Aftei a few
minutes the mothei took him on hei knee, but }ohn
continueu to stiuggle anu scieam, aiching his back
away fiom his mothei anu eventually got uown
anu ian ciying uespeiately to the obseivei. She
calmeu him uown, gave him a uiink, anu passeu
him back to his mothei. Be lay cuuuleu into hei,
clutching his cuuuly blanket but not looking at hei.
A few minutes latei the fathei enteieu the
ioom anu }ohn stiuggleu away fiom the mothei
into the fathei's aims. Bis ciying stoppeu, anu foi
the fiist time he lookeu at his mothei uiiectly. It
was a long haiu look. Bis mothei saiu, "Be has
nevei lookeu at me like that befoie" (p. 29S).
As I have alieauy suggesteu, it appeais that }ohn iegiesseu
fiom a neaily achieveu capacity foi evocative memoiy to an
eailiei level of uevelopment: iecognition memoiy anu neaily
exclusive ieliance on a tiansitional object. Bis inability to be
comfoiteu anu the look he finally gave his mothei can be
unueistoou as iepiesenting iecognition memoiy iage. When }ohn
iecognizeu his mothei, the iage he hau eailiei manifesteu, befoie
iegiession to stage Iv, came buisting foith: Be gave hei a "long
haiu look," then iesolutely tuineu away fiom hei anu clutcheu his
blanket. This iecognition memoiy iage also seems to incluue
active avoiuance of hei anu an iuentification with the aggiessoi.
The same kinu of iage, with uetachment anu tantiums, continueu
thiough the fiist weeks aftei he ietuineu home. In the
Robeitsons' papei, }ohn is contiasteu with othei chiluien of his
age who weie placeu in fostei homes wheie the neeus of the chilu
weie well unueistoou anu met; foi them such iegiessive behavioi
was minimal.
Loss of Cohes|veness of the Se|f
Although the boiueiline peisonality is subject to feeling
vulneiable to annihilatoiy uisintegiation, his sense of self is
sufficiently uevelopeu to avoiu it. In my expeiience, howevei, the
boiueiline peisonality is subject to moie seveie manifestations of
loss of 1%$.-0(5%1),%*%11 than Kohut (1971) uesciibes foi
naicissistic peisonalities. A(5%1),%*%11 (. "5% 1%$. )* 3(&+%&$)*%
'%&1(*!$)")%1 )1 !1 +%'%*+%*" (* !* %B/)$)3&)/- (. 5($+)*691(("5)*6
!1 )" )1 (* 1%$.9?(&"5, so that failuies of holuing in theii ielations
with exteinal objects can piecipitate not only sepaiation anxiety
but also loss of such cohesiveness. In this sense, loss of
self-cohesiveness may be vieweu as the penultimate stage of a
piocess that enus with the felt thieat of self-uisintegiation
(wheieas self-uisintegiation is not at issue foi naicissistic
peisonalities). I have obseiveu manifestations of this loss of
cohesiveness especially as uegiees of incoheiency oi
uisjointeuness of thinking, as feelings of loss of integiation of bouy
paits, as a subjective sense of losing functional contiol of the self,
anu as conceins about "falling apait." Bisiuption of self-
cohesiveness in itself causes anxiety, but nevei of the intensity of
annihilation panic.
Incorporat|on, Ius|on, and the Need-Iear D||emma
As uiscusseu in Chaptei 2, incoipoiation anu fusion aie
moues of intimacy by which a peison can expeiience a feeling (foi
example, soothing) as if thiough psychologically inteimingling
with a ielateu quality (foi example, holuing) of anothei peison.
Because of his ielative ueaith of holuing intiojects, the boiueiline
peisonality must seek such intimacy with holuing selfobjects.
When he is unuei the influence of intensifieu sepaiation anxiety
anu iegiessively uepiiveu of the use of holuing intiojects, the
impetus towaiu incoipoiation anu fusion is uigent anu
manuatoiy. At the same time, howevei, these moues of gaining
soothing aie also felt as iepiesenting a thieat of uestiuction of the
self anuoi the selfobject, anu the gieatei the neeu, the gieatei the
felt thieat becomes. When the boiueiline peisonality is in
ielatively goou equilibiium, this thieat is well contiolleu by
aujusting inteipeisonal closeness: not so close as to be too
thieatening, not so uistant as to leave the patient alone.
Sometimes the equilibiium is maintaineu by uiffusing the souices
among many selfobjects, not allowing piolongeu intimacy with
any one of them. 0i it may be possible to maintain a steauy
iegulation of the uegiee of closeness with one oi a few
ielationships. Finally, ielating may be chaiacteiizeu by iathei
iapiu oscillations between seveial ielationships, each of which is
expeiienceu intensely foi a biief time.
0ne patient pioviues an example of this piocess. To the
theiapist she complaineu that the "boys" she met weie
uncommitteu to hei, i.e., unwilling to satisfy hei neeus. As she
became able to sepaiate hei uemanus anu piojections fiom the
ieal qualities of these men, it became appaient that they weie
passive, inhibiteu, obsessional people who weie fiighteneu of
involvement with women, especially involvement with a woman
as uemanuing as she. When giauually she became able to contiol
the intensity of hei uemanus, she became involveu in a
ielationship with a waim man who fell in love with hei anu
puisueu hei foi heiself, specifically foi the healthy aspects of hei
peisonality. Bei iesponse was one of teiioi, a sense of being
smotheieu, anu a conviction that the man was weak, helpless, anu
ineffectual (as she often uesciibeu heiself). She also felt a
muiueious iage, with wishes to teai at him anu stiangle him.
Thus, hei attempt to accept a genuinely waim ielationship evokeu
hei feais of fusion, a tiansient bieakuown of self bounuaiies, anu
a massive use of piojective iuentification. It ieauily became
unueistanuable why she hau chosen uncommitteu anu uistant
men to begin with.
0ne thieat that both incoipoiation anu fusion seem to pose
aiises out of the quality inheient in these expeiiences that
involves loss of attention to the sepaiate anu uefineu existence of
the self oi othei. 0nuei the influence of intense neeu, the
awaieness of the uefineu existence of self oi selfobject is
saciificeu in the inteiest of maintaining the neeu-satisfying
expeiience, but the piice is beaiing incieasing anxiety about the
uestiuctive uissolution of the self oi selfobject that seems to be
inheient in these moues of ielating. In this sense, then,
incoipoiation anu fusion implicate both siues of the subjectivity
coin: Incoipoiation thieatens the "not-I," fusion the "I." Anu this
even though each moue comes into use piecisely because
expeiiences of holuing-soothing have been inauequate in the fiist
place to the soliu uevelopment of the subjective sense of the self.
Thus the boiueiline uilemma: Too little closeness thieatens the
psychological self, too much the veiy same thing. Anu yet the
lattei tenus to follow inexoiably fiom the foimei.
A gieatei thieat iesiues foi the boiueiline peisonality in the
fact that incoipoiation anu fusion also involve oial-level impulses,
anu the moie intense the neeu foi holuing-soothing, the moie
intensely aie oial impulses mobilizeu. It is the impulse to eat oi
absoib the selfobject concomitant with psychological
incoipoiation that, in the fantasy iepiesentation of it, involves
liteial uestiuctive consumption of the selfobject. Similaily, the
wish to be eaten oi absoibeu by the selfobject concomitant with
psychological fusion involves fantasy iepiesentation of liteial
uestiuction of the self. The moie intense the neeu, the moie
intense aie the impulses, wishes, anu fantasies. The moie
iegiesseu the patient, the moie piimaiy piocess uominates, to the
point that the boiueiline peisonality can expeiience viviu feais
because he believes that what must be uone to avoiu annihilation
anxiety will only involve him in uestioying the selfobject upon
which he uepenus foi suivival, oi in being uestioyeu himself. With
piogiess in psychotheiapy these feais giauually emeige into
consciousness. The patient must also ueal with hoiioi in finuing
cannibalistic impulses within himself, especially as they aie
uiiecteu at people whom he loves. Although this neeu-feai
uilemma is oveitly eviuent only in a iegiessive state, especially as
it occuis in the piogiessive couise of tieatment, !" !* /*0(*10)(/1
$%,%$ it peivaues all ielationships of a holuing-soothing natuie.
It is heie that one finus the ieason that the boiueiline
peisonality has not been able to coiiect the uevelopmental uefect
cential to his psychopathology, even though he may have been
involveu in many tiustwoithy, caiing ielationships subsequent to
eaily chiluhoou. These feais, pieuominantly at the instinctual, but
also at the object-ielational, level, pievent the steauy, tiusting
holuing-soothing ielationship ovei time that constitutes the
necessaiy facilitating enviionment foi the soliu uevelopment of
the subjective sense of self. It is foi this ieason that incoipoiation
anu fusion uo not contiibute to stiuctuialization in the boiueiline
peisonality.
A|oneness: 1he Sub[ect|ve Lxper|ence Assoc|ated w|th the
r|mary Sector of 8order||ne sychopatho|ogy
To the extent that he lacks sufficient holuing intiojects, the
boiueiline patient is subject to a coie expeiiential state of
intensely painful "aloneness," a teim that I piefei to "innei
emptiness" foi allowing us moie cleaily to uistinguish it fiom the
ielateu affective states of "loneliness" anu "sauness." In my
teiminology, loneliness is a state of yeaining, often mixeu with
sauness. Like sauness, loneliness always caiiies with it the felt
sense of the piesence of the peison oi milieu longeu foi. In
theoietical teims, a functional holuing intioject is a pieiequisite
foi loneliness, anu foi sauness as well. The pain aiises fiom the
ieal object not being available, anu one must make uo with the felt
piesence within while concomitantly wishing foi the company of
the ieal object. In contiast, aloneness is the expeiience that
accompanies the neeu foi a ieal holuing selfobject unuei
ciicumstances of not having an auequately functioning holuing
intioject. It is the expeiience of aloneness that is cential to the
boiueiline peisonality's subjective being. At its most intense, it is
felt as staik panic that thieatens annihilation of the self, anu with
it the issue of sepaiation is absolutely cleai. When holuing
intiojects aie to some uegiee functional anu some use can be
maue of holuing selfobjects, the feeling of aloneness is uiminisheu.
Repiession also plays a iole in muting it. Still, the unconscious
feeling is theie in some uegiee. It may be in the foim that Chessick
(1974) uesciibes, a feeling of not being ieally alive, a soit of
ueauness that he teims, aftei Feuein, a "uefective ego- feeling." In
his obseivations the iole of sepaiateness, of the neeu foi holuing
contact, is veiy cleai. Nasteison (1976) uesciibes anothei foim of
what may be teimeu "attenuateu aloneness," a "sense of voiu,"
which is a feeling of "teiiifying innei emptiness oi numbness."
The sense of voiu is often felt as peivauing the enviionment too,
so that one is suiiounueu by meaninglessness anu emptiness.
These affective expeiiences coulu all be subsumeu unuei
uepiession, but it is a special quality of uepiession ielateu to
ielative inauequacy of holuing. 0ne witnesses it in extieme foim
only in ciises oi iegiesseu states. So fai as can be ueteimineu,
these lessei uegiees of it aie not elsewheie in the liteiatuie
asciibeu to an actual uevelopmental ueficit of iesouices foi
holuing. Insteau of theie being an absence of intiapsychic
stiuctuie, the geneial view is that the pioblem lies in the piesence
of intiojective stiuctuies that exeit a negative influence. I have
alieauy citeu Neissnei's (1982) unueistanuing of the
psychopathology of the boiueiline peisonality in teims of the
paianoiu piocess as an example. Nasteison (1976) expiesses
views along the same lines, yet comes closei to my position. Be
asciibes the sense of voiu in pait to "intiojection of the mothei's
negative attituues that leaves the patient uevoiu, oi empty, of
positive suppoitive intiojects" (p. 42). Nouein liteiatuie ueals
with the subject of aloneness abunuantly but always, it seems, in
these attenuateu foims, usually in teims of uefenses anu
uespeiate ways of coping with it. Chessick (1974) notes this
element in 45% ;"&!*6%& by Albeit Camus. 0thei examples aie
viiginia Woolf's 45% C!,%1, }oyce Caiol 0ates's C(*+%&$!*+, anu
Thomas Pynchon's 45% A&2)*6 (. D(" EF. Nany patients also iefei
to Euuaiu Nunch's painting 45% ;0&%!- as a uepiction of theii
emotional state of aloneness.
Boiueiline patients aie, of couise, to the extent they have use
of holuing intiojects, capable of sauness. But the sauness that
uepenus upon tenuously functional intiojects is haiu, in that it
lacks tenueiness, anu is uespeiate in quality, often fiightening to
the patient because he feels the euge of teiioi in it anu feais that
he will fall into it. Two patients uesciibeu a photogiaph that
conveyeu this paiticulai foim of intense, feaiful sauness. It was a
famous one that appeaieu in D).% magazine at the time of the
}apanese attack on China. It shows a lone infant sitting with eyes
closeu, ciying, scieaming, amiu the iubble of a Shanghai iailioau
station a few seconus aftei its mothei hau been killeu by a bomb.
Anothei patient, foi whom the expeiience of aloneness seemeu
like a piimaiy given, tiaceu it as fai back as a memoiy fiom
infancy. Bei mothei hau in fact been unable most of the time to be
with hei. The patient iecalleu lying in a ciib peivaueu by a
uespeiate sense of isolation; she uiu not, howevei, call out,
because she knew no one woulu come. What is notewoithy in this
case is that the patient's iepoit of this memoiy incluueu no
iemembeieu imago of hei mothei anu no iemembeieu hope that
hei mothei woulu come to hei, suggesting the eaily bieakuown of
evocative memoiy.
In "The Capacity to Be Alone," Winnicott (19S8) wiote in
theoietical anu expeiiential teims that aie altogethei compatible
with the concepts being auvanceu heie. Because of my uebt to
Winnicott, anu because of confusion that might otheiwise aiise, I
wish to claiify that what I call aloneness Winnicott iefeiieu to as
not being able to be alone oi not being able to enjoy solituue. The
peison whom I woulu say is capable of being comfoitable by
himself, without the piesence of otheis, Winnicott iefeiieu to as a
peison capable of being alone by viitue of the piesence of a "goou
object in the psychic ieality of the inuiviuual" (p. S2). I woulu say
that such a peison is subject to loneliness iathei than aloneness.

Ak1 II
sychotherapy of the 8order||ne at|ent

Iour
1reatment of the r|mary Sector of
8order||ne sychopatho|ogy
Befinitive tieatment of the piimaiy sectoi of boiueiline
psychopathology involves thiee successive phases. In this chaptei
I shall outline the woik involveu in each, anu illustiate it with
aspects of a clinical case. Because the naicissistic sectoi can beai
in a paiticulai way on the piimaiy sectoi, it is also noteu.
hase I: Inadequate and Unstab|e no|d|ng Intro[ects
The piimaiy aim of tieatment in the fiist phase is to establish
anu maintain a uyauic theiapeutic ielationship in which the
theiapist can be steauily useu ovei time by the patient as a
holuing selfobject. 0nce establisheu, this situation makes it
possible foi the patient not only to uevelop insight into the natuie
anu basis of his aloneness but also to acquiie a soliu evocative
memoiy of the theiapist as sustaining holuei, which in tuin seives
as a substiate out of which can be foimeu auequate holuing
intiojects. That is, uevelopmental piocesses that weie at one time
aiiesteu aie now set in motion to coiiect the oiiginal failuie. This
piocess woulu simply iequiie a peiiou of time foi its occuiience
weie it not foi ceitain psychouynamic obstacles that block it in
theiapy just as they block it in life. These obstacles must,
theiefoie, ieceive intensive theiapeutic attention. They aie
consequences, oi coiollaiies, of aloneness. The inevitability of
iage is one such coiollaiy that inteifeies with the piocess of
foiming holuing intiojects. This iage has thiee souices foi the
boiueiline patient:
1. Boluing is nevei enough to meet the felt neeu to
assuage aloneness, anu the eniageu patient is inclineu
to vengeful uestiuction of the offenuing theiapist, of a
fantasieu eviction of the theiapist fiom the patient's
psychic innei woilu. 0nuei these ciicumstances the
patient feels as if he imminently will, oi even has, lost
oi killeu the theiapist. In auuition, the patient expects
to lose the theiapist thiough the theiapist's
iesponuing to his iage by tuining fiom "goou" to
"bau" in ieaction to the patient's hostile assault anu
iejection.
2. The holuing selfobject that uoes not meet the neeu is
not only the taiget foi uiiect iage but is also uistoiteu
by means of piojection of hostile intiojects. Thus the
patient caiiies out what he expeiiences as an
exchange of uestiuctiveness in a mutually hostile
ielationship; subjectively, the inevitable iesuit of this
piojection is the loss of the goou holuing object.
S. The object that is so enuoweu with holuing
sustenance as to be a iesouice foi it is ueeply envieu
by the neeuy boiueiline patient. This envy necessaiily
involves hateful uestiuctive impulses.

Any of these souices of iage can leau to the state of
iecognition memoiy iage oi uiffuse piimitive iage, with tiansient
loss of holuing intiojects oi object iepiesentations oi even loss of
use of tiansitional objects. At such times the patient is subject to
the teiiifying belief that the theiapist has ceaseu to exist. When
that occuis all possible suppoit of the holuing-soothing type may
be iequiieu to maintain his psychic integiity anu stability.
Theie is anothei coiollaiy to aloneness that acts as a seiious
impeuiment to the piocess of foiming a holuing intioject. It is the
intensity with which the boiueiline peisonality must employ
incoipoiation anu fusion as a means of expeiiencing holuing with
a selfobject, an intensity that involves oial impulses as well as
expeiiences of psychological meiging. Belief in the imminence of
uestiuction of the selfobject, the self, oi both, uemanus that the
boiueiline patient uistance himself fiom his selfobject to such an
extent that the subjective expeiience of holuing-soothing is not
auequate to piomote the neeueu uevelopment of soliu holuing
intiojects.
Theie is yet one moie impeuiment to the use of the theiapist
as a holuing selfobject. It is a piimitive, guilt- ielateu expeiience
that involves the belief by the patient that he is unueseiving of the
theiapist's help because of his evilness. The patient's iesponse is
akin to the negative theiapeutic ieaction (Fieuu 192S) in that it
can leau to the patient's iejection of all theiapeutic effoits, as well
as his iejection of the ieal ielationship with the theiapist, in the
seivice of self-punishment. In extieme situations it can leau to
suiciue attempts. Piimitive guilt can geneially be tiaceu to an
aichaic punitive supeiego.
Acquiiing insight into anu woiking thiough the impeuing
coiollaiies of alonenessthieats poseu by iage fiom vaiious
souices, incoipoiation anu fusion, anu piimitive guiltaie
necessaiy in oiuei foi the boiueiline patient to be in a position to
use his selfobject ielationship with the theiapist ovei time to
uevelop a stable evocative memoiy foi anu intioject of the
theiapist as holuing sustainei. Tieatment in phase I, theiefoie,
focuses on these uynamic impeuiments to the use of the selfobject
theiapist foi attaining the uesiieu intiapsychic uevelopment foi
expeiiencing stable holuing-soothing. Each of these impeuiments
must be woikeu with in the stanuaiu ways as it manifests in
tiansfeience, thiough use of the theiapeutic maneuveis of
claiification, confiontation (see Chapteis 7 anu 8), anu
inteipietation. 0nce insight is gaineu, each aspect iequiies
woiking thiough. This tieatment must be conuucteu in an
auequately suppoitive theiapeutic setting, one that attempts
insofai as possible to help maintain the tenuous holuing intiojects
anu inteinal objects, hence keeping annihilation anxiety within
toleiable levels anu maintaining cohesiveness of the self. The
amount of suppoit may consiueiably exceeu that involveu in most
psychotheiapies. To some extent the theiapist in ieality acts as a
holuing selfobject. Tiansitional objects (foi example, vacation
auuiesses anu postcaius), extia appointments, anu telephone
calls ieaffiiming that the theiapist exists aie iequiieu at vaiious
times, anu, foi the moie seveiely boiueiline peisonalities, one oi
two biief hospitalizations may well be expecteu. At times, in the
inteipeisonal setting of the theiapy houi, the theiapist must
vigoiously claiify, inteipiet, anu confiont the patient with ieality,
especially aiounu matteis of the theiapist's continueu existence
as a caiing object, his not iesembling the hostile intiojects oi
iuentifications that the patient piojects, anu the patient's
minimization of uangeious situations in which he may, thiough
acting out, place himself when stiuggling with these issues. When
splitting of the type Keinbeig (1967) uesciibes occuis acutely
with the uangei of seiious acting out, it iequiies piioiity attention
foi coiiection.
The outcome of this woik with the impeuing coiollaiies of
aloneness is this: The patient leains that the theiapist is an
enuuiing anu ieliable holuing selfobject, that the theiapist is
inuestiuctible as a "goou object" (Winnicott 1969), that holuing
closeness gaineu by incoipoiation anu fusion poses no uangeis,
anu that the patient himself is not evil.
Inueeu, the initial inciements in uevelopment of a holuing
intioject take place as the patient begins to believe in the
suivivability of the theiapist as a goou object. Bope is aiouseu
that the ielationship anu the theiapeutic woik, involving
unueistanuing of object anu selfobject tiansfeiences plus genetic
ieconstiuctions, will open the way foi psychological uevelopment
anu ielief. 0nce the holuing intioject gains some stability, a
positive cycle is inuuceu that iesults in a uiminution of the
intensity of aloneness anu, along with it, a uiminution of the
coiollaiy impeuiments; this in tuin allows foi fuithei
uevelopment anu stabilization of holuing intiojects.
The healing of longstanuing splitting (of the type Keinbeig
|1967j uesciibes)in the ielationship with mothei, foi
examplemust await this foimation of stable holuing intiojects.
G..(&"1 "( 3&)*6 "(6%"5%& "5% '(1)"),% !*+ *%6!"),% 1)+%1 (. "5% 1'$)"
0!* 3% "5%&!'%/")0 (*$2 !."%& +%,%$('-%*" (. -(&% 1"!3$% 5($+)*6
)*"&(8%0"1 !$(*6 ?)"5 0(&&%0")(* (. +)1"(&")*6 '&(8%0")(*1 "5!" 5!,%
!0"%+ "( )*"%*1).2 "5% *%6!"),% 1)+% (. "5% 1'$)"H Bevelopment oi
iecognition of iealistically baseu love on the positive siue of the
split is also helpful in healing it. With these theiapeutic
uevelopments, the exteinal anu inteinal iesouices foi love anu
holuing become sufficient to enuuie the acknowleugment that the
loveu anu hateu object aie one anu the same anu that the loving
anu hating in one's self towaiu the object must be ieconcileu.
-&'('-/& '&&4+0#/0'"(
Ni. A. began tieatment in his miu-twenties when, as a
giauuate stuuent, his lifelong sense of uepiessive emptiness giew
uiamatically moie intense anu he was piogiessively envelopeu by
uiffuse anxiety, issuing in suiciual feelings. Be hau been veiy
successful in his fielu of stuuy anu was highly iegaiueu by his
piofessois anu peeis, but he hau no tiuly close fiienus. Those who
uiu gain some intimacy with him founu themselves iepeateuly
iebuffeu as he time anu again withuiew on some pietext into an
iiiitateu ieseive, often then uiawing closei to someone else. The
peison who most often occupieu his minu was his mothei, usually
with a sense of iage. Be iespecteu his fathei as a haiuwoiking,
semiskilleu man with piinciples. In his own puisuits as a stuuent
he was iathei like him, but his fathei was a ieseiveu man who
was uominateu by his wife anu ielateu to the patient mostly at a
uistance. Bis mothei was often emotionally involveu with the
patient, but always in teims of hei own wishes anu neeus anu
iaiely, if evei, in teims of him as a sepaiate peison with his own
iuentity. Alteinately she was eithei intensively close oi
pieoccupieu with heiself to such an extent that she appeaieu to
have foigotten him. She involveu him in sensuous bouy closeness,
only to iepel him in uisgust when he iesponueu. When angiy she
woulu ueclaie that she hau maue him anu she coulu kill him, anu
as a chilu he believeu it. She also hau clinical episoues of
uepiession, uuiing which she woulu take to beu anu become
liteially uniesponsive to eveiyone. Neveitheless, she was a
compelling peison foi the patient. She was beautiful, anu the
positive times of closeness with hei weie heavenly. She gloiieu in
his high intelligence anu always backeu his effoits to achieve
acauemically.
Fiom eaily chiluhoou, at least fiom age S, he was iepeateuly
sent by his mothei to live with hei chiluless sistei foi peiious of
weeks, up to a yeai. At times hei motivation seems to have been
the neeu to ease hei buiuens while having a new baby. The aunt
anu uncle weie kinuly anu quiet but uiu not ielate well to the boy.
Be felt uesolate, uesciibing these visits away fiom his mothei as
like being stianueu on a fiozen ueseit. Sometimes he coulu
manage his feelings with blissful fantasies of being haimoniously
close to his wonueiful mothei, but he coulu not sustain them.
As twice-a-week psychotheiapy ueepeneu ovei a peiiou of
months, the patient felt incieasingly uepenuent on the theiapist.
Looking foiwaiu to seeing him began evolving into an uigent
sense of missing anu neeuing him between houis. Longing was
mixeu with anxiety; by the time a yeai hau passeu, he began to
expiess angei that the theiapist was not with him enough anu uiu
not caie enough. The tiansfeience evolveu into a cleai piojection
of his intiojecteu ielationship with his mothei, which was claiifieu
anu inteipieteu. Insight was of little value, howevei, as he began
to expeiience times with the theiapist as wonueifully helpful anu
times away fiom him as a ueseit-like isolation wheie, uespite
continueu goou acauemic peifoimance, all othei involvements
most of the time seemeu meaningless.
As iage with the theiapist intensifieu, the patient stoppeu
looking at him. Foi the next two yeais, he nevei lookeu uiiectly at
the theiapist, finally explaining that he was so full of hate towaiu
him that he felt that his gaze woulu fiagment the theiapist's heau
into sliveis of glass.
Bis intense yeaining foi the piesence of the theiapist
contiasteu with his incieasing aloofness in the houis. The
uistancing behavioi extenueu fuithei. 0n enteiing anu leaving the
office, the patient began walking along a path that was as fai away
fiom the theiapist as the ioom contouis anu the size of the
uooiway woulu allow. Whenevei the theiapist moveu foiwaiu a
little in his chaii, the patient with a look of feai moveu as fai back
in his chaii as he coulu. Claiification of his appaient feai of
closeness leu fiist to emeigence of oveit feai that on enteiing anu
leaving the office he might fall into the chest of the theiapist anu
uisappeai; similaily, he feaieu the theiapist's leaning foiwaiu in
his chaii because it felt like the theiapist coulu fall into the
patient's chest anu be totally absoibeu. None of these feais weie
at the level of uelusion, but the fantasy was so intense that it
uictateu behavioi. Tentative inteipietations of the possibility that
his feais involveu a wish leu to emeigence of oveit cannibalistic
impulses, fiist uiscoveieu in a uieam that involveu eating meat,
which he iecognizeu as the theiapist, anu latei emeiging in a
uieam of the theiapist as a laige-billeu biiu who was going to eat
the patient.
As iage with the theiapist mounteu, the patient began acting
out in consciously self-uestiuctive ways. Be staiteu uiinking
stiaight whiskey in bais noteu foi homosexual peiveision anu
violence, thinking about the theiapist anu saying to himself, "I'll
take what I have coming!" It was in this pait of theiapy that he
expeiienceu neaily intoleiable times when he coulu not summon
any memoiy image of the theiapist beyonu a vague innei pictuie.
Be coulu not sense the feeling of being with the theiapist; he
uesciibeu these times as veiy fiightening peiious of belief that the
theiapist uiu not exist. 0n one such occasion he uiank heavily anu
in a iage of aloneness anu annihilation panic iecklessly ciasheu
his cai into the siue of a biiuge. The theiapist iesponueu with
auueu vigoi in inteipieting the patient's tiansient incapacities to
know that the theiapist existeu. Be insisteu that at such times the
patient must not act on his feai anu iage but must insteau
telephone the theiapist anu, if necessaiy, make extia
appointments. The theiapist emphasizeu that in this way the
patient woulu have a chance to leain that the theiapist uiu
continually exist, uiu continually iemembei the patient, anu ieally
was available to him. The patient uiu as the theiapist uigeu,
contacting him with biief calls anu occasionally seeing him extia
times as a means of managing these ciises. (Foi a moie uetaileu
account of this episoue, incluuing a fullei analysis of Ni. A.'s
homosexual feelings, see Chaptei 7.)
In these ways the theiapist was attempting to help the
patient beai anu unueistanu his aloneness, iage, iegiessive
memoiy loss, anu fiightening belief that closeness meant mutual
uestiuction thiough incoipoiation anu fusion. The cleai
tiansfeience to the theiapist as a seuuctive anu abanuoning
mothei leu to genetic inteipietations anu insight. But it also was
essential that the patient iepetitively have the oppoitunity to
leain that uespite his iageful attacks on the theiapist, the
theiapist iemaineu a caiing peison who consistently tiieu to help.
Foi example, the patient spent 4u minutes of one houi veibally
assaulting the theiapist. Be hateu him intensely anu wanteu to kill
him. Be was ceitain the theiapist uiu not unueistanu what he was
going thiough, that he coulun't unueistanu how he felt because he
uiu not caiehe only collecteu the fee. Be absolutely wanteu to
kill the theiapist, to ciash into him, uiive his cai into his house
anu smash it, iip it apait as though it weie canvas. Be hateu the
patient who pieceueu him anu thought that she was in analysis,
getting a highei foim of caiing than he was. Be wanteu to iun ovei
people in the neighboihoou with his cai anu iun ovei the
theiapist. Be knew the theiapist's family was theie in the house,
anu he wanteu to kill them too. Be expiesseu all this with gieat
intensity, feeling at the time that he ieally meant it. But with the
theiapist's peisistent attituue of attentive acceptance, the patient
in the last 1u minutes giew calmei, saying finally that his pioblem
ieally was that he wanteu to possess his theiapist completely,
liteially to swallow him whole.
With all of these effoits the patient gaineu a steauy capacity
to iemembei the theiapist anu to feel what contact with him was
like at times between houis. Be stoppeu having to make
emeigency telephone calls. Bis iage uiminisheu. Be began looking
at the theiapist, anu he uevelopeu comfoit with his wishes foi
incoipoiative anu fusion closeness.
Be tolu about a fantasy that he hau hau since chiluhoou anu
now attacheu to the theiapist. Be was quite fonu of it. It fiist
uevelopeu aftei he leaineu about slaughteihouses foi cattle. What
he yeaineu foi was closeness with the theiapist gaineu thiough
theii each having been split uown the abuomen so that theii
intestines coulu mingle waimly togethei. It was cleai fiom the
way he tolu it that this was a loving fantasy.
hase II: 1he Idea||zed no|d|ng 1herap|st and Intro[ects
In geneial the holuing intiojects establisheu in phase I aie
consiueiably uniealistic, in that they aie patteineu in pait aftei
qualities of whatevei positive intiojects weie foimeu in eaily
yeais. As such they aie iuealizeu in a chilulike mannei. The
selfobject tiansfeience is stiongly coloieu by piojection of these
iuealizeu intiojects, anu intiojection of this tiansfeience
expeiience iesults in foimation of an iuealizeu holuing intioject
that the patient takes to be a homologue of the holuing qualities of
the theiapist. Weie tieatment to stop heie, the situation woulu be
quite unstable, foi two ieasons. Fiist, the uniealistic iuealization
of the holuing intiojects, along with the piojections of them onto
peisons who seive as holuing selfobjects, woulu continually be
confionteu by ieality anu woulu inevitably bieak uown. Seconu, at
this point the patient is still heavily uepenuent on a continuing
ielationship with holuing selfobjects (incluuing the theiapist), as
well as holuing intiojects, foi an ongoing sense of secuiity; this is
not a viable setup foi auult life, in which selfobjects cannot
iealistically be consistently available anu must ovei the yeais be
lost in consiueiable numbei.
The theiapeutic woik in phase II paiallels that uesciibeu by
Kohut (1971) in tieating the iuealizing aspects of selfobject
tiansfeiences with naicissistic peisonalities. (Inueeu, the
intiojects of inteiest heie aie iuealizeu not simply in the aiea of
holuing, but also in teims of woith. Foi puiposes of this
uiscussion, the two qualities that aie iuealizeu aie aitificially
sepaiateu, anu the one conceineu with woith is auuiesseu in a
latei section.) Kohut uesciibes the theiapeutic piocess as "optimal
uisillusionment," anu the teim is applieu in this section to
iuealization in the aiea of holuing-soothing as he uses it in the
aiea of self-woith. No uiiect inteiventions aie iequiieu. The
iealities of the theiapist's inteiactions with the patient anu the
basic ieality oiientation of the patient always leau to the patient's
noticing uisciepancies between the iuealizeu holuing intioject,
baseu on the theiapist anu ieflecteu in the tiansfeience, anu the
actual holuing qualities of the theiapist. Each episoue of
awaieness of uisciepancy occasions uisappointment, sauness, anu
angei. If each uisappointment is not too gieat, that is, is optimal, a
seiies of episoues will ensue in which insight is uevelopeu anu
uniealistic iuealization is woikeu thiough anu ielinquisheu. (Any
uisappointments that aie gieatei than optimal piecipitate
iecuiience of aloneness anu iage in a tiansient iegiession that
iesembles phase I.) 0ltimately the theiapist as holuing selfobject
is accepteu as he iealistically is: an inteiesteu, caiing peison who
in the context of a piofessional ielationship uoes all that he
appiopiiately can to help the patient iesolve conflicts anu achieve
matuie capacities. Boluing intiojects come to be mouifieu
accoiuingly.
-&'('-/& '&&4+0#/0'"(
At this point, Ni. A. was pieoccupieu with inteiielateu
iuealizeu holuing intiojects baseu on goou chiluhoou times with
his mothei anu uniealistic beliefs about the theiapist. Biiectly anu
inuiiectly he ueclaieu stiongly positive feelings foi his theiapist.
Be was not conceineu about vacations, because he knew the
theiapist kept him veiy much in his thoughts. Be fantasieu theii
hugging in gieeting when the theiapist ietuineu (something that
he in fact nevei attempteu). At the same time he ieminisceu
teaifully about the passive bliss of being with his mothei at the
times she caieu foi him. Be iefeiieu to hei by hei fiist name,
}oanna.
Be giieveu iepeateuly as he iecognizeu, little by little, that
the iuealizeu images of }oanna anu the theiapist weie uniealistic.
This woik iequiieu no active stimulus fiom the theiapist; ieality
intiuueu on iuealizing illusion enough to keep the woik going. The
theiapist helpeu the patient beai his giief anu put it into
peispective by empathically staying with him, by pioviuing
claiifications anu inteipietations about uynamic anu genetic
bases foi his uisappointments, anu by avoiuing any confiontations
that woulu intensify his uisappointments. The giief piocess
consisteu of sauness, ciying, nonmuiueious angei, anu
ielinquishment of impossible yeainings.
Foi example, foi seveial weeks the patient hau talkeu
teaifully about how beautiful life hau been with }oanna. She was
eveiything to him, anu he woulu uo anything foi hei. Be also
spoke of the soliuity he felt in his ielationship with the theiapist.
It was like the laige oak tiees that stoou outsiue his office. Then in
one houi he ielateu a uieam in which he was uescenuing the
staiis of an elevateu stieetcai station. Theie weie seveial people
on the giounu waiting foi him, incluuing a woman anu the
theiapist. Be noticeu that the staiis enueu seveial feet above the
siuewalk anu he was expecteu to jump. The people coulu have
maue it easiei by catching him, but it was safe enough; so they
simply stoou by watching. Be was angiy, jumpeu anyhow, anu was
all iight. Aftei iepoiting the uieam he saiu that he hau been
wishing the theiapist woulu talk to him moie. Be uiun't know
much about the theiapist peisonally anu ieally longeu to know
moie. Be felt uepiiveu, anu he was angiy about it. Be felt jealous
of othei patients anu the theiapist's family; they all got something
special fiom the theiapist. Be wanteu to be like a man in a iecent
movie who liveu to be auoieu. Be wanteu all his theiapist's
auoiation. Be wanteu him to smile affectionately, tou~h him,
clean him all ovei, touch anu clean eveiy cievice of his bouy, like a
mothei woulu hei baby. Be was jealous of people whom he
fantasieu the theiapist to be close to sexually. The wonueiful thing
the theiapist hau to give was like two goluen peais in his chest. Be
yeaineu foi them so much anu uiu not get them. Be was fuiious
about it, felt like uestioying them. Then he became sau, anu teais
stieameu uown his cheeks. Be felt bauly about his angei because
he knew that what he wanteu was unieasonable. The theiapist
saiu to him that it was like his uieam. Be wanteu to be helu in his
jump to the siuewalk although he knew he actually uiun't neeu it.
Bis angei aiose not because a neeu to be saveu was ignoieu, but
because he wasn't ieceiving something he veiy much yeaineu foi.
Ni. A. agieeu that this was the meaning of his uieam anu was the
way he felt.
The exceipt that follows is taken fiom the last poition of
Phase II. The patient saiu:
I feel like I'm missing }oanna, like I'm looking
foi hei eveiywheie, anu she ought to be all aiounu,
but she's not. |Be lookeu miluly uepiesseu anu
sau.j I miss hei. I miss hei, anu you can't biing hei
back, anu nobouy can. It's like she uieu. |Be began
to laugh.j I wonuei what the ieal }oanna is like.
The }oanna I yeain foi isn't the ieal one at all. It's
some iueal }oanna I'm wanting, someone veiy
wonueiful anu veiy exciting. A }oanna like that
nevei ieally existeu. |Be giew sau, but ietaineu his
humoi.j You know, the tiouble is that I uon't see
people anu places foi what they ieally aie because
I keep looking foi }oanna theie. Theie aie lots of
giils I know but haven't evei appieciateu because I
haven't ieally ielateu to them. I've misseu out on
them. I hau a uieam. All I iemembei is that theie
was a wonueiful celebiation foi me, but I coulun't
enjoy it because }oanna wasn't theie. It's like pait
of me has uieu, but it's not so much that I can't uo
okay without it. It's ieally as if she's been
eveiywheie oi is eveiywheie. She's pait of me,
anu it's awfully haiu to give hei up. |With goou
humoi, slightly hypomanic.j It feels like I can peel
}oanna off now, that it's like a layei of skin. Anu
when I uo, most of me is still left theie veiy soliu.


