Hi! We are two Norwegian students writing our thesis on ISTDP and therapy with patients suffering from Borderline personality organization. How do you work with these patients? And where do these patients belong, on the spectrum of psychoneurotic disorders or the spectrum of fragile character structure? Are they highly resistant or fragile?
We want to emphasize the defenses of splitting, projection and projective identification with this patient group. We want to understand the therapy methods of ISTDP with these patients compared to the therapy methods of Transference focused therapy. How does ISTDP understand the personality structure and defense pattern of patients with Borderline personality organization? We appreciate it a lot if you take your time! Emilie & Katrina
First of all, as you know, patients who have the diagnosis of borderline personality disorder share only a set of symptoms, not a common character structure. That is why Kernberg has proposed that we differentiate the DSM-V diagnosis of borderline personality structure (a set of symptoms which can be found in people with psychotic, borderline, or neurotic levels of character structure) from borderline level of character structure itself.
Patients with a borderline level of character structure use projection, projective identification, and splitting as their primary defenses. Thus, they have what we call in ISTDP a fragile character structure. Their anxiety is discharged into cognitive/perceptual disruption and they can tolerate only a low level of mixed feelings before they use primitive defenses based on projection and splitting (e.g. acting out, discharge, dissociation, projective identification).
Patients with a fragile character structure require the graded format. A gradual exposure to mixed feelings to build the capacity to bear feelings without anxiety moving into cognitive/perceptual disruption and without using the defenses of splitting and projection. This graded format requires the therapist to use only very low levels of feeling in the session tailored to the patient’s very low level of affect tolerance.
When fragile patients split, we use pressure to consciousness of splitting to build the patient’s capacity to bear mixed thoughts, urges, and feelings internally without splitting them apart.
When fragile patients project, we restructure the projection to re-establish reality testing with the therapist, then we invite the patient to experience the feeling internally that he previously projected externally. After all, if he cannot build the capacity to bear the feeling inside, he will project it outside next time.
Thus, we cognitively restructure the projection first. Then we use pressure to help the patient experience internally what he projected externally. As he bears the feeling internally, as soon as he starts to get dizzy or disrupt we do bracing. That is, we remind him of the internal feeling while cognizing. This builds his capacity to bear that level of feeling while cognizing and without projecting. As we do the bracing, we watch the patient. We continue bracing until he sighs or intellectualizes. That shows us he can now tolerate that level of feeling without projecting. Thus, we have built a new level of unconscious affect tolerance.
In contrast to transference focused therapy, we rely less on interpretation. We rely more on building the capacity to bear feelings internally without projecting or splitting. We have two primary tasks we focus on: 1) restructuring the unconscious pathway of anxiety discharge so the patient can tolerate 100% of his feelings while anxiety remains in the striated muscles; and 2) restructuring the system of resistance so the patient can tolerate 100% of his feelings without the use of splitting and projection.
Another distinction from transference focused therapy is that ISTDP has a theory of anxiety based upon the somatic and autonomic nervous systems that allows us to determine what is the optimal level of anxiety for learning in therapy. Patients with a borderline level of character structure have a very low capacity for affect tolerance or anxiety tolerance. As a result, many of these patients suffer because therapists are working at levels of feeling and anxiety are far too high for the patient, leading to the regressive phenomena for which these patients are famous. Thus, if the therapist can recognize the physical signs of anxiety and the resistance systems with which they are correlated, it is much more possible to work with these patients in an effective manner that does not lead to regression.