Borderline Personality Disorder: Tailoring the Psychotherapy to the Patient

Seven experienced researchers and clinicians from the Menninger Clinic embarked a decade ago on intensive research focusing on the borderline personality disorder spectrum. This group is part of the Menninger Clinic's research tradition that began in the 1940s with work done by David Rapaport and was exemplified by Robert Wallerstein's publication1of the work of the Menninger psychotherapy research project from 1954 to 1982. The current book on psychotherapy with the borderline patient is the latest product of this rich heritage in psychoanalytic research.

The book's thesis is stated in its subtitle: tailoring the psychotherapy to the patient. The authors' assumption is that "borderline personality represents a broad spectrum of conditions and that the optimal intervention for one patient may be inappropriate for another." Their research design is anchored to a hypothesis that shifts in the therapeutic alliance would be the most valuable indicator of the effectiveness of the therapist's interventions.

Six senior clinicians studied transcripts of randomly selected psychotherapy hours, focusing on the effect that interventions by the therapist had on the patient's ability to collaborate in the treatment. The researchers modified or constructed several clinically oriented scales for use in the work. One measure of collaboration was Lester Luborsky's therapeutic alliance scales, which reflect a global assessment of an entire session. The other measures, which were intended to identify changes within sessions, dealt with 50-line segments of transcripts, with thirds of sessions, and with collaboration across an entire session.

Although Horwitz and his associates used a single-case-study design, they selected three patients, each of whom had been diagnosed as having borderline personality disorder according toDSM-III-Rcriteria and Gunderson's Diagnostic Interview for Borderline Patients and had received twice-weekly therapy. The patients were treated by members of the core research team.

A major flaw in this book is that the researchers, while relying heavily on the validity of the single-case study, refer to the literature for such studies in a very cursory manner. They allow barely a page for a discussion of all that is published about single-case-study design and implementation. Many of us who are immersed in using psychoanalytic psychotherapy and psychoanalysis have convictions about the value and relevance of single-case studies. However, an elaborately constructed research project with single-case design as its cornerstone weakens its conclusions considerably by not presenting the detailed, cogent logic for its validity.

Some of what emerged in this study reinforces principles of treatment that are becoming respected dogmas. Affective attunement of the therapist to the patient is one of them; the authors state that "the therapist's attunement to the patient's emotional state seemed to create a therapeutic climate that fostered expressive work. Pine's notion of interpreting within the context of support appeared to be just as relevant."

In the authors' view, a significant mechanism of change is the process of repairing ruptures in the collaborative effort; the repair would be accomplished through interpretation or (my italics)"some other combination of interventions."Even though the mechanism of change has important implications for clinical theory, the authors' assumption about the genesis of the ruptures is based squarely on contemporary, mainstream psychoanalytic theory; that is, transference-countertransference enactments account for the rifts that develop between patient and therapist. From this perspective, further exploration of the shifts from a one-person psychoanalytic psychology of treatment to a two-person psychoanalytic psychology becomes a logical next step.

Some of Horwitz and associates' other conclusions inBorderline Personality Disorderare relevant: "Shifting flexibly from expressive to supportive techniques is essential in the psychotherapy of borderline patients." "Transference interpretation should be regarded as high-risk, high-gain interventions." "Partial transference gratifications are inevitable and often therapeutic." "The idealizing pole of a split transference may be internalized and lead to constructive changes." And, "Maintaining professional boundaries makes effective psychotherapy possible."

The conclusions of the book, as well as the detailed presentation and discussion of transcript material, are what make this a valuable book to read in depth.

Dr. Lebovitz is assistant clinical professor of psychiatry and behavioral science at Finch University of the Health Sciences and the Chicago Medical School and a member of the faculty of the Chicago Institute for Psychoanalysis.