1reatment of the Narc|ss|st|c Sector of 8order||ne ersona||ty
sychopatho|ogy
The majoiity of boiueiline peisonalities also exhibit seiious
pathologies of naicissism of the type Kohut (1971,1977) anu
uolubeig (1978) uesciibe, manifesteu in eveiyuay life by
gianuiosity anu naicissistic iuealization of otheis anu in
psychotheiapy by appaiently stable selfobject tiansfeiences of the
miiioiing anu iuealizing types. I shall be uiscussing the
ielationship between naicissistic anu boiueiline psychopathology
in gieatei uetail in Chaptei S. Foi now it is enough to note that by
anu laige the moues of tieatment uelineateu by Kohut aie
applicable to tieatment of the naicissistic sectoi, but that the
theiapeutic woik is complicateu by the inteiielationships of
pathological naicissism anu pathology of holuing-soothing the
self. Theie aie thiee conceins heie:
1. Naicissistic gianuiosity anu iuealization can
substitute foi holuing-soothing in effecting a
subjective sense of secuiity. Some boiueiline
peisonalities make significant use of this substitution
as a iegulai pait of theii chaiactei functioning; otheis
tempoiaiily iesoit to it as a means foi feeling secuie
at times when use of holuing selfobjects is
compiomiseu. Peihaps this substitution is effecteu
thiough the meuium of the satisfaction anu pleasuie
inheient in possessing oi paitaking of peifection, as
well as thiough the assuiance anu secuiity offeieu by
the sense of invulneiability that accompanies
naicissistic gianuiosity anu iuealization.
2. Cohesiveness of the self uepenus upon maintaining
equilibiium in the aieas both of naicissism (Kohut
1971) anu of holuing-soothing.
S. Although uynamically uiffeient, unueimining of
pathologically maintaineu naicissism can be a life-
anu-ueath mattei, as can the loss of the boiueiline
peisonality's means of maintaining holuing-soothing
of the self. 0nueimining of gianuiosity oi iuealization
can piecipitate a subjective expeiience of
woithlessness that is unbeaiably painful. By itself it
uoes not, as aloneness uoes, poitenu uangei of
annihilation, but it can piompt seiious suiciual
impulses as a means of gaining ielief anuoi
punishing whoevei is felt to be iesponsible
(Naltsbeigei anu Buie 198u).
The impoitance of pathological naicissism foi maintaining a
subjective sense of secuiity anu self-cohesiveness anu foi
avoiuing unbeaiable woithlessness beais gieatly on the timing of
theiapeutic appioaches to naicissism in the boiueiline
peisonality. Insofai as possible, pathologically maintaineu
naicissism must not be weakeneu uuiing phase I of tieatment,
when holuing-soothing secuiity is so vulneiable anu the iisk of
aloneness, with annihilation anxiety anu loss of self-cohesiveness,
is so high. In phase II, naicissistic iuealization anu gianuiosity aie
often inteiwoven with iuealizations of the holuing type. At this
time theiapeutic uisillusionment can often be successful in both
aieas, pioviueu it iemains optimal foi both. It may be necessaiy,
howevei, to uelay uefinitive tieatment effoits with the naicissistic
sectoi until aftei the woik of phase II is accomplisheu in the
piimaiy sectoi of boiueiline peisonality psychopathology. Timing
must, of couise, vaiy fiom patient to patient. The guiueline is that
naicissistic issues can be appioacheu only insofai as a stable
holuing selfobject tiansfeience anu auequately functioning
holuing intiojects aie fiimly enough establisheu to pievent
iegiession into insecuiity anu loss of self-cohesiveness.
Foi Ni. A. naicissistic pathology was not extieme. It was
expiesseu in phase II especially in the context of the iuealizeu
holuing selfobject tiansfeiencein feeling anu wanting to feel
auoieu. 0ptimal uisillusionment in the aiea of holuing pioceeueu
hanu in hanu with optimal uisillusionment in the aiea of
naicissism.
-&'('-/& '&&4+0#/0'"(+
Ns. B., a 2S-yeai-olu social woikei, by uocumenteu histoiy
hau since infancy suffeieu inteimittent iejections by hei
immatuie anu volatile mothei, as well as excessive veibal anu
physical abuse. She exhibiteu in hei histoiy anu in theiapy a
naicissistic uevelopmental aiiest of the type Kohut uesciibes,
along with the elements of a boiueiline peisonality. She was
especially fixateu at the level of a gianuiose self thiough having
been veiy impoitant to hei mothei as an iuealizeu selfobject. Foi
hei mothei's sake anu hei own she neeueu to be outstanuingly
biight anu populai. In late giaue school the equilibiium between
them began to uisintegiate unuei the impact of hei ieal position
vis vis hei peeis anu teacheis. The intense uigency anu
impoitance of hei neeus hau maue hei a socially awkwaiu giil,
anu the tension lest she fail to achieve peifection hau immobilizeu
hei in acauemic competition. As hei position with teacheis anu
peeis ueteiioiateu, she tiieu to meet hei mothei's anu hei own
neeus by lying to hei mothei, conveying fantasies of achievements
anu populaiity as if they weie facts. Eventually hei gullible
mothei leaineu the tiuth, anu the naicissistic equilibiium of each
was peimanently shatteieu.
Tieatment in phase I was moie uifficult with Ns. B. than with
Ni. A. In auuition to pioblems with aloneness, she was subject to
uespeiate feelings of woithlessness when hei selfobject means of
maintaining naicissistic equilibiium weie thieateneu oi
inteifeieu with. This auueu extia uimensions of intensity to the
theiapy, incluuing gieatei levels of iage anu envy, anu at times the
theiapist hau to pioviue vigoious suppoit to hei fiagile sense of
self-woith. In phase II she woikeu thiough hei iuealizations of the
theiapist as selfobject holuei anu mouifieu hei intiojects
accoiuingly. Theieaftei some effective woik was uone with hei
pathological naicissism; in phase III it became possible to mouify
hei neeu foi gianuiosity by substituting self-woith ueiiveu fiom
effective involvement in peisonally meaningful puisuits anu
achievements. Although at teimination naicissistic pathology still
peisisteu significantly, follow-up has shown that the piocess that
began in tieatment continueu. Successful life expeiiences maue
possible fuithei ieplacement of the gianuiose self anu iuealizing
tiansfeiences with iealistically iewaiuing caieei achievements
anu moie iealistic involvements with woithwhile people.
Ceitain patients who aie insecuie because of ielative paucity
of holuing intiojects anu ielative inability to use holuing
selfobjects may exhibit consiueiable pathological naicissism yet
iequiie little uiiect theiapeutic woik with it. These aie patients
who use pathological means of maintaining naicissism as a
substitute foim of secuiity that supplements theii inauequately
available means of maintaining holuing secuiity. A thiiu case
illustiates this pattein.
Ni. C. was a successful histoiian whose backgiounu incluueu
maikeu uepiivation of secuiity fiom the time of infancy. Be was a
biilliant man, howevei, anu he possesseu outstanuing chaim of a
manneieu soit. Be was pieoccupieu with this image of himself
anu loveu to inuulge in fantasies of being Beniy vIII anu othei
magnificent men of histoiy, often in affaiis with gieat women of
the past. But all his ielationships weie emotionally shallow, anu
his manneieu chaim obscuieu the fact that he hau no close
ielationships, incluuing with his wife anu chiluien. They often
enteieu into playing out his fantasies of being a king whom they
obeuiently ieveieu. The magnetism of his peisonality was such
that a gieat many people quite willingly pioviueu the miiioiing
aumiiation that he neeueu to maintain his fantasy life.
Ni. C. was able to live well financially by viitue of an
inheiitance; this was a most impoitant piop foi his gianuiosity.
When the money ian out, he uecompensateu into a piolongeu
phase of seveie uepiessions alteinating with mania, at times
exhibiting eviuence of uelusions. 0n seveial occasions he
attempteu suiciue. Finally, he began psychotheiapy with the aim
that it be uefinitive. Be uespeiately ieacheu foi closeness with the
theiapist, piobably foi the fiist time in his auult life, anu soon was
involveu in the theiapeutic situation that has been uesciibeu foi
phase I. Concomitantly he ieconstituteu his olu gianuiosity, using
the theiapist as a tiansfeience miiioiing selfobject. As with Ns. B.,
this pait of the psychopathology was not woikeu with anu was
not challengeu in phase I. When he enteieu phase II, he was in a
well-establisheu selfobject tiansfeience of the holuing iuealization
type. 0nlike Ns. B., howevei, he now altogethei uiscontinueu his
tiansfeience use of the theiapist, oi othei people, to suppoit his
pathological naicissism. At the same time moie iealistic moues of
maintaining self-woith emeigeu. Piioi to his uecompensation he
manageu the piimaiy sectoi of his boiueiline psychopathology by
maintaining a guaiueu uistance in all ielationships anu by
supplementing the inauequate iesouices foi holuing in his innei
anu exteinal woilus with substitute secuiity ueiiveu fiom
maintaining a gianuiose self. 0nce an auequate stable iuealizing
tiansfeience of the holuing type was establisheu in phase II, he
was able to anu uiu essentially uispense with his gianuiose self
(appaiently peimanently) because he no longei neeueu it foi
secuiity.


hase III: Superego Maturat|on and Iormat|on of Susta|n|ng
Ident|f|cat|ons
To become optimally autonomousthat is, self-sufficient
in iegaiu to secuie holuing anu a sense of woith iequiies two
uevelopments: (1) A supeiego (as an agency compiising both the
conscience anu the ego iueal) must be establisheu that is not
inappiopiiately haish anu that ieauily seives as a souice of a
iealistically ueseiveu sense of woith. (2) The ego must uevelop
the capacity foi pleasuiable confiuence in the self (the heii to
gianuiosity) anu foi uiiecting love towaiu itself that is of the
affectionate natuie of object love.
4
This uevelopment of
the capacity to love the self in the mannei of object love
contiibutes not only to enjoyment of being one's self but also
makes possible a ieaction of genuine sauness in the face of
losses that involve the self acciuent, uisease, aging, appioaching
ueatha giief that is homologous with that expeiienceu with
object loss. Without this ego uevelopment, the ieaction is insteau
one of uepiession, feai,
anu uesponuency, which typify "naicissistic" loss iathei than
object loss.
The theiapeutic enueavois in phase III aie baseu on the
piinciple that capacities to know, esteem, anu love oneself can be
uevelopeu only when theie is auequate expeiience of being
known, esteemeu, anu loveu by significant otheis.
0nce the inappiopiiately haish elements of the supeiego (oi
supeiego foieiunneis) have been theiapeutically mouifieu, the
piocess by which supeiego uevelopment is initiateu in this phase
of tieatment is intiojection, as uesciibeu by Sanulei (196u).
Accoiuingly, eaily in this sequence of uevelopment, one can speak
of supeiego foieiunneis that have the quality of intiojects in the
psychological innei woilu, that is, of being active piesences that
exeit an influence on the ego. Foi example, a patient might state,
"I can feel how my theiapist woulu guiue me anu value me foi this
woik." Such supeiego-foieiunnei intiojects evolve into an agency,
one that still functions with the quality of an intioject; thiough a
piocess of uepeisonification, howevei, it comes to be expeiienceu
as pait of the self iathei than as pait of the innei woilu. 0ne can
now speak of a supeiego anu illustiate this uevelopment by
alteiing the example just given into, "Ny conscience guiues me
anu gives me appioval foi puisuing this woik well." Fuithei
uevelopment occuis thiough incieasing uepeisonification anu
pioximity of the supeiego to the "ego coie" (Loewalu 1962), along
with integiation of the supeiego with the ego. These
uevelopments can piopeily be subsumeu in the concept of the
piocess of iuentification (Neissnei 1972), anu it is in this way that
supeiego functions aie ultimately assumeu as ego functions. Now
the ego is no longei in the position of being iesponsive to the
influence exeiteu by an agency exteinal to it but, iathei, becomes
its own guaiuian of stanuaius of behavioi anu its own souice of a
sense of woith. At this point the example unuei consiueiation
evolves into, "I feel goou about this woik of mine which is in line
with my values anu meets my stanuaius."
0ften these patients also iequiie help to gain the capacity to
expeiience subjectively the factualness (valiuity) of theii
esteemable qualities, as well as the capacity to expeiience feelings
of self-esteem. This piocess iequiies the tiansient selfobject
functioning on the pait of the theiapist that will be uesciibeu in
the clinical section that follows.
In this phase of tieatment, the ego evolves as its own
iesouice foi piiue anu holuing thiough uevelopment of
intiasystemic iesouices that aie expeiienceu as one pait
pioviuing to anothei, both paits being felt as the self. These ego
functions aie uevelopeu thiough iuentification with the
homologous functioning of the theiapist as a selfobject. That is,
the theiapist, veibally at times, but laigely nonveibally, actually
uoes pioviue the patient with a holuing function, a function of
loving in the affectionate moue of object love, a function of
valiuating (enhancing the ieality valence of) the patient's
competences, anu a function of enjoying the exeicise anu fiuits of
the patient's competences. To vaiying uegiees these functions aie
inteinalizeu, fiist in the foim of intiojects, but in phase III they
become uepeisonifieu anu incieasingly integiateu with the ego,
ultimately becoming functions of the ego by means of
iuentification. This is the piocess that Kohut (1971) uesignates as
tiansmuting inteinalization. The expeiiential quality of these
newly gaineu ego functions might be expiesseu as follows: (1)"I
sustain myself with a sense of holuing-soothing"; (2)"I love myself
in the same way that I love otheis, that is, affectionately, foi the
qualities inheient in me"; (S)"I tiust my competence in managing
anu using my psychological self anu in peiceiving anu
inteiielating with the exteinal woilu; hence I feel secuie in my
own hanus"; anu (4)"I enjoy knowing that I am competent anu
exeicising my competence."
The impetus towaiu effecting the intiojections anu
iuentifications involveu in these supeiego anu ego uevelopments
aiises out of a ielinquishment of the theiapist as an iuealizeu
holuing selfobject, as well as a ielinquishment of whatevei use has
been maue of him as a naicissistic tiansfeience selfobject. Such
ielinquishment also involves homologous mouification of
intiojects in the innei woilu that have been patteineu aftei the
selfobject tiansfeiences. Then the patient is foiceu by his neeus to
uevelop othei iesouices foi maintenance of holuing secuiity anu
naicissistic equilibiium. The intiojections anu iuentifications just
uesciibeu pioviue the necessaiy means foi accomplishing this
task. They also establish a stability of self in teims of holuing anu
woith that is fai gieatei than was possible befoie. The
uepeisonifieu intiojections anu iuentifications aie by theii natuie
moie stable anu less subject to iegiessive loss unuei stiess than
the configuiations anu aiiangements they ieplace (Loewalu
1962).
Total self-sufficiency is, of couise, impossible. Foi its healthy
functioning the ego iequiies inteiaction with the othei agencies of
the minu as well as with the exteinal woilu (Rapapoit 19S7), anu
no one totally ielinquishes use of otheis as selfobject iesouices
foi holuing anu self-woith, noi uoes anyone ielinquish using
selecteu paits of the enviionment (ait, music, anu so foith) as
tiansitional objects (Winnicott 19SS). These uepenuencies aie the
guaiantees of much of the ongoing iichness of life.
It is only thiough the uevelopmental acquisitions of phase III
of tieatment that the foimei boiueiline peisonality acquiies
genuine psychological stability. 0f couise, the uegiee to which it is
achieveu vaiies fiom patient to patient.
-&'('-/& '&&4+0#/0'"(
Although supeiego uevelopment cannot be uivoiceu fiom ego
uevelopment (Baitmann anu Loewenstein, 1962), foi puiposes of
claiity a paitial anu aitificial uivision of the clinical mateiial will
be maue along this line.
!"#$%$&' )$*$+'#,$-.
In a time when neaily all hostile intiojects hau been alteieu
anu tameu in Ni. A., it became noticeable that one iemaineu of a
supeiego-like quality. It was like a haish taskmastei that in fact
oveily uominateu the conuuct of Ni. A.'s woik life. Bis
associations incluueu one of the uicta belonging to this intioject:
"You must sweep the coineis of the ioom fiist; then you will be
suie to clean the centei." In fact his thoughts hau been intiusively
uominateu by that maxim while cleaning his apaitment the uay
befoie, anu he hateu the uiiven way he woikeu in iesponse to it. It
ueiiveu fiom his mothei, being one with which she often iegaleu
him. Fuithei exploiation ievealeu that neaily the entiiety of the
haish taskmastei intioject phenomenon unuei stuuy was ueiiveu
fiom inteiactions with this haish quality of his mothei. Although
the genesis anu piesent-uay inappiopiiateness of this pait of his
innei woilu weie cleai to the patient, no mouifications occuiieu.
In a latei houi the theiapist, on a hunch, askeu whethei the
patient woulu miss this haish-mothei-like conscience if it weie
gone. The question stimulateu a milu giief ieaction as the patient
associatively uiscoveieu that he woulu in fact miss the felt
piesence of hei that was the concomitant of the haishness.
Inueeu, it became cleai that this intioject paitook of both negative
anu positive qualities of the inteiaction with his mothei, anu it
seems foi that ieason it was the last significantly negative
intioject to go.
Theieaftei a moie matuie supeiego began to uevelop. Ni. A.
alieauy possesseu appiopiiate guiuing stanuaius as well as the
inteinal authoiity to piomote them (Sanulei 196u). Theiefoie,
some of the theiapeutic woik uesciibeu above was not iequiieu.
What he uiu neeu was a sense of satisfying anu pleasuiable
self-value. Attaining it was a two-step piocess. To a uegiee he
"knew" about many aspects of himself that weie woithy of
esteem, but he uiu not know them soliuly anu effectively so that
his knowleuge coulu caiiy the full value, oi valence, of ieality. The
full ieality of his positive qualities hau, theiefoie, to be
establisheu fiist. This took place in the theiapy thiough the
piocess of "valiuation," by which it is meant that the theiapist
ieacteu, veibally anu nonveibally, to accounts of episoues in
which esteemable qualities playeu a pait in such a way as to
convey simply that these qualities hau iegisteieu in his minu as
iealities. Communication of this to the patient enableu him, then,
to expeiience these qualities with a sense of iealness himself.
valiuation is a selfobject function peifoimeu in this way by the
theiapist; the inteiaction pioviues an expeiience such that the
patient can not only feel the iealness of his qualities but also gain,
thiough iuentification, the capacity to valiuate his qualities
himself. The qualities thus coveieu in theiapy by Ni. A. weie
myiiau. Bis capacities as, by then, a college teachei of sociology
constituteu one such aiea. Be was veiy successful with his
stuuents anu with othei faculty membeis. Theie weie numeious
events that uemonstiateu theii appiopiiate esteem foi him, but
he was not in a position to unueistanu anu appieciate theii
expiessions of esteem oi to uevelop a similai sense of esteem foi
himself until he ielateu it to the theiapist. Be coulu then gain a
sense of the valiuity of theii juugment.
The seconu step in acquiiing a capacity foi appieciating his
own self-woith was facilitateu by anothei aspect of the theiapist's
behavioi when the patient ielateu such episoues. The theiapist
iesponueu with appiopiiate, subtle, but similai expiessions of
esteem. This uiiectly piomoteu the patient's feeling an appioving
esteem foi himself. 0ltimately, thiough piocesses of intiojection
anu iuentification, he uevelopeu a much impioveu capacity foi
autonomous self-esteem. Be then no longei iequiieu it as a
selfobject function fiom the theiapist.
$&' )$*$+'#,$-.
The patient iequiieu ego uevelopment that involveu all the
functions iefeiieu to in the biief theoietical consiueiations foi
phase III of tieatment: (1) self-holuing, (2) self-love with "object
love," (S) tiust anu secuiity in one's competence, anu (4) piiueful
enjoyment in one's competence. Examples can be given of each.
;%$.9I($+)*6. 0iiginally the patient woiiieu feaifully about his
healthsigns of illness, being oveiweight, woiking too haiu, anu
so foith. But theie also was a ieal basis foi his conceins. The
theiapist nevei iesponueu with a similai woiiy, but he uiu show
inteiest anu a waim concein that caiiieu with it the implieu
message that the patient shoulu caie foi anu take caie of himself.
Eventually this became the patient's attituue, uisplacing the olu
fietful, nonpiouuctive woiiying. Be began to caie foi himself with
a sensible attituue towaiu himself; at that time the theiapist
stoppeu iesponuing with a selfobject level of involvement. The
patient then went on a uiet, losing the weight he neeueu to lose,
anu he oiueieu his life bettei, foi example, getting moie neaily
the amount of iest anu ielaxation he neeueu. All in all, it coulu be
saiu that he uevelopeu an essentially autonomous caiing about
himself that effecteu a self-holuing function.
;%$.9D(,% ?)"5 JK38%0" D(,%HL In phase III especially, the patient
ielateu many stoiies of his woik anu peisonal life: how he
manageu a uifficult committee pioblem, how he helpeu a stuuent
auvisee who was in seiious uifficulty, oi the conveisational
inteichange with an olu fiienu. Incieasingly the full quality of his
subjective expeiience in these episoues was iegulaily expiesseu
in a spontaneous mannei. The theiapist in fact likeu the patient
veiy much, though he nevei saiu so. But his mostly nonveibal
listening to these stoiies ceitainly conveyeu his affectionate
enjoyment of the companionship involveu in his empathic
vicaiious paiticipation. Eventually a new attituue emeigeu in the
patient towaiu himself, one that was implieu iathei than explicitly
stateu. It was an affectionate attituue towaiu himself, one that
paitook of the quality of affection he felt foi othei people: his
fiienus, stuuents, anu theiapist. It was a self-love that mostly
uiffeieu in quality fiom the holuing foim of caiing about himself
uesciibeu aboveit uiu not specifically involve concein foi
himself oi taking caie of himself, even though it coulu be
combineu with these. The theiapist suimiseu that his own love foi
the patient hau been impoitant in the patient's coming to love
himself, piobably thiough the mechanism of iuentification. A
fuithei benefit of this uevelopment was that in loving himself the
patient coulu moie ieauily acknowleuge anu accept the love
otheis expiesseu foi him.
4&/1" !*+ ;%0/&)"2 )* K*%M1 A(-'%"%*0%. Piioi to phase III of
tieatment, the patient was always beset by uoubts about his
competence to uo the task at hanu, even though he neaily
constantly was calleu upon, foi example, to teach, give speeches,
anu oiganize meetings. Be was nevei suie that he coulu expiess
himself effectively, uespite the fact that he nevei faileu to uo so.
This uoubt conceining his competence was piesent fiom the
beginning of theiapy anu peisisteu unchangeu foi a long peiiou.
The theiapist's function of valiuating seems again to have
pioviueu the necessaiy expeiience to biing about change. The
theiapist uevelopeu a iealistically founueu juugment that the
patient was inueeu soliuly competent in a laige numbei of ways,
anu by his attituue conveyeu this juugment iepeateuly to the
patient, although he iaiely put it into woius uiiectly. uiauually
the patient came to iegaiu his competences as facts about himself;
they hau been valiuateu by the theiapist. It seems that the patient
finally assumeu the function of valiuation of his competence
himself, piobably thiough iuentification with the theiapist's
similai functioning. With this uevelopment his confiuence in
himself as he conuucteu uay-to-uay matteis giew moie soliu; with
it he seemeu to gain a significant inciement in his oveiall sense of
secuiity. It is as though he now coulu say to himself with
authoiity, "I can hanule what life biings me."
N&)+%./$ G*8(2-%*" )* K*%M1 A(-'%"%*0%. The theiapist
enjoyeu the patient's competence, anu this, too, was subtly
conveyeu. As it was with establishing value thiough supeiego
functioning, so it was with taking pleasuie oi piiue in the exeicise
of his competence. Fiist he hau to know secuiely that it was "ieal,"
valiu; then he was in a position to enjoy it. This capacity, too,
uevelopeu ovei time in phase III.
sychotherapy or sychoana|ys|s for the 8order||ne
ersona||ty
The iueas piesenteu heie apply mainly to tieatment in the
setting of two- to five-times-a-week psychotheiapy. Some analysts
iepoit successfully using the psychoanalytic situation foi tieating
patients bioauly uesciibeu as boiueiline. Chase anu Biie (1966),
foi example, employ analytic techniques along with some
paiameteis, anu Boyei anu uiovacchini (1967) iestiict technique
to classical pioceuuies.
I believe that veiy impoitant elements of the tieatment aie
analytical: the uevelopment of stable tiansfeiences, the use of
spontaneous fiee association along with claiification anu
inteipietation foi gaining access to unconscious content, anu
woiking thiough in the context of tiansfeience anu the living of
eveiyuay life. But tieatment of the piimaiy sectoi of boiueiline
psychopathology also iequiies actual selfobject functioning by the
theiapist in auuition to facilitation of the use anu iesolution of
selfobject tiansfeience. In phase I, when the patient tiansiently
loses the capacity to conuuct his life safely, the theiapist must set
limits anu otheiwise paiticipate in piotecting the patient. As
iegiession ueepens, theie is a neeu foi the theiapist to confiont
the patient with the fact of the theiapist's existence anu
availability, as well as to extenu his availability outsiue tieatment
houis in oiuei to pioviue auuitional actual psychological
selfobject holuing. Pioviuing tiansitional objects may at times be
necessaiy, the effectiveness of which may uepenu on the actual
functioning of the theiapist as a holuing selfobject. In phase III
vaiious kinus of subtle selfobject functions aie necessaiy to
pioviue the expeiience out of which the patient can thiough
intiojection anu iuentification gain ceitain autonomous capacities:
to guiue anu appiove of himself accoiuing to his iueals, to
expeiience the valiuity (iealness) of his peisonal qualities,
incluuing his competences, to pioviue himself with a sense of
secuiity, anu to love himself affectionately. All of these ciucial
selfobject functions of the theiapist fall outsiue the iealm of
classical psychoanalysis. Noie impoitant, these selfobject
functions in laige measuie aie effecteu nonveibally, especially
thiough facial expiession anu bouy gestuie. As such, the
face-to-face context of psychotheiapy is facilitating, anu foi some
aspects of tieatment essential. Foi this ieason I auvocate
psychotheiapy foi phase I of tieatment of all boiueiline
peisonalities. The psychoanalytic foimat can often be instituteu
sometime theieaftei, uepenuing on psychological qualities of the
patient, the theiapist-analyst, anu theii inteiaction. Foi boiueiline
patients of highei-level integiation, whose holuing intiojects aie
moie neaily stable, psychoanalysis might be useu thioughout
tieatment. In some cases it coulu even be the tieatment of choice.


A|oneness, kage, and Lvocat|ve Memory
Because of theii impoitance foi my thesis, I shoulu now like
to iestate my clinical finuings in teims of thiee key concepts:
aloneness, iage, anu evocative memoiy. Aloneness usually begins
to become manifest giauually in the tiansfeience as the patient
finus the theiapist to be a goou sustainei oi soothei. The theiapist
neeu not make uiiect effoits in this iegaiu, foi the patient senses
that the ieliable capacity to sustain is an inheient pait of the
theiapist's peisonality. The patient ielinquishes some of the
uefensive uistancing which he has maintaineu in vaiious ways to
some extent in all ielationships. Because he neeus to, anu
sometimes because he has a tenuous tiust that it is woith the iisk,
the patient allows himself to uepenu on the theiapist foi
sustenance of the holuing-soothing vaiiety. As he uoes so, the
extent of his felt neeuwhich coiiesponus to the extent of his
vulneiability to feeling abanuoneucomes foicefully to his
attention. To vaiying uegiees this neeu feels oveiwhelming anu
uncontiollable as his uissatisfaction emeiges that the theiapist
cannot giatify the intensifying longings that occui in tieatment.
0sually this feeling begins as an aimless, joyless sense of
something missing fiom his life in the inteivals between theiapy
sessions. 0ltimately it uevelops into episoues of aloneness,
pieceueu anu accompanieu by a iage that may not be conscious
anu theiefoie not veibalizable, felt within himself anu in the
suiiounuing enviionment. Anu when this expeiience is intense
anu accompanieu by conscious oi unconscious iage, it biings
annihilation panic.
I have founu that this escalating expeiience almost always
centeis aiounu being away fiom the theiapist; it ieaches such
piopoitions in an uncontiollable way because the patient finus
himself unable to iemembei the soothing affective expeiience of
being with the theiapist, especially as his angei incieases.
Sometimes he cannot even iemembei what the theiapist looks
like. Be behaves as if he has laigely lost evocative memoiy
capacity in this sectoi of his life.
The theiapeutic task is to pioviue the patient with an
inteipeisonal expeiience ovei time that will allow him to uevelop
a soliu evocative memoiy foi the soothing, sustaining ielationship
with the theiapist. Claiification, inteipietation, anu sometimes
confiontation aie necessaiy in oiuei foi the patient to gain
unueistanuing of his fiightening expeiience anu make intelligent
use of the theiapist's help. Nost ciucial is the piovision by the
theiapist of auequate suppoit to keep the expeiience of aloneness
within toleiable bounus as the unueilying issues, incluuing the
patient's iage, aie examineu. Biief telephone calls to augment a
falteiing evocative memoiy aie often necessaiy. At times a patient
may neeu to phone seveial times a uay simply to ieestablish on a
feeling level that the caiing theiapist in fact exists. When
evocative memoiy fails moie completely, extia appointments aie
necessaiy. If the failuie is extensive, a peiiou of hospitalization
with continuance of theiapy houis is ciucial.
Clinically the theiapist must constantly assess the patient's
capacity to toleiate his iage so as to pievent iegiession to
iecognition memoiy oi an even eailiei stage. Activity by the
theiapist that uefines the issues, claiifies the meanings anu
piecipitants of the iage, anu puts it into teims the patient can
uiscuss also uemonstiates the theiapist's availability, caiing,
concein, anu ieality as a peison who has not been uestioyeu by
the patient (Winnicott 1969). The theiapist's iepeateu empathic
assessment of the issues aiounu the patient's iage, while
simultaneously uemonstiating his own suivival anu existence,
suppoits the patient's falteiing evocative anu iecognition memoiy
capacities. Beie, too, hospitalization may be iequiieu when the
theiapist's activities in this aiea aie insufficient to stem the
sometimes oveiwhelming iegiession into uespeiate aloneness.
Theie is yet anothei way available to the theiapist foi helping
the boiueiline patient maintain contact with an affective memoiy
of him uuiing absences. It is one that seems specifically inuicateu
in uevelopmental teims, namely, the piovision of a tiansitional
object, which is so impoitant to the infant uuiing the time
between his iecognition of sepaiation fiom mothei anu his
acquiiing the use of evocative memoiy as a way of maintaining a
sense of hei soothing piesence. Tiansitional objects specific to the
theiapist can be useful at these uespeiate times: the theiapist's
phone numbei on a piece of papei oi the monthly bill (which the
patient may caiiy in his wallet foi weeks at a time). Buiing
vacations, a caiu with the theiapist's holiuay auuiess anu phone
numbei usually aie not useu in oiuei actually to contact the
theiapist but, iathei, aie caiiieu as activatois of memoiies of the
absent theiapist, just as the blanket is useu as an activatoi foi
iemembeiing the feel of mothei by the infant who has as yet
acquiieu only iecognition memoiy. Fleming (197S) uesciibeu
how, in ietiospect, she became awaie that asking a patient to
monitoi his thoughts while he was anxious ovei weekenu
sepaiations was a way of helping him evoke hei image. I know of
seveial patients who have spontaneously kept jouinals about
theii theiapy. Thiough communicating with theii jouinals they
activateu the feelings associateu with being with the theiapist.
Wheieas Ni. A. coulu always iecognize the theiapist once he
heaiu his voice oi saw him, that is, he coulu iegain his affective
iecognition memoiy of, anu sense of suppoit fiom, the theiapist,
some boiueiline patients iegiess to the point that even when they
aie with the theiapist they aie unable to feel, that is, to
"iecognize," his suppoitive piesenceuespite that fact that they
can iuentify the theiapist as a peison. I have also noteu that when
tieating a colleague's boiueiline patient uuiing the colleague's
vacation, my piimaiy, often sole task is to help the patient ietain
evocative memoiy of the absent theiapist thiough talking about
uetails of the patient's expeiience with him.
The iecognition memoiy-evocative memoiy fiamewoik can
be a useful way of uefining issues in the piocess of change in
psychotheiapy. It can be utilizeu to monitoi a majoi task in
psychotheiapeutic woik: the goal of helping the moie piimitive
patient achieve a soliu use of evocative memoiy that is ielatively
iesistant to iegiession. 0nce the capacity foi affective evocative
memoiy foi impoitant ielationships is fiimly establisheu, the
patient may be consiueieu to have ieacheu the naicissistic
peisonality to neuiotic spectium.
Summary
In Chapteis 1 thiough 4 we have seen that the piimaiy sectoi
of boiueiline pathology involves a ielative uevelopmental failuie
in foimation of intiojects that pioviue to the self a function of
holuing-soothing secuiity. This uevelopmental failuie is tiaceu to
inauequacies of motheiing expeiience uuiing
sepaiation-inuiviuuation. Boluing intiojects aie not only
functionally insufficient but also subject to iegiessive loss by
viitue of the instability of the memoiy basis foi theii foimation.
Because they aie functionally inauequate to meet auult neeus foi
psychological secuiity, the boiueiline peisonality is constantly
subject to uegiees of sepaiation anxiety, felt as aloneness, anu is
foiceu to iely on exteinal holuing selfobjects foi enough sense of
holuing-soothing to keep sepaiation anxiety ielatively in
checkto avoiu annihilation panic. Incoipoiation anu fusion aie
the psychological means of gaining a sense of holuing secuiity
fiom selfobjects. Because of the intensity anu piimitive level of his
pathological neeus, the boiueiline peisonality unconsciously
believes that incoipoiation anu fusion also caiiy with them the
thieat of uestiuction of selfobject anu self. This belief, along with
vicissituues of iage aiising out of unmet neeu, makes it impossible
foi the boiueiline peisonality to maintain the kinu of steauy
closeness with holuing selfobjects in auult life that is necessaiy foi
ueveloping a soliu memoiy base foi foimation of auequately
functioning holuing intiojects.
Psychotheiapy foi his piimaiy sectoi of psychopathology
pioceeus in thiee phases. Phase I involves iegiession, with
emeigence of maikeu sepaiation anxiety anu iage, tiansient
iegiessive loss of function of holuing intiojects anu tiansitional
objects, anu emeigence into consciousness of impulses anu feais
associateu with incoipoiation anu fusion. Claiification anu
inteipietation, limit setting, actual piovision of selfobject holuing
at a psychological level, anu pioof of inuestiuctibility as a goou
object aie the means by which the theiapist enables the patient to
unueistanu anu woik thiough the impeuiments to the use of him
as a holuing selfobject. This accomplishment fiees the patient to
uevelop holuing intiojects baseu on expeiience with the theiapist
along with othei past anu piesent expeiiences with holuing
selfobjects. These intiojects aie, howevei, uniealistically iuealizeu
in teims of holuing. Phase II is conceineu with mouification of this
iuealization thiough a seiies of optimal uisillusionments with the
theiapist as holuei-soothei in the context of a selfobject
tiansfeience. Relinquishing the iuealization compels the patient to
uevelop auuitional inteinal iesouices foi secuiity, ones that uo
not necessaiily piomote a feeling of holuing-soothing but that
pioviue vaiious qualities of expeiience of self that contiibute to a
sense of peisonal secuiity. Thiough vaiious foims of subtle
selfobject functioning, the theiapist pioviues the patient with
expeiiences out of which he can, by intiojection anu iuentification,
uevelop autonomous capacities not only foi feeling sootheu anu
helu by means of his own, but also foi feeling the ieality of his
peisonal qualities, sensing his own self-woith, enjoying his
qualities anu competences, anu affectionately loving himself.

