This article is published in the book:

"Psych 101 -
What you didn't learn in nursing school."

by Kathi Stringer
Paperback: 320 pages
ISBN-13: 978-0615193137

Effective Inpatient Treatment
And the
Amelioration of the Therapeutic Alliance
Resistive Individuals with
Borderline Personality Disorder

Written by Kathi Stringer

December 2000, Revision [B] – Pages 1 – 22
February 2001, Revision [C] – Pages 23 – 30

Letter from a helping professional

Hello Kathi,

I've found your site enormously helpful. I work in a one to one situation with a 14 year old who has been diagnosed BPD. I am this girls' team leader and so I'm searching the net for some info about BPD so that I may best help my client.

I appreciate that you must be snowed under with responses to your site and so I'll understand if you can't respond, however, if you have time I wonder if you could help me.

 I'm looking specifically for information about a therapeutic approach to working with adolescents with BPD. I've found all the info about diagnosis and characteristics extremely interesting, now I'd like some more information about treatment. Thank you.

Jen Slade


February 1, 2001, 2:50 P.M.


Who cares what other people think? So what if you are different. You are an individual. Just be yourself and you should be proud of being yourself, and that is what makes you an individualist.

Joanne Witkowski M.D.


To Glen Gabbard M.D., an innovative thinker and effective teacher of our time. To Sam Vaknin Ph.D. who’s acute honesty and intelligence inspired and supported me. To the great writers that took the initiative to publish their thought provoking theories. To Joanne Witkowski M.D who never gave up on me and proved to me that a strong therapeutic alliance can be attained. To all the professionals, team leaders and students who wrote inquiring about treatment modalities for difficult patients. I heard your frustration from the current emphasis on symptomlogy and debatable etiology, while scarce on effective treatment. And finally, to Cristina Cabrera my best friend who held me during my worst fears.



It is this writer’s experience that no other function of inpatient care is more critical than the establishment and perseverance of a positive therapeutic alliance. Individuals on the multidisciplinary team must continually examine treatment approaches and address the patient’s transference effects on the individual attitudes of staff. Some theorists may argue that derivatives of countertransference-reaction from staff to the patient is helpful to condition the patient to tolerate higher levels of stress and support the use of new coping strategies and adaptive defense mechanisms. While there is an element of logic to this, it should be noted that if the treater’s countertransference-reaction is in doses consistency higher than patient can endure, severe regressive mechanisms may be activated and the result could set back treatment significantly or destroy the collective trust all together.

Perry & Bond (2000) stress the importance of a positive therapeutic alliance: “In the early phase of therapy for personality disorders, therapists should monitor changes in the alliance carefully, addressing concerns about the alliance when it deteriorates or fails to improve.” Of course, one cannot develop or address the alliance without the use of empathy, the ability of the treater to take on a trial-mind-set of the patient. Applegate & Bonovitz describe the usefulness of empathy in this way: “A capacity to identify empathically with the feelings of others and to step back and perceive them objectively.”

As a patient sufficiently developments trust supported by the treater’s empathic connection, a role-identification is more acceptable to the patient. In a supportive stance, Mish (2000) elaborates: “The patient is offered the opportunity to identify with the healthy psychological structure and function of the therapist, especially with respect to reality testing, affect modulation, impulse control, problem solving, and interpersonal interactions.” Once the patient is actively relating to the treatment team and joined in a positive partnership, effective developmental progress will begin. It is my sincerest wish this paper will serve to enlighten and assist professionals that are perplexed with resistive patients.


Certainly one intention of this work is to provide encouragement for effective inpatient psychotherapeutic treatment from a market driven standpoint. An additional facet to achieve this cost-effective objective would suggest a review of psychotherapeutic dynamics using a supportive stance. I hope to inspire administers and professionals to consider agency waste (the dreaded inpatient revolving-door) and of course, the possible solutions. The aim of this material is to offer a straightforward explanation of concepts and functions while minimizing their complexity. Thus, I will painfully avoid breaking down theory into nested micro-subcomponents with multifaceted abstraction and archaic language to preserve clarity. Result: Useful treatment modalities.

