EFFECTIVE PSYCHOTHERAPY WITH BORDERLINE PATIENTS:CASE STUDIES
Robert J. Waldinger, M.D .John G. Gunderson, M.D.
New York, Macmillan 1987, 232 page

Sullivan, MD, Gregory B.

English

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Jefferson Journal of PsychiatryVolume 5 | Issue 2 Article 14January 1987Book Review: Towards a Practical Guide to theTherapy of the Borderline PatientGregory B. Sullivan, MDThomas Jefferson University HospitalFollow this and additional works at: https://jdc.jefferson.edu/jeffjpsychiatryPart of the Psychiatry CommonsLet us know how access to this document benefits youThis Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of ThomasJefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarlypublications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers andinterested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion inJefferson Journal of Psychiatry by an authorized administrator of the Jefferson Digital Commons. For more information, please contact:JeffersonDigitalCommons@jefferson.edu.Recommended CitationSullivan, MD, Gregory B. (1987) "Book Review: Towards a Practical Guide to the Therapy of the Borderline Patient," Jefferson Journalof Psychiatry: Vol. 5 : Iss. 2 , Article 14.DOI: https://doi.org/10.29046/JJP.005.2.013Available at: https://jdc.jefferson.edu/jeffjpsychiatry/vol5/iss2/14Towards a Practical Guide to the Therapy ofthe Borderline PatientEFFECTIVE PSYCHOTHERAPY WITH BORDERLINE PATI ENT S:CASE STU DI ESRobert J. Waldinger, M.D .John G. Gunderson, M.D.New York, Macmillan1987, 232 pagesGregory B. Sullivan, M.D.Doctors are the most practical of men , and psychiatrists the mostpractical doctors. They deal in the obscure but make it obvious, andthey treat it with common sense. ... They take their time, th ey areslower than lawyers, they have a kind of selfish patience.Paul Theroux ( I)Waldinger and Gunderson's recent book, Effective Psychotherapy with Border-line Patients: Case Studies, (2) , while not intended specifically for residents, is animportant work which deserves a broad audience and has some special rel evanceto psychiatric trainees. Residents, from the earliest stages of their training, willfind these patients remarkably even dismayingly common in emergency room ,inpatient unit, consultation/liaison , and outpatient clinic settings. T he colli sionof a patient population "notoriously difficult to treat and prone to developsevere and sometimes life- th reaten ing transference reactions in exp lo ra to rytreatment" with a beginning therapist will be a mutually trying one. Morelimited in skills, experience, and confidence, residents may be prone to acceptthe projected helplessness and hostility of the borderline patient; pessimism andburnout become the resident's refuge.As Wa ldinger points out in the book's introductory overview, thi s pessi-mism involving the use of psychodynamic therapy dates back to th e earl ies tclinical descript ions of the borderline patient wh ich arose from the difficultiesinherent in this treatment method. Thus, Zetzel and others found highlystructured supportive work the only option for these patients almost by defin i-tion excluded from dynamic therapy. There is some nihilistic comfort in suc hviews for residen ts for whom the very term borderline is an epithet, and indeedan epitaph ca lling for a hasty termination and distant retreat from any a tt ac h-Dr. Sullivan is a third year resident in the Department of Psychiatry at the Thomas J effersonUniversity School ofMedicine.92BOOK REVI EW 93meri t. In our eagerness to "turf' these patients e lsewhere, we ca n no t avoidco nfirming the pati ent 's notion of being " tox ic" to others. Waldinger andGunderson 's work offers an antido te to this tox icity fo r residents wh o ma y berelative ly unaware of th e prevalent, if not necessar ily prevailing, body ofpubl ish ed case histories attest ing to th e efficacy of intensive exploratory psycho-therapy .The authors review these previous effo rts while pointing up th e more orless obvious deficiencies of sing le-case reports. T hese include diagnostic disarrayand possibl e bias of th e individual reporting th e rapists, an d prevent ma ny suchreports fr om providing ge nera lizab le data of benefi t to interested residents. T heauthors summarize th eir own more ambitious goals:In this way, we are attempting to bridge th e gap between qualitati veand quantitative modes of studyi ng the psychotherapy of Borde rl inePersonality Disorder, remaining close to the experiences of therapistsand pa tients, but exa min ing th em in a way that may increase th egeneralizab ility of our concl usions. We attempt to loo k for cha rac te r-istics ofpat ients, thera pists, and treatment p rocesses that are co mmonamong th erapies of borderline individuals which have good o ut-comes. We hope to co nt r ibute hypotheses in th is area that can beinvestigated more rigorously in th e future . We a lso hope to make adata base of detailed case reports on psych odynamic therapy availableto other research ers.T he primary, but no less ambitious sta ted ai m of this book is " to address th eq uest ion of whether and to what ex te nt Borderl ine Personal ity Disorder can be'cu red ' by psych otherapeutic mean s." It begins wit h a se lective but thorou ghreview differentiating amo ng theories of etio logy, core pa th ology, an d t reat-ment. This section in itself will be useful to resid e nts for its clarity; it is amodified version of Waldinger's recen t review article (3).The introducto r y review fin ishes wit h an in teresting d iscussion of th e rol eof th e therapist 's personality in affect ing th e co urse and outcome of treatment,and even in th e therapist's co nception of the natu re of the borderl ine conditionitsel f. This ex p lanation is invoked in pa rt to attempt to " reconcile the fact th at[m ajor th eorists] wh o hold suc h different views o n borderline pathology an dtreatment claim to be able to treat borderline pati ents successfull y usingdivergent techniques." This ana lysis actually ma y be more convincing toresidents who , wh ile sti ll forming an identity in th ese matt ers, have the benefit ofa broad exposu re to sty les of superviso rs and co lleagues and have witn essed th evicissitudes of th erapist /patient " fit." For resid ents, attention to this point maymake patient selection and treatment of borderline