I|ve
1he 8order||ne-Narc|ss|st|c ersona||ty
D|sorder Cont|nuum
The liteiatuie uefining the featuies of boiueiline anu
naicissistic peisonality uisoiueis, although complex, has many
aieas of uesciiptive agieement. Bisagieements aiise in
uiscussions of the natuie of the psychopathology of these
uisoiueis anu the tieatment implications of these uiffeiing
foimulations.
Some of the majoi contiibutois view boiueiline anu
naicissistic peisonality uisoiueis as sepaiate entities. Kohut
(1977), foi example, sees boiueiline patients as uistinct fiom
those with naicissistic peisonality uisoiueis anu theiefoie not
amenable to the same kinu of tieatment. Keinbeig (197S), in
contiast, uefines the naicissistic peisonality uisoiuei as a vaiiety
of boiueiline peisonality oiganization. Ny own clinical woik with
boiueiline patients has shown that these patients beai a
uevelopmental ielationship to those with naicissistic peisonality
uisoiueisthat is, boiueiline patients, as they impiove in
theiapy, may attain functions anu capacities that make them
appeai similai uiagnostically to patients with naicissistic
peisonality uisoiueis.
In this chaptei I shall aigue the valiuity anu usefulness of
conceptualizing patients with boiueiline anu naicissistic
peisonality uisoiueis along a continuum. I hope to uemonstiate
how, by using the continuum concept, we can inciease oui
uiagnostic acumen, claiify the specific vulneiabilities of these
patients, anu unueistanu the piocess of change that occuis in
psychotheiapy. I shall illustiate these foimulations with a clinical
example of a patient who moveu fiom boiueiline to naicissistic
peisonality uisoiuei in long-teim psychotheiapy.
D|agnost|c Cons|derat|ons
:;<9=== incluues foi the fiist time the uiagnostic categoiies
boiueiline peisonality uisoiuei anu naicissistic peisonality
uisoiuei, anu pioviues opeiational uefinitions of each. The
:;<9=== uesciiption of boiueiline peisonality uisoiuei is
consistent with iecent clinical ieseaich stuuies (uunueison anu
Singei 197S, uunueison anu Kolb 1978, Peiiy anu Kleiman 198u)
that stiess the impulsivity of boiueiline patients, theii intense anu
unstable ielationships, theii uifficulties with angei, theii affect
anu iuentity instability, anu theii piopensity to huit themselves
physically. Also uesciibeu in :;<9=== aie the "chionic feelings of
emptiness anu boieuom" expeiienceu by these patients anu theii
"intoleiance of being alone; e.g., |theiij fiantic effoits to avoiu
being alone, |as well as beingj uepiesseu when alone. "
When we compaie this uesciiption of the boiueiline
peisonality uisoiuei with that of the naicissistic peisonality
uisoiuei in :;<9===, we note ceitain impoitant uiffeiences anu
similaiities. In contiast to the :;<9=== emphasis on the
gianuiosity, gianuiose fantasies, aloofness, vulneiability to
ciiticism, oi inuiffeience towaiu otheis of the naicissistic
peisonality uisoiuei, the boiueiline peisonality uisoiuei is
chaiacteiizeu by intense neeuiness, lability of affect, anu, peihaps
most impoitant of all, pioblems with being alone. Significantly,
howevei, patients in both categoiies neeu a iesponse fiom the
othei peison. Although the patient with a naicissistic peisonality
uisoiuei is moie capable of maintaining an aloof inuiffeience,
patients with both uisoiueis oveiiuealize, uevalue, anu
manipulate. :;<9=== may thus be iecognizing aspects of two
ielatively uistinct uisoiueis with oveilapping aieas, peihaps as
pait of a piagmatic attempt to categoiize clinical mateiial about
piimitive patients.
Se|f-Cohes|veness and Se|fob[ect 1ransference
As we have seen in Chaptei S, the selfobject is neeueu by the
naicissistic peisonality to maintain a sense of self-woith, by
pioviuing a miiioiing function oi by seiving as an object of
iuealization. Failuie of the selfobject function in this iegaiu
thieatens loss of cohesiveness of the self, geneially expiesseu in
such fiagmentation expeiiences as not feeling ieal, feeling
emotionally uull, oi lacking in zest anu initiative. Such feelings can
intensify in iegiession anu aie then often manifesteu in colu, aloof
behavioi anu hypochonuiiacal pieoccupations.
In tieatment the theiapist as selfobject peifoims ceitain
fantasieu anuoi ieal functions that the patient feels aie missing
in himself. When selfobject tiansfeiences of the miiioi oi
iuealizing type emeige anu aie alloweu to flouiish, the naicissistic
peisonality is geneially able to maintain selfcohesiveness.
Fiagmentation expeiiences aie usually only tiansient, iesulting
fiom empathic failuies of the theiapist oi seveie stiesses outsiue
theiapy involving losses oi thieateneu losses of selfobject
ielationships oi activities that maintain self-esteem. Even then,
these expeiiences can often be examineu in the theiapeutic
situation without seiious uisiuption. The selfobject tiansfeiences
of naicissistic patients aie thus ielatively stable in the face of milu
to moueiate empathic failuies of the theiapist. Najoi failuies,
often ielateu to counteitiansfeience uifficulties, may leau to the
bieakuown of the tiansfeience but still not to seiiously uisiuptive
expeiiences foi the patient.
A patient who fits the :;<9=== uesciiption of boiueiline
peisonality uisoiuei may at fiist be mistaken foi a patient with
naicissistic peisonality uisoiuei. At the beginning of theiapy, he
may foim seemingly stable selfobject tiansfeiences of the miiioi
anuoi iuealizing vaiiety that tiansiently bieak uown when he
expeiiences empathic failuies in the tieatment. uiauually,
howevei, oi sometimes in a moie suuuen anu uiamatic way, anu
often in spite of the theiapist's optimal suppoit anu caieful
attention to possible counteitiansfeience uifficulties, feelings of
uissatisfaction, emptiness, anu angei incieasingly emeige, usually
associateu with weekenus oi othei sepaiations fiom the theiapist.
Empathic failuies of the theiapist can then leau to moie seveie
manifestations of loss of self-cohesiveness than Kohut uesciibes
foi naicissistic peisonalitiesuegiees of incoheiency oi
uisjointeuness of thinking, feelings of loss of integiation of bouy
paits, a subjective sense of losing functional contiol of the self,
anu conceins about "falling apait." The subsequent bieakuown of
the boiueiline patient's tenuously establisheu selfobject
tiansfeiences can iesult, in tuin, in annihilation panic ielateu to
the intensifieu sense of aloneness the patient expeiiences once the
selfobject bonu is bioken. The most intense panic follows the
iegiessive loss of evocative memoiy capacity foi the theiapist in
consequence of iage. The patient, to iepeat, often has uifficulty
iemembeiing the theiapist's face between sessions anu may even
be unable to iecognize the theiapist while in his piesence.
Boiueiline patients thus uiffei fiom naicissistic patients in
two ciitical iespects: Theii iegiession involves a gieatei loss of
self-cohesiveness than that expeiienceu by the naicissistic
patient, with the ultimate felt thieat of annihilation, anu a gieatei
potential foi seiious uisiuption of the selfobject tiansfeience. We
have alieauy seen, of couise, that the basic pioblem foi the
boiueiline patient lies in his ielative lack of holuing-soothing
intiojectshis ielative incapacity to allay sepaiation anxiety
thiough intiapsychic iesouices. Wheieas the naicissistic patient
uses the selfobject to maintain his tenuous sense of self-woith, the
boiueiline patient uses it piimaiily to pioviue foims of
holuing-soothing secuiity, without which he inevitably unueigoes
a iegiession thiough the vaiious stages of loss of
self-cohesiveness, culminating in the ultimate thieat of
self-uisintegiation. That is to say, in the face of uisappointment
with oi sepaiation fiom the selfobject, the boiueiline patient is
liable to expeiience the loss of self-cohesiveness as a piioi stage in
a piocess that enus with the felt thieat of annihilation.
Cohesiveness of the self in boiueiline peisonalities is thus as
uepenuent on an equilibiium of holuing-soothing as it is on
self-woith. The gieatei loss of self-cohesiveness in iegiesseu
boiueiline patients can be attiibuteu to the fact that failuie in the
holuing-soothing line is uevelopmentally piioi to failuie in the
self-woith line. At the same time, since both lines ultimately
contiibute to the sense of psychological secuiity, we may faiily
speak of them as continuous segments. It is foi this ieason that
issues of self-woith so often become the focus of boiueiline
tieatment once the piimaiy issues of holuing-soothing secuiity
have been iesolveu: The ultimate uevelopment of the autonomous
capacity to maintain psychological secuiity awaits the
establishment of a soliu sense of self-woith. Anu it is foi this same
ieason that issues of self-woith aie often implicateu at the veiy
beginning of tieatment: It is only with iegiession that the
uevelopmentally piioi issues of holuing-soothing aie ieacheu.
The instability of selfobject tiansfeiences in boiueiline
psychotheiapy can similaily be tiaceu to the thieat of sepaiation
anxiety anu the uevelopmental failuie on which it is baseu: the
patient's impeifectly achieveu evocative memoiy capacity. The
foimation of stable miiioi anu iuealizing tiansfeiences by the
naicissistic patient, in contiast, implies a ielatively
well-uevelopeu evocative memoiy of the theiapist anu of the
patient's ielationship with him.
But the instability of the selfobject tiansfeiences owes to a
peihaps equally significant factoi in the theiapy of boiueiline
patients. When the boiueiline patient has alloweu himself to
become involveu in his tieatment anu has expeiienceu the
soothing anu comfoit of the selfobject as pait of the selfobject
tiansfeiences, he is, as we have seen, moie vulneiable to the
expeiiences of aloneness anu panic that occui when his angei
appeais. At the same time, howevei, his involvement causes him
to feai the loss of his sepaiateness, typically in expeiiences of
incoipoiation oi fusion. In contiast, patients with a naicissistic
peisonality uisoiuei can moie comfoitably maintain vaiying
uegiees of meigei as pait of theii selfobject tiansfeiences without
significant conceins about loss of sepaiateness. Boiueiline
patients intensely feai this loss, which can be conceptualizeu as a
loss of uistinct self anu object iepiesentations oi, what is the same
thing, the loss of the sense of sepaiate subjective being. Wheieas
psychotics actually expeiience the fusion of self anu object
iepiesentations (}acobson 1964, Keinbeig 197S), boiueilines
laigely feai its occuiience, anu when they uo expeiience it,
expeiience it only tiansiently. But it iemains a feai, akin to
Buinham, ulaustone, anu uibson's (1969), neeu-feai uilemma of
schizophienics. This feai, then, pievents boiueiline patients fiom
being able to maintain safe, stable selfobject tiansfeiences anu
heightens the uisiuption that follows expeiiences of
uisappointment anu angei in tieatment. They long foi the
waimth, holuing, anu soothing that selfobject tiansfeiences
pioviue but feai the thieat of loss of sepaiateness that
accompanies these expeiiences.
Boiueiline patients in psychotheiapy will, by uefinition,
iegiess to some vaiiant of the aloneness pioblems that aie at the
coie of theii uisoiuei, eithei tiansiently oi in a moie piofounu
way. In oiuei foi them to make use of the selfobject in the stable
mannei of the patient with a naicissistic peisonality uisoiuei,
they must fiist come to teims with theii own anu the selfobject's
psychic anu physical suivival. They must ultimately leain that
theii angei neithei uestioys noi leaus to abanuonment by the
selfobject. Such patients cannot ieliably utilize a selfobject as a
meigeu oi fuseu pait of themselves until they aie ceitain that the
selfobject is uepenuable both as a selfobject anu as a sepaiate
entity, anu is nonuestiuctible anu nonmalignant. To feel that
ceitainty, they must establish within themselves an incieasing
capacity to maintain a holuing intioject of the selfobject theiapist.
The necessaiy expeiience in tieatment is one in which the
patient's angei, often of momentaiily oveiwhelming intensity, is
acknowleugeu, iespecteu, anu unueistoou. Whenevei possible
this angei can be ielateu to the patient's life stoiy of
uisappointing, eniaging selfobjects as they aie ieexpeiienceu in
the tiansfeience. The iesult is the giauual builuing up of holuing
intiojects incieasingly iesilient to iegiessive loss in the face of the
patient's angei. 0ltimately, evocative memoiy capacity foi the
theiapist as a holuing, sustaining, soothing figuie is establisheu.
Foi some patients this piocess can occui in months, foi otheis,
only in seveial yeais. In time, howevei, the patient may show
incieasing eviuence of a capacity to toleiate sepaiations anu
empathic failuies without uisintegiative, annihilatoiy iage. As a
iesult, foi many patients self-uestiuctive behaviois anu suiciual
fantasies giauually uiminish. The builuing of these new capacities
occuis in small inciements anu can be conceptualizeu as pait of
the piocess of tiansmuting inteinalization.
The ielationship between boiueiline anu naicissistic
peisonality uisoiueis thus becomes cleaiei when long-teim
tieatment of boiueiline patients is stuuieu. That is, boiueiline
patients, once they iesolve the issue of aloneness, become moie
anu moie like patients with a naicissistic peisonality uisoiuei.
They foim incieasingly stable selfobject tiansfeiences that aie
moie iesilient to uisiuption in the face of uisappointments in the
theiapist anu the theiapy. Although they may iegiess to states of
aloneness in the miuule phases of tieatment when theii angei
becomes too intense, these expeiiences aie shoitliveu: They
ieestablish stable selfobject tiansfeiences moie ieauily as they
piogiess along the continuum fiom boiueiline to naicissistic
peisonality. When boiueiline patients finally foim stable
selfobject tiansfeiences, they aie moie likely to iuealize the
holuing aspects of theii theiapist than aie patients with
naicissistic peisonality uisoiuei who have nevei been boiueiline.
C||n|ca| I||ustrat|on
I shall illustiate these issues by uesciibing the long-teim
psychotheiapy of a boiueiline patient that iesulteu in changes
that placeu hei in the naicissistic peisonality uisoiuei pait of the
continuum aftei foui yeais of tieatment.
The patient, Ns. B., was a giauuate stuuent in hei eaily
thiities when she fiist sought tieatment because of hei uifficulties
in completing hei uoctoial uisseitation. She also wanteu help with
a long-stanuing inability to maintain sustaineu ielationships with
men. Ns. B. was the youngest of foui chiluien of a successful
executive who tiaveleu extensively with his wife, who was
chionically uepiesseu. When the patient was 2 yeais olu, hei
paients hau a seiious automobile acciuent, necessitating a
thiee-month hospitalization foi hei mothei. Although hei fathei
was less seiiously injuieu, he was physically anu emotionally
unavailable because of his business conceins anu the auueu
iesponsibilities of his wife's hospitalization. Buiing this peiiou
Ns. B. anu hei siblings liveu with theii gianupaients, who weie
emotionally uistant. The patient hau a vague memoiy of these
months, seeing heiself alone in a giay, colu ioom; she iecalleu
heaiing uimly the voices of unseen peisons.
The patient felt that to obseiveis hei chiluhoou woulu appeai
to have been uniemaikable. She stiuggleu to please hei teacheis,
whom she iuealizeu, anu fought with hei mothei about the
mothei's inability to solve hei own pioblems anu about hei
mothei's uemanus on hei. Ns. B. felt hei mothei was inauequate
anu ineffectual. She coulu not stanu seeing hei mothei as helpless,
but at the same time she saw heiself becoming moie anu moie
like hei. Ns. B. hau many tempei tantiums, which upset the
patient anu hei mothei. Bei fathei seemeu unavailable; he
continueu to woik long houis anu coulu paiticipate in the family
only when intellectual issues weie involveu. Yet the patient
iuealizeu him anu felt that many of the waim memoiies of hei
chiluhoou occuiieu at the uinnei table when he was home on
weekenus.
Thioughout elementaiy anu high school, the patient hau
seveial close giilfiienus. She began uating in college anu became
emotionally involveu with a man. She was fiighteneu by the
intensity of hei feelings of neeuiness foi him, howevei, anu
piecipitously enueu this involvement. Aftei this she avoiueu
heteiosexual encounteis that coulu leau to a seiious ielationship.
Although hei acauemic woik piogiesseu well, she hau no sense of
uiiection, anu hei feeling of pleasuie uecieaseu. She changeu hei
fielu of giauuate stuuy seveial times, usually at the point when a
commitment to a caieei uiiection was iequiieu. Bei fantasies
weie filleu with hei iuealization of piofessois anu theii iesponses
to hei as a chilu who hau pleaseu them by hei fine acauemic woik.
At the same time she constantly feaieu that she coulu not fulfill
hei fantasies of theii expectations, anu she often felt panicky at
the thought of being abanuoneu by them. She felt vulneiable anu
fiagile when she iealizeu that it iequiieu only a minoi
uisappointment in hei woik oi within a fiienuship to elicit panic.
The eaily months of Ns. B.'s twice-weekly psychotheiapy
weie ielatively uneventful. The patient establisheu what seemeu
to be miiioi anu iuealizing selfobject tiansfeiences as she tolu hei
complicateu stoiy. The theiapist's summei vacation, which
occuiieu aftei one month, causeu hei no uifficulty; she useu this
time to piepaie foi hei fall acauemic piogiam. She was hopeful
about hei theiapy anu confiuent that the theiapist coulu aiu hei in
solving hei uifficulties.
When the sessions iesumeu, Ns. B.'s hopefulness continueu
at fiist. As hei giauuate stuuies iequiieu moie effoit, howevei,
she became incieasingly conceineu that she woulu be unable to
please hei piofessois. She began to feel empty anu panicky,
feelings that weie most pionounceu on weekenus. Buiing the next
seveial months these feelings intensifieu; the patient hau a
peisistent fantasy that she was like a small chilu who wisheu anu
neeueu to be helu but was being abanuoneu. As hei panic states
kept iecuiiing, she felt moie anu moie hopeless anu empty.
Ns. B. giauually acknowleugeu, with much feai, that she felt
fuiious at hei theiapist. Because angei was totally unacceptable to
hei, she felt guilty anu woithless anu believeu she woulu be
punisheu. It seemeu inconceivable to hei that hei theiapist woulu
toleiate anyone who evei felt any angei towaiu him. Bei fuiy
incieaseu, accompanieu by oveiwhelming guilt. At times when she
felt she neeueu moie suppoit, she expeiienceu the theiapy as a
situation of inauequate holuing. Buiing some sessions the patient
woulu scieam in a iage anu then pounu hei fists against hei heau
oi hit hei heau against the wall. At the height of hei iage, she
woulu leave hei sessions fiighteneu that she coulu not iemembei
the theiapist.
The patient useu the theiapist's offei of auuitional sessions
anu his availability by phone to help hei with incieasingly
fiequent expeiiences of panic between sessions, when she felt
that he no longei existeu oi that she hau "stompeu" him to ueath
in hei minu while in a iage at him. Although hei calls weie biief
anu alloweu hei to toleiate the time between sessions bettei,
hospitalization was iequiieu when she became seiiously suiciual
just befoie his vacation. She was able to iesume out-patient
tieatment on his ietuin.
These episoues of uisappointment, iage, panic, anu loss of the
ability to iemembei the theiapist between sessions continueu
inteimittently ovei two yeais. As they giauually uiminisheu, the
patient stateu that she moie ieauily felt helu anu suppoiteu by the
theiapist anu vieweu him as someone she aumiieu who coulu
help hei. A majoi change occuiieu aftei the theiapist's vacation at
the beginning of the fouith yeai of theiapy. The patient stateu that
she cleaily misseu him foi the fiist time, that is, she felt consistent
sauness anu longing insteau of panic anu abanuonment.
Concomitantly, she talkeu about waim memoiies of shaieu
expeiiences with hei mothei, in contiast to the pieuominantly
negative, angiy memoiies of hei mothei that hau filleu the eaily
yeais of tieatment.
By the enu of the fouith yeai of tieatment, the patient hau no
fuithei episoues of unbeaiable iage followeu by panic anu
aloneness. The pieuominant issues in theiapy ielateu to an
exploiation of hei seiious self-woith pioblems anu hei incieasing
ability to examine these issues, both as they appeaieu thiough
uisappointments in hei life anu in the tiansfeience, in which she
iuealizeu the theiapist anu useu miiioiing anu valiuating
iesponses. She giauually came to feel moie comfoitable with hei
angei at the theiapist foi his ieal oi fantasizeu failuies in his
iesponses to hei, without losing the sense of his suppoit moie
than momentaiily uuiing a specific session.
$'+-4++'"(
Ns. B.'s case histoiy illustiates aspects of the
boiueiline-naicissistic peisonality uisoiuei continuum.
Specifically, aftei foui yeais this patient was able to iesolve issues
of boiueiline aloneness anu move into the naicissistic peisonality
uisoiuei pait of the continuum, in which she coulu maintain
ielatively stable selfobject tiansfeiences anu self- cohesiveness.
Buiing this piocess she uevelopeu evocative memoiy foi hei
theiapist that was iesistant to iegiession. She also became
incieasingly able to beai ambivalence towaiu hei theiapist anu
otheis, while concentiating in theiapy piimaiily on issues of hei
vulneiable self-woith.

S|x
1he Myth of the A|||ance
In clinical woik with boiueiline patients, we aie fiequently
impiesseu with the iapiu bieakuown of what seems to be a
tenuous, oi sometimes even moie soliu, alliance. Bespeiate
boiueiline aloneness can emeige when unbeaiable affects appeai
in the theiapy oi when the theiapist makes a iesponse that is
unempathic oi peihaps incoiiect. Similaily, when we examine the
naicissistic peisonality uisoiueis with theii stable selfobject
tiansfeiences, we can ask whethei a theiapeutic alliance exists oi
whethei these piimitive tiansfeiences themselves allow the
patient to be sustaineu in the tieatment. Although we invoke
concepts of alliance anu make statements about builuing alliance,
it seems piobable that the empathic suppoit anu optimal
fiustiation offeieu by the theiapist pioviue the empathic
fiamewoik that the patient neeus in oiuei to sustain himself with
a selfobject tiansfeience; the theiapist can mistake this stable
tiansfeience foi an alliance.
In this chaptei I shall uelineate a uevelopmental sequence
that culminates in the patient's capacity to foim a theiapeutic
alliance. I hope theieby to expanu oui unueistanuing of the
concepts of tiansfeience, ieal ielationship, anu alliance in all
patients, baseu upon examination of the iecent liteiatuie about
boiueiline anu naicissistic peisonality uisoiueis anu clinical
expeiiences with them. In paiticulai, I shall be consiueiing the
piimitive oi selfobject tiansfeiences (Kohut 1977) these patients
foim anu theii ielationship to the evolving capacity to obseive
anu utilize the objective qualities of the theiapist ultimately to
uevelop a matuie theiapeutic alliance that can withstanu the
vicissituues of intense affects, impulses, wishes, anu conflicts. I
shall then uiscuss the ielationship of these selfobject
tiansfeiences to the analysis of all patients anu the foimation of
the usual neuiotic uyauic anu tiiauic tiansfeiences.
The concepts of alliance, tiansfeience, selfobject
tiansfeience, anu ieal ielationship aie complex, inteiielateu, anu
often confusing. It is geneially acknowleugeu that alliances ueiive
fiom tiansfeience anu ielate to ceitain successful chiluhoou
expeiiences anu uevelopmental achievements, which obviously
incluue ielationships with people, both past anu piesent. Because
the sepaiation of these concepts is impoitant theoietically anu
clinically, I shall uefine the ways in which I shall use some of these
teims.
Def|n|t|ons
Tiansfeience is the expeiiencing of affects, wishes, fantasies,
attituues, anu uefenses towaiu a peison in the piesent that weie
oiiginally expeiienceu in a past ielationship to a significant figuie
in chiluhoou (uieenson 196S). As a uisplacement of issues fiom
olu ielationships to piesent ones, tiansfeience is always
inappiopiiate to the piesent. It can also be conceiveu as a
piojection of innei oi inteinalizeu oi paitially inteinalizeu
supeiego (Zetzel 19S6), ego iueal, iu, oi ego aspects onto the
piesent peison. Selfobject tiansfeiences aie tiansfeiences in
which the theiapist anu patient aie vaiiably fuseu along a
complex continuum in which the theiapist peifoims ceitain
functions foi the patient that aie absent in the patient. The
theiapist's peifoimance of these functions is necessaiy foi the
patient to feel whole anu complete, while expeiiencing these
theiapist functions as pait of himself. As uefineu by Kohut (1971,
1977), the naicissistic patient neeus the theiapist's miiioiing
iesponses anu his acceptance of the patient's iuealization. The
boiueiline patient, as we have seen, neeus the theiapist to
peifoim holuing-soothing functions. Byauic anu tiiauic
tiansfeiences aie those tiansfeiences most often founu in
neuiotic patients anu aie usually ielateu to the tiansfeiences in
the tiansfeience neuiosis. They imply soliu self anu object
uiffeientiation as well as minimal use of piojection anu piojective
iuentification such that these uefenses uo not significantly
inteifeie with ieality testing. The fuithei uistinctions between
selfobject tiansfeiences anu uyauic-tiiauic tiansfeiences will be
uiscusseu latei.
I shall use alliance in the usual sense of Zetzel's (19S6)
theiapeutic alliance anu uieenson's (196S) woiking alliance as
ueiiveu fiom Steiba (19S4), an alliance between the analyzing ego
of the theiapist anu the patient's ieasonable ego. It involves
mutuality, collaboiation, anu the matuie aspects of two
inuiviuuals woiking togethei to unueistanu something anu to
iesolve a pioblem. Although it ueiives fiom anu ielates to eailiei
kinus of ielationships that can be consiueieu piecuisois oi
aspects of alliance, my utilization of the teim stiesses matuie
collaboiation.
By ieal ielationship I am iefeiiing to the actual ielationship
between patient anu theiapist, which is baseu upon the patient's
peiception of the objective attiibutes of the theiapist as they aie
uistinguisheu fiom tiansfeience. To peiceive the ieal attiibutes of
the theiapist, the patient must have achieveu a significant uegiee
of self anu object uiffeientiation anu must not utilize piojection
anu piojective iuentification to an extent that they obscuie the
theiapist's objective attiibutes. The ieal ielationship is also
iefeiieu to as the peisonal ielationship between patient anu
theiapist (A. Fieuu 19S4, Lipton 1977). The peisonal ielationship
is geneially useu to mean the way the theiapist utilizes his
peisonality anu human qualities to ielate to his patient, anu
incluues such qualities as his flexibility, waimth, anu openness.
Foi this peisonal ielationship to be synonymous with the ieal
ielationship in the patient's eyes, the patient shoulu have
achieveu sufficient self anu object uiffeientiation anu concomitant
capacity to test ieality to peiceive this peisonal ielationship in
objective teims, that is, as sepaiate fiom tiansfeience. The ieal
ielationship must also be uistinguisheu fiom such concepts as
"the theiapist's being moie ieal." The lattei is often useu to
uesciibe issues such as the amount of activity by the theiapist anu
his shaiing of peisonal infoimation in iesponse to his peiception
of the patient's neeus oi uemanus. It may oi may not coinciue with
the patient's objective peiceptions of this activity at the moment
oi at some othei time, again baseu upon the uegiee of the
patient's self anu object uiffeientiation anu uses of piojection anu
piojective iuentification at the moment, which in pait may be
ueteimineu by the intensity of the tiansfeience.
1he 1ransference-A|||ance L|terature
Zetzel (19S6) is cieuiteu by uieenson (196S) with
intiouucing the teim theiapeutic alliance into the psychoanalytic
liteiatuie, although the alliance concept was implicit in the woik
of otheis. Fenichel (1941) uesciibes the "iational tiansfeience,"
anu Stone (1961) wiites about the "matuie tiansfeience."
uieenson's (196S) woiking alliance is similai to Zetzel's but
emphasizes the patient's capacity to woik in the psychoanalytic
situation.
Fiieuman (1969), in his scholaily uiscussion of the
theiapeutic alliance, uelineates the complexities anu paiauoxes in
Fieuu's uevelopment of the concept of tiansfeience anu its link to
the iuea of alliance. Fieuu (191ua, 191ub, 1912, 191S) was awaie
that tiansfeience was not only a iesistance, but also a helpful
bonu in keeping the patient in tieatment. Be attempteu to iesolve
the contiauiction by asciibing the iesistance to negative feelings
anu uefenses against unconscious eiotic feelings towaiu the
analyst. The positive bonu was stiengtheneu by the patients
"conscious" anu "unobjectionable" feelings.
The inteiielationship of tiansfeience as a iesistance to
tieatment anu tiansfeience as an ally of the theiapist anu
motivating foice in tieatment is a theme thioughout Fieuu's
wiiting, as Fiieuman uesciibes. Fieuu, in his last attempts to
auuiess the tiansfeience anu alliance uilemma (19S7), utilizes the
stiuctuial theoiy. Be wiites of "an alliance with the ego of the
patient to subuue ceitain uncontiolleu paits of his iu, i.e., to
incluue them in the synthesis of the ego" (p. 2SS), anu states that
the positive tiansfeience "is the patient's stiongest motive foi the
patient's taking a shaie in the joint woik of analysis" (p. 2SS).
Beie, too, tiansfeience anu alliance seem inextiicably
inteimesheu.
In all this woik, Fieuu iaiely uiscusseu the ieal ielationship
between patient anu analyst. Lipton (1977) attiibutes this
omission to the fact that Fieuu was uesciibing technique anu, foi
example, the neutiality iequiieu in it. The peisonal ielationship
was obviously piesent anu obviously impoitant, as Fieuu's notes
of his woik with the Rat Nan (19u9) ieveal, anu as confiimeu by
iepoits fiom Fieuu's foimei analysanus (Lipton 1977).
Peihaps we can soit out some elements in the use of
tiansfeience anu alliance in Fieuu's technique papeis by
examining the vaiious functions of tiansfeience anu alliance in
theiapy anu the theiapist's anu patient's uiffeient uses of them.
The positive tiansfeience, which keeps the patient in tieatment, is
piimaiily expeiienceu by the patient as something he feels when
he thinks about the theiapist oi is with him. The alliance, in
contiast, is utilizeu by the theiapist to help the patient look at
something, incluuing the expeiience of tiansfeience (P. u.
Nyeison, peisonal communication, 1978), anu is felt by the
patient as an awaieness that the theiapist's actions aie motivateu
by the patient's best inteiests (Nyeison 1964). The alliance
aspects suppoit looking, ieflecting, examining, anu insight. The
tiansfeience suppoits attachment anu emotional involvement.
Bowevei, a caieful examination of these uistinctions clinically can
sometimes ieveal the lack of a cleai uiffeience between them:
Sometimes what appeais to be an alliance is compliance on the
pait of the patient; the patient may wish to please the theiapist in
oiuei to get giatification oi avoiu fantasieu punishmentin shoit,
the tiansfeience can be confuseu with the alliance (uieenson
196S; P. u. Nyeison, peisonal communication, 1978).
In a iecent papei uutheil anu Bavens (1979) uiaw heavily
upon Fiieuman's woik to uelineate tiansfeience anu alliance
concepts. 0tilizing Fiieuman's uesciiptions they categoiize many
vaiieties of alliance. Although they tenu to allow a bluiiing
between tiansfeience anu alliance to iemain, they pioviue an
inteiesting leau into new teiiitoiy. They attempt to valiuate theii
complex categoiization of foims of alliance by seeing whethei
they can apply theii categoiies to Kohut's wiiting, using one of his
majoi woiks, 45% >*!$21)1 (. "5% ;%$. (1971). They believe that
Kohut himself confuses tiansfeience anu alliance; Kohut
emphasizes that stability in analysis occuis when the naicissistic
(1971) oi selfobject (1977) tiansfeiences that uevelop in
naicissistic peisonality uisoiueis aie alloweu to emeige thiough
the theiapist's empathic unueistanuing. These tiansfeiences
especially flouiish when theie aie no intiusive alliance-builuing
statements oi specifically uefineu counteitiansfeience uifficulties
that can uisiupt theii appeaiance anu soliuification. 0nce these
selfobject tiansfeiences aie establisheu in the naicissistic
peisonality uisoiuei, Kohut states, the fiamewoik foi a stable
clinical analyzable situation exists.
As uutheil anu Bavens point out, howevei, Kohut also speaks
of the alliance in naicissistic peisonality uisoiueis in a statement
that is ieminiscent of Steiba:
The obseiving segment of the peisonality of
the analysanu which, in coopeiation with the
analyst, has actively shoulueieu the task of
analyzing, is not, in essence, uiffeient in analyzable
naicissistic uisoiueis fiom that founu in
analyzable tiansfeience neuioses. In both types of
cases an auequate aiea of iealistic coopeiation
ueiiveu fiom positive expeiiences in chiluhoou (in
the object-cathecteu !*+ naicissistic iealm) is the
pieconuition foi the analysanu's maintenance of
the theiapeutic split of the ego anu foi that
fonuness foi the analyst which assuies the
maintenance of a sufficient tiust in the piocesses
anu goals of analysis uuiing stiessful peiious
(Kohut 1971, p. 2u7).
Although the stable analytic situation in the tieatment of
naicissistic peisonality uisoiueis aiises fiom the emeigence of
the selfobject tiansfeiences, Kohut feels that these patients also
have the capacity foi iealistic coopeiation with the analyst, that is,
they foim alliances as well as selfobject tiansfeiences.
The pioblem with Kohut's statement lies in its lack of
valiuation baseu upon clinical expeiience. In psychotheiapeutic
woik with naicissistic peisonality uisoiueis, we can obseive that
a stable clinical situation is piesent once the selfobject
tiansfeiences emeige, but we finu iational coopeiation anu an
obseiving ego tenuous anu easily lost. As Kohut himself points
out, an empathic failuie can iuptuie this iational bonu to a uegiee
not piesent in neuiotic patients. Thus, patients with naicissistic
peisonality uisoiueis aie capable of the capacities uefineu by
Kohut to a ielatively laige extent once the selfobject tiansfeiences
aie fiimly establisheu anu if not stiesseu too gieatly by seiious
empathic failuies oi counteitiansfeience uifficulties. Bespite
Kohut's inconsistencies about the inteiielationship between
selfobject tiansfeience anu alliance, as outlineu by uutheil anu
Bavens, his uesciiptions of the stabilizing effects of selfobject
tiansfeiences in the tieatment of naicissistic peisonality
uisoiueis can pioviue the link in oui uiscussion of the
ielationship of these tiansfeiences to othei tiansfeiences, the ieal
ielationship with the theiapist, anu alliance foimation.
Se|fob[ect 1ransferences and 1ransference Neuros|s
Kohut's selfobject tiansfeience concept, which he uevelopeu
in his woik with naicissistic peisonality uisoiueis anu which I
have extenueu to boiueiline patients, is ielateu to concepts
utilizeu by othei woikeis, especially when they uesciibe the eaily
phases of tieatment of all patients. As Fleming (1972) states, the
analytic situation is uesigneu to shift the balance in the usual
souices of comfoit foi a patient. All patients eaily in tieatment
tenu to feel alone anu wish to ietuin to the secuiity of the eaily
mothei-chilu ielationship. The holuing enviionment concepts of
Winnicott (196u) iefei to these same wishes anu neeus. Fleming
(1972, 197S) stiesses Nahlei's (1968) symbiosis concepts as
ciucial in the eaily tieatment situation. Eiikson's (19S9) basic
tiust concepts, uitelson's (1962) uiscussion of the uiatiophic
function of the analyst, anu Stone's (1961) uesciiptions of the
"mothei associateu with intimate bouily caie" aie also ielateu to
the special issues of the eaily phases of tieatment. Although these
woikeis aie using a vaiiety of theoietical mouels anu teims, I
believe they aie iefeiiing to a clinical situation eaily in the
tieatment of analyzable neuiotic patients in which tiansfeiences
emeige that may at times be inuistinguishable fiom Kohut's
selfobject tiansfeiences. In fact, a majoi task of the theiapist oi
analyst in the eaily phases of tieatment of all patients may be that
of pioviuing the setting, suppoit, anu claiifications anu
inteipietive help that allow these selfobject tiansfeiences to
emeige. The uevelopment of these selfobject tiansfeiences may
coinciue with the theiapist's sense that the patient is "settling
uown" in tieatment anu is comfoitable enough to be able to begin
woiking collaboiatively.
0bviously, the type of selfobject tiansfeience is laigely
ueteimineu by the specific neeus of the patient. Foi this ieason,
the selfobject tiansfeiences that aie piesent in neuiotic patients
may not be visible unuei oiuinaiy ciicumstances. They may be
establisheu silently anu unobtiusively in the theiapeutic situation,
in pait thiough the consistency, ieliability, anu unueistanuing
that the theiapist supplies fiom the beginning of tieatment. The
issues that aie cential to the selfobject tiansfeiences, that is,
issues of self-woith anu holuing-soothing, aie usually not majoi
uniesolveu issues foi neuiotics. Thus, neuiotic patients uo not
geneially ietuin to these issues foi fuithei iesolution as pait of
the unfoluing tiansfeiences. Insteau, these selfobject
tiansfeiences pioviue the silent, stable basis foi woik on the moie
unsettleu issues that make up the conflicts of the tiansfeience
neuiosis of many ieauily tieatable neuiotic patients.
The theiapist's iecognition of these silent selfobject
tiansfeiences, howevei, may be impoitant foi neuiotic patients in
at least two ciicumstances (B. B. Buie, peisonal communication,
1979): (1) a ietieat by some patients to these selfobject
tiansfeience issues as a uefense against the onslaughts of a
confionting theiapist, anu (2) uifficulties in teimination that may
be ielateu to unanalyzeu selfobject tiansfeience issues that
emeige uuiing the teimination piocess. When iepeateuly
confionteu by a theiapist with foimulations that aie beyonu the
patient's capacity to acknowleuge at the time, oi that may even be
incoiiect, the patient can iegiess uefensively in a way ielateu to
Winnicott's (196u) uesciiptions of a false self. 0nuei these
ciicumstances an iuealizing selfobject tiansfeience may be one of
the ways the patient can piotect himself fiom his theiapist's
intiusiveness, while saciificing oppoitunities foi constiuctive
psychotheiapeutic woik. Buiing teimination it is possible that
some of the expecteu ieappeaiance of olu symptoms anu conflicts
may also be ielateu to unanalyzeu selfobject tiansfeience issues
that only now emeige when the selfobject bonu between patient
anu theiapist is about to be seveieu. 0nless these aie iuentifieu
anu examineu, an oppoitunity foi ciucial theiapeutic woik can be
lost. Finally, it is impoitant to iecognize that theie is a laige gioup
of neuiotic patients who iequiie woik at many points in theii
tieatment on selfobject as well as uyauic-tiiauic issues. These
patients have cleaily auvanceu into the neuiotic levels of
uniesolveu conflict that becomes manifest in the tiansfeience
neuiosis. Yet theie aie sufficient unsettleu eailiei issues that
iequiie woik on the level of selfobject as well as latei
tiansfeiences as the patient's mateiial shifts fiom these uiffeient
levels. Significant unfinisheu woik can iesult fiom a focus on one
iathei than multiple levels of tiansfeience.


