The transference in psychotherapy: the old vs. the new, analytic vs. dynamic.

This article takes a look at the concept of transference from several contemporary perspectives. It compares the traditional (or classical) view of transference with a more contemporary view based on the joint creation of the transference. It then discusses the relevance of transference to the dynamically based psychotherapies. From this perspective analytically oriented psychotherapy is contrasted to dynamically oriented psychotherapy.

Dynamically oriented psychotherapy with borderline patients.

This article outlines a basic framework and strategy for a dynamically oriented psychotherapy with borderline patients. Focus includes arrangements and guidelines for psychotherapy, neutrality, the stability of the therapeutic environment, the therapeutic alliance, transference, the countertransference, activity of the therapist, types of interventions, style of interventions, interventions regarding core difficulties, the conceptual framework of anxiety and defense, trends in the psychotherapy, and termination. A differentiation between analytically oriented psychotherapy and dynamically oriented psychotherapy is provided. For one group of borderline patients, a modified analytically oriented approach is utilized throughout the entire treatment. For a second group, there is a switch from analytically oriented psychotherapy to a dynamically oriented psychotherapy, after the therapeutic alliance has become reasonably stable. Two clinical vignettes are provided.

The borderline patient: update on the diagnosis, theory, and treatment from a psychodynamic perspective.

This paper presents an overview regarding the borderline patient including historical background, diagnosis, developmental theory, prognosis, and psychotherapy, all from a psychodynamic perspective. The overview is succinct, current, and practical; it is comprehensive although certainly not all-inclusive. Five clinical vignettes are presented, reflecting various aspects of borderline patients. These vignettes are used to illustrate phenomena elaborated later in the paper. Regarding diagnosis, an approach based on ego strengths and ego weaknesses is detailed. This "ego-psychological diagnostic approach" leans on the ideas of Kernberg, but simplifies and occasionally modifies his work, in addition to including aspects of the borderline patient not stressed by him. It provides a simple, integrated summary of current psychodynamic diagnostic thinking. The paper compares and contrasts two of the most useful developmental theories regarding the borderline patient, those of Kernberg and Adler. The clinical usefulness of the two theories is noted, as is their relationship to etiology. Relying on the work of Stone, there is a brief section on prognosis, followed by an even briefer discussion of referral yield. The paper concludes with a discussion of psychotherapy. A continuum of psychodynamically related psychotherapies is detailed, then related to borderline individuals.

Psychotherapy with the borderline patient: an introduction.

This paper serves as an introduction and orientation to six articles written by renowned experts on psychotherapy with borderline patients: Adler, Meissner, Chessick, Giovacchini, Kernberg, and Stone. Because the articles focus most explicitly on treatment and only touch on diagnosis, a brief excursion into diagnosis is provided. A section on conceptual framework for psychotherapy is presented, helping the reader to place the different authors' approaches into a continuum of exploratory psychotherapy. Finally brief summaries of this six articles are offered.

Clarification of projective identification.

This paper clarifies the various current usages of the term "projective identification." The author presents a broad reference model of projective identification based on the work of Ogden. This model divides projective identification into three steps. Step 1 is the projection of a part of oneself onto an external object. Step 1a is the blurring of self and object representations. Step 2 is an interpersonal interaction in which the projector actively pressures the recipient to think, feel, and act in accordance with the projection. Step 3 is the reinternalization of the projection after it has been psychologically processed by the recipient. The different definitions of projective identification are shown to relate to exactly how the term "projection" is conceptualized (in step 1), to whether step 1a is deemed necessary, and to how many of the three steps are required for the definition of projective identification. The author reviews the work of Ogden, Kernberg, Meissner, Sandler, Malin and Grotstein, Porder, and Zinner et al. Six detailed case examples are provided from within and outside psychotherapy to illustrate all three steps of projective identification.

An integration of the views of Kernberg and Adler on borderline pathology.

Kernberg's writings on borderline pathology have greatly influenced the mental health world. More recently, Adler has emerged as another psychodynamic authority on this disorder. Adler challenges Kernberg with a different conceptual framework and posits a different core problem for borderline patients. Some writers have contrasted Kernberg's "conflict" theory with Adler's "deficit" theory. The author contends that it is erroneous to contrapose Kernberg and Adler. He demonstrates that the controversy between conflict and deficit is invalid because, in the final analysis, Kernberg and Adler subscribe to theories that involve both. The author shows how their theories can be combined into an integrated model.

Update on psychodynamic thinking regarding the diagnosis of the borderline patient.

An ego-psychological diagnostic approach to the borderline patient has been presented and detailed in previous publications. This paper modifies and expands this approach, providing a new, up-to-date model. This new model tries to accomplish the somewhat contradictory tasks of: (1) providing a current generally accepted psychodynamic framework, and (2) being more compatible with DSM-III-R. Both historical and current concepts of the borderline patient are reviewed and related to this new model. The concept of the borderline patient as someone with a specific structural configuration, to be differentiated from the normal-neurotic, the narcissistic, and the psychotic configurations, is retained.

Beginning psychotherapy with the borderline patient.