patients more realistic andeffec t ive.The analysis of th erapeutic " fit" is car r ied th rough to th e middle section ofth e book , in whi ch five exte ns ive case reports from five di stin ct therapists arepresented. The five the rap ists (whi ch include both authors) are male , psychoan-94 JEFFERSON JOURNAL OF PSYCHI ATRYalytically trained physicians in the early to middle phases of their careers; all areaffiliated with McLean Hospital. The issues in regard to generalizing from th esetherapists' performance are briefly discussed. By turns grim, wr y o r touching,the cases are not wanting for clarity and readability. The honesty of thetherapists in reporting their uncertainty and perceived mistakes prevents th ereports from seeming sanitized and allows identification for residents end ur ingsimilar difficulties. The authors have fashioned a stylistically cohere nt group ofnarrative reports each followed by a parallel discussion section. T he uni formdiscussion format, ("patient strengths: amenability to analytically orientedtherapy; transference; countertransference; technique; outcome level of func-tion versus baseline") allows the reader to compensate for one shor tcomi ng ofthe work, which mostly does not compare and contrast between th e cases unt ilthe concluding chapters. Some persistent misprinting, transposing th e identifi-cation of figures furnishes another structural annoyance in the book. O nceagain, the case histories in themselves are to be recommended to re sidents.The fina l section of the book contains the authors' attempts at generatinghypotheses about common patterns in the successful psychotherapy of border-line disorders. Although the cases were selected as examples of good outcome , itis important to note, as the authors do, that "the description of th ese patternscan also be applied to the many borderline patients who do not ac hieve goodoutcomes." The diagnostic validity of the patients presented is co nv inci nglydocumented by retrospective use of the Diagnostic Interview for Borderlines(DIB-R) and DSM-III, with the exception of a patient described in th e case reportas possibly meeting cyclothymic criteria "given her swings from depression tomild elation and increased activity," whereas the summary states, "none hadperiods of elation or hyperactivity that would have raised diagnostic questions ofcyclothymia." This error represents more the exception that proves th e ru le inthis carefully defended section. This five patient sample seems to ac hieve,despite its small size and de r ivat io n , a fortunate representation of th e gen eralpopulation of patients with th is disorder.Perhaps most interesting are the "yardsticks" obtained to assess yea r-by-year (treatment lengths cluster around five years) patterns of change in theareas of acting out, separation responses, social roles, affects, and relationship tothe therapist. Residents without the opportunity to follow their clinic pat ientsbeyond two years may not be heartened by the news that estab lish ment of basictrust and the decline in severity and frequency of patients ' self-destructive actingout does not occur until year three of treatment. Early, middle, middle-late , andlate phases can be distinguished, which .a re both consistent among th esevariously treated cases, as well as consistent with the recapitulation of develop-mental "templates" thought to be involved in the pathogenesis of th e borderl inecondition.In terms of comparing the interventions of the therapist , the sample size ismore limiting, and the authors wisely avoid any attempt at resolving debat esover technique. T hey offer the limited comment, " the re is room for a consider-BOOK REVI EW 95able range of therapeut ic techniques," while noting th a t th is may ac tua lly be animportant finding , one whi ch argues aga inst dogmatism. T here is an encourag-ing finding for re sidents who ma y at tim es co nsider a sh ift from more supportiveto more interpretive and co nfronta tiona l technique with some borderl inepa tients in th erapy (either becau se of reassessment of po tential for insi ght , inmisguided a tt empt to " upgrade" caseload unil at erally, o r as covert attempt todrive the patient out of therapy). Waldinger and Gunderson 's analysis, asopposed to Kernberg 's views, shows that thi s was possible fo r some patien ts,providing th e patient se nsed cons iste nt co mmitme nt by the therapist to continuethe treatment. T hey note th at "such shi fts in technique are p robably far lesstenable wh en derived primarily from feelings of hopelessn ess o r ange r. "Preserving the treatment thus asks th e same of both patient and the residenttherapist-an ability to move beyond our primitive defen ses and to attend to ou rfeelings without acting on th em .The book closes with a thorough description of outcome from th e pheno m-eno logic/ descr ip t ive , structural/defenses, core co nflicts and deficits, and func-tional perspectives. The authors co nclude: " despite significa nt variat ions in thequality of th e outcome , none of th e patients was ma nifes t ly d iagnosable asborderline after fou r years of treatment. This is th e central observation of thisbook." They remind us th at this outcome is not co mmo n, but the workconvincingly documents th at it is possible. Those residents who seriouslydoubted this ma y not be willing to tak e the time to read thi s book , but should.For those who were already convinced, th e above co nclusion may seem tenta-tiv e , but th ere are still enough associated fr esh insights to satisfy . Keeping th eauthors' rea list ic caveats in mind, this book sho uld serve as a "soothingintroject" for th e resident engaged in psychodynamic the ra py with a borderlinepatient.REFERENCESI . T heroux P: The Man on th e Clapham Omnibus, in T he London Embassy. New York,Penguin Books , 1983, pp 121-1222. Waldinger RJ, GundersonJG: Effec tive Psych o th erapy with Borderl ine Pati ents: CaseStudies. Ne w York, Macm illan , 19873. Waldinger RJ: Inten sive psych odynamic therapy with borderline patients: an over-view . Am] Psychiatry 144:267- 274, 1987

Book Review: Towards a Practical Guide to the Therapy of the Borderline Patient

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Book Review: Towards a Practical Guide to the Therapy of the Borderline Patient

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