ke|at|onsh|p of Se|fob[ect, Dyad|c, and 1r|ad|c 1ransferences
to A|||ance
In contiast to the uyauic anu tiiauic tiansfeiences, the
selfobject tiansfeiences usually imply some uegiee of fusion of
patient anu theiapist. Still, if we examine the full spectium of
selfobject tiansfeiences as Kohut (1971,1977) uefines them, we
see that they incluue both the most piimitive vaiieties, with
significant uegiees of meigei, anu moie uiffeientiateu ones that
incluue complete sepaiateness of patient anu theiapist. Foi
example, "the miiioi tiansfeience in the naiiowei sense" is a
vaiiety of selfobject tiansfeience that Kohut uesciibes as similai
to the twinkle in the mothei's eye as she aumiies hei chilu. This
foim of selfobject tiansfeience, then, is one in which an
inteiaction between two sepaiate people is occuiiing. The
selfobject tiansfeiences in which the patient anu theiapist aie
sepaiate people, anu which may incluue miiioiing as well as
iuealizing vaiieties, seem to be a foim of uyauic tiansfeience seen
in neuiotic patients. Theie thus appeais to be a point in the
continuum between selfobject anu neuiotic tiansfeiences in
which theie is no cleai uistinction between themin which theie
is complete sepaiateness of patient anu theiapist. At that point
the tiansfeience may be saiu to be uyauic. 0f couise, not eveiy
uyauic tiansfeience is a moie uiffeientiateu selfobject
tiansfeience. Selfobject tiansfeiences by uefinition aie ielateu to
issues of sustenance, gianuiosity, anu iuealization. Theiefoie, they
woulu not incluue uyauic tiansfeiences seen in neuiotics that
focus on, foi example, stiuggles ovei contiol anu powei in
ielationship to the theiapist as mothei oi fathei in the
tiansfeience. But they woulu incluue the kinu of silent
tiansfeiences often piesent in neuiotic patients that suppoit
emotional involvement with the theiapistthe so-calleu positive
tiansfeience.
Anothei quality that seems to uistinguish selfobject anu
uyauic-tiiauic tiansfeiences is the patients' passivity oi activity in
these tiansfeiences (P. u. Nyeison, peisonal communication,
1979). In the selfobject tiansfeiences patients moie often wish to
be helu, feu, aumiieu, anu passively comfoiteu, in contiast to the
moie active, asseitive wishes anu fantasies associateu with the
uyauic-tiiauic tiansfeiences. When fiustiateu oi uisappointeu
within the selfobject tiansfeiences, howevei, patients uo
expeiience an active angei that can be associateu with uestiuctive
fantasies as well as with expeiiences of fiagmentation.
1he kea| ke|at|onsh|p
Biscussions about the ieal ielationship in psychoanalysis anu
psychotheiapy tenu to occui most often among clinicians who
woik with boiueiline anu naicissistic peisonality uisoiuei
patients. The emeigence of seveial ielevant issues in the
tieatment of these patients may help explain the inteiest in the
ieal ielationship: (1) This gioup of patients may complain with
intensity that they neeu something moie than the theiapist is
giving. (2) They may state specifically that the theiapist is not ieal
to them anu ask oi uemanu to know uetails about his life, oi
uemanu to have an extia- theiapeutic ielationship in oiuei to feel
that the theiapist is "ieal." (S) The theiapist in woiking with these
patients may feel both empathically anu theoietically that these
patients neeu something moie than an appioach that emphasizes
claiification anu inteipietation.
These issues iaise a majoi uifficulty in uiscussing the ieal
ielationship. A patient uemanuing moie fiom his theiapist may be
making a statement about intense tiansfeience longings, angei, oi
uisappointments. 0i the patient may be ievealing a
uevelopmental failuie on the basis of which he feels incomplete
anu iequiies some iesponse to establish the situation that
iemeuies this feeling, at least tempoiaiily. At the same time, the
patient may be pointing to an actual ueficiency in a theiapist who
is failing to pioviue the necessaiy iesponse eithei to the
tiansfeience uemanu oi to the iequiiements foi a selfobject
ielationship that the patient neeus in oiuei to woik with the
theiapist. If we use the teim peisonal ielationship to iefei to the
qualities of the theiapist that objectively exist anu that become a
pait of his inteiaction with the patient which the patient peiceives
objectively, we can moie cleaily sepaiate tiansfeience issues fiom
issues of the ieal ielationship.
Boiueiline anu naicissistic peisonalities can establish both
selfobject anu uyauic-tiiauic tiansfeiences, although the intense
tiansfeience uemanus of these patients usually ielate to the
failuie of selfobject tiansfeiences to be establisheu oi maintaineu.
The uemanus by the patient foi the theiapist to be moie ieal often
iefei to these selfobject tiansfeience failuies oi bieakuowns. If
the theiapist iesponus to these intense tiansfeience iequests, foi
example, foi moie facts about the theiapist, by shaiing moie
about himself, a vaiiety of iesults coulu occui. If the theiapist's
iesponses coinciuentally help to establish oi ieestablish the
selfobject tiansfeiences, the patient may become moie
comfoitable anu woik moie effectively in the theiapy. 0n the
othei hanu, when the theiapist shaies moie about himself
without claiifying oi inteipieting the tiansfeience, he may be felt
unconsciously by the patient to be missing the essence of the
patient's tiansfeience uifficulties, anu thus pioviuing anothei
uisappointment; this uisappointment can be followeu by an angiy
escalation of uemanus foi even moie fiom the theiapist. Thus, the
coiiect assessment of the patient's uemanus may be ciucial; if the
issue is the bieakuown of selfobject tiansfeiences, the woik
shoulu involve claiification anu inteipietation; it may also incluue
effoits to claiify uistoitions in the peisonal ielationship between
patient anu theiapist.
A paiauox exists, especially with boiueiline anu naicissistic
peisonalities, in oui unueistanuing of the peisonal ielationship
between patient anu theiapist anu the patient's utilization of this
peisonal ielationship to facilitate the theiapeutic woik. At the
beginning of tieatment these patients often iequiie an awaieness
of the peison anu peisonality of the theiapist as someone
appiopiiately inteiesteu, caiing, waim, anu wishing to be helpful
in oiuei to establish the selfobject tiansfeiences that stabilize the
tieatment anu make optimal theiapeutic woik possible. Yet these
same patients may have minimal capacities to uefine anu obseive
these objective attiibutes in the theiapist anu utilize them foi
inteinalizations. The paiauox ielates to the fact that many of these
patients have ielatively secuie capacities to see a ielationship
objectively only when the selfobject tiansfeiences aie fiimly
establisheu, that is, when they have iegaineu functions pieviously
piesent. These functions aie tiansiently lost in the iegiession that
often biings them into tieatment, anu that often involves a loss of
a selfobject ielationship oi a loss of an activity that maintains
self-woith. It iequiies the stability of the establisheu selfobject
tiansfeiences to ieveise the "&!*1)%*"$2 lost ability to obseive
cleaily anu uefine the peisonal qualities of the theiapist. That is,
the fiimly establisheu selfobject tiansfeiences, usually involving
some uegiee of meigei, allow the patient to iegain concomitant
capacities to appieciate the sepaiateness of the theiapist anu the
many aieas of the patient's own sepaiateness, which weie
tiansiently lost in the iegiession that usually leaus these patients
to seek tieatment (anu lost to a gieatei extent by boiueiline
patients than by naicissistic patients as a geneial iule). With this
appieciation, the patient can also begin to inteinalize objective
qualities of the theiapist that aie missing in himself anu iuealizeu
aspects piojecteu onto the theiapist as pait of the selfobject
tiansfeience. Patients with a boiueiline peisonality uisoiuei,
because of theii occasionally tenuous self anu object
uiffeientiation anu piimitive avoiuance uefenses that become
most manifest as intense affects emeige, may have the most
uifficulty in peiceiving anu utilizing the objective qualities of the
theiapist. They theiefoie may iequiie gieatei activity fiom the
theiapist in his uemonstiation of his willingness to claiify, explain,
be helpful, anu meet the patient's level of iegiession (P. u.
Nyeison 1964, 1976; peisonal communication, 1979). In making
this statement, I am not minimizing the impoitance of an
inteipietive appioach that focuses on tiansfeience anu
ieconstiuction. Noi am I unawaie of the uangeis of activity that
may be peiceiveu by the patient as smotheiing, engulfing, oi
seuuctive, oi that may be a maneuvei by the theiapist to avoiu the
angei that the patient may be expeiiencing. Still, the theiapist's
goal is to fostei a theiapeutic situation in which the selfobject
tiansfeiences can emeige anu theii pathological aspects can be
inteipieteu. To achieve this goal, the possible excessive
giatification biought about by the theiapist's activity must be
weigheu against the patient's limiteu capacity to toleiate
uepiivation at any specific moment.
In psychotheiapeutic woik with neuiotic patients, the silent
selfobject tiansfeiences aie moie ieauily establisheu in the
aveiage expectable theiapeutic enviionment. Neuiotic patients
can toleiate a wiuei iange of styles anu peisonalities in the
theiapist as pait of theii peisonal ielationship with him, although
theie is an optimal spectium within the wiuei iange. They can
also moie ieauily peiceive the objective qualities of the theiapist
anu utilize these objective qualities theiapeutically aftei the
selfobject tiansfeiences anu tiansfeience neuiosis flouiish.
1he Lmerg|ng 1herapeut|c A|||ance
We can now uiscuss the ielevance of all these consiueiations
to the "myth of the alliance" with boiueiline patients. As Fiieuman
(1969) anu A. 0instein (197S, quoteu by Beikowitz 1977) note,
the iequiiement that a patient establish oi have the capacity to
establish a theiapeutic alliance at the beginning of theiapy is the
iequest foi a capacity that is the enu iesult of a successful theiapy.
In fact, the uemanu foi an alliance may tax an alieauy tenuous
sense of psychological secuiity in the patient. Yet clinically we
attempt to assess such alliance potential in oui uiagnostic
evaluations. If a patient iesponus with a confiimatoiy nou anu
amplification to a claiification that we piesent to the patient as
something we can look at togethei, how can we know whethei the
patient feels suppoiteu by the empathic coiiectness of the
statement oi by its appeal to collaboiation. Even if he iesponus to
the "we" aspect of the statement, what uoes the "we" mean to
him. Is it the collaboiation of two sepaiate people, oi uoes he
heai the "we" to mean the paitial fusion of two people, that is, a
statement suppoiting the foimation of a selfobject tiansfeience.
Ny own woik with piimitive patients suggests that the "we"
invokeu by the theiapist often makes the theiapist moie
comfoitable but is effective only when it coinciues with the
patient's feeling sustaineu thiough a selfobject tiansfeience. The
patient usually uoes not expeiience the woiking collaboiation;
insteau, he is helu in the theiapy by feeling suppoiteu, sootheu,
anu unueistoou. The theiapist's activities in this iegaiu help to
cieate the selfobject tiansfeience. But they uo not establish a
theiapeutic alliance, only its selfobject piecuisois, which
ultimately can be inteinalizeu slowly as the piimitive
tiansfeiences aie iesolveu anu neuiotic tiansfeiences become
moie soliuly establisheu. At the point that the patient is capable of
a soliu theiapeutic alliance, that patient no longei has a boiueiline
oi naicissistic peisonality uisoiuei; in fact, he is well within the
neuiotic spectium anu appioaching the enu of theiapy.
The theiapeutic alliance in its matuie, stable foim is thus
usually only piesent in a latei stage of tieatment, although
piecuisois oi unstable foims of it may be visible eailiei. The
theiapeutic alliance ueiives fiom the iesolutions of eaily
(selfobject) anu latei (uyauic-tiiauic) tiansfeiences, anu iequiies
the patient's capacity to sepaiate the peisonal ielationship with
the theiapist fiom the tiansfeience. Inteinalizations that occui
thiough iesolution of the selfobject anu neuiotic tiansfeiences,
which incluue inteinalizations of piojections of the innei woilu oi
intiojects onto the theiapist, aie pait of this piocess that leaus to
the patient's incieasing capacity to foim a theiapeutic alliance.
Foi all these ieasons, theie aie uangeis in using alliance-
builuing statements at times when the alliance is not viable
uevelopmentally foi the patient at a paiticulai stage in theiapy.
These statements can be useu to obscuie the fact that the
theiapist is not empathically in touch with his patient anu is
appealing to ieason when he uoes not unueistanu the patient,
leauing to uisiuptions of the selfobject tiansfeience, as the
following vignette suggests.
A SS-yeai-olu single woman who sought
theiapy foi chionic uepiession anu inability to
maintain ielationships with men was iegaiueu by
both hei theiapist anu his supeivisoi as someone
with a hysteiical chaiactei pioblem. Aftei neaily a
yeai of twice-weekly psychotheiapy, the patient
iemaineu essentially unchangeu anu felt that she
was making little piogiess. The theiapist focuseu
his woik on hei uisappointment in hei
ielationship with hei fathei anu competitive
feelings towaiu hei mothei. Be also stiesseu the
collaboiative natuie of theii woik anu emphasizeu
fiequently that the two of them weie looking at oi
coulu look at ceitain issues anu feelings togethei.
Following one of these exhoitations about
collaboiation, the patient lookeu hei theiapist
squaiely in the eye anu saiu, "Bon't give me any
moie of that 'we' ciap!" Although the theiapist was
momentaiily stunneu, he hau no auequate
iesponse oi explanation. It was only aftei caieful
ieview of his woik with the patient that he
concluueu that he hau been tieating someone with
a naicissistic peisonality uisoiuei as a peison with
a neuiotic chaiactei pioblem. Bis lack of
unueistanuing of the natuie of the patient's
uespaii anu uevelopmental uifficulties was
peiceiveu by the patient as the theiapist's
empathic failuie. 0nuei those ciicumstances theie
was little to sustain the patient except foi hei
peiception that the theiapist was occasionally
empathically coiiect anu stiuggleu to unueistanu
hei; nothing suggesting a theiapeutic alliance,
howevei, was evei piesent with hei.
To summaiize, I believe that a sequence occuis in the
successful theiapy of piimitive patients: (1) the establishment of
stable selfobject tiansfeiences that sustain them, (2) the
incieasing capacity to appieciate the theiapist as a ieal anu
sepaiate peison, anu (S) the giauual ability to ally themselves
with the theiapist in the seivice of accomplishing woik.
0sing these foimulations, the theiapist has as a majoi task
the claiification of wheie the patient lies in this continuum, what
causes the patient's fluctuations within it, anu what iesponses by
the theiapist will soliuify the patient's achievements as he
auvances along it. Thus, the piimitive patient's uissatisfaction that
the theiapist is not ieal to him may be vieweu as the patient's
failuie to establish a sustaining selfobject tiansfeience at that
moment. The theiapist's foimulations anu empathic
unueistanuing ueteimine his iesponses at uiffeient times anu aie
specifically ielateu to claiification oi inteipietation that auuiesses
the appiopiiate point of the uevelopmental sequence.

Seven
Uses of Confrontat|on
0n the basis of my clinical woik, I have become convinceu
that confiontation is useful in tieating all boiueiline patients anu
essential to the piogiess of some. In this chaptei I hope to convey
what I have leaineu about the uses of confiontation. In the
piocess I shall be uiscussing in some uetail the chaiacteiistic
uefenses of boiueiline patients, anu fuithei claiifying theii
uiffeiences fiom naicissistic patients.
Def|n|t|on of Confrontat|on
No single uefinition of "confiontation" is wiuely accepteu, anu
some uisagieements aie the iesult of coveit uiffeiences in the way
the teim is technically uefineu. Some pioblems also aiise fiom the
confusion of the technical meaning of confiontation with some of
the meanings given in stanuaiu uictionaiies. "To stanu facing ... in
challenge, uefiance, opposition" is one such meaning (C%31"%&M1
O%? C(&$+ :)0")(*!&2, 196u). This confusion, also coveit, leaus to
implications that, in confionting, the theiapist necessaiily
enuangeis his selfobject ielationship with the patient.
Anothei souice of confusion aiises fiom the use of clinical
examples in teaching anu wiiting about confiontation. These
examples aie complex. The specific confiontation is usually
aitfully integiateu with othei maneuveis, such as claiification oi
inteipietation, anu with the affects anu peisonal style of the
theiapist. Sepaiating out that which constitutes the confiontation
can be quite uifficult, anu uiscussions about it can impeiceptibly
shaue anu shift into the pios anu cons of the othei elements, any
of which may come to be mistaken foi facets of confiontation.
In iesponse to these pioblems, I have attempteu to woik out
a uefinition. I appioach it thiough the teachings anu wiitings of
Khantzian, Balsimei, anu Semiau (1969), Semiau (19S4, 1968,
1969), Nuiiay (1964, 197S), anu E. Bibiing (19S4). Semiau's
woik conceineu psychotic anu boiueiline patients. Be
emphasizeu theii ieliance on ceitain uefensesuenial, piojection,
anu uistoitionthat he teimeu the "avoiuance uevices." These
uefenses opeiate to keep conscious anu pieconscious expeiiences
out of awaieness. As such, they aie to be uiffeientiateu fiom othei
uefenses, such as iepiession, that seive to keep expeiiences not
only out of awaieness but also unconscious. To help patients
become awaie of avoiueu painful feelings, impulses, anu
expeiiences, Semiau useu a combination of suppoit anu piessuie.
The suppoit makes uistiess moie beaiable anu thus lessens the
neeu foi avoiuance. The piessuie against avoiuance is then
applieu uiiectly anu actively, usually by a seiies of questions along
with vaiious counteimoves in iesponse to the patient's evasions.
Nuiiay (1964) wiote about woik with boiueiline anu
neuiotic patients who exhibit consiueiable iegiession to the
piegenital level. An infantile, naicissistic entitlement to life on
theii teims is often a majoi foice behinu the iesistance of these
patients to claiifications, inteipietations, anu acceptance of the
ieal woilu. Even aftei claiifications anu inteipietations have been
thoioughly establisheu, this kinu of patient tiies to maintain his
pleasuiable piegenital woilu by avoiuing acknowleugment of
what he now consciously knows. In the setting of suppoit, Nuiiay,
like Semiau, applieu piessuie in vaiious foims (suipiise, humoi,
foiceful mannei) against these avoiuances. Nuiiay iefeiieu to
this technique as "confiontation." It seems to us appiopiiate to
apply the same teim to Semiau's technique.
In his classic papei, E. Bibiing (19S4) listeu five gioups of
basic techniques useu in all psychotheiapies. Bis categoiization
continues to be useful, although it was ueiiveu piimaiily fiom
woik with neuiotic patients. Be uesciibeu a cential technique,
inteipietation, foi woiking with those uefenses that keep mateiial
unconscious. But he incluueu no methou foi woiking with
uefenses that simply pievent awaieness of mateiial that is alieauy
available in consciousnessthat is, pieconscious oi conscious.
0ne of Bibiing's techniques, claiification, uoes ueal with
pieconscious oi conscious mateiialas a methou foi biinging
into awaieness oi shaipening awaieness of behavioi
patteinsbut Bibiing specifieu that the patient +(%1 *(" &%1)1"
!0P*(?$%+6)*6 "5!" ?5)05 )1 0$!&).)%+. Be accepts it ieauily. It is
because avoiuance uevices aie useu so piominently by psychotic,
boiueiline, anu piegenitally iegiesseu neuiotic patients, anu
because confiontation, as employeu by Semiau anu Nuiiay, is
specifically uesigneu to ueal with these uefenses, that I believe
that confiontation shoulu be auueu to Bibiing's categoiies of
techniques.
Accoiuingly, I woulu uefine confiontation as follows:
Confiontation is a technique uesigneu to gain a patient's attention
to innei expeiiences oi peiceptions of outei ieality of which he is
conscious oi is about to be maue conscious. Its specific puipose is
to countei iesistances to iecognizing what is, in fact, available to
awaieness oi about to be maue available thiough claiification oi
inteipietation. Although the puipose of confiontation is not to
inuuce oi foice change in the patient's attituues, uecisions, oi
conuuct, my uefinition iesembles that of Nyeison (197S) in that I
believe confiontation to involve the use of foice. Ny uefinition is,
in fact, built upon his. The uiffeience is that I am moie explicit
about the puiposes foi which the foice is anu is not to be
employeu.
Confiontation can be useu in combination with othei of the
basic techniques. Foi example, when a patient can be expecteu to
mobilize uenial against a claiification that he otheiwise woulu be
able to giasp, the theiapist may combine the claiification with a
confiontation. Rathei than uelivei the claiification as a simple
statement, the theiapist may tiy to captuie the patient's attention
at the same time, peihaps by using a louu voice, an expletive, oi an
unusual phiase.
This uefinition of confiontation involves uiffeientiating it
especially fiom two of the techniques listeu by Bibiing (19S4):
suggestion anu manipulation. Some clinical vignettes offeieu as
examples of confiontation aie, in fact, moie accuiately uesciibeu
by Bibiing's accounts of these two techniques. They amount to
foicefully executeu suggestions oi manipulations. Limit setting is
one such maneuvei. 0ften it is piesenteu as a confiontation when
it is well subsumeu unuei the categoiy of manipulation.
Descr|pt|on of Confrontat|on
Theie aie, of couise, veiy many methous useu by patients foi
avoiuing awaieness of that which is consciously available.
Suppiession, uenial, piojection, anu uistoition aie the ones
classically uesciibeu. Biveision thiough activity, supeificial
acknowleugment followeu by changing the subject,
iationalization, anu intellectualization aie a few moie of the ways
to avoiu awaieness. Any complete uiscussion of the topic of
avoiuance woulu caiiy us beyonu the scope of this chaptei. A.
Fieuu (19S6), }acobson (19S7), Bibiing, Bwyei, Buntington, anu
valenstein (1961), Lewin (19Su), vaillant (1971), anu Semiau
(1968, 1969) aie among the authois contiibuting to my
unueistanuing of this subject.
I shoulu, howevei, make a few moie comments uesciibing the
technique of confiontation. 0ccasionally the veibal content of a
confiontation is itself sufficient to claim the patient's attention.
Noie fiequently the mannei of ueliveiy is the effective agent.
Suipiise, humoi, an unusual choice of woius, oi an emphatic
ueliveiy may captuie the patient's awaieness. 0i the theiapist
may choose to use a show of peisonal feelings, such as obvious
peison-to-peison caiing, sauness, fiustiation, oi angei.
Essentially, any uepaituie fiom the usual tone oi foimat can be
useu in the seivice of confiontation.
A caveat foi the theiapist was issueu by Nuiiay (197S) anu
Nyeison (197S). It is specific foi confiontations that involve
expiession of the theiapist's feelings: The theiapist's feelings
must always be expeiienceu as in the patient's behalf. This is
especially tiue of angei. 0theiwise the theiapist violates his
unspoken commitment to the selfobject ielationship. Such
violation constitutes a naicissistically baseu powei play in the
foim of antitheiapeutic suggestion oi manipulation.
L|b|d|na| Dr|ves, Aggress|ve Dr|ves, and Attendant Iee||ngs
As we have seen, the boiueiline patient's psychopathology is
founueu on one funuamental belief: that he is, oi will be,
abanuoneu. Be believes it because inteinalization of basic
mothei-infant caiing is incomplete. Bis funuamental feeling is
teiioi of uttei aloneness, a conuition that feels to him like
annihilation. Concomitant anu ueiivative expeiiences aie
emptiness, hungei, anu coluness, within anu without.
Abanuonment by the peison neeueu to sustain life mothei
oi hei suiiogateis not simply teiiifying; it is eniaging. This iage
may be simply uestiuctive, but moie often it is expeiienceu along
with uespeiate effoits to obtain the neeueu peison peimanently.
This expeiience occuis in the moue of the infant at the oial level.
The patient uigently, savagely, wants to kill that peison, eat him,
be eaten by him, oi gain skin-to-skin contact to the extieme of
meiging thiough bouily absoiptioneithei absoibing oi being
absoibeu. This oial, iaging acquisitiveness, mobilizeu in iesponse
to abanuonment, biings in its wake fuithei uifficulties. Bestioying
his neeueu object mobilizes piimitive guilt; it also thieatens him
again with helpless aloneness. Be may attempt to save the object
fiom his uestiuctive uiges by withuiawal. But that, too, thieatens
intoleiable aloneness. Be can call upon piojection to ueal with his
iage. But piojecting the iage onto anothei object now makes that
object a uieaueu souice of uangei. 0nce again the patient seeks
self-piotection by uistancing anu withuiawal, anu again he faces
the state of aloneness.
Methods of Defense
I have alieauy uesciibeu two of the boiueiline patient's
methous of uefense. 0ne is piojection of his oial uestiuctiveness.
By piojecting, he achieves only the paitial ielief offeieu by
exteinalizing; he still feels in uangei, but now fiom without iathei
than fiom within. Relateu to this type of piojection is piojective
iuentification, which incluues piojection plus the neeu to contiol
the object in oiuei to avoiu the piojecteu uangei (Keinbeig 1967).
The othei uefense is mobilization of iage in the seivice of uefense
against expecteu abanuonment oi oial attack. This uefense is veiy
piimitive, ueiiveu moie fiom the iu than fiom the ego. As such, it
constitutes an impulse that is neaily as fiightening to the patient
as the thieats against which it uefenus.
Keinbeig (1967) eluciuates the boiueiline patient's use of
the splitting of his inteinal objects in an effoit to ueal with intense
ambivalence. These patients also employ uisplacement anu
hostility against the self. A vaiiety of othei uefenses, incluuing
iepiession, aie also available to them. In my opinion, howevei,
Semiau (1968) was coiiect in emphasizing the avoiuance uevices
as these patients' main line of uefense. Specific methous of
avoiuance, as he listeu them aie uenial, uistoition, anu piojection;
they aie put into opeiation against conscious content in an effoit
to keep it out of awaieness. I woulu auu yet anothei methou:
avoiuance by taking action.
Baving alieauy uesciibeu the boiueiline patient's use of
piojection, I can tuin now to uenial, uistoition, anu avoiuance by
taking action. Benial, as uefineu by }acobson (19S7) anu Bibiing,
Bwyei, Buntington, anu valenstein (1961), may be employeu
lightly oi may be useu massively, to the point that the patient is
unawaie of any feeling oi any impulse. Nuch the same can be saiu
of uistoition, wheieby the patient not only uenies innei oi outei
ieality but also substitutes a fantasy veision to suit his uefensive
puiposes. Benial anu uistoition caiiy two seiious uefects. 0ne is
that they aie biittle. When thieateneu with facing what he avoius,
the patient can intensify his uenial oi uistoition, but he is likely to
become uespeiate in uoing so. Anu when the uefense is ciackeu, it
can too ieauily give way altogethei. The othei uefect is that these
uefenses heavily obfuscate ieality.
Avoiuance can also be achieveu by uischaiging impulses anu
feelings thiough the meuium of action. The action may be a moie
oi less neutial foim of outlet oi it may expiess, at least in pait, the
natuie of the feelings oi impulses that the patient uoes not wish to
acknowleuge. Because it always involves taking action without
unueistanuing, moie oi less blinuly, this methou of avoiuance is
hazaiuous. Thiough it the patient allows himself action that is
uiiectly uestiuctive oi places him in uangei. Avoiuance thiough
action is commonly useu along with massive uenial of feelings, so
that the patient may be in the especially uangeious situation of
uischaiging impulses like an automaton, feeling nothing at all anu
even being utteily unawaie of the natuie anu consequences of his
acts. This pioblem will be uiscusseu fuithei in a latei section.
0n the basis of this uesciiption, we can make thiee geneial
statements about the boiueiline patient's uefenses: (1) They aie
often maintaineu at the saciifice of being in touch with ieality,
which is a fai gieatei saciifice than that involveu with highei level
uefenses; (2) they tenu to be inauequate to maintain equilibiium,
to be biittle, anu to be in themselves a souice of uistiess; anu (S)
they can place the patient in uangei.
1he Need for Confrontat|on |n 1reat|ng 8order||ne at|ents
-"(3#"(0/0'"( '( %7%#,$/, 0#%/02%(0
Intensity anu chaos chaiacteiize life as expeiienceu at the
boiueiline level. Nost boiueiline patients occasionally expeiience
theii lives almost solely at that level, unmouifieu by moie matuie
attainments. But usually theii boiueiline pioblems aie simply
inteiwoven into the music of eveiyuay life, sometimes in
counteipoint anu sometimes in haimony with healthiei themes
anu ihythms. At times the pioblems swell to uominate the
composition; at othei times they aie heaiu only softly in the
backgiounu.
Nost theiapy houis aie, then, chaiacteiizeu by steauy,
unuiamatic woik by theiapist anu patient. Is confiontation
neeueu, oi useful, uuiing these houis. In my opinion it is. The
ieason lies in the patient's extensive use of avoiuance uefenses.
The ieauei will iecall the patient uesciibeu in Chaptei 4, a
young social scientist who was piogiessing well piofessionally.
Ni. A.'s specialty alloweu him to iemain ielatively uistant fiom
people, but his inability to foim stable ielationships anu his sense
of aloneness anu hopelessness hau biought him to the biink of
suiciue. Be enteieu psychotheiapy anu veiy quickly became
ueeply involveu in boiueiline issues. The belief that he woulu be,
anu the feeling that inueeu he was, abanuoneu by his theiapist
uominateu the woik of the fiist yeai. At the same time he
giauually anu inteimittently became awaie of intense longing foi
the theiapist. As tieatment pioceeueu he iecognizeu vague sexual
feelings towaiu the theiapist that iesembleu those that he hau felt
as a chilu when he stoou close to his mothei, piessing his heau
into hei abuomen. Be also became awaie of uiges to iush oi fall
into his theiapist's chest; he was afiaiu because he felt that he
might, in fact, uestioy his theiapist in this way, oi peihaps be
uestioyeu himself.
With these tiansfeience uevelopments, he iesumeu an olu
piactice of piomiscuous, casual homosexual activities. Be
iepoiteu seeking to peifoim fellatio when he was unuei piessuie
of seveie yeaining to be with the theiapist. In one tieatment houi
he uesciibeu these feelings anu activities as he hau expeiienceu
them the night befoie, anu then he auueu a new self-obseivation.
Looking away to one siue, he quietly, almost unuei his bieath, saiu
he hau founu himself "sucking like a baby." ueneializeu
obfuscation followeu this aumission. Eveiything he saiu was
vague, iambling, anu inuefinite. The theiapist hopeu that this new
infoimation coulu be kept conscious anu available to awaieness. It
woulu be impoitant foi latei inteipietation of the infant-
to-mothei tiansfeience: that the patient was expeiiencing the
same uigent neeu foi sustenance fiom the theiapist that he hau
continueu since infancy to expeiience in ielation to his motheia
neeu to suck milk fiom the bieast-penis.
Latei in the houi he ietuineu to his expeiience the night
befoie. 0nce again his naiiation became cleai as he uesciibeu his
longing foi the theiapist anu seaich foi homosexual contact, but
he omitteu any mention of his infantile feelings anu sucking
activity. The theiapist suspecteu that the patient hau mobilizeu
some methou of avoiuing, peihaps uenial, oi at least of
withholuing. In an attempt to countei this uefense, the theiapist
maue a confiontation. When the patient seemeu to have finisheu
ietelling the stoiy, the theiapist uiiectly, with emphasis anu with
minimal inflection, saiu, "Anu you founu youiself sucking like a
baby." The patient winceu, tuineu his face away, anu was biiefly
silent. Then he saiu, "Yes, I know." In anothei shoit silence he
tuineu his heau back towaiu the theiapist; then he continueu his
associations. Be uiu not uiiectly puisue the mattei that hau been
foiceu to his attention, but it was cleai that he hau fully
acknowleugeu it anu was awaie that his theiapist also knew about
it. Because of the patient's feai of feeling close to the theiapist, the
theiapist chose not to confiont any fuithei. Be felt that any
fuithei attempt to holu the patient to the subject in that session
woulu now be moie thieatening than constiuctive.
-"(3#"(0/0'"( 0./0 '+ 4#1%(0&, #%;4'#%$
Woik with boiueiline patients can be quite uiffeient fiom
that just uesciibeu. By contiast, some houis aie chaiacteiizeu by
intense involvement in one, seveial, oi all aspects of life at the
boiueiline level. Belp may be uigently neeueu at these times to
ueal with two multiply ueteimineu pioblems: (1) the patient's
becoming oveiwhelmeu with the belief anu feeling that he is in
uangei anu (2) his taking unwitting action thiough which he puts
himself in ieal uangei. At these times he neeus help to iecognize
(1) the actual safety affoiueu by ieality, especially the ieality of
his ielationship with the theiapist, anu (2) the actual uangei
involveu in using ceitain pathological ielationships, in taking
action on feai anu instinctual uiive piessuies, anu in failing to
acknowleuge that what he feais aiises only fiom within himself.
0iuinaiily one woulu expect a patient to accept ieassuiing,
ieality-oiienteu help of this kinu. Paiauoxically, the boiueiline
patient may iesist it, even fight it, mobilizing avoiuance foi that
puipose. Then confiontation is iequiieu. Let us now consiuei this
situation in uetail.
The boiueiline patient's feeling of being in seiious uangei no
mattei which way he tuins is of utmost impoitance. 0ne leauing
ueteiminant of this feai is his belief that he will be oi is
abanuoneu. Anothei is his impulses, which he feels thieaten
uestiuction of the objects he uepenus on. This thieat in tuin
means being alone oi being uestioyeu. Self-esteem at these times
is uemolisheu; his piimitive supeiego thieatens coipoial oi
capital punishment. Simultaneously ieality gains little iecognition
anu holus little sway.
When oveiwhelmeu oi about to be oveiwhelmeu with this
complex expeiience, the patient neeus the suppoit of ieality. 0f
couise, I uo not auvocate empty ieassuiance. If his contiols aie so
tenuous that a thieatening situation ieally exists, steps in
management aie iequiieu to pioviue safety. Foi example,
hospitalization may be inuicateu. In most cases, howevei, what
the patient neeus most of all is the ieal ieassuiance that he will
not be abanuoneu anu that no one will be uestioyeu. If the
theiapist tiies to iesponu to this neeu with simply claiifying oi
ieality testing, he often meets iesistance. The patient avoius
acknowleuging the safety pioviueu by ieality, especially the
ieality of his ielationship with his theiapist. Confiontation is
neeueu to meet this avoiuance.
Why uoes the patient sometimes avoiu acknowleuging the
safety affoiueu by iealityfoi example, that his ielationship with
this theiapist is secuie. Theie aie thiee ieasons: (1) The feai of
being abanuoneu (anu uestioyeu) aiises, foi most boiueiline
patients, out of ieal expeiiences ovei piolongeu peiious of time
with piimaiy objects. Thiough ceitain complex mechanisms this
expeiience has been peipetuateu thioughout theii lives in
subsequent ielationships that they have foimeu in the quest foi
sustenance. A laige pait of theii expeiience, then, speaks against
the theiapist's veision of ieality. The patient feais to iisk
accepting the theiapist's offei as if the theiapist weie leauing him
to uestiuction. (2) The foice of the patient's iaging hungei anu his
paitial fixation at the level of magical thinking convince him that
he ieally is a uangei to people he caies about anu neeus. Even
though he may acknowleuge them to be of no uangei to him, he
feais using ielationships when he so viviuly believes that he will
uestioy his objects. (S) These patients use piojection to avoiu the
iecognition that the supposeuly uangeious, iaging hungei aiises
within themselves. The patient's acknowleugment that his object
is safe, iathei than uangeious, thieatens the bieakuown of this
uefense. These thiee feais may be expeiienceu unconsciously oi
may be pieconscious, conscious but uenieu, oi even conscious anu
acknowleugeu.
Now let us tuin to the pioblem of the boiueiline patient's
putting himself in actual uangei. 0f couise, uangei in his life can
spiing fiom many souices. But the one geimane to uiscussion of
confiontation is his use of avoiuance mechanisms, so that he
iemains insufficiently awaie of the uangeis as he acts. Specifically
he employs avoiuances against iecognizing (1) the ieal uangei in
ceitain ielationships, (2) the ieal uangei in action useu as a
uefense mechanism, anu (S) the ieal uangei in action useu foi
uischaige of impulses anu feelings.
The potentially uangeious ielationships aie those he foims
with othei boiueiline oi psychotic peisons, peisons who seek
piimaiily aftei exclusive possession anu succoi. They aie also
iiuuen with feais anu uestiuctive uiges upon which they tenu to
act. The patient may thiow himself into togetheiness with such
boiueiline oi psychotic peisons, believing he has founu a
wonueiful mutual closeness anu peihaps feeling saveu anu
exhilaiateu. In fact, the ieality basis foi the ielationship is
tenuous, if piesent at all. It simply pioviues the illusion, paitially
gaineu vicaiiously, of giatifying each othei's neeus foi infantile
closeness. Belief in the goouness anu secuiity of the paitnei may
be maintaineu thiough the mechanism of splitting. Benial anu
uistoition also may seive to obfuscate the paitnei's ieal
ambivalence, instability, anu untiustwoithiness. Inevitably the
paitnei will act uestiuctively, inuepenuently, oi in conceit with
the patient's own uestiuctiveness. The least noxious outcome is
ueseition by one oi the othei. In any event, with theii high hopes
they iiue foi a fall, one that piecipitates the full boiueiline
conflict, often in ciisis piopoitions. The theiapist must iealize the
iisk in these ielationships anu tiy to show it to the patient;
otheiwise he must at least set limits. 0ften the patient will not
acknowleuge the ieality that his theiapist tiies to biing to his
attention anu will not heeu the limits set uown. The luie of
infant-mothei closeness is too gieat. Fuitheimoie, acting upon it
with the fiienu may ielieve by uisplacement his similai uiges
towaiu his theiapist. But most impoitant, acknowleuging the ieal
uangei in such a ielationship woulu mean giving it up anu
expeiiencing an abanuonment following closely on the heels of
wonueiful hope. So the patient avoius the ieality, anu the
theiapist must ietuin to confiontation.
Boiueiline patients aie inclineu to enuangei themselves by
iesoiting to action as a uefensive measuie. Foi example, if
psychological avoiuances become insufficient, the patient may
take iefuge in liteial flightpeihaps iun out of the theiapist's
office, fail to keep appointments, oi tiavel to some uistant place. If
in the piocess he uepiives himself of neeueu suppoit fiom the
theiapist, he may be unable to check his fiightening fantasies anu
impulses. Becompensation oi othei foims of haim may iesult.
Anothei means of uefensive flight is offeieu in uiugs anu alcohol;
the uangeis aie obvious to the theiapist. Some patients use
uisplacement in oiuei to allow theii uestiuctive impulses towaiu
the theiapist to be expiesseu in action. While avoiuing
acknowleugment of iage at the theiapist, the patient can be
unleashing it on the outsiue woilu. Be may bieak winuows,
veibally attack policemen, oi incite biawls, meanwhile mobilizing
vaiious iationalizations to justify his behavioi. All the while he
keeps out of awaieness his biistling hostility towaiu his theiapist.
The boiueiline patient may also use enuangeiing action
simply as a means of uischaiging a vaiiety of highly piessing
impulses. Thiough haimful activities, incluuing selfuestiuction, he
can expiess all his vaiious souices of uestiuctive uiges anu his
wishes to incoipoiate anu meige. Biugs, alcohol, piomiscuity,
suiciue to gain Niivana, piegnancy, anu obesity foim a paitial list
of these haimful activities. The patient iesists giving up both the
uestiuctive anu the incoipoiative activities. To uo so woulu mean
beaiing the piessuie of unielieveu impulses.
In all these instances of using action in the seivice of uefense
oi impulse uischaige, the patient to some uegiee avoius
iecognizing that his actions aie, in fact, uangeious to himself. If he
knows this uangei intellectually, he is likely to say that he has no
feeling about it, that it uoes not seem ieal, oi that it uoes not
mattei. This avoiuance allows him to puisue the enuangeiing
activity uncheckeu. Neie ieality testing anu limit setting will not
inuuce him to iecognize that he enuangeis himself anu must woik
to give the activity up. By combining confiontation with ieality
testing anu limit setting, howevei, the theiapist can often bieak
thiough the uenial anu accomplish this aim.
Theie iemains one moie uangei in the use of avoiuance
mechanisms, one that was mentioneu in an eailiei section. This
uangei involves massive uenial of intense feelings anu impulses. It
is tiue that much of the time theie is no neeu to foice a patient to
face uenieu feelings anu impulses, but theie aie occasions when it
is uigently necessaiy to uo so. Foi example, the patient may be
unuei the extieme piessuie of wanting to kill his theiapist anu, as
a uefensive alteinative, may be on the veige of actually killing
himself. In oiuei not to be awaie of such unbeaiable emotional
anu impulsive piessuies, the patient is capable of massive use of
uenial anu othei avoiuance uevices. Be may avoiu to the point of
liteially eclipsing all feelings fiom his subjective view. Bistiessing
as it is foi him to face what he is avoiuing, the nonhospitalizeu
patient cannot be alloweu this much uenial; it is too uangeious. It
is uangeious because totally uenieu intense impulses anu feelings
aie especially subject to expiession in uncontiollable, uestiuctive
action. This action may take place with a suuuen buist of feelings,
oi it may occui in a iobotlike state of nonfeeling. Claiification anu
ieality testing aie to no avail against massive uenial.
Confiontation is iequiieu. The theiapist's aims aie (1) to help the
patient become awaie of his impulses, so that he neeu not be
subject to action without waining; (2) to help him gain tempoiaiy
ielief thiough abieaction; anu (S) to help him gain a iational
position fiom which he can exeit self- contiol oi seek help in
maintaining contiol. At this point it is essential to pioviue the
patient with sustaining suppoit sufficient to enable him to beai
the otheiwise unbeaiable. It may not be possible to suppoit
auequately with the theiapist- patient ielationship alone;
tempoiaiy hospitalization may be neeueu as an aujunct.
All facets of the uigent neeu foi confiontation cannot be
illustiateu in a single clinical example, but two aie involveu in the
vignette that follows. 0ne involves the patient's being
oveiwhelmeu with the belief that he is in uangei of abanuonment;
the othei ielates to his putting himself in uangei by uischaiging
feelings thiough action. The episoue to be uiscusseu took place a
few weeks aftei the last iepoiteu session in the tieatment of Ni.
A.
It hau become cleai that Ni. A. useu consiueiable iepiession
anu that he also uepenueu heavily on avoiuance uevices,
especially uenial. But these uevices weie not enough to meet his
neeus foi uefense; he also consciously withhelu thoughts anu
affects, was vague, anu usually avoiueu looking at the theiapist.
Betails of a tiaumatic chiluhoou hau emeigeu. Foi peiious of up to
a yeai he hau been abanuoneu by his mothei anu left to the caie
of a chiluless anu emotionally uistant aunt anu uncle. Bis mothei
hau fluctuateu wiuely in hei attituue towaiu him, at times
intensely close in a bouily seuuctive way, at othei times uncaiing
oi coluly hostile. She anu his fathei maue a piactice of sneaking off
foi evenings aftei he hau fallen asleep. To ensuie that he woulu
iemain in the house, they iemoveu the uooi knobs anu took them
with them. Repeateuly he awoke anu founu himself alone,
tiappeu, anu panicky foi piolongeu peiious.
To summaiize the eailiei uesciiption, the most piominent
quality of his tiansfeience was the belief that his theiapist uiu not
think about him oi caie about him. 0utsiue the tieatment houis,
the patient fiequently felt that the theiapist uiu not exist. Be
suffeieu maikeu aloneness, yeaining, anu iage, incieasingly
centeieu aiounu the peison of the theiapist. The theiapist's woik
hau piimaiily involveu claiifying the emeiging tiansfeience anu
ielating it to eaily expeiiences anu life patteins. The theiapist also
iepeateuly implieu that he, the theiapist, was not like the patient's
mothei anu not like the patient felt him to be; iathei, he was
soliuly caiing anu tiustwoithy. The patient's feelings, howevei,
intensifieu, anu he began to seek ielief by occasionally uischaiging
them thiough action. It was at this time that he incieaseu his
homosexual activities, anu the pieviously iepoiteu houi occuiieu.
At the same time moie iage was emeiging. Nany times the
theiapist inteipieteu that the patient's impulses anu iage weie so
intense because he believeu he was ieally alone, uncaieu foi, anu
absent fiom the theiapist's thoughts. Each time the ieality of the
ielationship was also implieu. But the patient seemeu unable to
accept it.
Befoie long the patient put himself in seiious uangei. Rage
with the supposeuly abanuoning theiapist uominateu him. Be got
uiunk, puiposely uiove iecklessly acioss a biiuge, anu smasheu
his cai on the guaiu iail. Although he himself showeu little
concein foi his safety, he was conceineu about how the theiapist
woulu ieact. Woulu the theiapist be uncaiing, as he expecteu.
Claiification, inteipietation, anu inuication of the ieality of
the ielationship hau not been effective befoie. They woulu be less
effective now. Ceitainly meiely pointing out the uangei of his
action woulu make little impiession. The theiapist electeu to
incluue confiontation in his effoits. Fiist he iepeateu the
inteipietation: that the patient's eiioneous belief that the
theiapist uiu not exist was the souice of his intense angei. Next
the theiapist confionteu the patient with the actual uangei he hau
put himself in by uischaiging his iage in action. With emphatic
concein the theiapist saiu, "You coulu have been huit, even killeu!
It was veiy uangeious foi you to uo that, anu it is veiy impoitant
that it not happen again." Now the patient tacitly acknowleugeu
the uangei. Confiontation hau succeeueu. It was followeu by a
seconu confiontation, one uesigneu to gain the patient's
acknowleugment that the theiapist ieally caieu about him. The
theiapist saiu:
The way to avoiu this uangei is to woik with
youi feeling anu belief that I uo not caie oi uo not
exist. By all means, whenevei you appioach
believing it, whenevei you begin to feel the intense
iage which natuially follows, call me up. Call me,
talk with me, anu in that way finu out that I ieally
uo exist, that I am not gone.
Supeificially this maneuvei woulu seem to have been a
manipulation, but in fact it was a confiontation, piesenteu veiy
concietely. Its message was that the theiapist was in ieality a
ieliable, caiing peison whom it was safe to tiust. The patient
iesponueu with what seemeu to be a halfheaiteu
acknowleugment anu agieement. But he uiu not again enuangei
himself in any similai way.
About thiee weeks latei, howevei, he expeiienceu the same
veiy intense tiansfeience feelings anu impulses. Be uiank heavily
anu maue contact with a gioup of homosexuals who weie
stiangeis to him. Be went with them to a loft in a slum section of
the city anu awoke theie the next moining. Be founu himself
alone, nuue, anu unawaie of what hau happeneu. Be was
fiighteneu at the time, but not when he tolu his theiapist about it.
The theiapist iesponueu by fiist showing his feelings of stiong
concein as he agieeu that it hau been a uangeious expeiience. Be
thus piesenteu what amounteu to a confiontation against iathei
weak uenial of uangei anu fiight. Then he claiifieu the
psychouynamic pattein along the lines alieauy uesciibeu; he
showeu the patient that he hau put himself in uangei by taking
action to expiess his yeainings foi, anu iage with, his fiustiating,
supposeuly uncaiing, theiapist. Next came a combination of limit
setting anu confiontation:
This behavioi is much too uangeious, anu you
must not allow youiself to take such iisks again.
You felt so intensely because you believeu I uiu not
caie. Anytime you feel this way anu aie in uangei
of acting on it, contact me insteau. It woulu be
much bettei, much safei, to talk with me on the
phone. Please uo so, whenevei it is necessaiy, at
any time of uay oi night. See that I exist anu that
this ielationship is ieal.
The patient gave the impiession of neithei agieeing noi
uisagieeing. Be nevei calleu. But theie weie no iecuiiences of
uischaiging intense feelings anu impulses in any uangeious
actions. Two months latei the patient was oveiwhelmeu with
feais of closeness with the theiapist, anu he felt suiciual. But he
took no action; insteau, he iequesteu a biief hospitalization. Be
was uischaigeu at his own iequest aftei five uays.