Section One: Incentive

In today’s ever changing shift in health care, behavioral health care organizations are increasingly resistive to comprehensive treatment modalities. Sabin (2000) argues that we can on longer cling to the past era of an optimistic ‘no-limits’ mentality. If reasonable health care is to survive, limits must be imposed to contain costs and priorities set. The Nation’s managed care system we have today is “relatively unregulated, market-driven, largely for-profit.”

A 1996 study by Milliman & Robertson in cooperation with Open Minds solicited information from six managed health care organizations. The database of the instrument applied represents 13 percent, or 16.5 million lives covered by mental health in the Nation. Of this figure 46,199 were inpatient admissions for a mean stay of 8.7 days. In addition to the short-term inpatient results above, IMD placement of the long term severely mentally ill fell into the States ‘safety net’ of public social services. The Federal Government refuses to accept economical responsibility claiming to encourage the least restrictive setting for the patient and prevent endless treatment. This of course places a burden on the local agencies that has spawned a heightened public awareness in a period of cost-cutting strategies and elimination of services.

As the new millennium progresses, the managerial vision or lack of it will shape and delineate mental health tomorrow. Since we are a predominantly market-driven country, one criteria is certain, treatment effectiveness must be intrinsic and ever diligent if the provider is to survive.

Therapeutic Skills

Successful companies have learned long ago that investment of superior tooling is a presquete to maintain quality standards and prevent waste. Lack of tooling, poorly designed tooling or substandard tooling leads to failures. These failures cause a loss of resources and debt when resolving or repairing products built with inadequate tooling.

Incentive to invest and strengthen the staffs therapeutic tools (skills) are in direct parallel to prevent failures or downtime. Think of downtime as: patient failure manifested from staff resistance to employ tools or lack of tools, causing the patient to resist or be non-responsive. Downtime will cause a lag or delay in a strong therapeutic alliance aimed at resistive patients.

Section Two: Lenses For Observation

Effective inpatient treatment requires the knowledge and adaptation of adequate therapeutic tools. It is an axiom that a treater must identify the behavior and affect prior to arriving at a diagnosis. Once identified, the underlying psychodynamic complex that drives the symptoms or syndrome may be examined. Observing the patient with professional tools will lead to understanding the patient and decrease a sense of helplessness from the treater. Familiar use of observation tools helps the treater identify the patient’s weakness. Once identified, the treater can offer his specific ego strengths so they are available to the patient. This section will provide a review of observational applications to aid the therapeutic alliance.


Transference as identified by Freud is the patient’s impulse to target the treater with primitive drives established earlier in life that was ascribed to the original individual. Widely accepted today, transference are those feelings that belonged to significant others from previously formed relationships that are ‘transferred’ to the treater. Transference could have negative or positive components and both are seen as useful. By way of example, the treater may have similar physical characteristics and gestures of the patient’s admired schoolteacher that would distort patient’s perception from experiencing the treater in his true form.

Transference is considered the principle vehicle to bring the unconscious to consciousness where it may be examined and re-worked.

Transference Management

As mentioned earlier, positive and negative transference are useful in strengthening the therapeutic alliance. For expedient results, the use of transference will be the focus as a management tool rather than it’s interpretation as practiced in psychoanalysis. For example, the patient may relate to the treater as omnipresent, infallible and unfailing. These characterlogical traits transferred to the treater may be from the patient’s fantasy of the all good provider and parental figure wished for from childhood. These distorted notions can be used to direct and vacillate treatment compliance.

Negative transference is also useful but dealt with aggressively as the issues arise. For example, a treater abruptly ended a session on the unit with the patient when interrupted by a private message from staff. The session was terminated and the patient, now feeling abandoned began rejecting medication in transference of the rejecting caregiver. Again, from the supportive stance transference is to be managed and not interpreted. (You are rejecting me by rejecting your medication as your father rejected you). Alternatively, the treater should manage the negative transference by saying, “I’m sorry I had to leave our session so abruptly yesterday. I had an emergency on another unit that was life threatening.” Confronting the patient when appropriate, especially sensitive or paranoid patients will help block the deteration of the treater-patient alliance.