Written as a guide for those about to begin psychotherapy with a borderline patient, this paper succinctly addresses the early stages of therapy. Because it is most helpful to think in accordance with a conceptual framework, the first section of this paper reviews four types of individual psychotherapy, relating these to the borderline patient. The second section deals with larger issues regarding psychotherapy, and the third section focuses on specific interventions.

The diagnosis of depression and the DSMs.

The classification of depression in DSM-III and DSM-III-R is radically changed from that of DSM-I and DSM-II. To understand the many changes, this paper explores early diagnostic systems, newer research studies, DSM-I, DSM-II, DSM-III, and DSM-III-R. A conclusion is reached that DSM-III and DSM-III-R offer both advantages and disadvantages to DSM-I and DSM-II. These are detailed in the paper.

The depressive impulse-ridden character and the core borderline personality.

The depressive impulse-ridden character is differentiated from the more pathological core borderline personality by a focus on reality testing, defenses, and identity. In accordance with the differentiation, conclusions are drawn bringing new understanding to the term borderline personality.

Current dynamic thinking regarding the diagnosis of the borderline patient.

This paper succinctly discusses the current dynamic thinking regarding the diagnosis of the borderline patient. After a brief historical perspective, an ego-psychological diagnostic approach to the borderline patient is presented. Influenced heavily by Kernberg, yet quite simple, this approach provides an integrative summary of current diagnostic concepts of the borderline personality. That presentation is followed by introductory excursions into four current areas of focus regarding the diagnosis of the borderline patient.

Obsessive-compulsive behavior, DSM-III, and a psychodynamic classification of psychopathology.

This paper reviews obsessive-compulsive behavior, both neurosis and character, and relates these to DSM-III, as well as to a psychodynamic classification of psychopathology. The DSM-III obsessive-compulsive disorder and the classical obsessive-compulsive neurosis are found to be very similar descriptively. In contrast, the DSM-III compulsive-personality disorder is found to be a much more psychopathological entity than the classical obsessive-compulsive character.

DSM III and the narcissistic personality.

In order to achieve more understanding of the term narcissistic personality, particularly as it relates to DSM III, the works of Kohut and Kernberg are examined in much detail. Focus is placed on descriptive and dynamic aspects of these works, along with the question of the relationship of the narcissistic personality to the borderline. The descriptive aspects of both Kohut's and Kernberg's works are each recast in a symptom-oriented check-list approach, to provide direct comparisons to DSM III. The DSM III criteria for the narcissistic personality are found to nicely represent a descriptive compilation of the work of these two predominant psychoanalysts. Although the DSM III criteria do not yet supply reliability or validity, they do describe a distinct group of patients, appear highly useful clinically, and are viewed very favorably.

Confirmation of the borderline personality within a psychodynamic framework.

Using a psychodynamic framework and an underlying structural configuration, the borderline patient is described. Statistical methods are then used to differentiate this group from both a schizophrenic and a character disorder group of patients. The borderline group emerges as a clear-cut entity characterized by (1) the lack of an integrated self concept, and (2) a particular ego structure consisting of a specific pattern of superficial ego strengths and underlying ego weaknesses.

DSM-III and the diagnosis of borderline.

In order to achieve more understanding of the diagnosis of borderline personality, particularly as it relates to DSM-III, a historical review of influential diagnostic approaches is undertaken. DSM-III defines the borderline personality disorder in a simple way, enhancing reliability and research value. In comparison to other influential approaches, however, there is an overemphasis on affective disturbance, plus an obvious omission amongst the diagnostic criteria of the vulnerability to brief psychotic regressions under stress. The checklist approach of DSM-III greatly takes away from dynamic understanding and makes potentially valuable items such as defensive organization difficult to include. The DSM-III concept of the borderline personality as one of many distinct personality disorders seems unfounded. The concept of the borderline as a superordinate diagnosis under which more specific personality disorders would fall, appears more reasonable.

DSM-III and the diagnosis of schizophrenia.

In order to achieve more understanding of the diagnosis of schizophrenia, particularly as it relates to DSM-III, a historical review of influential diagnostic systems is undertaken. It is noted which systems are most relevant to DSM-III and which systems DSM-III neglects. With this in mind, strengths and weaknesses of DSM-III are discussed. Although DSM-III provides a precise, reliable, and research-oriented system, it does not provide construct validity, identifies only the most chronic schizophrenics, does not provide either genetic or psychodynamic understanding, and implies therapeutic nihilism. A conclusion is reached, that, regarding the diagnosis of schizophrenia, DSM-III provides diagnostic criteria that are simply arbitrary and of no more use than a number of other systems.

A study of impulse control in the borderline patient.

This study focuses on the ego function of impulse control in the borderline patient. An attempt is made to ascertain whether the borderline patient is characterized by an obvious defect in this area, and whether this defect can distinguish the borderline patient from other groups of patients. 94 schizophrenics, 34 borderline patients and 21 patients with character disorders admitted to the psychiatry service at a Veterans Administration hospital were compared. The conclusion was that there was an obvious defect in impulse control in the borderline group, quantitatively different from the character disorder group, and qualitatively different from the schizophrenic group.