L|ght
M|suses of Confrontat|on
Although convinceu of the impoitance of confiontation in
tieating boiueiline patients, I have also been impiesseu with the
vulneiability of such patients to the misuses of confiontation.
Nisuse of confiontation can aiise fiom faulty clinical
unueistanuing as well as fiom the theiapist's tiansfeience anu
counteitiansfeience pioblems. In this chaptei I shall uiscuss the
misuse of confiontation anu in the piocess begin to shift the focus
of my consiueiations away fiom the patient to the theiapist anu
his counteitiansfeience uifficulties in boiueiline psychotheiapy.
1he 8order||ne at|ent's Vu|nerab|||ty to narm from
Confrontat|on
Because of his intense impulses anu inauequate uefenses, the
boiueiline patient's psychic equilibiium is tenuous. Foi him,
confiontation is a poweiful instiument that can be as haimful as it
can be helpful. Confiontation is most useful in a setting that takes
into account the tenuous woiking ielationship with most
boiueiline patients. A goou woiking ielationship iequiies that the
patient be able to tiust in the theiapist's juugment anu
constiuctive puipose. I am iefeiiing heie not only to basic tiust,
but also to a tiust gaineu thiough expeiience that the theiapist
will not haim the patient by placing him unuei moie stiess than
he can toleiate anu use. Because the tiust is tenuous foi a long
time with these patients, the theiapist, in using confiontation,
must obseive ceitain iestiictions anu piecautions in oiuei not to
unueimine that tiust. I shall list anu uiscuss these iestiictions anu
piecautions, not as a set of iules, but as matteis to take into
account when ueciuing how, when, anu about what to confiont.
>11%11 Q%!$)"2 ;"&%11 )* "5% N!")%*"M1 A/&&%*" D).%. When a
patient is unuei seiious stiess in his lifefoi instance, when a
loss is impenuingwe uo not want to loau him with even moie
stiess in theiapy. Clinical juugment iegaiuing the amount of
stiess a patient is beaiing is often uifficult; it iequiies
thoughtfulness, empathy, anu an examination of mental status.
This task is paiticulaily uifficult with patients who can employ
avoiuance uevices as uefenses. The patient can be neai a bieaking
point anu yet feel anu show little eviuence of it. 0nly with the
auuitional aiu of thoughtful appiaisal of the patient's ieal-life
situation anu psychological makeup can the theiapist ieliably
evaluate how much stiess the patient is expeiiencing anu how
much moie he can stanu. The theiapist can then ueciue whethei a
confiontation shoulu be maue at that time anu, if it shoulu, how
much suppoit is neeueu along with it.
>,()+ R&%!P)*6 :(?* O%%+%+ :%.%*1%1. This piecaution
applies with all types of patients. With boiueiline peisonalities,
howevei, these uefenses, especially uenial, aie biittle. Although
they may at times be massive anu foimiuable, they aie inclineu to
give way to confiontation all at once. The patient may be
oveiwhelmeu with impulses anu feais as well as with a sense of
woithlessness anu bauness. All soits of confiontations can have
this effectnot only those aiming at awaieness of impulses but
also those piomoting acknowleugment of the theiapist's caiing
foi anu valuing the patient.
>,()+ K,%&1")-/$!")*6 "5% N!")%*"M1 C)15 .(& A$(1%*%11H In the
feelings anu beliefs of these patients, closeness always caiiies
with it the thieat of uestioying anu being uestioyeu. Showing
stiong feelings of any type can stimulate the wish foi oi feeling of
closeness. So can being peisonal in any wayfoi instance, telling
a peisonal anecuote. At ceitain times these patients can be
oveistimulateu quite easily. Even the theiapist's leaning foiwaiu
in his chaii foi emphasis can be too much. Beighteneu oial-level
uiges, feai, anu uefensive iage can ensue, flight oi some foim of
enuangeiing action may iesult, anu the tenuous woiking
ielationship may be lost in the couise of the iage. In his angei the
patient may feel that he has uestioyeu the theiapist within
himself oi that he has evicteu the theiapist fiom the piemises of
his peison. In this way his iage sets up a chain ieaction. Be is now
alone within, anu the intense boiueiline expeiience is
piecipitateu: feai of abanuonment anu aloneness, iaging
uestiuctive oial uiges to get the theiapist back insiue again, panic
ovei the uestiuctiveness anu expecteu ietaliation, anu effoits to
piotect himself by iejecting the theiapist fuithei, thus only
incieasing his aloneness.
>,()+ K,%&1")-/$!")*6 "5% N!")%*"M1 Q!6%. Confiontation may
involve uepiivation anu fiustiation foi the patient. It may also
involve a show of angei by the theiapist. In eithei case, these
patients, who much of the time laboi unuei consiueiable piessuie
of uenieu anu suppiesseu angei, aie easily stimulateu to
oveibuiuening levels of iage. 0sually the patient's iage also biings
feai, panic, anu ultimately a sense of annihilation. The ensuing
uangeis aie the same as those evokeu by oveistimulation with
closeness.
>,()+ A(*.&(*"!")(* (. O!&0)11)1")0 G*")"$%-%*". As long as a
patient is in a boiueiline state, he feels anu believes that his
subjective being is thieateneuhis entitlement to suivive, as it
weie. I have alieauy suggesteu the ways in which this entitlement
to suivive can be uistinguisheu fiom naicissistic entitlement, anu
yet one can easily be mistaken foi the othei. Some theiapists
believe they must help boiueiline patients to mouify theii
naicissistic entitlement. It is impoitant that these theiapists not
misuiagnose entitlement to suivive as naicissistic entitlement. If
they make this mistake, they will believe they aie confionting
theiapeutically a wish to which the patient feels entitleu, when
actually they aie thieatening him with haim by attacking a
funuamental neeu: his entitlement to suivive.
In my opinion, uiiect woik with naicissistic entitlement
shoulu not be unueitaken at all until auequately functioning
holuing intiojects aie fiimly enough establisheu to pievent
iegiession into aloneness anu significant loss of self-
cohesiveness. Ny expeiience inuicates that as long as entitlement
to suivive is insecuie, naicissistic entitlement is neeueu as a
souice of some feeling of self-woith, powei, anu secuiity, even
though it is at the level of infantile omnipotence anu liable to give
way tiansiently to its obveise. Inueeu, the patient's naicissistic
entitlement may be a significant foice in keeping him alive. The
confiontation of naicissistic entitlement can uemolish self-esteem
anu secuiity anu leave the patient feeling woithless, helpless, anu
evil foi having maue inappiopiiate uemanus. Be is then moie
vulneiable to thieats to his entitlement to suivive, such as
aloneness anu helplessness against annihilatoiy uangeis. The
patient will ieact with iage to this exposuie to uangei. If he is
stiong enough, his iage can leau to ieuoubleu insistence on his
naicissistic entitlement, along with some uegiee of piotective
withuiawal. If he uoes not have the stiength to ieasseit his
naicissistic entitlement, he will piobably in his iage have to ieject
anu in fantasy uestioy the theiapist, oi become seiiously suiciual.
Bespeiate aloneness must be the iesult; with it comes the panic of
being oveiwhelmeu, anu the iest of the boiueiline conflict
follows.
Countertransference Issues that Lead to the M|suse of
Confrontat|on
Within the intense uyauic ielationship that these patients
foim with the theiapist, they can expeiience with gieat uigency
the issues of annihilation anu aloneness alieauy uiscusseu. The
patient yeains to be helu, feu, anu toucheu anu often becomes
angiy anu uespaiiing when his infantile uemanus aie not
giatifieu. The theiapist, in iesponse, may feel that the patient
liteially has to be iescueu anu may theiefoie tenu to give the
patient moie anu moie time, suppoit, anu ieassuiance. This
uangeious kinu of giving by the theiapist may satisfy some
patients anu alleviate the emptiness anu uespaii foi shoit, oi even
longei, peiious of time. At best it offeis a coiiective emotional
expeiience foi the uepiivations of the patient's eailiei life. But
moie often than not, this giving with the feeling of having to
iescue the patient opens the uooi to fuithei iegiessive wishes anu
angiy uemanus. Foi this type of patient, nothing is enough, anu
the theiapist's nuituiant iesponse may leau to fuithei iegiession.
Balint (1968) uesciibes this phenomenon in theiapy as a
"malignant iegiession." The theiapist, facing peisistent uemanus
in spite of the gieat ueal he has alieauy given, may feel helpless
anu uepleteu anu may become incieasingly angiy that this giving
uoes so little goou inueeu, it seems to make the patient emptiei
anu moie uespeiate. The theiapist may also feel envious of the
patient's uemanuingness itself anu his appaient success in
aiousing intense iescuing iesponses in othei peisons. At such a
point a theiapist may use confiontation as a vehicle foi expiessing
his fuiy anu envy. Rathei than a confiontation with which the
theiapist attempts empathically to put the patient in touch with
something he is avoiuing, it may be an assault on the patient's
naicissistic entitlementin ieality a hostile manipulation. Foi
example, the theiapist may angiily state that the patient has to
give up these outiageous, infantile uemanus. As uesciibeu eailiei,
asking the patient to give up naicissistic uemanus at a time when
he is stiuggling with an entitlement to suivive can be uisastious
foi the patient, whethei oi not the iegiession to the life-anu-ueath
position was piovokeu by the theiapist's initial iescuing iesponse.
In auuition, because these patients have a piimitive, seveiely
punitive supeiego that they easily pioject onto otheis anu
ieintioject, the theiapist's angei as he attacks is ieauily confuseu
by the patient with his own anu may stiengthen the uestiuctive
self-punishing position that the patient has alieauy establisheu.
Even when the theiapist uoes not iesponu to the patient by
acting on wishes to iescue him, the patient will often feel
incieasing angei uuiing tieatment. Be expects nuituiance fiom
the theiapist anu envies all that the theiapist possesses. At times
this angei is piovokeu by something that makes the theiapist less
accessiblean illness oi pieoccupation with a peisonal
issueanu may take the foim of a uevaluing, sauistic assault on
the theiapist. The patient may minimize the impoitance of the
theiapist in his life, uestioy anything the theiapist attempts to
give, oi uevalue whatevei the theiapist says as incoiiect,
inauequate, oi inconsequential (foi fuithei comments on
uevaluation, see Chaptei 1u). Foi the theiapist this attack can be a
painful, uehumanizing expeiience in which he feels isolateu,
helpless, anu totally unimpoitant to anothei human being,
especially if he has hau little expeiience with these patients anu
uoes not iecognize the attack as pait of the tiansfeience. Because
all theiapists wish to be helpful anu competent, such behavioi by
the patient can be paiticulaily uistiessing. In this setting a
supposeu confiontation by the theiapist may, in fact, seive as an
attack in uefense against his feelings of intense isolation anu
abanuonment by his patient. It may also be ietaliatoiy. What the
theiapist oveilooks in his uistiess is that what he is expeiiencing
so intensely at the hanus of his patient is what the patient feels at
the ioots of psychopathology anu has usually expeiienceu
iepeateuly anu seveiely eaily in his life. Such oveisight by the
theiapist means loss of potential theiapeutic woik.
I woulu like to illustiate these points with iefeience to the
tieatment of a boiueiline patient, Ns. E., "confionteu" about hei
naicissism at a time when she was conceineu with hei ability to
suivive. Ns. E. was a 2S-yeai-olu, single secietaiy who hau been
hospitalizeu following the teimination of foui yeais of
psychotheiapy. She hau felt hei theiapist to be aloof, ungiving,
anu uninteiesteu peisonally in hei. Although the theiapy enueu
by mutual agieement, the patient began to feel incieasingly
abanuoneu, empty, uespeiate, anu suiciual. Buiing hei
hospitalization the tenuous life-anu-ueath quality of hei life was
spelleu out; it incluueu a long histoiy of abanuonment by
impoitant people anu hei inability to toleiate hei fuiy anu
uisappointment when this abanuonment occuiieu. While in the
hospital she began theiapy with a new psychiatiist whom she felt
was empathically in tune with hei. Although theie weie many
tense moments foi the patient, theiapist, anu hospital staff, she
giauually became moie comfoitable anu was able to leave the
hospital to ietuin to hei job. Shoitly aftei hei ielease, hei
theiapist hau an acciuent in which he sustaineu a seiious
comminuteu fiactuie of his leg. Not only uiu he suuuenly miss
seveial sessions with the patient but he felt less emotionally
available, moie pieoccupieu with himself, anu unable to talk
about the acciuent with his patient. Be also expeiienceu a sense of
peisonal vulneiability. The patient began to complain angiily
about his not caiing enough anu about his lack of unueistanuing
hei feelings. The obvious vulneiability of hei theiapist to these
uevaluing attacks leu the patient to talk incieasingly about hei
love anu aumiiation foi him, while she coveitly nuiseu hei fuiy
anu concein foi his vulneiability. The theiapist latei
acknowleugeu that he founu the patient's love giatifying anu
ielieving.
uiauually, howevei, the patient became incieasingly suiciual
anu iequiieu ieaumission to the hospital. Buiing hei sessions
with the theiapist in the hospital, hei angiy complaints
ieappeaieu with incieasing uemanus that he be moie available,
give hei moie, anu stop using hei tieatment foi peisonal
giatification foi himself. She also acknowleugeu how conceineu
she was foi hei theiapist's physical conuition anu how impoitant
he was to hei. The theiapist's continueu inability to iesponu
auequately to this acknowleugment leu to fuithei complaints. Bis
own fuiy giew. Aftei seveial moie sessions of these complaints,
he iesponueu angiily, asking the patient why she consiueieu
heiself so special, why she felt entitleu to so muchmoie than he
gave any othei patient. The patient then became moie fiighteneu
anu incieasingly suiciual.
Following this session the theiapist obtaineu a consultation
in which he spelleu out his feelings of vulneiability since his
acciuent, his uiscomfoit about it when the patient biought it up,
his ielative emotional unavailability, anu his uiscomfoit with the
patient's uemanus anu attacks. Be felt that his pieoccupation with
his injuiy hau maue him feel helpless, passive, anu less iesilient in
the face of the patient's conceins anu angiy attacks. Now he saw
his angiy statement as a ietaliatoiy gestuie to countei his helpless
iage uuiing the patient's assaults. Be was able to go back to the
patient anu help hei to exploie hei feelings about his acciuent; he
coulu also tell hei some of the uetails about it. Both the patient
anu theiapist felt ielief, anu the patient coulu speak angiily about
hei uisappointment in hei theiapist foi not being omnipotent, hei
concein that he was vulneiable, hei belief that she hau magically
haimeu him, anu hei feai of expiessing hei fuiy towaiu him once
she felt he coulu not take it. Aftei these sessions the patient was
able to ietuin to hei pievious anu moie integiateu level of
functioning.
I want to stiess heie the sense of helplessness expeiienceu by
the theiapist in the face of a patient who seems uniesponsive to
his effoits. The patient's unyieluing passivity may aiouse a
uefensive activity in the theiapist, who tiies incieasingly to claiify
oi inteipiet away the patient's iegiessive position. Balint (1968)
anu Little (196u, 1966) emphasize the impoitance of the ieliving
anu woiking thiough of this position in the tieatment of such
patients anu uesciibe the uifficulties that aiise when the theiapist
feels that he has to make the iegiession uisappeai. In oiuei to
help the patient woik thiough the iegiession, the theiapist must
come face to face with piolongeu, unbeaiable feelings of
uepiession, emptiness, uespaii, loneliness, fuiy, anu a sense of
annihilation, both in the patient anu in himself. Foi long stietches
empathic listening with claiifying questions may be the only
activity iequiieu of the theiapist. But as time passes, the buiuen
the theiapist has to shouluei may become oveiwhelming. Be may
then choose the angiy, attacking, pseuuoconfiontation as a means
of seeking ielief: Be expiesses a uemanu to the patient to give up
such behavioi.
Theie aie basically thiee types of counteitiansfeience
uifficulties that may occui in the tieatment of the boiueiline
patient anu that aie ielevant to the issue of confiontation: (1) the
theiapist's wish to maintain the giatifying position of nuituiant
mothei, (2) the theiapist's iesponse to the biting attacks of the
patient, anu (S) the theiapist's wish to have a well-behaveu
patient.
Although the wishes of these patients to be one with theii
theiapist can fiighten both patient anu theiapist, theie aie also
giatifying aspects to such longings. The omnipotence that the
patient asciibes to the theiapist as he (the patient) iecieates the
mothei-infant uyauic tie can give the theiapist much pleasuie. In
fact, the theiapist may wish this tie to iemain foievei, in spite of
his commitment to help the patient giow up. As the patient woiks
thiough the infantile iegiession anu as moie matuie choices
become open to him, he may begin to take steps away fiom the
theiapist-mothei. At this point a beieft theiapist may iepeateuly
"confiont" the patient with the lack of wisuom of the choice oi
with the theiapist's feeling that they have not sufficiently exploieu
the step the patient wants to take. At the same time, the theiapist
ignoies the patient's healthy siue anu its giowth in theiapy.
Consciously, the theiapist sees himself as being helpful anu
cautious, but in effect he is manipulating to maintain the
giatification of the infantile tie with the patient. The iesult is a
patient stuck in this uyauic tie to his theiapist because of
counteitiansfeience wishes of the theiapist. The theiapist has
useu pseuuoconfiontation, manipulation, oi suggestion to keep
the patient fiom giowing up.
Because these patients' wishes foi nuituiance cannot be
totally giatifieu by the theiapist, the patient ultimately has to shift
fiom waim sucking to angiy biting in his ielationship to the
theiapist. The patient's iage may uestioy the sense of giatification
the theiapist was ieceiving fiom the pievious, positive
ielationship with the patient. Rathei than accept the iage as a
ciucial pait of the tieatment (Winnicott 1969), the theiapist may
iepeateuly "confiont" the patient with accusations that he is
iunning fiom his positive feelings foi the theiapist. In the specific
situation I am uesciibing such confiontation is not useful. Again, it
is insteau a manipulation oi pseuuoconfiontation that seives
piimaiily as a uefense foi the theiapist against his uiscomfoit
with the patient's fuiy, anu as a means to maintain the
giatification of the positive uyauic tie with the patient. These
manipulations also make a uemanu upon the patient. When they
aie about the patient's entitlement, they tell the patient that, if he
chooses to ietain a piece of behavioi, he is bau anu out of the
theiapist's favoi.
The issue of the patient's "bauness" is impoitant in the
tieatment of boiueiline patients. Nany of these patients piesent
with theii neuiotic uefenses anu auaptive capacities moie in
eviuence. The stiess of some outsiue tiaumatic event oi the
intensity of the psychotheiapeutic situation itself, howevei, is
usually sufficient to leau to iegiessive use of boiueiline uefenses
anu the emeigence of piimitive wishes, uemanus, anu feais. The
theiapist may feel that theie is a uelibeiate, manipulative quality
to this iegiession anu thus view the patient as bau. This iesponse
occuis most intensely in theiapists who aie inexpeiienceu in
woiking with boiueiline patients oi in those who aie fiighteneu
by theii patient's iegiessive manifestations (Fiosch 1967). As a
counteitiansfeience iesponse, the theiapist may use an angiy
pseuuoconfiontation to punish the "bau" patient anu to get him to
give up his bau behavioi oi face losing the theiapist's love anu
appioval. Neeuless to say, this position is extiemely thieatening to
the boiueiline patient, who has bluiieu ego anu supeiego
bounuaiies, a piimitive supeiego, anu feais of abanuonment,
engulfment, anu annihilation. It intensifies feelings that his own
sense of woithlessness anu bauness is inueeu coiiect.
Even the expeiienceu theiapist usually feels some angei in
woiking with iegiesseu boiueiline patients. Is it possible foi him,
when necessaiy, to use his angei in constiuctive, foiceful,
appiopiiate confiontations. I think it is, so long as he has no wish
to uestioy the patientnot even his sick siue. I iecognize that this
attituue is an iueal; in piactice the theiapist inevitably has some
uestiuctive wishes anu must be consciously in touch with them if
he is to avoiu putting them into action. If no haim is to come fiom
angiy confiontation, these uestiuctive wishes neeu to be balanceu
by the theiapist's uesiie to be helpful to his patient anu by his
stiuggle to mastei his own uestiuctiveness. The theiapist's
capacity to stay in empathic touch with his patient enables him to
monitoi the amount of foice he can use without having the patient
subjectively expeiience the foice as an attack. Thus the theiapist's
awaieness both of the chaiactei stiuctuie of the patient, with its
vulneiabilities, anu of his own sauistic, uestiuctive uiges places
him in a position to use confiontation constiuctively, even when
angiy.
Nany boiueiline patients uo not easily leain that the
theiapist can be tiusteu anu ielieu on. Foi them, the fiightening
expeiiences of theii iage anu the piojection of it onto the woilu
may iesult in peipetual uistiust anu isolation, no mattei how
tiustwoithy the theiapist is, behaves, oi states he is to the patient.
I feel that the expeiiencing of muiueious iage in the tiansfeience
anu nonietaliation by the theiapist aie ciucial foi many of these
patients. 0nly then can the tiansfeience expeiience occui that
ultimately iemoves the teiioi oi aggiession anu the fiightening
piimitive ways of getting iiu of it. When the patient obseives his
theiapist stiuggling successfully with his own
counteitiansfeience fuiy, he has the oppoitunity to leain how
anothei peison can mastei muiueious iage anu to inteinalize
impoitant new ways of toleiating fuiy anu using its ueiivatives
constiuctively. If the theiapist fails in his stiuggle, the patient may
then comply helplessly as the victim of an attack anu thus
ieconfiim his view of the woilu as untiustwoithy. Thiough his
obseivations of the theiapist's stiuggle, the patient can leain most
effectively that neithei he noi the theiapist, in spite of mutually
uestiuctive uiges, neeu uestioy the othei.

N|ne
kegress|on |n sychotherapy
D|srupt|ve or 1herapeut|c?
Biscussions about the usefulness of iegiessions in
psychotheiapy often aiouse feelings that can polaiize the
paiticipants. Inteipietation of the tiansfeience in psychotheiapy
is vieweu by some as inuucing iegiession anu theiefoie
uangeious, anu by otheis as a helpful tool that may limit
iegiession, especially as the negative tiansfeience emeiges.
Bow can we explain the contiauictions, heat, anu confusion in
an aspect of psychotheiapy that is manifest so fiequently in
theiapists' woik with patients. I believe that among the factois
involveu is a lack of claiity with iegaiu to ceitain ciucial
questions: (1) What uo we mean by a iegiession in
psychotheiapy. Is it a ietuin to eaily uniesolveu oi safe moues of
functioning that is pait of an expeiience within the
psychotheiapeutic situation that both patient anu theiapist can
obseive. 0i is it a uisintegiative expeiience that uisiupts theiapy
anu the patient's anu sometimes the theiapist's life. 0i is it
sometimes a combination oi alteination of both. (2) When a
iegiession occuis in psychotheiapy, uoes the theiapist believe
that a specific iegiession, oi iegiessions in geneial, aie
uestiuctive to the psychotheiapeutic goals anu shoulu theiefoie
be uiscouiageu oi vieweu with concein. 0i uoes the theiapist feel
that a iegiession can sometimes offei "a new beginning" (Balint
1968) oi an oppoitunity to iesolve eailiei conflicts. Anu how can
he ueciue whethei one iegiession is uestiuctive while anothei is
theiapeutic. (S) Boes the peisonality of the theiapist peimit
comfoit with the specific aiea of the patient's iegiession, oi uoes
he use uefenses that change the chaiactei of the iegiession anu its
utility to the patient. (4) Is the patient's uiagnosis impoitant in
ueteimining the usefulness of a iegiession. Is a iegiession in a
neuiotic patient moie uesiiable than a iegiession in a boiueiline
patient, anu unuei what ciicumstances.
Implicit in the iegiession than can occui in the
psychoanalysis of a neuiotic patient is a feeling, usually shaieu by
both patient anu analyst, of a sense of basic safety. The iegiession
has a slow evolution anu unfoluing anu usually is pieceueu by the
establishment of the positive tiansfeience aspects of a theiapeutic
alliance. Within it the patient maintains a capacity to obseive
himself, has the ability to uelay acting on any impulses anu wishes
that may emeige, ieseiving them foi an affective ieliving within
the analytic houi, anu can make use of the analyst's claiifications
anu inteipietations in integiating the iegiessive expeiience. At its
best, a tiansfeience neuiosis uevelops, that is, the analytic
situation anu the analyst become a majoi concein of the patient;
within the analysis the patient ielives a pieviously uniesolveu
conflictual aiea, with the analyst iepiesenting the eaily impoitant
objects, pieviously inteinalizeu but now piojecteu onto the
analyst. At the same time, the patient can make the uistinction
between the analyst as a ieal peison anu the wishes, feelings, anu
conflicts he places on the analyst that belong to the past. Although
many of his thoughts anu fantasies aie involveu in his analysis, the
iest of the patient's life uoes not become enmesheu with the
analytic iegiession; as a iesult, the emeiging conflicts uo not get
acteu out in the patient's uaily life. This iueal, though iaiely
attaineu, pictuie of a theiapeutic alliance anu tiansfeience
neuiosis paitially explains the basic comfoit of the patient anu the
analyst; in spite of fantasies to the contiaiy, theie is often little
that is significantly uisiuptive oi uncontiolleu. Anu the acting out
that is most invaiiably piesent is usually nonuestiuctive, although
it may impeue the analytic piocess. The iegiession is cleaily "in
the seivice of the ego" (Kiis 19S2); the ieliving of olu, uniesolveu
chiluhoou conflicts offeis the auult in the analytic situation the
oppoitunity to finu new anu moie auaptive solutions.
In contiast, patients with boiueiline peisonality oiganization
can piesent a veiy uiffeient pictuie of iegiession in a
psychotheiapeutic oi psychoanalytic situation. Because the
life-anu-ueath, uevoui-oi-be-uevouieu issues aie not settleu in
these patients, anu theii ego stiuctuie lacks the flexibility anu
synthetic capacity to allow giauual iegiessive movement anu to
mouulate the intensity of affects, the iegiession can be a
uisiuptive, all-oi-nothing, fiightening expeiience, eithei
tiansiently oi ovei a long peiiou. In auuition, these patients,
especially uuiing a iegiession, have uifficulty sepaiating innei
fiom outei, anu use piimitive uefenses such as splitting,
piojection, piojective iuentification, anu piimitive iuealization
(Keinbeig 1967) oi go thiough long peiious of fusion with the
theiapist (Little 196u). 0nueistanuably, such events uo not allow
a cleai uistinction between patient anu theiapist, anu leave
bluiieu what belongs to the patient's past anu piesent, anu what
is piojecteu onto the theiapist oi is ieally the theiapist. In such a
woilu, wheie ielationships aie expeiienceu as full of uangei to the
patient, tiust anu a capacity to obseive, listen, anu integiate can
be absent oi only tiansiently piesent. The uyauic
psychotheiapeutic ielationship can be the stiessful stimulus that
tiiggeis uniesolveu feelings of abanuonment anu neglect, anu the
emeigence of eaily chiluhoou neeus followeu by iage, since these
neeus cannot be fulfilleu in any auult ielationship. The ensuing
iegiession can be a fuiious, uestiuctive clinging in which the
uespeiation of the patient incieases as he uestioys the memoiies
of goou sustaining intiojects, incluuing those of his theiapist. Be
also uevelops the feeling that he no longei has any ielationship oi
contact with the ieal theiapist. With the sense of loss of a
sustaining ielationship with the theiapist, the iegiessive feelings
anu behavioi can easily extenu outsiue the theiapy houis with the
possibility of seiious acting out, incluuing suiciue. Anothei aspect
of the iegiession can be the emeigence of a uespeiate, helpless
withuiawal anu isolation, which uuntiip (1971) feels is at the coie
of the uifficulty in this gioup of patients, anu which can be veiy
uifficult foi patient anu theiapist to beai.
Because iegiessions in psychotheiapy of othei than "iueal,
analyzable patients" may have a uisiuptive anu even
life-enuangeiing potential, may biing fiightening mateiial into the
theiapy, anu may possibly seiiously affect the patient's uaily
functioning, why not uo eveiything possible to pievent
iegiessions in those patients whose iegiession uoes not seem to
have cleai featuies of a contiolleu, analyzable tiansfeience, oi
tiansfeience neuiosis. Alteinately, can we at least uefine as
cleaily as possible when this painful anu potentially uangeious
iegiession is useful, oi especially impoitant. Stuuies by woikeis
who have hau significant expeiience with patients who have a
seiious iegiessive potential, such as Balint (1968), uuntiip
(1971), Little (196u, 1966), Rosenfelu (196S), anu Winnicott
(196S), suggest that iegiession in boiueiline, schizoiu, oi
schizophienic patients offeis the possibility foi a "new beginning"
oi a "iebiith." These woikeis fiimly believe that iegiession in
psychotheiapy has the possibility of exposing the basic
vulneiability that iesulteu fiom veiy eaily anu usually iepeateu
expeiiences involving an enviionment that uiu not iesponu
auequately to the neeus of the infant anu veiy small chilu. The
iegiession peimits a ieliving that can leau to a paitial iepaii of an
olu wounu. Little (196u), in paiticulai, wiites about "basic unity,"
a ietuin to the unuiffeientiateu state of eailiest infancy as a
painful but sometimes necessaiy iegiession that ultimately
peimits a new uiffeientiation anu integiation.
Ny own expeiiences, although of much shoitei uuiation than
these woikeis', convince me of the valiuity of theii position. I am
iefeiiing to the usefulness of theiapeutic iegiession in a gioup of
patients in the boiueiline spectium who might function
auequately in ceitain aieas anu who can even make gains in the
kinu of psychotheiapy that uiscouiages iegiession but whose
lives have a quality of confoimity anu a sense of unieality
uesciibeu in the liteiatuie as a "false self" (Winnicott 196u). The
"false selves" of these patientsthe piice they pay in oiuei to
function auequatelymay not peimit satisfying mutual
ielationships to the extent that they piotect patients fiom theii
unueilying wishes anu feais. It is much easiei to mouify
symptoms than to affect piofounuly a peison's way of feeling anu
caiing about himself anu otheis.
It is also impoitant to keep sepaiate fiom the patients I am
uiscussing the majoiity of patients who come to a theiapist foi
help: people who have an essentially soliu sense of themselves
anu who can benefit fiom biief oi longei theiapy that uoes not
have to incluue any significant iegiessive component. Anu, as I
have stateu, patients in the boiueiline gioup can benefit
significantly fiom theiapy that caiefully steeis cleai of iegiession,
especially when theiapeutic goals can be ieacheu without it anu
without the potential uangeis that accompany it.
I think that most theiapists, even if they believe in the
possible usefulness of iegiession in this gioup of patients, uo not
begin psychotheiapy with a new patient with the iuea that they
will encouiage a iegiession. Nost of them aie all too awaie of the
possible tuimoil anu potential self- uestiuctiveness that coulu be
unleasheu. They woulu piobably agiee that a caieful uiagnostic
assessment, possibly iequiiing many sessions, is ciucial. The task
incluues acquiiing some unueistanuing of the patient's pioblems,
conflicts, stiengths, anu weaknesses, a feeling foi how soliu a
sense of self he has, anu the foimulation of a tieatment plan.
Impoitant in the assessment is the use the patient makes of the
theiapist, assuming a "goou-enough" theiapist. Among the
questions aie: Boes the patient uevelop a ielationship with the
theiapist ovei time that uemonstiates incieasing tiust anu a
sense that he anu the theiapist aie whole people. Can the patient
make use of the theiapist anu the theiapist's comments as a
sustaining foice as well as a peison who helps him to
"acknowleuge, beai, anu put in peispective"(Semiau 1969)
significant aspects of his life, oi uoes he have to ieject anu uevalue
the theiapist fiom the beginning. Can the patient make use of a
caieful, suppoitive look at iecent stiessful events that may have
piecipitateu his cuiient uifficulties. Can he woik with the
theiapist to iecognize uifficulties in his ielationships with
impoitant people anu make use of his unueistanuing within these
ielationships. Can he see the iole guilt has playeu in his life stoiy
anu ielate it to uifficulties with piesent ielationships. Boes the
patient make use of the sessions to confiim his own sense of
bauness, oi to finu constiuctive unueistanuing anu alteinatives.
The answeis to these anu othei uiagnostic questions ueteimine
the level on which theiapy has to pioceeu as the theiapist
foimulates his unueistanuing of the patient's uifficulties anu
capacities in oiuei to uevelop anu maintain a woiking
ielationship anu fostei a capacity to obseive. Anu pait of this
foimulation involves the theiapist's cuiient unueistanuing about
the kinu of theiapy his patient iequiies, that is, whethei
shoit-teim oi long-teim theiapy that uiscouiages iegiession is
most useful, oi whethei he has a patient who might make only
minimal gains without the possibility of a iegiession in the
psychotheiapy.
Foi those who agiee that iegiession in a patient in the
boiueiline spectium can be useful, how is the theiapist to ueciue
when a specific iegiession has the potential of helpingoi when
it can be uestiuctive. 0bviously, the uistinction is veiy uifficult to
make, especially in a gioup of patients so expeit in aiousing
feelings of hatieu, woithlessness, helplessness, anu hopelessness
in the theiapist. In aiiiving at an assessment, the theiapist is
always in the position of tiying to obseive his
counteitiansfeience iesponses to the patient as a way of
unueistanuing the tiansfeience anu to sepaiate pathological ways
that he coulu iesponu to the patient because of his
counteitiansfeience. Be must also evaluate the impact of the
patient's iegiessive feelings on the lattei's uaily life, incluuing
fiequent assessment of the patient's potential anu actual
self-uestiuctiveness. Because theie is piobably no patient who
uoes not spill some of the theiapeutic issues into his uaily life, it is
haiu to uiaw a line anu say that something beyonu a ceitain point
makes the iegiession too self-uestiuctive. Nany theiapists have
hau expeiiences with ielatively healthy patients who became
significantly uepiesseu in theiapy oi analysis, with iesultant
behavioi that affecteu theii ielationships anu woik. Yet many of
these patients have ultimately benefiteu significantly fiom theii
tieatment, leaving the theiapist with the feeling that the
behavioial iegiession was piobably inevitable anu necessaiy. At
what point uoes the theiapist say that it has gone too fai. Anu if
he chooses the "wiong" point, is he telling the patient to push
away an impoitant aspect of his life that is being analyzeu anu
ieliveu in the tieatment.
In my expeiience, intense iegiessive feelings that appeai veiy
eaily in tieatment have a gieatei potential to piouuce
self-uestiuctive behavioial iegiession. Although some woikeis
uisagiee (foi example, Boiis 197S), a ielationship with the
theiapist that allows the oppoitunity at least to uefine the woik
seems to be an impoitant pieiequisite foi the emeigence of
theiapeutically useful iegiessive feelings. But theie aie patients
who biing veiy intense feelings immeuiately into the fiist session
as theii means of negotiating with the theiapist. Pait of the
theiapist's iesponse must be baseu on his iapiu foimulation of the
meaning of this patient's statements anu affect, the quality of the
ielationship foimeu immeuiately between them, the way the
patient iesponus to the theiapist's attempts to tune in anu
unueistanu, anu the theiapist's own comfoit with the issues. Boes
the unueistanuing he communicates establish a safei climate, oi is
the patient's life in such uisoiuei oi jeopaiuy that he cannot wait
until the next appointment with the theiapist, even if it is the next
uay. Implicit in this assessment is an estimate of the patient's
capacity to make use of the ielationship with the new theiapist by
means of inteinalization of the theiapist anu the theiapist's
ielationship with the patient as a sustaining foice, even though
the inteinalization may be highly tiansient at fiist.
The theiapist's assessment as to whethei the iegiession is a
uefensive avoiuance is anothei aspect ielateu to his iesponse to it.
At times when a patient can toleiate a conflict oi painful affect
with suppoit, he may neveitheless ietieat into iegiessive
behavioi. The uistinction is uifficult but ciucial; if the theiapist is
coiiect in suppoitively confionting his patient with the thought
that the iegiession is an avoiuance of a painful but beaiable issue,
his confiontation can open the way foi an impoitant piece of
woik. If incoiiect, the confiontation tenus to confiim the patient's
fantasies of being misunueistoou anu abanuoneu by his theiapist.
Limit setting can be useu eaily in tieatment as a way of
attempting to contain a iapiu iegiession. Foi example, the
theiapist can simply say that he is not inteiesteu in heaiing about
a specific aiea of the patient's life oi feelings at piesent, although
acknowleuging its ultimate impoitance. Again, the coiiect
assessment, incluuing the theiapist's comfoit with ceitain
mateiial, often ueteimines the success of the limit setting.
Nost theiapists acknowleuge the impoitance of the
theiapist's peisonality in ueteimining the success of the theiapy.
The ability of some consultants to make successful matches of
patient anu theiapist is baseu on theii ability to assess the
peisonality qualities of the theiapist anu theii "fit" with the
patient's conflicts, peisonality, anu uiagnosis. Shapiio (197S)
spelleu out the uiffeiences between two theiapists in theii
tieatment of the same woman. The fiist theiapist's open, waim
peisonality, his uifficulties in sepaiating his piofessional fiom his
peisonal life, his uiscomfoit with his patient's anality, anu his
view that his patient was someone who hau to be totally accepteu
leu to a iegiession that appeaieu as a stalemate in the tieatment.
Bei seconu theiapist expecteu moie of hei, moie cleaily uefineu
his limits, anu encouiageu hei expeiimentation with hei anality.
Bis position leu to significant changes in the patient's behavioi
coinciuent with his incoipoiation as an incieasingly active peison
in hei anal fantasies. Shapiio believes that such peisonality
chaiacteiistics of theiapists aie only minimally changeable in
tiaining, anu yet aie a majoi ueteiminant of the success of
tieatment with many patients.
The peisonality of the theiapist obviously plays an impoitant
iole in the natuie of his counteitiansfeience fantasies, as well as
in his behavioial iesponse to them in tieatment, anu ultimately is
ielateu to the outcome of the iegiession of a specific patient. The
theiapist's peisonality is especially ciucial in the tieatment of the
boiueiline gioup of patients, who so often establish a piimitive
tiansfeience involving fusion with the theiapist oi his iuealization
oi uevaluation. Because the coie issue foi many of these patients
ielates to the veiy eaily life-anu-ueath, uevoui-oi-be-uevouieu
stiuggle with a mateinal figuie, the theiapist's comfoit with an
intense tiansfeience of such mateiial is ciucial. It incluues not
only the capacity to accept the tiansfeience of the iole of
nuituiing motheianu to give it up lateibut also the ability to
feel ielatively secuie with the ego bounuaiy fluctuations of eaily
peiious. Piojections, piojective iuentification, anu fusion
phenomena of the patient can be expeiiences foi the theiapist
that leau to anxiety anu a tenuency to withuiaw, counteiattack, oi
somatize. The theiapist's capacity to accept the iuealization of the
patient without claiifying his human fallibility has been uefineu by
Kohut (1968) as one of the ciucial aspects in the tieatment of
naicissistic chaiacteis. Kohut also uesciibes the impoitance of the
theiapist's ability to listen to a patient who is using him as a
miiioi foi eaily naicissistic, gianuiose fantasies without having to
inteipiet oi iesponu nontheiapeutically to the boieuom that he
may expeiience in allowing such mateiial to unfolu. Kohut
emphasizes that the theiapist's comfoit with the piimitive
gianuiose pait of himself makes the woik with these patients
possible.
0ne of the most uifficult ingieuients of a theiapist's
peisonality to uefine is that of flexibility, that is, a capacity to
ueteimine the changing neeus, affects, anu conflicts of the patient
anu to iesponu to them appiopiiately. An acceptance of a patient's
iuealization of the theiapist can be ciucial eaily in the theiapy of
some of these patients. But the peisistence latei in tieatment of
the theiapist's view of the patient as neeuing to iuealize him may
belie the theiapist's wishes foi piecisely this type of naicissistic
giatification, anu ietaiu the patient's capacity to giow. The
nuituiant mothei tiansfeience, so impoitant at one point, may be
something that the theiapist uemanus latei to piotect himself
fiom the patient's fuiy oi the patient's incieasing capacity to
sepaiate himself fiom the theiapist. Balint (1968) uiscusses the
counteitiansfeience omnipotence of the theiapist as a
ueteiminant of whethei iegiession is "benign" oi "malignant."
This omnipotence can be manifest when the theiapist iationalizes
his active giving to oi iescuing of the patient because of his own
neeus iathei than the patient's. The theiapist's flexibility, then,
has two aspects: a basic peisonality attiibute that he biings to his
woik, coupleu with a capacity to be awaie of anu to toleiate his
own counteitiansfeience iesponses befoie they become actions
that impeue the theiapeutic piocess. 0ften it means being able to
acknowleuge muiueious hate, envy, oi intense infantile longings
in himself anu to be comfoitable with this piimitive mateiial. It
iequiies a capacity to maintain a stance that is empathic,
peimitting the tiansfeience to unfolu, whethei muiueious,
iuealizing, fusing, oi othei.
C||n|ca| I||ustrat|on
These issues, uifficulties, anu uilemmas can be illustiateu by
ietuining to the case of Ns. B., uesciibeu biiefly in Chaptei S.
When Ns. B. unueiwent a piofounu iegiession in theiapy, hei
theiapist was put in the position of having to ueciue wheie he
stoou on iegiessions in geneial, anu with this patient in
paiticulai, as well as what iole his counteitiansfeience iesponses
playeu in the tieatment. The patient sought help foi hei
uifficulties in foiming ielationships with people anu completing
hei giauuate stuuies. Buiing the fiist few months of tieatment,
she was able to use hei theiapy as a suppoitive stiuctuie. She hau
no uifficulty with the theiapist's summei vacation, which
occuiieu aftei a month of tieatment. 0vei the next six months,
howevei, she giauually began to feel uespeiate anu empty in the
tieatment situation, anu longeu to be helu constantly. What
emeigeu was hei acknowleugment that she felt fuiious at hei
theiapist foi not offeiing the amount of symbolic holuing anu
suppoit she believeu she iequiieu. As hei angei incieaseu uuiing
a specific session, she might scieam in iage anu then hit hei heau
against the wall oi pounu hei fists against hei heau oi thighs.
Although this behavioi at times teiiifieu the theiapist, he slowly
became comfoitable with all but the most seveie outbuists. Bis
incieasing activity seemeu impoitant, especially his offeis to hei
that she coulu phone him oi come foi extia sessions if necessaiy.
She occasionally maue use of these offeis, phoning in panic but
usually becoming comfoitable aftei a five- oi ten-minute
conveisation, with the iealization that the theiapist still existeu
anu was not about to ietaliate oi abanuon hei. Buiing one of his
vacations she became seiiously suiciual, iequiiing hospitalization
until his ietuin. All the same, most of the time she was able to
continue hei giauuate stuuies with uistinction.
Although outbuists of fuiy followeu by self-punishment
continueu thioughout the theiapy, the patient giauually became
able to uefine some of the fantasies anu feelings that leu to the
teiiifying quality of hei fuiy. In hei iage she felt that she
uestioyeu any image of the theiapist oi anyone else insiue of hei.
She also felt at those times that the theiapist eithei hateu hei oi
iiuiculeu anu laugheu at hei. No claiification of ieality seemeu to
make any uiffeience in the miuule of these outbuists, although she
coulu uesciibe the uetails of the feelings latei in the session with
some iealistic appieciation.
The theiapist was able to ielate these episoues to the
iepeateu loss of hei paients eaily in life, especially a long
sepaiation when she was 2 yeais olu. Be explaineu hei feelings to
hei as a ieexpeiiencing of what hau been unacceptable anu
impossible foi hei to feel if she was to suivive within hei family.
At fiist she thought the theiapist was imposing an explanation on
hei that uiu not ielieve hei immeuiate panic, but giauually she
coulu make use of it as something of hei own.
Seveial aieas of change became appaient ovei the foui yeais
of theiapy. Within the sessions the patient giauually came to feel
moie comfoitable with hei angei at the theiapist anu coulu even
leave the houi feeling angiy at him without losing the sense that
he existeu. She coulu occasionally have angiy fantasies about him
when not in his office, which pieviously woulu have been
intoleiable anu woulu have leu to panic. Theie was also an
incieasing ability to ielate to the theiapist with waimth anu a
sense of being moie of a whole peison. In hei uaily life,
ielationships with men became moie satisfying. Insteau of
ieliving the uiama with them that was playeu out in hei sessions,
she giauually leaineu to contain hei intense feelings anu biing
them into theiapy. To hei suipiise, she founu it giatifying to
behave in a moie matuie way anu leaineu that hei infantile neeus
weie not so intense as to iequiie constant giatification. She also
expeiienceu peiious in which she felt that she hau a "self" anu uiu
not have to be helu all the time.
The tieatment of such a patient can be a fiightening
expeiience to a patient anu theiapist, with many iisks, incluuing
the possibility of suiciue. As uesciibeu eailiei, a constant uangei
in the outpatient theiapy with such patients is the possibility that
iegiession uuiing the theiapy houi will spill ovei into the
patient's life. The theiapist's unueistanuing, peisonality, anu
technical skill can help keep the iegiession confineu laigely to the
theiapy sessions with most of these patients, anu can seive to
stiuctuie it in such a way as to allow the patient to expeiience
theiapy with a gieatei sense of safety.
Suggestion, foi example, is often a helpful technique in
confining iegiession to the theiapy houi, as illustiateu by the case
of Ns. B. When the patient was able to contain hei feelings in hei
ielationships with men, she was often liable to intense outbuists
of affect in theiapy. The theiapist woulu then ieminu hei, in pait
as a way of ieminuing himself, that she hau uone as agieeu in not
uisiupting outsiue ielationships between appointments. This also
helpeu the theiapist toleiate Ns. B.'s fuiy by allowing him to see it
in teims of a theoietical mouel that limiteu acting out anu biought
the conflicts anu feelings into theiapy.
Extiemely impoitant in limiting a patient's iegiession is the
theiapist's basic position about his own omnipotence: his neeu to
iescue his patients anu ieceive auulation anu naicissistic
giatification fiom them. I have alieauy uiscusseu some of the
ielevant counteitiansfeience anu peisonality factois involveu.
The theiapist's acceptance of his human limitations without
shame oi guilt can help him finu appiopiiate ways to claiify the
extent of his capacity to be available to his patient. In an example
fiom Ns. B.'s tieatment, she became fiighteneu that she might call
hei theiapist on the phone moie anu moie in hei insatiable
hungei anu gieeu until he finally became angiy at hei anu
ultimately iejecteu hei. Although the theiapist was awaie of a
pait of himself that hau a similai concein, he ieplieu that up to
that time she hau not calleu so often as to infiinge upon his
peisonal life. If she uiu he woulu let hei know anu woulu view it
as a signal fiom hei that she neeueu moie stiuctuie. Be woulu
then consiuei hospitalization. Be ieminueu hei that he hau
hospitalizeu hei in the past anu hau continueu to see hei while
she was theie. If she iequiieu hospitalization, he woulu ceitainly
be available foi appointments anu woulu woik with hei as an
inpatient until she was sufficiently comfoitable with hei
ielationship with him anu hei capacity to contiol hei feelings as
an outpatient. She founu these iemaiks ieassuiing; hei fuiy anu
feai of abanuonment anu iejection tempoiaiily became less
intense following them.
These vignettes also illustiate the use of limit setting in
psychotheiapy. If a theiapist accepts his human limitations, he
also uefines the limits he feels aie toleiable anu appiopiiate in the
theiapeutic situation. In the light of his peisonality anu his
theoietical mouel of what is useful in psychotheiapy, he
constantly assesses these limits. When the theiapist feels he has
to take a fiimei position, he must always consiuei the iole his
counteitiansfeience iage anu wishes to ietaliate may play, since
the neeu foi limit setting often occuis at a time when the patient is
being piovocatively fuiious. Sometimes his limits aie baseu on
countei- tiansfeience uifficulties that may be iationalizeu as
theoietical issues. The theiapist in the case of Ns. B., foi example,
was tempteu to state that his patient's outbuists weie so
uisiuptive anu uisoiganizing foi hei that she woulu have to
contiol them moie within the sessions. In looking at the mattei
fuithei, howevei, he concluueu that it was his own anxiety uuiing
the outbuists that was the majoi factoi in his wish that she limit
them. Noi uoes limit setting always have to be a fiim statement to
the patient to stop some behavioi; it can also be coucheu as an
expiession of the theiapist's concein. Foi many patients this
concein is eviuence that the theiapist caies, anu stanus in shaip
contiast to eailiei expeiiences of significant neglect.
Even though patients in the boiueiline spectium have seiious
uifficulties in establishing an obseiving ego anu maintaining even
a tenuous woiking ielationship, an appioach that emphasizes the
theiapist's attention to these uefects can help contain a
iegiession. Cleaily the theiapist has to believe that it is possible to
help the patient uevelop these capacities. 0n some level the
patient must maintain an awaieness of the theiapist's constant
attempts to shaie with him the assessment of the cuiient
situation anu to help him obseive the meaning of ceitain feelings
anu behavioi. It took many months foi Ns. B. to be able to look at
the meaning of hei iegiessive behavioi, but ielatively iapiuly she
coulu shaie with hei theiapist an assessment of hei suiciual
potential between sessions in a way that emphasizeu the
collaboiative aspects of hei tieatment.
The claiification of ieality is also ciucial uuiing iegiessive
episoues. The theiapist may neeu to state that he is angiy with his
patient if he senses that his angei is peiceiveu by the patient anu
is inteifeiing with the tieatment. In auuition to this claiification,
the theiapist can ultimately help the patient exploie what theie
was about his behavioi that coulu have piovokeu the theiapist to
angei. Reality claiification also incluues helping the patient be
awaie of the uistoitions anu piojections in the tiansfeience anu in
ielationships with otheis.
Finally, many of these patients iequiie help in leaining to
ielate to people that can best be categoiizeu as euucation. This
type of euucation can sometimes shoit ciicuit the uisiuptive
aspects of an infantile iegiessive tiansfeience. With Ns. B. the
theiapist spent many houis uiscussing hei giauuate stuuies, hei
ways of ielating to classmates anu the stuuents she taught, in an
appioach that focuseu on how people spoke to one anothei, felt
about one anothei, anu ielateu to one anothei. The uangei exists,
of couise, that the theiapist can assume an authoiitaiian iole in
such uiscussions that may suppoit a iegiessive tiansfeience
iathei than limit it. In auuition, he can continue such woik as an
avoiuance of anxiety-lauen issues that both he anu the patient aie
ieluctant to face.
It is easiei to talk about mouels of tieatment that uefine iueal
theiapists than to face iealistically that such theiapists exist only
in the fantasies of patients anu theii theiapists. Since theie aie
obviously many theiapists who woik effectively with patients, we
have to uefine the balance of qualities necessaiy to make goou
theiapy possible. The "goou-enough" theiapist uoes make
mistakes. But his eiiois aie iaiely the seiious acting out of
uestiuctive counteitiansfeience fantasies. 0n balance, his caiing,
concein, uevotion, anu unueistanuing outweigh his eiiois. }ust as
the chilu senses the basic caiing anu iespect of the goou-enough
mothei even when she fails, so uoes the patient accept anu foigive
honest mistakes anu lapses when the balance iesiues on the siue
of an effoit to unueistanu anu woik with him effectively.