Objective Transference

It could be argued that some treaters present so obnoxious, curt, annoyed or burned-out that the patient responds objectively and not as a result of regressed inner disturbances. Put differently, the treaters bed-side-manner would activate the same internal mechanisms in the patient that are culturally imbued, and reality orientated with societal norms, and the patient’s affect to the treater is the same as the every one else. Essentially, the treater has a lack of personal regard for most, if not all his patients.


A 45 year-old woman with chronic depression and repeated hospitalizations, with a previous hospitalization 18 months ago, was being assessed by the weekend MD. Her impression of this MD was that he seemed curt and annoyed. He spoke quickly asking questions. His words ran together and the patient reluctantly had to ask the MD to repeat his questions. This annoyed him further. The patient felt his tone and lack of empathy prevented her from offering more information and she kept her answers short as she felt uncomfortable and hoped the assessment would end soon.

She dwelled on this interaction as it weakened the alliance. In a scheduled inpatient group meeting that evening she recounted her thoughts of this interview with the MD and made a brief comment. When asked by the vacillator how her day was she responded, I had a rough meeting with Dr. Michaels, perhaps we have a personality conflict. At the moment a different patient said, That’s a huge understatement and putting it politely. Then a third patient followed up with a response, the guy really needs to work on his bedside manner. He doesn’t come off well at all.

In this vignette the MD was perhaps unaware of his attitudes toward the patients. He seemed as though a machine, like a bulldozer running over a bunch of ants. In this case, the patients experience this MD with objective transference. Even though it wasn’t personal toward the patient, this MD was in a position to damage the genesis of the fragile therapeutic alliance.


Since Freud’s introduction of countertransference it has taken on multiple definitions. Over nearly a century professionals have argued and assigned uniquely different properties to explain the phenomena. Freud explained his initial awareness in 1910 as “We have become aware of the ‘counter-transference,’ which arises in [the physician] as a result of the patients influence on this unconscious feelings…” Countertransference in this representation would be articulated as the treater’s transference to the patient. This is referred to as the narrow sense.

In 1953 Countertransference takes on an additional property as outlined in Paula Heimann’s classic paper. Heimann expanded the concept as a useful instrument to provide insight into the patient’s unconscious. Freud however, believed countertransference would contaminate or hinder the blank or neutral reflection of the patient and would indicate that the analyst would need further psychoanalysis. In contrast, Heimann felt when appropriate countertransference should be used as the treater’s internal gage or barometer to measure reactions to the patient’s transference relatedness. Melanie Klein disagreed with the Heimann expansion as she felt the patient would be the target of blame for the treater’s reactions. Heimann’s perspective is regarded as the broad or totalistic view.

Today’s contemporary treaters (Gabbard, 2000) are moving in the direction of viewing the treater’s countertransference as transference from the patient colored with the treater’s own subjectivity. This is a jointly created countertransference. This colored subjectivity is understood by Epstin & Feiner as, “Countertransference reaction is therefore based on an emotional attitude which is due to neurotic remnants in the analyst, reactivated by the conflicts posed by the patient.” Scharff & Scharff (1992) expresses countertransference in the purest form: “The set of feelings and attitudes stirred up in the therapist form a model of what happens inside the people with whom the patient is in a relationship.” For Scharffs model to work as a useful measurement, the treater must be aware of his impending unresolved conflicts. From a scientific point of view, one must consider the result when subjectivity (patient’s transference) is measured with the subjectivity of the treater rather than a constant with established proprieties. This helps us acknowledge that for the treater to use this modern view of countertransference as a gage, it would be imperative to have a clear understanding of the psychodynamics that identify this dyad’s complexly.

The Transference-Countertransference Relationship

Countertransference Management

As Dubin reported, “Patients angry explosions do not usually come out of the blue; but rather, they are in response to subtle insults and unrecognized punitive reactions that develop out of the staff’s frustration, anxiety, or unconscious.”

Poor countertransference management could be viewed as countertransference activated from Freud’s narrow sense. This is because the treater’s reaction to the patient has more to do with the treater’s neurotic conflicts than the patient’s transference. For instance, a skilled treater should seek to establish a psychic space to observe ‘to whom does what’ during the transference-countertransference interaction. This psychic space would help provide objectivity when visited intermittently to keep countertransference reaction under control.

