Dynamically Oriented Psychotherapy with Borderline Patients

Article excerpt

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, countertransference, activity of the therapist, types of interventions, style of interventions, interventions regarding core difficulties, the conceptual framework of anxiety and defense, the differentiation between analytically oriented and dynamically oriented psychotherapy, trends in the psychotherapy, and termination.

Dynamically Oriented Psychotherapy with Borderline Patients*

CONTINUUM OF PSYCHODYNAMICALLY RELATED PSYCHOTHERAPY Psychodynamically related psychotherapy can be conceptualized as occurring on a continuum, with the most insight-oriented and exploratory types at one end and the most supportive at the other.l ,2 Five types of psychotherapy along this continuum can be described: psychoanalysis, analytically oriented psychotherapy, modified analytically oriented psychotherapy, dynamically oriented psychotherapy, and supportive psychotherapy. I will not elaborate on the details of these five types in this article, but will succinctly differentiate what I call analytically oriented psychotherapy from what I call dynamically oriented psychotherapy.

Analytically Oriented Psychotherapy

In analytically oriented psychotherapy, the therapist attempts to conduct therapy in a manner as similar as possible to psychoanalysis. The therapist remains neutral, relies on clarifications and interpretations as much as possible, and tries to make maximum use of the transference. The establishment and working through of the transference is deemed the most important modality for successful outcome in this type of treatment. Differences from psychoanalysis include the frequency of sessions, the use of the chair versus the couch, and the lessening of the importance of free association. In analytically oriented psychotherapy, sessions are usually twice a week, but can be more frequent.

Dynamically Oriented Psychotherapy

Dynamically oriented psychotherapy also takes place sitting up, with a similar number of sessions. The main difference between this form of psychotherapy and analytically oriented psychotherapy is in the downplaying of the use of the transference as a therapeutic modality in the former. In dynamically oriented psychotherapy, transference reactions are always noted, but usually only interpreted if there are negative components or if they serve as resistances to the treatment. The elaboration of the transference is not considered a major ingredient for change. Rather, a positive working or therapeutic alliance is emphasized, and within that alliance the therapist and patient focus mainly on present-day interactions and relationships and their correlation to the patient's early upbringing and past.

PSYCHOTHERAPY WITH THE BORDERLINE PATIENT

Regarding the borderline patient, all five types of psychotherapy have been recommended. The treatment advocated reflects not only the therapist's theoretical persuasion and orientation, but also his definition of the term borderline. Thus, a number of psychoanalysts of the Kleinian school3-5 who recommend psychoanalysis for psychotic individuals also recommend it for borderline patients. Giovacchini67 and Volkan8 also do psychoanalysis with borderline individuals and have written extensively about it. Their methods and technique, however, vary somewhat from classical psychoanalysis. In contrast Abend, Porder, and Willick9 have given a detailed account of classical psychoanalyses with four "borderline" patients. Although all four patients clearly displayed marked psychopathology, some1,l0 ll have questioned whether these patients were troubled enough to warrant the borderline diagnosis.

Because of the borderline patients' problems with many of their ego functions, their proclivity to regress in the unstructured setting, and their difficulty in trust and in establishing and maintaining a therapeutic alliance, attempts at psychoanalysis are difficult and fraught with dangers. …