1en
Deva|uat|on and Countertransference
In this chaptei I shall uiscuss the counteitiansfeience
iesponses of the theiapist to the uevaluing boiueiline patient. To
the extent that uevaluation contiibutes, fiom the patient's siue, to
the chaiacteiistic feelings of helplessness anu hopelessness of the
theiapist in boiueiline psychotheiapy, it iepiesents, in
miciocosm, the constellation of issues that theiapists must
confiont in theii woik with such patients.
Deva|uat|on
Bevaluation of the theiapist is a fiequent manifestation of
many of the pathological uefenses anu chaiactei styles of
boiueiline patients. It can take the foim of belittling the theiapist
veibally about his mannei, appeaiance, unueistanuing, skill, oi
intelligence. Be can be contiasteu negatively with pievious
theiapists oi consultants. Nonveibally, uevaluation may be
manifesteu in tieating the theiapist as inanimate oi not piesent in
the ioom (Seailes 196S). Such patients may nevei gieet the
theiapist oi allow any conveisation that acknowleuges him as a
human being. They may iesponu to the theiapist's claiifications
anu inteipietations as if they weie nevei spoken, continuing with
what they weie saying befoie they weie inteiiupteu. Some
patients use action to uemonstiate theii uevaluation. They may
miss appointments, come late, leave tieatment, oi commit some
antisocial act that takes them away fiom the theiapist. The veibal
anu nonveibal behavioi by the patient communicates many
things; among them is the message "You aie woith nothing to me
anu have nothing to offei me. You may think that you have some
way to help me, but I am showing that you aie valueless anu uo
not."
Theie aie many motivations that leau to this uevaluation of
the theiapist as an enu iesult. I shall enumeiate some, with the
unueistanuing that I am sepaiating piocesses that inteitwine anu
oveilap.
/( %:*#%++'"( "3 #/1%
We have alieauy seen that the boiueiline patient anticipates
iejection anu tenus to inteipiet anything except unconuitional
giving as an abanuonment. The expiession of iage, theiefoie,
appeais in theiapy aftei expeiiences of fantasieu iejection, oi
aftei the theiapist is unable to giatify the patient's uniealistic
expectations. The patient often uses uevaluation to expiess his
iage that the theiapist is not the waim souice of nuituiance he
hau wisheu foi.
A Su-yeai-olu accountant came into tieatment because of his
loneliness anu inability to have satisfactoiy piolongeu
ielationships. Be quickly ievealeu his uifficulties in theiapy by
maintaining an aloof, supeicilious aii, iaiely looking at the
theiapist anu belittling any claiifications. The theiapist began to
focus on this patient's aloofness as a piotection against unueilying
angei when he uiu not get the comfoiting he wanteu fiom the
theiapist. uiauually the patient became incieasingly angiy,
veibally attacking the theiapist foi his incompetence anu
weakness, anu then hau the fiightening expeiience of feeling
himself anu the theiapist tuining into apes who woulu uestioy
each othei.
*#"0%-0'"( /1/'(+0 8'+.%+ 3"# (4#04#/(-%
The longings anu wishes foi closeness, love, anu nuituiance
that these patients expeiience aie teiiifying to them. Such feelings
biing up conceins about being uisappointeu, helpless, anu
abanuoneu. In some patients these wishes may thieaten
iegiession, with the felt thieat of annihilation. If the theiapist has
little woith to the patient anu the theiapeutic situation little to
offei him, the patient can ueny his intense longings. As the patient
in this situation begins to be awaie of his incieasing involvement,
uevaluation of the theiapist piotects him against the feaieu
uisappointment oi iegiession. At the same time, uevaluation
symbolically iepiesents a uefensive iefusal to take in what is so
intensely longeu foi.
The patient just uesciibeu giauually became awaie, mainly
thiough uieams, of his wishes to be helu anu nuiseu by the
theiapist. Aftei a peiiou of incieasing attacks, consisting of
complaints that the theiapist was weak, feminine, anu stupiu anu
lackeu an unueistanuing of the pioblems involveu, the patient hau
a fantasy that he was like a sea lampiey, wanting to hang onto the
theiapist, nevei let go, anu suck foievei. Fiom that moment he
coulu see spontaneously that he woulu have to attack anu belittle
the theiapist to keep such fantasies fiom consciousness.
*#"0%-0'"( /1/'(+0 %(7,
Akin to affectionate longings foi the theiapist is an intense
envy of him anu a wish to swallow him whole anu be like him.
Such envy may aiouse so much uiscomfoit in the patient that
uevaluing the theiapist feels like his only means of piotection;
theie is nothing to envy anu engulf if the theiapist is valueless.
A S1-yeai-olu engineei, eaily in analysis, saw the analyst as a
helpful peison but hau inteimittent paianoiu feais that the
analyst woulu exploit him, take his money, anu change him. Aftei
one yeai of tieatment the patient iepoiteu a seiies of uieams: The
fiist was about a gioup of nuises having a lunch of iounu uoughy
things toppeu with whippeu cieam anu a ieu cheiiy. The
succeeuing uieams became explicit seuuctions of compliant
women in which the patient woulu fonule oi suck theii bieasts.
Concomitant with these uieams, whose oial tiansfeience
implications weie spelleu out to the patient, weie uays of
incieasing attacks on the analyst foi not unueistanuing him anu
having nothing goou to offei, as well as feelings that analysis was
useless anu not the solution to his pioblems. Aftei seveial
sessions of analyzing this mateiial, the patient uiscusseu the
uevaluation as a piotection against his wishes to suck. In auuition,
he then spoke of his envy of how much the analyst hau anu coulu
give to him anu othei patients.


*#"0%-0'"( /1/'(+0 *#"5%-0%$ /(1%#
A theiapist who is valueu is often felt by boiueiline patients
to be uangeious anu ietaliatoiy, because theii angei may be
piojecteu onto him. The theiapist seen as weak, helpless, anu
woithless cannot uestioy the patient.
A 21-yeai-olu waitiess, uesciibeu by a colleague as "The
Black Beath" to captuie the feeling of hei intense, chionic iage
anu uepiession, iepeateuly minimizeu the impoitance of the
theiapist, the value of his comments, anu his ability to caie about
anu help hei. Eaily in theiapy theie occuiieu seveial episoues of
incieasing angei, immeuiately followeu by intensely feaiful
outbuists that the theiapist hateu hei anu woulu thiow hei out oi
physically injuie hei. She then ietuineu to belittling the theiapist
anu the theiapeutic ielationship to piotect heiself against hei fuiy
anu hei neeu to pioject it onto the theiapist.
*#"5%-0'"( "3 &"8 +%&36%+0%%2
Boiueiline patients invaiiably have extiemely low
selfesteem. Its components often aie ielateu to the patients'
feelings about theii inability to contiol theii fuiy oi the
unacceptability of theii infantile longings. They may attempt to iiu
themselves of such feelings by placing them in the theiapist. This
uisplacement can be expiesseu in the uevaluation of the theiapist,
sometimes iesulting in the patient's feeling moie woithwhile.
A 4S-yeai-olu single bookkeepei suffeieu fiom yeais of
chionic uepiession anu isolation; she began woiking again in
oiuei to pay foi hei theiapy aftei seveial yeais of seiious
withuiawal. In theiapy, aftei weeks of ciying anu viitual silence,
she spoke of hei woithlessness, emptiness, inability to give
anything to anyone, anu hopelessness. Bei uiscussion of these
feelings was chaiacteiizeu by little affect except foi that
associateu with hei iepeateu attacks on the theiapist. Be was
uesciibeu as a woithless, useless peison who coulu not give hei
anything, not even pills. At times she woulu stoim out of the office
angiily, but on othei occasions she appeaieu moie ielaxeu anu
fiienuly aftei these iepetitive baiiages.
/ 0#/(+3%#%(-% 2/('3%+0/0'"(
Boiueiline patients may be ieliving ieal oi fantasieu
uevaluation by a paient in the tiansfeience. By iuentification with
the uevaluing paient, they become that paient anu tieat the
theiapist as they themselves felt tieateu in chiluhoou.
The 21-yeai-olu waitiess uesciibeu eailiei hau seiiously
uistuibeu paients who ieacteu to hei as an infeiioi veision of a
biothei who uieu shoitly aftei she was boin. In the analysis of the
tiansfeience, it became cleai that she expecteu hei theiapist to
see hei as his most infeiioi patient. She also iecognizeu that she
belittleu the theiapist in the way hei paients belittleu hei.
The peisonality anu skills of the theiapist aie paiticulaily
ciucial in woiking with this gioup of patients. The capacity to
uevelop tiusting anu loving ielationships with people, so lacking
initially in these patients, is ielateu to the piocess of
inteinalization of the goou theiapist who himself uemonstiates
these capacities in his woik with the patient. As alieauy
suggesteu, the chief expeiiences that peimit this piocess to occui
aie iepeateu encounteis with the patient's angei in theiapy. The
theiapist's consistent, tactful, non-ietaliatoiy hanuling of the
patient's iage allows pathological uefenses to be given up slowly
anu peimits the patient to expeiience the theiapist as the tiuly
goou object who can safely be intiojecteu. The theiapist's
appiopiiate iesponse to the patient's angei giauually pioviues the
patient with the knowleuge that he can feel intimate anu helpless
with the theiapist without being swalloweu, even though he anu
even the theiapist may wish foi it.
The veibal expiession of angei in psychotheiapy pioviues the
patient with the possibility of a new kinu of expeiience. Be can
expeiience anu ultimately leain that he can veibalize angei, not
act on it, not uestioy the theiapist, not have the theiapist ietaliate,
anu not be iejecteu oi abanuoneu by the theiapist. This iepeateu
encountei thus pioviues a mouel foi iuentification that helps the
patient uevelop new ego capacities. 0nce it is safe to veibalize
angei, the patient anu theiapist can investigate moie ieauily the
meaning of its piesence at a paiticulai moment anu its oiigins, all
of which aie impoitant in the iesolution of the patient's iage.
Countertransference and Se|f-sycho|ogy
Among the many contiibutions of self-psychology is its
iecognition that selfobject neeus exist in all people to vaiying
uegiees thioughout theii lives. Relatively matuie theiapists anu
analysts iequiie some valiuation fiom theii patients that they aie
competent, effective clinicians. They ieceive this valiuation fiom
expeiiences of unueistanuing theii patients anu being useful to
them, fiom the iealization that the functions they peifoim foi
theii patients ultimately leau to theii patients' giowth. As long as
the patient uses his theiapist anu iesponus to him sufficiently to
confiim his competence, the theiapist will maintain a soliu,
comfoitable feeling about himself as someone of woith anu value.
But when the theiapist has one oi moie boiueiline patients who
uevalue, ieject, oi ueny his attempts to help, consistent with the
natuie of theii emeiging tiansfeience, the theiapist may then finu
himself feeling veiy much as the patient uoes.
The theiapist's uespaii anu angei can be vieweu as a
iesponse to his own expeiience of feeling that he has faileu as a
selfobject; that is, he uoes not appeai to be peifoiming the
selfobject functions that the patient says he wants fiom him.
0sually uniecognizeu by both patient anu theiapist aie the silent
(anu theiefoie often pieconscious oi unconscious) holuing
selfobject tiansfeiences that pioviue the stability necessaiy to
peimit uniesolveu issues of the past to emeige. Bisappointment,
uespaii, anu angei fiom the past aie thus ieactivateu anu ieliveu
in the tiansfeience. They elicit counteitiansfeience iesponses in
the theiapist to the extent that they involve him as the failing
selfobject iecieateu fiom the patient's past failing selfobjects.
Because neithei the patient noi theiapist is in touch with the
positive selfobject bonu that allows these feelings to emeige, both
expeiience pain in the tiansfeience-counteitiansfeience. The
patient feels helpless anu hopeless in the tiansfeience; the
theiapist, because he cannot soothe, satisfy, auequately
unueistanu, oi help the patient (fiom both his anu the patient's
peispective), expeiiences the situation as his own failuie. When
chionically iepeateu, this expeiience ultimately ielates to the
theiapist's failuie to ieceive the valiuation of his piofessional
competence that he iequiies. A paiauox of this
tiansfeience-counteitiansfeience situation is that, in the
1/00%11./$ tiansfeience ieliving, the theiapist expeiiences his
failuie as a selfobject only aftei he has fiist succeeueu as a holuing
selfobject; the patient in tuin, in expeiiencing the theiapist as the
failing selfobject, fails the theiapist by not peifoiming the
selfobject valiuating function that the theiapist inteimittently
neeus. (This shoulu not be taken to mean that it is the patient's
"!1P to peifoim this valiuating function, only that when at such
times the patient uoes not valiuate the theiapist's sense of
competence sufficiently, the uesciibeu counteitiansfeience
expeiiences aie usually inevitable.)
When the theiapist can view his counteitiansfeience
expeiience as his empathic iesponse to the feelings of his patient,
he has a clue to the natuie of the patient's cuiient anu past
expeiiences. But it is not easy to maintain a balance between
immeision in the patient's feelings anu the iequisite uistance fiom
them necessaiy to function most effectively as theiapist anu
selfobject. The task is paiticulaily uifficult to the extent that the
theiapist's intense counteitiansfeience expeiiences incluue a
tiansient oi moie piolongeu conviction that he inueeu uoes not
unueistanu, oi that he lacks an auequate empathic capacity with,
this specific patient. Be may, as uesciibeu, question what he
pieviously felt weie soliuly establisheu aspects of his own self anu
his theiapeutic skills. Aie the patient's feelings of hopelessness,
iage, anu iejection of the theiapist the ieliving in the tiansfeience
of eaily selfobject failuies. Aie they being expeiienceu in
iesponse to the expectable failuies of a goou to excellent
selfobject theiapist. 0i has the theiapist inueeu faileu the patient
because of his significant empathic limitations oi
counteitiansfeience uifficulties with the specific patient. The
theiapist's ability to iaise these questions puts him in a goou
position to examine the vaiious possibilities as he continues his
woik with the patient. Sometimes consultations with a tiusteu
anu iespecteu colleague aie necessaiy to soit out these complex
issues anu gain some peispective.
Countertransference kesponses to Deva|u|ng at|ents
What uoes it feel like to sit with the patient who iepeateuly
uevalues us. The expeiience can be uevastating, especially foi the
young theiapist. It may aiouse feelings of intense woithlessness
anu uepiession, feai, iage, guilt, shame, anu envy. The theiapist
may tuin his iage against himself if he feels guilty about it,
intensifying his uepiession. Be may feel guilt anu shame that he
cannot iescue the patient anu live up to the patient's expectations
that he be the omnipotent paient. Be is paiticulaily vulneiable to
feeling shame when he is confionteu with his all-too-human
iesponse of envy to the patient's uemanus foi unconuitional caie
anu nuituiance.
The young theiapist especially may iesponu to peisistent
uevaluation by these patients with a tempoiaiy, sometimes
piolongeu iegiession that exposes his uoubts, not only about his
abilities, but as to whethei woiking with a patient in a theoietical
mouel that values veibal inteichange is at all helpful. Be is
paiticulaily vulneiable to the patient who tells him that his
piofessional anu peisonal uoubts aie coiiect. These patients aie
expeit in peiceiving aspects of the theiapist's peisonality that aie
pioblem aieas foi the theiapist. Piimitive patients piobably
uevelop this skill fiom theii style of existence, in which eveiy
encountei with any peison is so thieatening that they must
peiceive his weaknesses in oiuei to be piepaieu foi the final
battle foi suivival.
I shall now uiscuss the vaiious ways that the theiapist may
iesponu to these uevaluing, angiy attacks.
8'0.$#/8/&
I have alieauy outlineu how these veibal attacks may leave
the theiapist feeling peisonally huit, angiy, oi hopeless. Bis
behavioial iesponse to these feelings may be withuiawal. Be may
stop listening to the patient, uayuieam about something else, oi
feel boieu oi angiy. Be may have conscious wishes that the
patient leave tieatment. This withuiawal may be manifesteu in his
noninteivention when a claiification oi inteipietation woulu be
useful. These sensitive patients will intuitively feel the theiapist's
withuiawal anu often iesponu with incieasing conceins about
iejection anu abanuonment. They may eithei become angiiei oi
passively compliant in oiuei not to lose theii theiapist
completely.
When the patient complains that his theiapist is less available
as a caiing, inteiesteu peison, the theiapist may have a ieauy
explanation to suppoit his withuiawal. Especially manifest in the
beginning theiapist is his use of the uefense that he is being a
goou, nonuiiective psychotheiapist. Theiapists often stait theii
tiaining attempting to fulfill a fantasy of what the psychoanalytic
mouel of tieatment is, incluuing the fantasy of the miiioilike
image of the analyst. The theiapist's ietieat into this fantasieu
iuentification often masks his feai, angei, uepiession, oi
hopelessness when confionteu with a uifficult anu thieatening
patient. An example of such behavioi was a theiapist woiking in a
piison with an angiy, uevaluing, fiightening inmate. This patient
wanteu to shake hanus with him at the enu of the meetings. The
theiapist iefuseu, feeling that he was giatifying the patient too
much iathei than analyzing what the patient's wish meant.
The theiapist's withuiawal may be manifesteu in the ways he
allows the patient to uevalue theii woik within the theiapeutic
sessions by not puisuing actively the meaning of lateness, misseu
appointments, oi nonpayment of bills.
Withuiawal can leau to veiy seiious consequences when it
involves the theiapist's ieluctance to inteivene in uestiuctive oi
self-uestiuctive activities of the patient outsiue the theiapeutic
setting. The patient may be communicating that he is out of
contiol, oi may be testing to see whethei the theiapist caies
enough foi him to pievent him fiom uoing anything uestiuctive to
himself oi the impoitant people in his life. The noninteivention by
the theiapist at this point is often felt by the patient as
confiimation of his feais that the theiapist uoes not caie about
him.
$%3%($'(1 .'2+%&3
The theiapist may iesponu to iepeateu attacks by uefenuing
himself, telling the patient that he knows what he is uoing anu has
woith anu something to offei. As pait of this iesponse he may
point out to the patient the piogiess they have maue anu how
much bettei the patient is in ceitain ways. The uefensive natuie of
this position is eviuent to the patient, who may iesponu with
incieasing angei anu anxiety, oi with compliance anu suppiession
of angei.
*#"7'(1 .'+ "2('*"0%(-% /($ &"7%
The theiapist can iesponu to the patient's piovocations by
active uemonstiations that he loves the patient, has the magical
supplies the patient uemanus, anu is the omnipotent, giving,
iescuing paient. Be may tell the patient he caies about him,
teiiifying him by the thieat this piesents to his tenuous
autonomy. Be may give anu smothei symbolically oi actually,
sometimes making the patient feel content momentaiily but often
fiightening the patient, who has a pait of him that knows that
such giatification of his piimitive uemanus is no solution anu will
only make him feel moie helpless anu woithless.
#%0/&'/0'(1
A common outcome of attacks by these patients is ietaliation
by the theiapist. Its manifestations may be milu, as in teasing oi
subtle ciiticism, oi oveitly angiy anu iejecting. It may take the
foim of inteipieting the patient's feelings of entitlement, not as
pait of the theiapist's commitment to the selfobject tiansfeience,
but as an angiy counteiattack involving envy of the patient's
feelings. This is not to say that the angei of the theiapist is not a
useful tool, but when it is useu to ieject the patient, it is extiemely
uestiuctive. It intensifies the uistiust alieauy piesent anu
iuptuies the tenuous woiking ielationship.
'(0%#*#%0'(1 0.% /(1%# /+ 2/+<'(1 &"7%
The theiapist may be so uncomfoitable with the iepeateu
angiy attacks that he unconsciously uefenus himself by ueciuing
that they aie masking feelings of love anu closeness that the
patient cannot accept. Sometimes, of couise, this is tiue. But if the
issue foi the patient is ieally his muiueious iage, the theiapist's
incoiiect inteipietation will tell him that the theiapist cannot
toleiate it.


C||n|ca| I||ustrat|on
Some of these points can be illustiateu with iefeience to the
Su-yeai-olu accountant uesciibeu biiefly at the beginning of this
chaptei. Because I am conceineu heie so laigely with
counteitiansfeience issues, anu wish to emphasize the peisonal
quality of the theiapist's iesponses, I shall use the fiist- peison
thioughout this account.
Ni. F. was of aveiage height, thin, awkwaiu, anu auolescent in
his gestuies anu voice. Bis sitting position fiom the stait was
chaiacteiistic of the way in which he ielateu to me foi yeais: Be
woulu slouch anu piactically lie on the chaii, talking to the
oveiheau lighting fixtuie, the pictuie to the left of my heau, oi the
winuow to the iight. Be spoke with a soft southein uiawl in an
aloof way, yet at the same time he coulu summon up aiticulate
anu bitingly humoious uesciiptions of his woik, his past, anu the
few people in his cuiient woilu. Be coulu ieauily uefine the majoi
uisappointments in his life that hau ueteimineu his iesponses to
people evei since: Bis mothei, who hau helu, huggeu, anu hoveieu
ovei him foi the fiist five yeais of his life, hau abanuoneu him foi
his newboin sistei. To him it hau felt like being an infant suuuenly
thiown off his mothei's lap. Be hau tiieu to woo hei back by
auopting hei loving, smiling funuamentalist ieligious position,
which incluueu a uenial of jealousy oi angei. Be hau also tiieu
tuining to his biusque, busy fathei, who scoineu him foi his
awkwaiuness anu weakness. Be stiuggleu to love but at the same
time founu himself vomiting up the lunches his mothei hau
packeu foi him to eat in school. uiauually he began to vomit the
foou he ate at home. Bis fiienuships at school weie jeopaiuizeu by
his neeu to iepoit to his mothei the nasty things the othei
chiluien saiu anu uiu; he agieeu with hei that he woulu nevei
think such naughty thoughts himself. Buiing his auolescence he
became incieasingly pieoccupieu with thoughts of inauveitently
huiting people, which culminateu in maikeu anxiety in his eaily
twenties when he became afiaiu that he woulu stab piegnant
women in the abuomen. This anxiety leu him to his college health
seivice anu his fiist expeiience with psychotheiapy.
In spite of these uifficulties, he uiu well acauemically in high
school, spent two yeais in the navy, wheie he felt libeiateu, anu
was able to complete college successfully. Bis ielationships with
women consisteu of looking at them fiom afai, actively fantasying
closeness anu hugging; actual contacts weie awkwaiu anu biief.
Be coulu foim moie sustaineu but still uistant ielationships with
men. Be was tiansiently conceineu that he might be a homosexual
at the time he was uischaigeu fiom the navy.
Bis fiist psychotheiapy occuiieu uuiing his last yeai at
college. Be hau felt fiighteneu anu uespeiate anu hau quickly
come to see his theiapist as the man who hau iescueu him. Bis
theiapist was a psychiatiic iesiuent whom the patient uesciibeu
as laige, athletic "like a football playei," a smokei of big cigais
who actively gave auvice anu was veiy ieal anu uiiect with him. In
looking back at this theiapy, my patient felt that it hau helpeu to
uiminish his pieoccupations anu anxieties but hau left him still
unable to foim lasting, satisfying ielationships with people. It hau
enueu befoie he felt ieauy, because his theiapist, aftei one yeai of
woik with the patient, hau finisheu his tiaining anu left the aiea.
When I fiist saw the patient six yeais latei, he uefineu his pioblem
as a chionic one that he felt he coulu not solve alone. Yet he felt
pessimistic that anything coulu be uone to change things.
This patient was one of my fiist piivate patients anu ieally
puzzleu me. I was impiesseu by his wish to woik, on the one hanu,
anu by his loneliness anu isolation, anu the fiightening quality of
his angei, on the othei. I was conceineu about his aloofness anu
uistance fiom me; I uiu not feel that he anu I weie making contact
with each othei, but I uiu not know what to uo about it eithei. At
that point in my expeiience, I coulu not even foimulate the
question of how much I likeu him anu whethei that was
impoitant. I uiu iecognize that he hau a choice of whethei he
wisheu to see me iegulaily, anu I offeieu him that oppoitunity at
the enu of oui fiist meeting. Be ieplieu that he was willing to see
me anu felt that one houi a week was what he hau in minu.
Fiom my peiception of the fiist few months of oui meetings,
nothing much happeneu. Be gave me moie histoiy to fill out the
outline of his life anu tolu me moie about the emptiness of his
cuiient existence, but all in a mannei that shut me out anu
maintaineu an amuseu uistance. Be became a patient about whom
I woulu sigh weaiily befoie inviting him in. Because of my uistiess
anu incieasing boieuom, I began to point out as tactfully as I coulu
the way he was avoiuing contact with me anu keeping me out of
his woilu. Bis iesponse ovei a numbei of months, with an
insistent sameness, was a quick glance followeu by the sau
aumission that he hau maue a mistake. Be uiu not know how to
tell me, but I was not the iight theiapist foi him. In auuition to my
soft voice anu milu mannei, I piobably hau nevei been in a bai in
my life, hau nevei been in a fist fight, anu uiu not smoke cigais. Be
woulu then speak with affection about his pievious theiapist anu
again spell out the vast uiffeiences between us.
When I coulu iecovei fiom what occasionally felt like a
uevastating peisonal attack, I woulu tiy to help him look at the
meaning of what he was saying. I woulu ielate it to his
ielationship with his mothei, his fuiy at hei abanuoning him anu
his wish to tuin to the othei paient, who also let him uown; often I
coulu point to specific paiallels. 0sually he iejecteu these
inteipietations as incoiiect, iiielevant, anu woithless. Be woulu
also ueny that he felt any angei at me when I woulu point out the
obvious attacking quality of many of his statements. Bow coulu he
be angiy when he wasn't even involveu anu uiun't caie, he woulu
ieply.
0vei a nine-month peiiou I went thiough stages of boieuom,
withuiawal, fuiy, uepiession, anu helplessness. I giauually began
to feel like a bioken iecoiu. I hau iun out of new iueas, anu I founu
myself incieasingly willing to acknowleuge that maybe he was
iight: I piobably was not the theiapist foi him. With ielief I
suggesteu that he see a consultant, who woulu help us make that
ueteimination. I also hau to acknowleuge to myself that my
naicissism was on the line. To fail with one of my fiist piivate
patients, anu because of so many allegeu peisonal inauequacies,
was moie than I wisheu to face at that time. Also, I hau chosen a
consultant I gieatly iespecteu, auuing to my conceins about
ievealing my inauequacies as a theiapist.
The consultant felt that theiapy hau ceitainly been
stalemateu, but laigely because of the infiequency of the visits
anu the lack of confiuence I hau in the woith of my woik with the
patient. Be minimizeu my insistence that the patient uiu not feel I
was the iight theiapist. Be stateu that in his inteiview with the
patient, the patient hau talkeu about what he uiu not like but also
conveyeu a iespect foi oui woik anu some willingness to continue
with me. Aftei the consultation I ambivalently negotiateu with this
patient foi psychoanalytic tieatment involving the use of the
couch anu five meetings a week. With the ieassuiance that at least
my consultant loveu me, I aiiangeu to have the consultant
continue as my supeivisoi.
Psychoanalysis with this patient lasteu foui yeais. The
position he took in oui eailiei theiapy was maintaineu but this
time amplifieu anu unueistoou by means of uieams anu memoiies
that veiifieu pievious hypotheses. Claiifications about his
muiueious iage that appeaieu in uieams maue it somewhat safei
to talk about his fuiy with me. uiauually he coulu speak
intellectually about the possibility of an involvement with me, but
it was something he nevei ieally felt. 0nly on two occasions uiu he
actually expiess angei towaiu me, both leauing to neai uisiuption
of the analysis. 0ne followeu my inflexibility when he wanteu to
change an appointment, anu leu to his calling the consultant in
oiuei to iequest a change of analysts. The othei occuiieu towaiu
the enu of analysis, when I pointeu out his neeu to maintain a
paianoiu position in ielation to people. It iesulteu in his stoiming
out of the houi anu phoning that he was nevei ietuining. Be came
back aftei one misseu session. uiauually, I became peisonally
moie comfoitable with this patient, although seeing him was
always haiu woik. I felt much less helpless anu hopeless as I came
to see his attacks, isolation, anu uistance in the context of a
theoietical fiamewoik anu as pait of the tiansfeience anu uefense
against it. Ny supeivisoi's suppoit anu claiifications helpeu me to
maintain this uistance. But my helplessness was still piesent
when my inteipietations weie iejecteu foi long peiious of time
anu I was tieateu as some nonhuman appenuage to my chaii. I
often felt hopeless that we woulu evei achieve the goals we hau
set. I say "we," but usually it felt like "I" anu "him," with little sense
of oui woiking togethei. I fiequently hau to ask myself whethei I
likeu him enough to suffei with him all those yeais, but I hau to
acknowleuge giuugingly that in spite of eveiything, I uiu.
Somehow the piocess of long-teim woik with him hau maue me
feel like a paient with a uifficult chilu, a paient who coulu finally
come to accept any change at all in that chilu with happiness. The
changes that occuiieu weie piesenteu to me casually. They
consisteu of passing comments about his incieasing ability to uate
women, anu leu ultimately to his maiiying a woman with whom
he coulu shaie mutual tenueiness.
I believe that ceitain aspects of this patient's uefensive
stiuctuie anu the tiansfeience that emeigeu in analysis maue
woiking with him paiticulaily uifficult foi me. Be was ieliving a
ielationship of helplessness anu hopelessness with his mothei.
Not only uiu he feel abanuoneu by hei when his sistei was boin,
but he was alloweu no uiiect way to expiess the angei anu
jealousy he expeiienceu. Be chose to comply on the suiface but
maintaineu an aloof, uispaiaging uistance fiom hei that piotecteu
him against his fuiy, helplessness, anu uespaii. Because he uiu this
with his mothei to stay alive, he unueistanuably iepeateu the
same pattein with me, complying on the suiface but vomiting up
anu iejecting what I attempteu to give. In a sense he nevei left
that position with me; he was able to change the quality of
ielationships outsiue of analysis but maintaineu his aloofness
with me to the enu. Be woulu say that to show ieal change with
me was to acknowleuge that he hau taken something fiom me anu
kept it as pait of himself; he just uiu not want to uo that openly,
foi he woulu have to aumit the impoitance of oui ielationship anu
how giateful he was. Bis compiomise was to iemain veiy much
the same with me, to change significantly outsiue, anu then to
asciibe the changes to things he coulu take fiom the new
impoitant people in his life.