To serve as an illustration; A patient presented in such a way that the treater was unconsciously reminded of her brother who was troublesome, antisocial and caused a family split. This activated countertransference hate toward the patient and could have prevented the treater from seeing the patient as she truly was. In this case the treater had developed sufficient psychic space to monitor the impending reaction was able to arrest her countertransference. If the treater had poor countertransference management, the patient may have been the target for punitive measures such as withholding empathic support, safety intervention or verbal resentment. Any of these would regress the therapeutic alliance and serve to help concrete and confirm the patient’s predominate regressive defenses.

Now that I have discussed the dynamics of transference and countertransference, I will construct a foundation for their interplay and significance in the therapeutic alliance. To assist in elaboration and clarification of this somewhat ambiguous concept, it would be obligatory to review the related principles and components grounded in object relations. First, before I continue, the characteristics of ‘splitting’ must be examined.


Splitting is a primitive defensive mechanism originating from infancy. The infant relates to the mother as all good, or all bad. Until the infant is able to adequately incorporate that the mother who provides is also the mother that rejects (removing the breast) into an organization of a whole continuous person, the infant will not be able to tolerate ambivalence (conflict). The infant will seek to ward off its anxieties with an ‘either-or’ defense. After the infant’s cognation has sufficiently developed through repeated patterns of engagement with the healthy mother, the infant will began to have an appreciation of love and hate toward the same person, which leads to the beginnings of ambivalent toleration.

Individuals with regressed areas of psychological development are unable to tolerate ambivalence and tend to see the world in ‘black or white’ or ‘all or nothing’ terms. In object relations theory, part of the self is made up of components or pieces of psychic structures and these ‘pieces’ are referred to as objects. A patient who sees the world in black and white terms also has an internalized good object, bad object, good self and bad self. These ‘all good’ or ‘all bad’ objects are separated and unintegrated. For instance, the good object may be internalized as able to do altruistic deeds, while the hated self-object is to be disavowed (projecting anger) or destroyed (suicide). The following vignettes are few distinctive modes of unconscious thinking when the defense mechanism splitting is employed:


A celebrated distinguished artist read a published commentary from a peer that was highly critical of his recent painting. The artist became discouraged and slumped into a acute depression that was florid with polarized thinking. “I am a complete failure and hated among my all peers. Everything I attempt is never worthwhile. No one cares if I live or die.”

Notice above the polarization of: complete, all, everything, never, no one, and the ‘either-or’ of live or die, and hated or [loved].


A resident asked a hospitalized priest charged with sexual misconduct why he would have sex with a child. The priest responded that would be impossible because he took a sacred vow and was a celebrate priest. When the resident confronted the priest with recent positive results of a sexually transmitted disease, the priest exclaimed, “What do you expect? I’m only human.”

In this example, the priest had unintegrated objects of the good priest vs. the pedophile. Both objects were ‘split’ and regarded with a bland lack of concern or denial. The internalized good priest preserves and resists contamination from the bad object (pedophile), which would cause an internal conflict (ambivalence).

Another example of splitting would be a trade fundamental for most psychiatric nurses. A patient on a psychiatric unit may divide the treatment team into all good or all bad camps. A nurse with a relaxed style may be a better fit for the patient’s internalized good object than a no-nonsense nurse who is experienced as hated or evil. The patient is thus unable to view the nurses in ambivalent good and bad parts and they become either angels or devils.

Section Three: Active Technique

See illustration / chart

Projective Identification

This tripartite model is where the waters can get muddy. The confusion lies in exactly what denotes the difference between the transference-countertransference dyad and the projective identification model. Some may speculate they are essentially the same except that projective identification has a third lever, intojective identification. I hope these barriers that impede understanding will dematerialize as I proceed and identify each of the components and their uniquely different functions.

Lever One: Projective Identification

According to Scharff & Scharff, focused transference and projective identification are the same, except transference is conceptualized from an object relations standpoint. To help make sense of this and correlate the two, think of an object described as an internal piece of psychic structure from an unconscious earlier experience with a person and its accompanying affects (knee-jerk reaction). Scharff & Scharff confirms, “Not a memory, nor a representation, it is a part of the self’s being. As the term suggests, projective identification, projects. As we have identified in splitting, a patient has the good & bad object and the good & bad self. To better suit our purposes for simplification I will discuss the projection of the bad object into the treater, albeit any object can be projected. This projection can be seen as the patient projecting anger for my next illustration.

Remembering our example of the patients past schoolteacher in transference to the treater, and although the teacher was admired by the patient, there was an occasion that patient’s teacher gave the patient a low grade on an exam. The patient felt the grade was undeserving and harbored ill feelings toward the teacher perceiving a sense of rejection. Likewise, when a critical interpretation (you do this because…) is explained by the treater to the patient, the patient drudges up the repressed unconscious rejecting object and then projects anger into the therapist (teacher). As one treater said the to the patient,

“This is your anger, not mine. Do you realize you are projecting this anger onto me?” The patient responded, “Can you think of anything better to do with it?”

In essence the patient seeks to disavow the disturbing object by projecting it into the treater and then thereby attempting to control the treater by controlling the project object. Put another way, the patient projected the bad object into the treater and can now identify with the treater, hence, projective identification.

Example: An angry patient has an internalized object of her abusive father, then projects this object – anger, and now identifies with the anger father – giving her an element of control. As one child psychologist said, “I know when I am with an abused child, when I feel like abusing her myself.”

Lever Two: Projective Counteridentification.

Projective counteridentification is similar with today’s contemporary jointly created countertransference with an added property. Projective counteridentification not only awakens remnants of the repressed unresolved conflicts in the treater but the projected object (anger) is received with an various amounts of ‘pressure’ or unconscious ‘cohesion’ (the added property) from the projective patient. Epstin & Feiner explains: “The analyst’s reaction stems, for the most part, independently of his own conflicts and corresponds in a predominant or exclusive way to the intensity and quality of the patient’s projective identification.” To see this set in motion, observe the following:

A borderline patient said to the doctor out of the blue, You don’t like me, do you? I know you don’t.

Why do you say I don’t like you?

Because I know you don’t! That’s why! You never have liked me!

That’s not so

“Yes it is so, you hate me! You are a liar! You HATE ME!”

“I don’t appreciate being called a liar!!”

The patient then said as if triumphantly, “See, I was right. Your face is red, your veins are bulging out of the side of your neck. I knew it all along!”

As you have seen, these first two levers happened instantaneously, snap, like that. Once the treater unconsciously accepts the projected object, the patient has a sense of control deriving from identify with the projected object, anger in this case. When this dynamic is active, the treater feels as though not herself, rather as though an alien force (Gabbard) has taken her over. Her day-to-day consistent self is overwhelmed by the energized projected object amalgamated with derivatives of her repressed conflicts brought to the surface. Because the repressed conflicts are awakened in the treater, it stands to reason that some treaters will be a better fit for the projected object than another treater. This ‘fit’ is what is referred to as the countertransference hook in projective counteridentification. Note that the patient cannot project into a hollow shell.

Lever Three: Introjective Identification

This third lever, introjective identification is what I consider the most critical step of this model. It is here that the patient’s ability to relate to the world and the concept of self will be modified, a positive vehicle for effective treatment.

Recall the patient projected a highly energized object – anger. The treater provided a countertransference hook, and the projected anger now resides in the treater. Once accepted unconsciously by the treater, the object may then be contained and detoxified by the treater and then introjected by the patient. The patient then assimilates the modified object, which will modify the patient’s constitution of self. Below is a beautiful example of this technique.

An angry inpatient borderline female was consistently contemptuous with a resident. The problems began after this pleasant-natured resident introduced himself and the patient reacted to him with a lack of personal regard.

Are you a resident?

The resident reluctantly confirmed that he was.

Oh God! How did I get stuck with a resident!? Well, you better go and read your text books so you will know how to treat me, because I have borderline personality disorder.

Of course this interaction frazzled the young resident giving rise to difficult countertransference issues. Finally, one day he was pushed over the edge while interacting with the patient.

Oh, bye-the-way, said the patient, I hope for your sake you don’t go into your own practice when you leave here. I mean, look at the way you dress! You’ll NEVER be able to attract any clients! You dress horribly!