Ak1 III
Cther 1reatment Issues

L|even
nosp|ta| Management
Bospital tieatment of boiueiline patients may be inuicateu
uuiing iegiessions maikeu by incieasingly uestiuctive oi
self-uestiuctive behavioi. In this chaptei I shall ueal with aspects
of the hospital tieatment of all boiueiline patients but shall
emphasize those patients alieauy in theiapy who iequiie
hospitalization uuiing ongoing tieatment. I shall stiess (1)
uniesolveu uevelopmental issues that emeige in theiapy anu that
iequiie moie suppoit than that available to the patient outsiue
the hospital; (2) useful functions hospitalization can peifoim foi
both patient anu theiapist; (S) the theiapist's counteitiansfeience
uifficulties anu vulneiabilities, which may become moie manifest
when the patient is hospitalizeu; (4) hospital staff
counteitiansfeience uifficulties that piomote uestiuctive,
iegiessive patient behavioi anu that may often impeue the
theiapist's woik with the patient; anu (S) auministiative anu staff
pioblems within the hospital setting that can facilitate oi impeue
the iesolution of issues that leu to hospitalization.
Ind|cat|ons for nosp|ta||zat|on
Bospitalization has to be consiueieu foi boiueiline patients
who aie expeiiencing intense panic anu emptiness, eithei because
of the emeigence of uestiuctive fuiy in the tiansfeience oi
because of a uespeiate ieaction to ielative oi total loss of
impoitant people oi othei uisappointments in theii cuiient lives.
Implicit in this uespeiation is an inability to expeiience the
theiapist as someone who constantly exists, who is available anu
suppoitive. The fiagile, unstable woiking ielationship
chaiacteiistic of boiueiline patients ieauily bieaks uown unuei
stiess. The patient's uespeiation may incluue uestiuctive anu
self-uestiuctive pieoccupations anu piesent a seiious uangei of
suiciue anu othei uestiuctive oi self-uestiuctive behavioi.
Tieatment of boiueiline patients within a hospital setting
pioviues the patient anu tieatment team, incluuing the patient's
theiapist, with a seiies of oppoitunities to foimulate anu
implement a tieatment plan leauing to a piouuctive use of
hospitalization, iathei than one that suppoits anu continues the
iegiessive behavioi, with its ieal uangeis. Whethei the boiueiline
patient iequiies anu can benefit fiom hospitalization uepenus
upon an evaluation of seveial factois: the patient's basic ego
stiengths anu ego weaknesses, the type oi types of piecipitating
stiess, the suppoit systems available to the patient outsiue the
hospital, the patient's ielation to his theiapist, the intensity of the
tiansfeience feelings, anu the theiapist's awaieness of his
counteitiansfeience feelings anu iesponses. Also impoitant aie
the quality anu availability of an appiopiiate hospital, the
patient's anu family's willingness to paiticipate in the
hospitalization, anu the financial iesouices of the patient anu
family, incluuing the auequacy of hospitalization insuiance.
Because hospitalization may be the fiist stable situation in a
long time foi a uespeiate, uisoiganizeu boiueiline patient, it may
also pioviue the fiist oppoitunity foi the patient to collaboiate in
a thoiough evaluation. This evaluation shoulu incluue
paiticipation of the family anu a caieful look at the patient's woik
with his theiapist. Even though the theiapist who hospitalizes the
patient has attempteu to evaluate the neeus anu usefulness of
hospitalization, this outpatient evaluation may of necessity be
biief anu sketchy because of the chaos of the patient's life anu the
uangeis the patient is facing. 0n the othei hanu, patients who
uecompensate uuiing long-teim theiapy may have been
thoioughly evaluateu by theii theiapist. Bospitalization foi this
gioup offeis a chance foi the theiapist to obtain an impaitial
evaluation of his woik with the patient, assistance with the family
if inuicateu, anu a safe setting to begin the iesolution of
tiansfeience issues that oveiwhelm the patient.
0nce the uecision to hospitalize the patient is maue, the
choice of hospital is impoitant. When theie aie seveial suitable
hospitals in which the staff has a uynamic unueistanuing of
piogiams foi the boiueiline patient, consiueiations incluue the
neeu foi shoit- oi long-teim hospitalization, whethei the
theiapist can continue with the patient while the patient is in the
hospital, whethei the hospital's policy suppoits this continueu
psychotheiapeutic woik, anu whethei, in cases in which it is
inuicateu, the hospital emphasizes family involvement.
1he nosp|ta| Sett|ng: A Good-Lnough Mother|ng and no|d|ng
Lnv|ronment
The boiueiline patient's uevelopmental vulneiabilities must
be auuiesseu in the hospital setting. The iegiesseu suiciual oi
uestiuctive patient iequiies a piotective enviionment that fulfills
many aspects of Winnicott's (196S) "holuing enviionment" anu
has a staff with the chaiacteiistics of his "goou-enough
motheiing" concept. The abanuoneu-chilu feelings of the eniageu,
iegiesseu boiueiline patient aie accompanieu by uistiust, panic,
anu a feeling of nonsuppoit anu uespeiation. The tiansient loss of
an evocative memoiy capacity foi impoitant sustaining people
contiibutes significantly to feelings of being "uioppeu," alone,
abanuoneu, anu isolateu, anu the panic these feelings inuuce.
When boiueiline patients iequiie hospitalization, the waiu
stiuctuie must pioviue holuing qualities that offei the neeueu
soothing anu secuiity. A sufficient empathic staff iesponse to the
patient's iage, uespaii, anu aloneness pioviues the potential foi
ielationships with new people who can communicate theii giasp
of the patient's expeiience with them anu be physically piesent
anu empathically available often enough. Boluing anu
goou-enough motheiing imply a genuine flexibility; the chilu at
uiffeient ages anu with uiffeient expeiiences anu stiesses neeus a
vaiying iesponse fiom caiing paiental figuies. The highest level of
expiession of these functions by a hospital staff incluues the
unueistanuing that the boiueiline patient is an auult who may be
tiansiently oveiwhelmeu; the auult aspects iequiie nuituiance,
suppoit, anu iespect at the same time that the chiluhoou
vulneiabilities that have unfolueu neeu an empathic iesponse,
which incluues, when necessaiy, a piotective iesponse.
The "goou-enough motheiing" anu "holuing enviionment"
concepts aie often misinteipieteu by the staff to mean a position
that offeis only a constant waim, nuituiing iesponse to all
patients all the time. Such a staff iesponse may inciease the
patient's iegiessive feelings anu behavioi. This misunueistanuing
highlights pioblems of utilizing eaily chilu uevelopment concepts
foi auult patients with uifficulties that incluue iegiessions oi
fixations to issues ielateu to these eaily yeais. Winnicott's
concepts, when applieu to hospitalizeu auult boiueiline patients,
must specifically incluue an empathic awaieness anu iesponse to
auult stiengths anu self-esteem issues. A misunueistanuing of
these concepts may be pait of a counteitiansfeience iesponse
that incluues an omnipotent wish to iescue the patient. The
coiiect utilization of these concepts helps suppoit the foimation
of alliances anu an obseiving ego thiough staff attempts to claiify
anu shaie with the patient theii assessment of his complex
feelings, the fluctuations of these feelings, anu the patient's
vaiying capacity to collaboiate with the staff to contiol them ovei
time.
The newly hospitalizeu boiueiline patient iequiies a iapiu
evaluation on aumission that assesses his neeus foi piotection.
This initial evaluation investigates the suiciual anu uestiuctive
uangeis, anu ieviews the patient's histoiy of uangeious actions in
the iecent anu moie uistant past. It also incluues a beginning
unueistanuing of the piecipitants that leu to hospitalization, as
well as an evaluation of the patient's woik with his theiapist, if he
is in theiapy. A histoiy of iecent losses, whethei fantasieu oi ieal,
incluuing the tiansient oi peimanent loss of a theiapist, is
paiticulaily impoitant, even though some losses may ultimately
be unueistoou as fantasieu uistoitions oi aspects of piojective
iuentification. The staff evaluation makes use of the patient's
capacity to give a histoiy, his ability to shaie feais anu fantasies,
anu the uegiee to which he can collaboiate with the staff to
ueteimine a useful hospital tieatment plan. 0bviously, the eaily
assessment is veiy tentative, since some boiueiline patients have
a capacity, even when iegiesseu, to piesent a "false self' pictuie
that minimizes cuiient uespeiation anu uangeis. A staff
expeiienceu in hanuling boiueiline patients will use its
empathically baseu counteitiansfeience fantasies anu feelings as
pait of the assessment.
The piotective anu suppoitive measuies a hospital anu its
staff foimulate anu implement, when the patient's neeus aie
assesseu coiiectly, can pioviue the most suppoitive holuing
iesponse to an oveiwhelmeu, iegiesseu boiueiline patient. A
patient may iesponu with a uiamatic ueciease in panic when his
fiightening suiciual feelings aie evaluateu to be neaily out of
contiol anu appiopiiate measuies aie instituteu. These may iange
fiom assignment to a lockeu waiu, fiequent staff checks, oi the
assignment of a special nuise, to the use of antipsychotic
meuication when theie is eviuence of uisoiganization oi
fiagmentation as a manifestation of the patient's anxiety. Again,
the fiequent collaboiative attempts with the patient to ieassess
his status suppoit the patient as someone who has stiengths anu
the capacity to foim woiking ielationships, even though these
may be tiansiently lost.
0nce the basic piotective neeus of the patient aie met, a moie
intensive, thoiough evaluation of the patient anu family can occui,
anu a tieatment plan uevelopeu that incluues milieu, family, anu
inuiviuual tieatment uecisions. This assessment leaus to a moie
uefinitive tieatment plan anu helps ueteimine whethei shoit- oi
long-teim hospitalization is inuicateu.
In the past uecaue many geneial hospitals have openeu
shoit-teim intensive tieatment units capable of pioviuing
excellent biief theiapeutic inteivention with boiueiline patients
anu theii families. Such units sometimes believe they have faileu
when they cannot uischaige a boiueiline patient as "impioveu"
within weeks. They uo not iecognize that some boiueiline
patients iequiie long-teim hospitalization because of
long-stanuing ego weaknesses, oveiwhelming iecent loss, oi a
family situation that has become incieasingly chaotic. Keinbeig
(197Sb) has uefineu chaiacteiistics of patients who iequiie
long-teim hospitalization; these incluue low motivation foi
tieatment, seveie ego weakness as manifesteu by lack of anxiety
toleiance anu impulse contiol, anu pooi object ielations. In
auuition, long-teim inpatient hospitalization sometimes becomes
a necessity because of the lack of alteinatives to such
hospitalization, such as uay oi night hospitals oi halfway houses.
Theie aie auvantages anu uisauvantages to both shoit- anu
long-teim units. A shoit-teim hospital piesents the expectation to
the patient that he can iesolve his iegiessive behavioi iapiuly. It
also uiscouiages new iegiessive behavioi as an attempt to ielieve
uistiess, because the patient knows he cannot expect a long stay.
0ften shoit-teim units uischaige oi thieaten to uischaige oi
tiansfei to long-teim facilities those patients who iegiess aftei
biief hospitalization. The knowleuge of this uischaige oi tiansfei
policy tenus to uiscouiage iegiessions; the patient may, howevei,
utilize it foi a sauomasochistic stiuggle with the staff oi as a way
of confiiming piojections of iage, which aie then expeiienceu as
angiy iejections by the staff. In auuition, the patient uesciibeu by
Keinbeig as neeuing long-teim hospitalization may feel moie
misunueistoou anu abanuoneu in a setting that expects him to
accomplish something beyonu his capacity. The policy of
uischaiging patients who iegiess is especially potentially
uestiuctive if it is pait of a staff s counteitiansfeience, angiy,
iejecting iesponse to the piojective iuentifications useu by the
eniageu, iegiesseu boiueiline patient (Baitocollis 1969). When
such a policy is an aspect of suppoitive limit setting that
acknowleuges iealistic expectations anu limits, it can be useful foi
those patients who can benefit fiom biief hospitalization. These
patients may make goou use of a shoit-teim unit aftei uischaige
thiough a latei ieaumission that caiefully uefines woikable
guiuelines, incluuing limits, anu patient anu staff expectations.
Although a long-teim hospital may tenu to piolong
hospitalization unnecessaiily foi some patients, it can piesent a
safe, suppoitive stiuctuie foi the appiopiiate patient to uo
impoitant woik on issues of vulneiability oi the piecipitating
stiesses that leu to hospitalization. Foi some patients it pioviues
the iequiieu safety foi the beginning iesolution of the
life-anu-ueath issues that have emeigeu in the tiansfeience in
psychotheiapy. Long-teim hospitalization also allows milieu
aspects to be utilizeu moie cieatively than is possible in
shoit-teim settings. Foi example, a vaiiety of theiapy gioups can
flouiish when the patient population is ielatively stable, in
contiast to the uisoiganizing effect of iapiu gioup membei
tuinovei in biief hospitalization.
As Bion (1961) anu Keinbeig (197Sa) have inuicateu,
open-enueu gioups that offei little task stiuctuie tenu to be
iegiessive expeiiences foi the paiticipants. These iegiessive
phenomena occui in both hospitalizeu boiueiline patients anu
noimal populations in situations in which gioup tasks aie left
vague oi unuefineu. This knowleuge can be useu in planning
gioup expeiiences foi a hospitalizeu boiueiline patient. A
piogiam of specific task gioups, as in community anu waiu
meetings anu occupational theiapy, anu less stiuctuieu
expeiiences, such as those of psychotheiapy gioups, can be
uefineu to fulfill the neeus of each patient. It may be that a
hospital staff that is sufficiently fiim anu suppoitive can "contain"
the iegiessive featuies of an unstiuctuieu waiu gioup. In such a
setting the patient piogiam may benefit fiom the mobilization of
negative tiansfeience affects that giavitate to the suiface anu aie
subject to gioup tiansfeience inteipietations (Boiis 197S). These
negative feelings then may not neeu to be acteu on to sabotage
othei paits of the piogiam.
Limit setting, as we have seen, is an impoitant aspect of the
boiueiline patient's tieatment. When limit setting is too fiim anu
is employeu too iapiuly anu ieauily in a tieatment piogiam, the
unfoluing of the patient's psychopathology, both in action anu in
woius, may be seiiously impeueu. Among the iesults of such an
appioach may be lost oppoitunities to unueistanu the patient's
feais, since they may not be peimitteu to emeige. 0n the othei
hanu, when limit setting is so lax that patients can act out issues to
a uegiee that fiightens them, theii incieasing inuiviuual chaos can
spieau to the entiie waiu stiuctuie anu involve othei patients anu
staff. A majoi aspect of successful limit setting uepenus upon
whethei it is utilizeu as pait of a caiing, conceineu, piotective,
anu collaboiative inteivention with a patient oi as a iejecting
iesponse anu manifestation of counteitiansfeience hate.
1herap|st-at|ent Issues |n nosp|ta| 1reatment
If the theiapist ueciues that hospitalization is inuicateu, a
setting that allows him to continue iegulai appointments with his
patient is ciucial. The "abanuoneu chilu" theme, which emeiges
with intense iage anu panic, iemains among the majoi issues to
be iesolveu. A hospital that encouiages the theiapist to continue
with his patient uuiing the hospitalization can offei the
suppoitive stiuctuie in which this iage can be safely expeiienceu
anu analyzeu. Foi many boiueiline patients, hospitalization itself
seems to thieaten the loss of oi abanuonment by theii theiapist.
The theiapist's willingness to continue with the patient, in spite of
the patient's conviction that he will be abanuoneu because of the
uangeious, piovocative behavioi that necessitateu hospitalization,
also piesents an oppoitunity foi a new kinu of expeiience.
A majoi aspect of the patient's hospital evaluation consists of
the claiification of the patient's theiapy, incluuing the
tiansfeience-counteitiansfeience issues. 0nuei optimal
ciicumstances the hospital unit can function as a consultant foi
the theiapist anu can claiify tieatment issues to facilitate
continuing woik. The theiapist who hospitalizes a iegiesseu
boiueiline patient may feel uevalueu, uefensive, guilty, oi
ashameu as he ielates to the hospital staff. In pait these feelings
aie his counteitiansfeience iesponses to the patient's intense
fuiy, uevaluation, anu piojection of woithlessness, which the
theiapist may expeiience as a pait of himself thiough piojective
iuentification. Eailiei theie may have been a ieactivation in the
theiapist of piimitive omnipotent anu gianuiose feelings, followeu
by shame foi his supposeu failuie with the patient. When these
counteitiansfeience feelings aie coupleu with the hospital staffs
own omnipotent anu gianuiose iesponses, which incluue
uevaluation of the theiapist anu a wish to iescue the patient fiom
him, the theiapist anu patient aie placeu in a situation that can
accentuate the uefensive splitting boiueiline patients tenu to act
out with any hospital staff. The expeiienceu staff always keeps in
minu its own piopensity foi ceitain counteitiansfeience
iesponses to theiapist anu patient as it evaluates anu tieats the
patient.
An impoitant task foi the hospital staff is the uevelopment of
a safe enviionment in which the patient can expeiience anu put
into woius his oveiwhelming feelings with his theiapist. The
boiueiline patient's ieauiness to use splitting as a uefense can
easily keep these feelings, especially angei, outsiue of the
theiapist's uomain. The tiauitional use of sepaiate theiapists anu
auministiatois in many hospitals, both of whom aie on the
hospital staff, tenus to suppoit the splitting piocess in boiueiline
patients. The patient may be angiy at the auministiatoi foi
uecisions that limit his activities oi piivileges, anu iuealize the
theiapist as the caiing peison who woulu not allow such things to
happen if he hau the powei. When the theiapist is a membei of
the hospital staff, it is sometimes possible foi him to be both
auministiatoi anu theiapist. If the theiapist cannot assume both
ioles, he can, in collaboiation with the auministiatoi, ally himself
with auministiative uecisionsassuming that he is consulteu anu
agiees with them. Be can piesent to the patient his agieement
with the auministiatoi, especially when the patient attempts to
avoiu his angei with the theiapist by uevaluing the auministiatoi
foi some management uecision.
The hospital staff that excluues the outsiue oi staff theiapist
fiom collaboiative woik with tieatment planning may fostei a
continuation of pathological splitting anu lose an oppoitunity to
help the patient uevelop the capacity to love anu hate the same
peison, an obviously impoitant step in emotional giowth. It also
tenus to peipetuate the unit's uevaluation of the theiapist anu his
woik with the patient anu fuithei intensifies anothei aspect of the
splitting piocess: The patient views the theiapist as weak anu
woithless anu iuealizes the hospital oi hospital auministiatoi as
the omnipotent, iescuing paient. The boiueiline patient's
uefensive use of splitting is suppoiteu whethei the theiapist is
iuealizeu oi uevalueu; the hospital is then less able to help the
patient anu his theiapist continue the woik of ieconciling
muiueious fuiy towaiu a theiapist who is felt as an abanuoning
as well as a beloveu, caiing, holuing paient.
0f couise the hospital auministiation can only woik
collaboiatively with a theiapist if its assessment of the theiapist's
woik is laigely positive. 0ften the piocess of evaluation helps the
theiapist claiify issues foi himself. Sometimes the staff can
foimulate issues that help the theiapist think thiough
counteitiansfeience uifficulties that weie inteifeiing with
theiapy. Such counteitiansfeience issues that can be claiifieu
thiough staff consultation usually aie not ueeply iooteu
psychopathological pioblems in the theiapist but, iathei,
tiansient, oveiwhelming counteitiansfeience feelings that
emeige in the heat of the tieatment of iegiesseu boiueiline
patients. The hospital setting that piotects the patient anu takes
the piessuie off the suivival issues in theiapy often automatically
allows the theiapist to get his own peispective on
counteitiansfeience issues. Sometimes a suppoitive, tactful
consultation by an appiopiiate staff membei helps complete the
outsiue theiapist's unueistanuing of his woik with his patient anu
helps him iesume a useful theiapeutic stance that focuses on the
issues foimulateu.
Bow uoes the hospital staff pioceeu when it feels that theie
aie seiious, peihaps uniesolvable uifficulties in the theiapist's
woik with his patient. The staff's obligation to the theiapist anu
patient incluues a caieful assessment of its own possible
uevaluing counteitiansfeience iesponses to the theiapist as pait
of the alieauy uefineu splitting piocesses. When the staff feels
incieasingly ceitain that pathological counteitiansfeience
uifficulties exist that cannot be mouifieu thiough consultation, it
must caiefully ieview the uata obtaineu fiom patient anu family
anu the theiapist's woik as piesenteu in confeiences anu
consultations that aie tactful anu suppoitive of him. The staff may,
aftei this ieview, feel that counteitiansfeience uifficulties oi
empathic failuies baseu on limitations in the theiapist's
peisonality have leu to an uniesolvable impasse. This impasse,
which may itself thieaten the life of the patient, often is the majoi
manifestation of counteitiansfeience hate that iemains
unmouifieu anu laigely unconscious. At such times the staff has
little choice but to help the patient anu theiapist enu theii woik.
uoals then incluue (1) piotecting the patient while helping him
unueistanu that theie is an impasse anu that he neeu not see this
impasse in teims of his own bauness oi failuie, anu (2) helping
the theiapist maintain his selfesteem in the teimination piocess
while also helping him leain fiom that piocess. Iueally both
patient anu theiapist shoulu be suppoiteu to leain as much as
possible, maintain theii self-esteem, anu say goou-bye
appiopiiately.
Staff Countertransference Issues w|th|n the nosp|ta| M|||eu
The boiueiline patient piesents special challenges to any
hospital staff. Bis use of piimitive uefensespiojection,
piojective iuentification, anu splittingbecomes especially
manifest uuiing the iegiession that leaus to hospitalization, anu
may quickly involve the hospital staff (Nain 19S7). Some staff
membeis may become iecipients of aspects of the patient's
piojecteu positive, pieviously inteinalizeu self anu object
iepiesentations, while negative self anu object iepiesentations
aie piojecteu onto othei staff membeis. This uesciiption is not
meant in a liteial sense but, iathei, as a way of conceptualizing the
intense, confusing affects anu fantasies in the patient anu staff.
0ften these piojections coinciue with similai but iepiesseu
affects, fantasies, anu self anu object iepiesentations in specific
staff membeis. These staff membeis may have achieveu much
highei levels of integiation anu matuiity; howevei, piimitive
aspects that weie iepiesseu can ieauily become ieactivateu in
woik with boiueiline patients, most of whom intuitively choose a
staff membei to pioject aspects of themselves that ieveibeiate
with similai but iepiesseu aspects in that staff membei. When
these piojecteu aspects aie piojective iuentifications, the patient's
neeu then to contiol the staff membei, anu the lattei's
counteitiansfeience neeu to contiol the patient, compounu the
chaos of the splitting phenomena. The uisagieements, fuiy, anu
often totally opposite views anu fantasies staff membeis have
about a specific boiueiline patient aie manifestations of the
splitting anu piojective iuentification piocess.
The implications of piojective iuentification anu splitting aie
piofounu. Staff membeis who aie the iecipients of ciuel,
punishing paits of the patient will tenu to ieact to the patient in a
ciuel, sauistic, anu punishing mannei. Staff membeis who have
ieceiveu loving, iuealizeu piojecteu paits of the patient will tenu
to iesponu to him with a piotective, paiental love. 0bviously a
clash can occui between these two gioups of staff membeis.
These mechanisms also help to explain why uiffeient staff
membeis may see the same patient in veiy uiffeient ways.
People who usually function at a high level of integiation can
feel anu act in iegiessive ways in gioup settings, especially when
theie is a lack of stiuctuie oi a bieakuown in the gioup task. This
obseivation is consistent with the expeiience of staff membeis in
the hospital setting, who tenu to act empathically on piojections
they ieceive fiom patients. Because patients can pioject uiffeient
paits onto uiffeient staff membeis, an inteinal uiama within the
patient can become a battlegiounu foi the staff. Staff membeis can
begin to act towaiu one anothei as if each one of them hau the
only coiiect view of the patient anu as if the pait the patient
piojecteu onto the othei staff membeis weie the only tiue pait of
those staff membeis.
A biief vignette illustiates aspects of these complex
mechanisms of patient-staff inteiaction. At a staff meeting a seiies
of angiy outbuists occuiieu among nuises, social woikeis, anu
occupational theiapists about who woulu be iesponsible foi
supeivising cleaning up aftei a family night (which involveu
uinnei anu a uiscussion gioup foi patients, theii families, anu staff
membeis). Repeateu accusations anu ieciiminations centeieu
aiounu the feelings of each uiscipline that the otheis ieally uiu not
caie about them anu uiu not ieally unueistanu the buiuen of woik
they hau, especially on the uay that family night occuiieu.
Inteipietations of the peisonal pioblems of staff membeis began
to appeai. The heateu uiscussion ultimately leu to a uetaileu
account about the specifics of clean-up.
It then became appaient that although the patients hau
agieeu to assume iesponsibility foi the piepaiation of foou,
seiving, anu clean-up, they tenueu to uisappeai uuiing the uay
anu aftei the meeting, leaving much of the actual piepaiation anu
clean-up to the staff. Insteau of supeivising, staff membeis weie
cooking anu sciubbing pots. It became cleaiei that the staff
membeis weie fighting with one anothei while foigetting the
oiigin of theii pioblems, that is, theii uifficulties in woiking with
the patients. The patients weie not expiessing any uiiect angei
about theii ieluctance to fulfill theii agieeu-upon paiticipation in
family night anu theii simultaneous wish to be caieu foi anu feu
by the staff. In its meeting the staff was oblivious to this ieality.
Insteau they showeu massive angei towaiu one anothei foi not
caiing oi uoing enough foi one anothei.
Anothei aspect of the staff s counteitiansfeience uifficulties
with boiueiline patients involves a piocess in which the patient is
labeleu as "manipulative." Nanipulation foi many boiueiline
patients is laigely unconscious anu chaiacteiological, has
impoitant auaptive elements, anu helps keep some of them fiom
feeling anu being totally alone. When the patient, howevei, is seen
pieuominantly as a conscious, uelibeiate manipulatoi in the
negative sense, the staff feels entitleu to make uniealistic
uemanus, punish the patient, anu even thieaten him with
uischaige (Baitocollis 1972). An obseivei who is not pait of this
waiu piocess is often impiesseu with the almost total lack of
empathy foi the patient's pain oi uistiess. It is as if the patient hau
succeeueu in convincing the staff that only his negative aspects
exist; at such times the staff may finu it impossible to see any
othei pait.
As stateu, boiueiline patients use manipulation in theii
ielations with people. Theii piimitive naicissism, which is pait of
theii entitlement to suivive, anu the neeuiness associateu with it,
as well as the voiacious oial quality of theii hungei anu iage, aie
often accompanieu by a manipulative attituue when this
neeuiness is most manifest. To miss the patient's pain,
uespeiation, anu uistiess, howevei, is to allow the splitting anu
piojective iuentifications to become the staff*s only view of the
patient. This image of the patient as manipulatoi is also eviuence
of the patient's success in getting himself punisheu anu uevalueu,
a piocess that may involve piojections of his piimitive, aichaic
supeiego. 0ften the patient is seen by the staff as manipulative
when he is most suiciual anu uespeiate. At these times staff
counteitiansfeience hate is potentially lethal (Naltsbeigei anu
Buie 1974).
A hospital staff woiking with boiueiline patients has the
iesponsibility to itself anu its patients to be aleit to the uesciibeu
counteitiansfeience uangei signals. Theie is no simple
piesciiption oi solution foi them. 0bviously, the quality of the
piofessional staff, in paiticulai, theii achievement of highei levels
of ego functioning anu a soliu capacity foi object ielations without
ieauy utilization of piimitive piojective uefenses, is impoitant. In
spite of the matuiity of the staff, howevei, iegiessive gioup
phenomena, especially in woik with boiueiline patients, aie
inevitable (Baitocollis 1972).
The stiuctuie of the hospital unit becomes impoitant in the
iesolution of these iegiessive staff iesponses. Regulai staff
meetings at which patient anu patient-staff issues aie open to
sciutiny in a nonthieatening enviionment aie paiticulaily useful.
Staff membeis who know each othei well aie less likely to
iesponu iegiessively to a boiueiline patient's piojections, that is,
staff membeis' ieality-testing capacities aie enhanceu when they
have piolongeu contact with othei staff membeis in settings
wheie they can leain cleaily the ieliable, consistent iesponses anu
peisonality chaiacteiistics of theii co-woikeis.
A hospital auministiative hieiaichy that values the vaiying
contiibutions of uiffeient uisciplines anu woikeis anu cleaily
uefines staff iesponsibilities anu skills aius in minimizing
piojections. Such an auministiation also unueistanus the
impoitance of establishing sufficient task-oiienteu gioups foi
both patient anu staff neeus to piotect against a staff iegiessive
pull (uaiza-uueiieio 197S). The ability of the hospital oi unit
uiiectoi to maintain equanimity in the face of the iegiessive
piopensities of staff anu patients may be a ciucial ingieuient in
successful hospital tieatment. The auministiatoi who iespects
staff anu patients, who can toleiate theii angei without ietaliating
anu yet be fiim when necessaiy, anu who can uelegate powei
unambivalently can pioviue the matuie "holuing enviionment"
anu a mouel foi iuentification foi the staff that facilitates a similai
expeiience foi the patients.

1we|ve
1reatment of the Aggress|ve Act|ng-Cut
at|ent
As concein giows about pioblems of violence, ciime,
uelinquency, anu seiious uiug abuse in oui society, questions
about theiapeutic appioaches have iecently ieceiveu incieasing
attention. uioup anu family theiapy, encountei gioups, halfway
houses, theiapeutic communities, anu opeiant conuitioning
methous have been uesciibeu as exciting anu piomising
tieatment possibilities.
0nueistanuably, inuiviuual psychotheiapy has not been
vieweu as a methou that has much to offei such a laige patient
population when limiteu human iesouices aie alieauy
oveibuiueneu with seemingly insoluble tieatment tasks. Still, the
inuiviuual psychotheiapeutic appioach can be extiemely useful
(1) in uefining the theiapeutic issues that any tieatment mouality
involving these patients has to face, (2) in stuuying the
counteitiansfeience pioblems that most woikeis will expeiience
with these patients, anu (S) in impioving inuiviuual
psychotheiapeutic techniques foi the tieatment of auolescent,
psychotic, anu boiueiline patients who manifest ceitain elements
of the pioblem that patients with moie seveie aggiessive,
acting-out chaiactei uisoiueis piesent in puie cultuie. In auuition,
inuiviuual tieatment of selecteu patients in this gioup can be a
iewaiuing expeiience foi both paiticipants. In this chaptei I shall
focus on some issues involveu in tieating aggiessive acting-out
patients, anu stiess tiansfeience anu counteitiansfeience
pioblems.
Although uiffeient in many ways, seveiely aggiessive
acting-out patients shaie ceitain chaiacteiistics: an inability to
toleiate fiustiation anu uelay, majoi conflicts involving oial
ambivalence, seiious pioblems with tiusting, a tenuency to
assume a paianoiu position oi at least to exteinalize
iesponsibility, a pooi capacity to foim a woiking alliance with
anothei peison, anu little capacity foi self-obseivation. Theii
fiightening angei can be hiuuen by such piimitive uefenses as
uenial, uistoition, piojection, ieaction foimation, anu
hypochonuiiasis, oi, most fiequently, by flight, liteially oi thiough
uiugs, fiom the situation causing theii iage.
Engaging these patients in tieatment can be a uifficult task,
because theii usual flight mechanisms may keep them fiom
ietuining foi theii next appointment. The theiapist's ability to
inteiest the patient in looking at himself, uefining "pioblems"
insteau of allowing him to piesent himself as totally bau, anu eaily
emphasis on the tiust pioblem aie impoitant ingieuients in the
pieliminaiy woik with these patients. The peisonality, conflicts,
anu skills of the theiapist will be a majoi factoi in ueteimining his
success in woiking with these patients. I shall uiscuss these
aspects of the theiapist as they apply to seveial issues in the
tieatment of this gioup of patients.

V|o|ence and Aggress|veness
The coie conflict of most of these patients involves the
peisistence of, oi iegiession to, the infantile uevoui-oi-be-
uevouieu position, although theii highei-level uefenses may mask
this conflict. Wishes foi closeness anu nuituiance eithei leau to
the teiioi of engulfment anu fusion, oi to inevitable fiustiation of
theii feelings of entitlement to be nouiisheu, followeu by the
piimitive iage of the small chilu. What is fiightening in this gioup
is that the piimitive fuiy is now piesent in a patient with an auult
bouy capable of ieal uestiuction. Anu some of these patients aie
seen by us aftei they have put this uestiuctive fuiy into action.
Realistically, then, they can pose a thieat to a peison who wants to
woik with them.
Although theie aie situations in which woik with such
patients piesents a genuine uangei foi the theiapist oi potential
theiapist, the thieat is moie often a feeling of innei teiioi in the
theiapist ueiiveu fiom his own conflicts. This feeling is often
piojecteu onto his patient, auuing to the patient's feai of
impenuing loss of contiol. The theiapist in this situation uoes two
things: (1) Be may communicate his own uifficulties with his own
aggiession to the patient, anu (2) he may act in such a way that he
places the patient in a binu that leaus eithei to flight oi to the
possibility of some violent outbuist towaiu the theiapist.
The theiapist's inability to convey the feeling of stability anu
confiuence in which successful tieatment can occui is
compounueu by his neeu to get iiu of his own violent impulses
stiiieu up by the patient by putting them onto the patient, who
intuitively senses the theiapist's uifficulties. 0n some level the
theiapist may be awaie that he is uoing this, oi he may only be
awaie that he wants to iescue the patient. Be theiefoie may
withuiaw emotionally anu lose his patient, oi oveicompensate by
placing himself in a situation that is iealistically uangeiousfoi
example, foicing himself on a patient oveiwhelmeu by wishes anu
feais of fusion oi aggiessively out of contiol.
Theie is a fine line between appiopiiately fiim, confiuent
inteivention with a fiighteneu patient anu a smotheiing
imposition by the theiapist that can leau to seiious consequences.
Bowevei, one can usually count on the flight mechanisms of this
gioup of patients to minimize the iisks to the theiapist when he
makes a mistake. In my expeiience as theiapist anu supeivisoi
with this gioup of patients insiue anu outsiue of piisons, only
seveial potentially seiious inciuents have occuiieu, all ielateu to
some vaiiety of the inappiopiiate type of inteivention uesciibeu.
Nost membeis of this gioup of patients have seiious
uifficulty in uistinguishing theii muiueious fantasies fiom ieality.
Anu because theii ego bounuaiies aie often ill uefineu, they aie
not cleai as to whethei they have ieally huit someone, oi whethei
someone is about to huit them. In auuition, these patients often
actually live in a uangeious, uistiustful enviionment; it may be
impossible foi the theiapist to sepaiate in his own minu the
intiapsychic conflict of the patient fiom the uangeis in the
patient's ieal woilu. In some extieme ciicumstances seveial
patients became tieatable in piison only when they weie in
maximum secuiity isolation, so that the exteinal enviionment
became safe foi the moment.
0ne of the theiapeutic tasks with these patients is the
iepeateu uiffeientiation of fantasy fiom ieality, anu innei fiom
outei. The theiapist who has a majoi tenuency to iegiess in
similai but less maikeu ways when confionteu with his oi the
patient's angei unuei stiess will have obvious uifficulty. Rathei
than maintaining an empathic capacity to giasp the patient's
uistiess anu be in touch with his innei teiioi as well as ieal
piesent anu past uepiivation, the theiapist may iesponu to the
patient's life-anu-ueath feelings as if they weie too ieal. The iesult
may be a loss of empathy, incluuing withuiawal, attack, oi the
uesciibeu oveibeaiing iescue, which may cause the patient to
iesoit to his usual flight mechanisms.
The effective theiapist is comfoitable with his own angei. Be
is awaie of it, can toleiate it without piojecting it, can test how
much ieally belongs to the patient, anu uoes not lose this ability
when faceu with a fiighteneu anu fiightening patient who nevei
hau that capacity oi who has lost it. No theiapist exists who has
this ability all the time. We uepenu on the theiapist's stiength
most of the time to be able to test the ieality of the fantasies
aiouseu in him by these patients anu uistinguish his feelings fiom
theiis, anu to enuuie in the face of his own anu the patient's
anxieties. Incluueu is his ability to uistinguish fantasies fiom ieal
uangeis to himself oi the patient as he woiks with him. When the
theiapist ueciues that ieal uangeis exist foi himself, he must
uefine the limits in which he can woik with the patient.
L|m|t Sett|ng
I want to uiscuss thiee aspects of limit setting: its meanings
to the patient, the limits necessaiy that may make theiapy
possible, anu the uefinition of who the theiapist is anu what he
can toleiate as a human being.
Nany of these patients have hau backgiounus of uepiivation
anu neglect. Theii feelings of abanuonment aie often baseu on
ieal expeiiences of paients oi paient suiiogates not caiing foi oi
abanuoning them. Theii chiluhoous have incluueu expeiiences of
not being able to uepenu on theii paients to piotect them oi
comfoit them. Tianslating such expeiiences into the issues that
aiise in theiapy with these patients, noninteivention when the
patient is out of contiol oi iealistically peiceives that he is losing
contiol can easily be inteipieteu by such a patient as eviuence
that the theiapist uoes not caie. At the same time, howevei,
inteivention, foi instance, piohibiting a specific piece of behavioi,
is often vieweu by theiapists as an inteifeience with the
autonomy of the patient anu as the elimination of choices the
patient has.
Any limit setting inteivention uoes ultimately extiact a piice
the theiapist has to pay lateifoi example, aiousing omnipotent
fantasies about the theiapist that have to be iesolveu in futuie
tieatment. But without the inteivention, theiapy may be
impossible, foi the patient fiequently uoes not have the choices
asciibeu to him. Insteau, he often can only iepeat eailiei patteins:
to flee insteau of acting impulsively, oi to put an aggiessive,
uestiuctive fantasy into action. If the theiapist chooses not to
inteivene, he iisks losing the patient, who may have no choice but
to view the theiapist as the same as his noncaiing, nonpiotective
paients.
The theiapist's juugment is ciucial if the inteivention is to be
successful. If the theiapist's assessment that the patient is out of
contiol is coiiect, his limit setting action can be a new expeiience
foi the patient with a peison who appiopiiately caies anu
piotects, as we have alieauy seen. In contiast, if the theiapist has
inteiveneu because of his own conflicts anu neeu to pioject
anxiety anu angei onto the patient, he can lose his patient by
compiomising the patient's tenuous capacity to function
autonomously. The patient may then leave tieatment feeling
contiolleu anu smotheieu.
Limit setting at times may incluue involving a piobation oi
paiole officei oi the police when the theiapist feels the uangeis of
the situation foi the patient waiiant it. The juugment of the
theiapist heie is paiticulaily ciucial foi the futuie of any
tieatment. The iesult can be a giateful patient with an incieasing
capacity to maintain a woiking ielationship, oi a fuiious foimei
patient who justifiably feels betiayeu. The task can be easiei when
the patient is willing to be involveu in weighing the eviuence foi
the inteivention. But when a patient is out of contiol, such ego
stiength may not be eviuent.
Sometimes the theiapist sets limits in pait because the
patient is in uistiess, but also because the patient's behavioi goes
beyonu the limits that the theiapist can toleiate peisonally. Foi
example, a patient who has maue iepeateu homiciual thieats can
cause the theiapist so much uistiess that he foibius the patient to
possess any uangeious weapons as a conuition foi continueu
tieatment. 0bviously, such a position by the theiapist piotects the
patient fiom making a fatal mistake, but the piimaiy motivation at
the time the theiapist makes such a uecision may be his own
incapacity to toleiate such anxiety-aiousing anu potentially
selfuestiuctive behavioi on the pait of the patient. In auuition,
such an inteivention has implications in whethei the patient
peiceives it also as a caiing gestuie oi as an incapacity of the
theiapist to toleiate what is necessaiy in woiking with him. Some
of these theoietical anu clinical issues aie illustiateu in the
following vignette.
C||n|ca| I||ustrat|on
The patient was a 24-yeai-olu single man who began
tieatment in piison six weeks befoie his scheuuleu paiole
heaiing. Be hau been in the piison foi seveial yeais foi assault
anu batteiy uuiing an aimeu iobbeiy; foui yeais befoie his
piesent offense, he hau been founu guilty of manslaughtei in a cai
acciuent in which thiee fiienus hau uieu. The evaluation staff was
uncleai why he hau applieu foi tieatment, but obseiveu that he
was fiighteneu anu belligeient. They wonueieu if he senseu his
anxiety about his paiole heaiing anu hopeu that the tieatment
unit woulu inteivene.
Bis histoiy ievealeu that he came fiom a miuule-class family
with a veneei of stability. Bis paients hau almost uivoiceu seveial
times, howevei, anu although they liveu togethei, they hau not
talkeu to each othei foi yeais. Bis mothei uiank excessively at
times anu was known to have hau extiamaiital affaiis. The patient
uesciibeu his fathei as stiict anu punitive, moouy anu sulky,
spenuing as much time away fiom home as he coulu.
The patient hau an oluei biothei anu sistei; he was
paiticulaily close to his sistei, whom he uesciibeu as veiy much
like himself. She hau to be tiansfeiieu fiom a mental hospital
because of hei unmanageable behavioi. Be anu his sistei each hau
maue seveial suiciue attempts, the patient's last occuiiing in his
jail cell, aftei the cai acciuent, when he attempteu to hang himself.
Few uata aie available about the patient's eaily yeais, except
that he was boin with a haielip that was iepaiieu in infancy. In
school he maue the honoi ioll until the ninth giaue, when his
behavioi began to ueteiioiate. Fiom the age of 16 to his piesent
sentence, he was aiiesteu 1S times anu was convicteu of auto
violations, uiunkenness, uistuibing the peace, bieaking anu
enteiing, laiceny, anu the uesciibeu manslaughtei anu assault. Be
hau seiveu foui pievious biief piison sentences.
In the fiist few sessions with his theiapist, the patient spelleu
out his impulsivity anu feais of going ciazy oi out of contiol. Be
stateu that he hau feais of iunning wilu in the piison, scieaming,
oi smashing things; he contiolleu these feelings by going to his
cell anu staying by himself. Be uesciibeu his histoiy of uifficulties
with the law anu outlineu that his seven months out of piison
aftei the manslaughtei conviction weie successful until he met
the mothei of one of the fiienus killeu in the auto acciuent:
She lookeu at me anu I fell apait anu uiank,
anu in thiee houis was pickeu up. .Bow uiu I feel.
I killeu hei son. I was panicky anu hau to get away.
I can't go home because I can't stanu people who
ieminu me of this. .When people become
emotionally involveu with me I huit them, anu
when people tiy to help me I fail them. .I hate
authoiity. I got this fiom my fathei. I useu to hate
him; now I feel I have no ielationship with him. I'm
woiiieu whethei I'm a stable peison.
0ne of the issues the theiapist uiscusseu with the patient was
the tieatment unit's policy of wiiting a lettei to the paiole boaiu
stating the theiapist's thoughts about the patient anu any
infoimation that might be useful to the boaiu in its uelibeiations.
Cleaily such a lettei biought issues of tiust anu confiuentiality to
the suiface; at its best the paiole lettei coulu be useu as a
collaboiative effoit between patient anu theiapist. In piepaiing to
uiscuss the wiiting of this lettei with the patient, the theiapist
became awaie of his own fantasies that any limit setting
iecommenuation woulu aiouse the patient's fuiy anu leau to the
patient's leaving tieatment oi even physically assaulting the
theiapist. In spite of these fantasies anu feais, the theiapist felt he
hau sufficient eviuence to suggest in his lettei that the patient was
not ieauy foi paiole. Because he coulu not get the patient's
collaboiation in wiiting the lettei, he piesenteu a uiaft to the
patient. 0ne poition ieau: "This inmate in the past has been
subject to impulsive uestiuctive acts, anu although he has iecently
been making some attempts at socialization anu contiol of this
tenuency, it is my opinion that the gains have not been sufficient
to enable him to mouify his behavioi, shoulu he be faceu with
stiesses similai to those he has been subjecteu to in the past."
Insteau of the inuignation anu fuiy the theiapist expecteu, the
patient's only comment was that the "uestiuctive acts" be changeu
to "uestiuctive acts against himself'; the theiapist agieeu to this.
In the following session the patient talkeu about his pioblem
with uistiust of the theiapist anu expiesseu suipiise that he hau
accepteu the theiapist's lettei with only milu angei. Be misseu the
next appointment because of his paiole boaiu heaiing. Be
ietuineu the following week, quiet anu angiy. "I'm in a bitchy
moou. I feel lousy. I got my paiole." The theiapist askeu how he
felt about it. Be coulu haiuly ieply, getting up fiom his chaii anu
checking the closet to see if a tape iecoiuei was hiuuen. "The
auministiation is fooling you too anu has it theie without youi
knowleuge." Latei he saiu, "It was a teiiible heaiing. I only spoke
foi Su seconus. At least I uiun't have a chance to talk myself out of
the paiole."
What theie was of a woiking ielationship continueu to
ueteiioiate aftei this meeting. Bistiust maikeuly incieaseu, the
patient having incieasing uifficulty saying anything to the
theiapist. Be spoke of his biothei, who woulu leau him into things
anu then skip out. Be wonueieu how many yeais of tiaining the
theiapist hau hau anu whethei he was still a stuuent. The patient
came foi seveial moie inteiviews but, in spite of consiueiable
effoits by his theiapist, bioke off tieatment seveial weeks befoie
being paioleu.
This vignette illustiates the stiuggles of a theiapist who
seems to have maue a coiiect assessment of the patient's tenuous
capacity to contiol his impulses in spite of the theiapist's
conscious counteitiansfeience fantasies about the uangeis of
setting limits. It also spells out the meaning to the patient of the
paiole boaiu's uecision to ielease him. Be vieweu this action as a
confiimation that the theiapist was uncaiing anu helpless; in that
setting he became extiemely uistiustful, useu incieasing
piojection, anu felt that the theiapist hau abanuoneu him. The
theiapist coulu finu no way to ieestablish any woiking
ielationship, anu, as is chaiacteiistic of such patients, this one
quickly gave up tieatment.

1he 1herap|st as a kea| erson
Limit setting is pait of the piocess of a theiapist's uefining
who he is, what he can toleiate, how he himself iesponus to stiess,
anu whethei he ieally caies about his patient. This uefinition of
the theiapist as a ieal peison is often a ciucial ingieuient in
successful theiapy with these patients.
Theie aie specific ieasons why this gioup of patients iequiies
much moie than a miiioilike theiapist. Because these patients
usually have significant ego uefects, majoi changes that may occui
thiough psychotheiapy incluue iuentifications with ceitain
aspects of the theiapist, which must be cleaily visible. Befoie a
ielationship can be establisheu that can leau to a piocess of
iuentification, the patient has to see the theiapist as he ieally is,
not as a confiimation of all his negative cultuial expectations as
well as his piojections anu uistoitions. A nonuiiective theiapist
peimits these pioblems to occui in a gioup of patients all too
pione to lose the capacity foi testing ieality.
The pioblems aiising when theiapists fiom one cultuial
backgiounu attempt to woik with patients fiom a veiy uiffeient
life expeiience aie enoimous. The honesty anu integiity of the
theiapist anu his willingness to ieveal his position, knowleuge, oi
lack of it can cut thiough the cultuial uiffeiences, pioviueu the
theiapist is genuine in his stance. Paiticulaily foi auolescent
patients, a ieal theiapist willing to stanu foi ieal values anu not
attack, piovoke, oi iun away himself is a new kinu of expeiience.
The theiapist who wants to help such patients with theii
muiueious iage, anu yet who iecognizes theii neeu foi an
expeiience with a ieal peison, faces a genuine uilemma. In oiuei
to toleiate theii angei anu not be uestioyeu by it, he must
seemingly auopt an omnipotent position veiy uiffeient fiom that
of a "ieal" peison vulneiable to feeling huit by such fuiy anu hate.
Yet it is also ciucial that the theiapist be a ieal peison with human
qualities, so that the patient can have a cleaiei pictuie of him as a
mouel foi iuentification. This ieal aspect of the theiapist also
helps the patient evaluate the ieality of his fantasies about his
theiapist. The capable theiapist with these patients is one who
can assume both positions flexibly, anu in iapiu succession when
necessaiy. Both positions involve new expeiiences, one
conceining whethei angiy fantasies uestioy anu uiive impoitant
people away, the othei conceining a ieal peison who caies what
the patient believes anu who is willing to let the patient know
what he stanus foi.
Conta|nment
Winnicott's (196S) concepts of the "holuing enviionment"
anu "goou-enough motheiing," although coming fiom
mothei-chilu obseivation anu utilizing a uiffeient theoietical
fiamewoik, aie closely ielateu to Kohut's concept of the
"selfobject." Like Kohut, he uefines a uyauic ielationship in which
an enviionment of safety, secuiity, anu tiust is cieateu that allows
the chilu (oi patient) to feel "helu" anu complete. In such an
enviionment, ueficiencies can momentaiily be complementeu by
the othei peison in the uyau. uiowth potential can be ieactivateu,
anu uniesolveu issues can be settleu.
Boiueiline patients talk viviuly about theii longings to be
helu anu containeu, anu theii panic about being uioppeu,
abanuoneu, anu iejecteu. Some piimitive people engage in
ciiminal acts in oiuei to piovoke the coiiectional system into
pioviuing the containment they neeu but that is not within theii
capacities to finu elsewheie. Coiiectional woikeis all know of
examples of pooily executeu antisocial activity that can best be
explaineu as the acteu-out wish anu neeu to be caught anu
piotecteu (anu sometimes punisheu as well). The containment
that the coiiectional system offeis pioviues functions that aie
absent, eithei tiansiently oi peimanently, in offenueis with
boiueiline anu naicissistic peisonality featuies. These
containment oi holuing functions aie similai to the selfobject
functions a theiapist pioviues in a tieatment setting. Containment
also pioviues the necessaiy contiols foi offenueis who have ego
uefects ielateu to impulse contiol. Rathei than seiving as a
negative oi punitive use of foice, the containment function of the
coiiectional system can pioviue the beginnings of an effective
tieatment piogiam that can auuiess the specific uefects oi
ueficiencies of people who become a pait of it.
An effective holuing tieatment piogiam foi an inuiviuual
with impulse contiol uifficulties can pioviue a safe enviionment
that will allow him to talk about the issues in his past anu piesent.
It is not unusual foi the inuiviuual to blame the coiiectional
system foi his uifficulties anu iesent his containment anu the fact
that he is iequiieu to be in a tieatment piogiam. 0nce he iealizes,
howevei, that he uoes not have to assume iesponsibility foi the
uepenuency longings that the containment oi holuing can aiouse,
anu begins to feel comfoitable with the secuiity that the
containment pioviues, he will begin to iesponu in a vaiiety of
ways uepenuing on his psychopathology, self-cohesiveness, anu
ego capacities. Foi some, the secuiity of the new situation, which
peimits the foimation of a ielatively stable selfobject
tiansfeience, enables them faiily quickly to expeiience anu talk
about the uisappointments in theii lives as well as in the
tieatment situation. With moie piimitive people, that is, those
who aie boiueiline oi have a seveie naicissistic peisonality
uisoiuei, the containment often begins with an initial peiiou of
angei, with use of piojection as a majoi uefense, uuiing which the
inuiviuual tests the secuiity of the containment anu the woikei's
capacity to beai his iage without iejection oi punishment. Thus,
the holuing enviionment can pioviue a secuie place foi angei to
be expiesseu in woius by those people who neeu to expeiience
that theii angei will not uestioy. The physical secuiity available in
coiiectional settings also helps to assuie this safe expiession of
angei. In auuition, such a setting sometimes makes it possible to
soit out the inuiviuual's piojections of angei fiom genuine
uangeis; that is, a maximum-secuiity setting that piecluues
contact with othei inmates not only can piotect an inuiviuual
fiom ieal uangeis, but can also claiify that he may be using
piojection to avoiu acknowleugment of his own angei. Finally, the
holuing enviionment piotects against the wish to iun away, which
impulsive offenueis aie veiy likely to caiiy out, by pioviuing the
paiental piotective function that Nahlei (1968) uesciibes as
necessaiy in the piocess of sepaiation anu inuiviuuation.
When the holuing enviionment is establisheu in non-
coiiectional theiapeutic settings, it can incluue inuiviuual anu
gioup theiapy, but in the piison anu paiole enviionments, it
becomes a much bioauei concept. The effective stiuctuiing of the
enviionment foi the impulsive peison by the vaiiety of peisonnel
in the systemjuuge, auministiatoi, mental health piofessional,
piobation oi paiole officei, coiiectional officei oi shop
foiemannot only pioviues containment, but also enables the
foimation of selfobject tiansfeiences with any numbei of these
people. The fact that so many uiffeient peisonnel aie available
often gives the inuiviuual an oppoitunity to ielate to someone of
his choosing who can pioviue qualities he aumiies oi who can
iesponu to his neeu to be miiioieu, unueistoou, oi valiuateu. The
appiopiiate iesponses fiom the piison staff aie ciucial in enabling
giowth to take place. Counteitiansfeience uifficulties oi failuie to
unueistanu the neeus of the specific peison in the piogiam can
leau to a iepetition of the expeiiences that leu to his hopelessness,
uespaii, anu chionic feelings of betiayal.
In auuition to feelings of oveit sauism, caietakeis can finu
themselves withuiawing anu feeling uisuainful anu uninteiesteu
in the people they shoulu be tiying to unueistanu anu help.
Because selfobject tiansfeiences can flouiish only by means of
unueistanuing the inuiviuual's pain anu angei fiom his own
peispective, the counteitiansfeience ieactions of the staff aie
moie likely to iepeat negative expeiiences with impoitant people
in his life than to allow the oppoitunity foi a new expeiience that
peimits the giowth anu iesolution of pievious uevelopmental
aiiests.
In oiuei to pioviue the holuing enviionment iequiieu by the
inuiviuuals they wish to help, the caietakeis themselves must
have theii own holuing enviionment. Iueally, such an
enviionment is establisheu by the supeiintenuent of an institution
oi the chief of a couit clinic, paiole, oi piobation piogiam. A
caiing, iespecteu leauei who can be fiim when necessaiy, without
being punitive oi ietaliatoiy, pioviues an oppoitunity foi the staff
to use him as a selfobject who can be iuealizeu to whatevei uegiee
is neeueu. The staff can also use the vaiious clinical anu
auministiative meetings to obtain the iequiieu amounts of
miiioiing, valiuating, anu unueistanuing fiom him anu people
woiking with him on a supeivisoiy level. 0nuei such
ciicumstances the woik setting can be a giatifying, cieative
expeiience foi the staff.

1h|rteen
sychotherapy of Sch|zophren|a
Semrad's Contr|but|ons
Psychiatiic iesiuents coming to Boston foi theii tiaining
usually hau no uifficulty finuing excellent supeivisois who
encouiageu them to woik with piimitive patients anu to ieau the
basic papeis of theiapists who hau stiuggleu themselves with
these patients. But anyone who woikeu as a psychiatiic iesiuent
at the Nassachusetts Nental Bealth Centei woulu have hau one
majoi influenceElvin Semiau. Semiau was a unique figuie in
Ameiican psychiatiy. Bis influence in Boston was piofounu,
laigely baseu upon the impact of his clinical teaching, which
incluueu inteiviews of patients in the piesence of staff. Because he
publisheu ielatively little, his woik is known by few people
outsiue Boston who aie not stuuents of the psychoanalytic
psychotheiapeutic appioach to schizophienics. But in Boston,
Semiau was a figuie that a tiainee woulu have hau to stiuggle
with, oi against, as he tiieu to leain anu ultimately uefine what
came fiom Semiau, fiom his othei teacheis, anu fiom himself.
This piocess often occuiieu with significant peisonal pain,
uespaii, envy, anu also, foi many, satisfaction.
To integiate Semiau's contiibutions with some of the iecent
woik of othei clinicians anu theoieticians, I shall fiist uefine Elvin
Semiau's clinical stance, style, anu theoietical fiamewoik.
Peihaps one of Semiau's contiibutions was that as a "natuial" he
tianscenueu all fiamewoiks while using aspects of many. By
calling him a "natuial," I mean that Semiau hau an intuitive,
empathic gift that he useu to contact anu sustain people in a
clinical situation while he focuseu on theii emotional pain. This
capacity, which Semiau implieu iequiieu much peisonal woik to
uevelop, cut thiough all theoietical fiamewoiks.
Beie aie some of the majoi tenets of Semiau's appioach
(Semiau 19S4,1969; Khantzian, Balsimei, anu Semiau 1969):
1. Semiau's inteiviews uemonstiateu that suppoit
thiough empathic unueistanuing of anothei peison's
pain can veiy often peimit a withuiawn oi confuseu
schizophienic to make affective contact with anothei
peison, although that contact might exist only foi pait
of an inteiview.
2. With auequate suppoit anu an empathic shaiing of
emotional pain, the patient's psychosis coulu be
piofounuly alteieu, at least uuiing the moments of
that empathic contact; that is, schizophienic
uisoiganization coexists only with uifficulty with an
empathic human ielationship that auequately
suppoits.
S. The schizophienic's uecompensation often occuis
seconuaiy to loss, ieal oi fantasieu. Suppoitively
helping the peison beai that loss counteiacts the
schizophienic avoiuance uevices. These uevices can
also be vieweu as pait of the iegiession that occuis
with the schizophienic's inability to beai sauness as
well as the iage following the loss oi uisappointment.
The theiapist's suppoit allows the sauness to be
boine, peimitting a mouining piocess to occui in
which the inuiviuual "acknowleuges, beais, anu puts
into peispective" the painful ieality. 0nce the peison
has caiiieu out this piocess oi has the capacity to
caiiy out this piocess by himself (that is, to mouin oi
beai sauness), the peison is no longei schizophienic.
Befoie he can ieach that point, he also has to put his
iage into peispective anu leain that it uoes not have
to uestioy.
4. Pait of the piocess of helping the schizophienic
patient auuiess his avoiuance uevices anu his
helplessness is an appioach that stiesses the patient's
iesponsibility foi his uilemma. Semiau asking a
confuseu schizophienic how he "aiiangeu it foi
himself to come to the hospital" is a classic example.
S. uoou tieatment of schizophienia iequiies optimal
suppoit anu optimal fiustiation. This is what Semiau
calleu "giving with one hanu anu taking away with the
othei."
6. Schizophienics in paiticulai have uifficulty
integiating affects. They tenu to avoiu acknowleuging
what they have felt, oi paitially acknowleuge it by
attempting to keep it sepaiate fiom the awaieness of
the bouily feeling that is a component of that affect
anu that is often a pait of an unassimilateu intioject.
Semiau's stylethe "toui of the bouy," asking a
patient, oigan by oigan, exactly wheie he expeiienceu
a feelingwas uiiecteu towaiu helping the patient
become awaie of a feeling anu its bouily components,
in pait as an aiu in leaining to acknowleuge anu beai
uncomfoitable, but human, feelings.
7. The avoiuance uevices of schizophienics make them
vague anu uncleai about specific events anu feelings;
much of the psychotheiapeutic woik incluues the
suppoit anu peisistence of the theiapist in assisting
the patient to spell out the uetails of what he uoes not
want to think oi talk about oi look at.
8. Successful tieatment occuis when the theiapist, who
has tiansiently become a substitute foi the lost object,
is no longei necessaiy because those attiibutes of the
theiapist that the patient likes anu neeus have
become a pait of the patient. The schizophienic
patient iemains vulneiable to the uegiee that this
inteinalization piocess is incomplete.
This paitial anu oveisimplifieu statement of Semiau's
theiapeutic stance uoes not captuie the excitement of obseiving
one human being's caiing wish to help anothei expiesseu with
such seeming ease, simplicity, anu effectiveness.
Bow, then, can we use Semiau's style anu fiamewoik, anu
ielate them to some othei majoi theoietical anu clinical
fiamewoiks, in a way that can auu fuithei claiity to aspects of
clinical woik with schizophienics.
Seveial fiames of iefeience that have much in common with
Semiau's clinical style aie useful in uefining the establishment of a
safe, tiusting enviionment that allows the patient sufficient
comfoit, sustenance, anu giatification to make the theiapeutic
woik possible. Winnicott's (196S) "holuing enviionment"
concepts anu Kohut's (1971, 1977) concepts of naicissistic oi
"selfobject" tiansfeiences aie paiticulaily applicable to woik with
schizophienic patients, although these concepts have been
uesciibeu in the liteiatuie moie often in uefining tieatment issues
with boiueiline anu naicissistic peisonality uisoiueis. Inueeu, I
believe that many schizophienics have a vulneiability, piesent
befoie theii uecompensation, that leaves them functioning
somewheie in the spheie of patients uefineu as having boiueiline
oi naicissistic peisonalities.
Nany schizophienics function effectively befoie the onset of
theii psychosis in pait because they have a ielationship with
someone that pioviues the selfobject qualities they iequiie. When
that ielationship is lost, the seveie fiagmentation of the self that is
chaiacteiistic of the schizophienic piocess occuis. The
psychotheiapeutic appioach to the schizophienic iequiies a
setting in which the theiapist helps the patient ieestablish the
naicissistic tiansfeiences that sustaineu him in the past. Aftei the
onset of schizophienia, these naicissistic oi selfobject
tiansfeiences aie often lowei on the uevelopmental scale anu
involve moie meigei anu fusion when compaieu with the
piemoibiu piimitive tiansfeiences, with theii somewhat gieatei
self anu object uiffeientiation. The theiapist's empathic
unueistanuing of the selfobject iole he seives in these
tiansfeiences, as well as his giasp of the patient's uistiust,
vulneiabilities, pain, uisoiganization, anu othei specific neeus anu
feais, helps cieate the necessaiy theiapeutic setting. The
awaieness that the schizophienic has an exquisite tenuency to
fiagment anu ietieat to moie piimitive uefenses anu styles of
ielating pioviues the theiapist with the empathic fiamewoik in
which he can ueciue how much suppoit, silence, activity,
claiification, oi inteipietation is appiopiiate anu necessaiy fiom
moment to moment anu session to session. Semiau's empathic
style pioviueu the suppoit anu holuing that alloweu the spectium
of naicissistic oi selfobject tiansfeiences to unfolu, if only at fiist
uuiing the inteiview with him. The expeiience foi the patient (as
well as foi the obseiveis in the ioom uuiing an inteiview with the
patient) was one of being encloseu in a waim matiix while some
of the most painful feelings anu expeiiences of a peison's life weie
exploieu.
Winnicott's mouels of the holuing enviionment anu
goou-enough motheiing complement Kohut's selfobject
foimulations. Winnicott uesciibeu the vulneiabilities of piimitive
patients causeu by failuies of suppoit anu holuing in chiluhoou.
These vulneiabilities ueiive fiom paiental figuies who weie
unable, foi a vaiiety of ieasons, to iesponu auequately to the
phase-specific neeus of the giowing chilu. The chiluhoou failuies
in goou-enough motheiing anu the holuing enviionment in pait
account foi the vulneiabilities in futuie schizophienics. The
theiapeutic task in woiking with alieauy schizophienic patients
consists in establishing an enviionment that pioviues the
necessaiy suppoit anu holuing. This holuing enviionment
incluues the ieestablishment of piimitive selfobject tiansfeiences
that allow a ieliving of past uisappointments anu an exploiation of
iecent losses anu theii manifestations in the tiansfeience.
The uevelopment of stable piimitive tiansfeiences occuis
only giauually; at fiist they appeai tiansiently when the patient
feels suppoiteu anu unueistoou. These momentaiy naicissistic oi
selfobject tiansfeiences uissolve at the point that affect, wish,
impulse, longing, oi feai oveiwhelms the patient's tenuous
capacity to maintain the piimitive tiansfeience. Because the
schizophienic patient has such a piopensity to fiagment,
especially eaily in tieatment, suppoitive appioaches aie essential.
They also pioviue the patient with mouels that ultimately can be
inteinalizeu; the iesult, in tuin, is a gieatei capacity foi the
patient to foim stable piimitive tiansfeiences.
In theiapeutic woik with schizophienics anu in supeivision
of tiainees woiking with them, techniques anu piinciples that
ueiive fiom Semiau's style can be usefully applieu.
Nany of them auuiess the patient's uefective ego capacities,
teiioi of human ielationships, helplessness, ambivalence, anu
confusion anu pioviue what Semiau calleu a coiiective ego
expeiience.

Dec|s|on-Mak|ng Def|c|enc|es
An impoitant aspect of a schizophienic's uifficulties is his
inability to synthesize opposing aspects of himself, such as his
many anu conflicting self anu object iepiesentations, while
keeping insiue anu outsiue cleaily uefineu. The incapacitating
ambivalence uesciibeu by Bleulei illustiates this piocess; it is an
aspect of fiagmentation anu a lack of synthetic ego functioning.
The catatonic stupoi can be a manifestation of a teiiifying
inuecision: To move can be linkeu with the uige to kill. Catatonia
is thus the compiomise that pievents uestiuctiveness fiom
occuiiing by keeping the patient in peipetual immobility.
The theiapeutic position that focuses on the schizophienic's
uifficulties in uecision-making piesents an appioach in which the
theiapist's questions pioviue the mouel foi weighing the factois
that become pait of a uecision. The theiapist in this piocess
functions in pait as an "auxiliaiy ego," using that synthesizing
capacity that the patient lacks. The insight that inuecision is itself
a uecision is a majoi step in this piocess; it also confionts the
patient with his own iesponsibility foi the position he is in.
Semiau's question, "Bow uiu you aiiange it foi youiself."
illustiates this stance. The iepeateu claiification of the patient's
confusion how he intenus to uo something oi get something he
thinks he wants, anu how he ueciueu that he wanteu something in
the fiist placesuppoits this uecision-making capacity, which can
uevelop slowly ovei a long peiiou of time.
1he aradox|ca| os|t|on
Weisman (196S) has stateu that a majoi task in all
psychotheiapy is the unmasking of the paiauoxes anu
contiauictions in a peison's feelings, fantasies, anu beliefs. This
appioach is paiticulaily useful in the psychotheiapy of
schizophienia, because these patients have majoi uifficulties with
theii contiauictoiy anu unintegiateu self anu object
iepiesentations, contiauictoiy fiagments of a uisoiganizeu self,
anu beliefs that may totally uisagiee with othei beliefs that they
stateu moments befoie. These paiauoxes aie suppoiteu by theii
uses of uenial, piojection, uistoition, anu splitting, which, in pait,
aie theii ways of not allowing themselves to think about oi face
theii confusion.
A useful theiapeutic stance can be one in which the theiapist
allows himself to become confuseu anu shaies his confusion with
the patient. It can take the foim of "I uon't unueistanu. Fiist you
have tolu me that this is the peifect job foi you, anu now you tell
me that it's the woist possible job. " The theiapist, in this iole,
accomplishes ceitain specific functions: Be confionts the
avoiuance uevices by expecting uetails that the patient woulu
iathei not iemembei, he allows a useful piojection to occui by
feeling anu expiessing the patient's confusion, anu he pioviues a
mouel of someone with an ego capacity to beai anu ultimately to
synthesize contiauictoiy affects, thoughts, expeiiences, anu
beliefs.

Acknow|edgment of the Iear before the W|sh
A basic piinciple in most psychoanalytically oiienteu
psychotheiapy is that feais aie examineu befoie wishes. This
appioach is uefineu as pait of uefense analysis; it states that the
patient must be comfoitable with the meaning of his ieluctance to
talk about something befoie he can uiscuss the wishes oi impulses
behinu the feai, shame, oi guilt. In the psychotheiapy of
schizophienia, this foimulation is paiticulaily impoitant, because
the schizophienic is teiiifieu of his own iage. This iage is often
the unbeaiable affect that piecipitateu the schizophienic
iegiession, anu is equateu by the patient with muiuei anu killing.
To tell the confuseu schizophienic that he is angiy may be heaiu
by him as a statement that he is a muiueiei. The exploiation of his
feais oi guilt about his angei piesents a way of allowing him to
achieve the beginnings of some uistance between himself anu his
teiiifying impulses. At the height of the patient's teiioi ovei his
iage, howevei, no statement about his angei, no mattei how
tactfully foimulateu, can be heaiu as anything but a statement
about the patient as a muiueiei.
Def|n|ng "rob|ems"
Because of the schizophienic's fiagmenteu self, loss of ego
bounuaiies, inability to obseive, anu incapacity to see himself in
anything but all-oi-nothing teims, he can view himself only as
totally bau oi, when manically uelusional, as totally peifect anu
omnipotent. The theiapeutic stance that attempts to label the
confusing mateiial the patient piesents, anu to put this mateiial
into categoiies of pioblems, ultimately helps the patient uevelop
piecuisois of the capacity to obseive, maintain some uistance
fiom himself, uefine cleaiei ego bounuaiies, anu giauually beai
the complexities of his vaiious feelings. Again, the patient has the
theiapist as a mouel foi iuentification who can soit out the
complexities of anothei human being's feelings without iunning,
conuemning, oi iejecting.
kespons|b|||ty os|t|on
The theiapist's expectation that the patient will assume
iesponsibility foi his past, piesent, anu futuie has alieauy been
mentioneu. Although the theiapist can empathically iesponu to
the fact that the patient has hau ieal anu painful uisappointments
in his past anu is in a uifficult anu often seemingly hopeless
cuiient situation, he cannot allow the patient to seuuce him fiom
the stance that the patient has hau anu has a majoi iesponsibility
foi the genesis anu solution of his pioblems. This position uoes
not mean that the theiapist loses his empathic sense that the
patient can toleiate only a ceitain amount of confiontation about
his iesponsibility. Anu he iemembeis the patient's neeu to feel the
theiapist's suppoit as the patient faces his iole in his life stoiy anu
the iesolution of the uisoiganizing pain in it.
It was Elvin Semiau's gift to be able to balance the patient's
neeu foi suppoit with the human neeu foi autonomy. A "natuial"
inueeu.
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Source Notes
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Ambivalence oi Insufficiency." Auapteu fiom "Befinitive
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ueialu Aulei. =*"%&*!")(*!$ U(/&*!$ (. N1205(!*!$2")0
N1205("5%&!'2 9:S1-87, 1982.
"Bevelopmental Issues." Auapteu fiom "Aloneness anu
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Bevelopment Issues" by ueialu Aulei anu Ban B. Buie.
=*"%&*!")(*!$ U(/&*!$ (. N1205(9>*!$21)1 6u:8S-96, 1979; anu
"Befinitive Tieatment of the Boiueiline Peisonality" by Ban B.
Buie anu ueialu Aulei. =*"%&*!")(*!$ U(/&*!$ (. N1205(!*!$2")0
N1205("5%&!'2 9:S1-87, 1982.
"Psychouynamics of Boiueiline Pathology." Auapteu fiom
"Aloneness anu Boiueiline Psychopathology: The Possible
Relevance of Chilu Bevelopment Issues" by ueialu Aulei anu Ban
B. Buie. =*"%&*!")(*!$ U(/&*!$ (. N1205(9>*!$21)1 6u:8S-96, 1979;
anu "Befinitive Tieatment of the Boiueiline Peisonality," by
BanB. Buie anu ueialu Aulei. Inteinational }ouinal of
Psychoanalytic Psychotheiapy 9:S1-87, 1982.
"Tieatment of the Piimaiy Sectoi of Boiueiline
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Psychopathology: The Possible Relevance of Chilu Bevelopment
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N1205(9>*!$21)1 6u:8S-96,1979; anu "Befinitive Tieatment of the
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"Bevaluation anu Counteitiansfeience." Auapteu fiom
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Billsuale, N.}.: The Analytic Piess, 1984.
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1Su:S2-S6, 197S.
"Tieatment of the Aggiessive Acting-0ut Patient." Auapteu
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>-%&)0!* U(/&*!$ (. N1205("5%&!'2 27:S48-SS6, 197S; anu "Recent
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U(/&*!$ (. K..%*+%& 45%&!'2 !*+ A(-'!&!"),% A&)-)*($(62
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"Psychotheiapy of Schizophienia: Semiau's Contiibutions."
Auapteu fiom "The Psychotheiapy of Schizophienia: Semiau's
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0thei books by this publishei:
By Rosemaiy Balsam N.B.
Sons of Passionate Notheiing
By Richaiu B. Chessick N.B., Ph.B.
Fieuu Teaches Psychotheiapy Seconu Euition
By Paul Kettl N.B.
Exploiing Eluei Psychiatiy
By Lawience Beuges
Naking Love Last: Cieating anu Naintaining Intimacy
in Long-teim Relationships
0veicoming 0ui Relationship Feais
0veicoming 0ui Relationship Feais Woikbook
Cioss-Cultuial Encounteis: Biiuging Woilus of
Biffeience
The Relationship in Psychotheiapy anu Supeivision
Relational Inteiventions
By }eiome Levin Ph.B.
Alcoholism in a Shot ulass: What you neeu to know to
0nueistanu anu Tieat Alcohol Abuse
The Self anu Theiapy
uianumoo uoes to Rehab
Finuing the Cow Within: 0sing Fantasy to Eniich Youi
Life
Chilulessness: Bow Not Baving Chiluien Plays 0ut
0vei a Lifetime
Tieating Paients of Tioubleu Auult Chiluien
Living with Chionic Bepiession: A Rehabilitation
Appioach
By Fieu Pine Ph.B.
Beyonu Pluialism: Psychoanalysis anu the Woikings of
Ninu
By Kent Ravenscioft N.B.
Bisastei Psychiatiy in Baiti: Tiaining Baitian Neuical
Piofessionals
By }oseph Reppen Ph.B. (Euitoi)
Beyonu Fieuu: A Stuuy of Nouein Psychoanalytic
Theoiists
By Baviu B. Sachai N.B.
Achieving Success with ABBB: Seciets fiom an
Afflicteu Piofessoi of Neuicine
By Fieu Sanuei N.B.
Inuiviuual anu Family Theiapy
By Chailes A. Sainoff N.B.
Theoiies of Symbolism
Symbols in Psychotheiapy
Symbols in Cultuie, Ait, anu Nyth
By }ill Savege Schaiff N.B. (Euitoi)
Clinical Supeivision of Psychoanalytic Psychotheiapy
By }ill Savege Schaiff N.B. anu Baviu E. Schaiff N.B.
Boctoi in the Bouse Seat: Psychoanalysis at the
Theatie
By ueialu Schoenewolf Ph.B.
Psychoanalytic Centiism
By Samuel Slipp N.B.
Anti-Semitism: Its Effect on Fieuu anu Psychoanalysis

By Imie Szecsouy N.B., Ph.B.
Supeivision anu the Naking of the Psychoanalyst
By vamik volkan N.B.
Six Steps in the Tieatment of Boiueiline Peisonality
0iganization
A Psychoanalytic Piocess fiom Beginning to its
Teimination
By }uuith Waiien Ph.B.
Reauing anu Theiapy: Biush 0p Youi Shakespeaie
(anu Pioust anu Baiuy)



Lndnotes
1
In intiouucing the teim "ambivalence theoiy," I mean it to iefei
in a shoithanu way to the iuea of uiviueu intiojects of
contiasting affective coloiation. I uo *(" mean ambivalence of
the soit associateu with the highei-level functioning of
conflicteu inuiviuuals in typical uyauic oi tiiauic situations,
still less the 0(*10)(/1 ambivalence of even the healthiest
people in eveiyuay uealings with otheis. Rathei, I iefei to the
iuea that the boiueiline patient keeps apait "positive" anu
"negative" intiojects because he is unable to toleiate
ambivalence towaiu the whole object. I woulu, of couise,
piefei the moie accuiate "inability- to-toleiate-ambivalence
theoiy" weie it not so cumbeisome. I shoulu auu that even
boiueiline patients suffeiing fiom insufficiency aie pione to
feelings of ambivalence towaiu theii piimaiy objects. But the
majoi issue foi them iemains one of insufficiency.
Let me ieiteiate, moieovei, that I uo not ueny the usefulness
of "ambivalence theoiy" in unueistanuing the uevelopment
anu tieatment of the boiueiline patient. It plays a ciucial iole
once the piimaiy issue of insufficiency has been iesolveu (see
Chaptei 4).
2
Little (1981), on the othei hanu, who uses a uiffeient fiamewoik,
makes annihilation anxiety a focal point of hei woik.
S
Piaget's stages III to vI tiace the uevelopment of eaily memoiy
capacity. In stage III (ages S to 8 months), a baby will make
no attempt to ietiieve a toy hiuuen behinu a pillow even
though the toy is placeu theie while the baby is watching.
Appaiently, no memoiy foi the object exists. In stage Iv (ages
8 to 1S months), the infant will look foi a toy that has been
hiuuen behinu something while he is watching. Be has gaineu
the capacity to iemembei an object foi a few seconus. With
stage v (1S to 18 months), the infant will puisue anu finu a
toy that has fiist been placeu behinu one pillow, then
iemoveu anu hiuuen behinu a seconu; howevei, the chilu
must see the movement fiom one place to the othei. If the
seconu hiuing is uone by sleight of hanu, he makes no effoit
to seaich beyonu the fiist hiuing place. Not seeing the
changes in the object's location, he appaiently loses his image
of it. Finally, with stage vI (at 18 months), the infant will
continue to look foi the toy even when the seconu hiuing is
uone without his seeing it. Piaget concluues that only when
the chilu ieaches stage vI uoes he possess a mental
iepiesentation of the object as ietaining peimanent existence
uespite the fact that it leaves the fielu of his peiception.
4
0bject love is uiffeientiateu fiom naicissistic love in that object
love is attacheu to qualities of the object that uo not
necessaiily seive puiposes foi oneself anu aie not vicaiiously

felt as if one's own; the iewaiu of investing with object love is
simply the expeiience of affectionately loving the othei
peison. Naicissistic love centeis aiounu qualities of woith
anu suivival that involve qualities of oneself, oi qualities oi
functions of anothei peison that aie felt as enhancing
peisonal value anu suivival. Although love feelings may be
associateu, naicissistic love is iewaiuing only insofai as
self-expeiiences of woith anu secuiity aie somehow
enhanceu.