By this time the resident was ready to pull his hair out. It was as if an alien force had taken him over. This calm young man was now seemly possessed. Taking the problem under supervision, the resident exclaimed, “You are going to have to get someone else to work with her. I don’t know what else to do. I’ve had it with her!”

This is a paradigm of the first two levers in motion. The patient projected the object that was accepted by the treater. The patient can now identify with the treater that is now ‘possessed’ by the projected object. It is here the patient will attempt to control the treater who has been transformed into a sort of hologram or a representation of the patient’s abusive father. The third lever is about to take place after direction from the resident’s supervisor.

When the resident empathically approached again, he asked, It there anything that I can do that would be helpful to you? It seems every time I try to help you we are at odds with each other. It seems you are in pain and perhaps you could help give me some ideas how I can help you? Do you think we can try to work this out together?

[Helpful note from a resistive patient: Help me when I deserve it the least. Help me in the face of my rage. It is easy to help me when I am the well behaved, the good-natured patient, but anyone without skill can treat me well when I am this way. I need your skills, your help when I am at my worst so that I can understand and identify something better than myself. You may have to show me over and over again that I have value and that my rage will not destroy you, because I learn these things slowly and my old ways are everywhere I look, they are in my thoughts and feelings. These thoughts and feelings feel like they will destroy me so I put them in you, because I hope you are stronger then I am. So please don’t be angry with me for putting these terrible feelings into you, and I hope that maybe you can do something with them because I don’t know how or I need you to show me how with your actions so that I can identify with you. I try to understand your words but sometimes your words can’t reach me because my emotions are asleep when you are talking but when my emotions are awake and disturb me, they are working in partnership with you, even if just a little. So thank you for accepting and holding these terrible parts of myself and then letting me take them back after you have made them softer, easier to tolerate. Thank you for helping me when I least deserve it.]

Bring to mind how the infant interrelates with the mother in repeated patterns to aid the infant in role-identification of the healthy mother. In much the same way, it would be necessary for introjective identification to be consistent to offer a sense of stability that is grounded in reality that would introduce a new and better world. The treater that takes on the attitude of viewing a specific problem as a opportunity, rather then a countertransference irritation is likely to advance treatment much quicker through the progressive steps.

Below is a concrete table of what this highly abstract concept may look like as a reference. In action it would be impossible to see this model in a liner modality. Each lever is feeding off the other, overlapped and interrelated. This table may help clarify and define this model in simplistic terms, a nearly impossible task.

Countertransference Hook = unconscious, unresolved impulses from the treater.

Projective Identification = Transference in object relations terms.

Projective Counteridentification = (Projective Identification + Hook) + Energy from Patient

Introjective Identification = Patient self + modified assimilated object from the treater.

See illustration / chart

Building Object Constancy to Facilitate Role-Identification

Object Constancy

Object constancy is a term coined by object relations theorist Margaret Mahler and is the next developmental phase after splitting. Usually resistive patients have not crossed this developmental threshold since splitting is still prevalent and the patient is not able to tolerate ambivalence. Recall earlier that we discussed the primitive defense mechanism, splitting – the ‘either-or’ and ‘black and white’ thinking. For example, this black and white thinking may translate into the patient’s mode of perception of the treater. Either the treater is on the unit or he is not. If the treater is off the unit the patient may unconsciously feel abandoned and this may give rise to the patient’s disturbed pathology (impulsiveness & unregulated affect) that was temporary ‘split-off’ and held in abeyance when the treater was on the unit. When the treater is constant, returning for sessions in a structured environment, the patient begins to appreciate a sense that the treater will not abandon her. The patient over time will begin to formulate an image of the treater in the absence of the treater’s physical presence. This of course is only one small aspect of helping the patient develop object constancy.

Other areas that will vacillate this developmental phase are addressing the physical and emotional characteristics of the milieu. The physical properties include the safety of the unit and time structure for therapeutic activities. Equally important, if not more so with some patients is the emotional construct. A forum should be provided in which the patient is able to vent, converse new therapeutic ideas, receive appropriate validation and as mentioned earlier, confront negative transference. These physical and emotional components along with their consistency and reliability will help develop object constancy. Once the beginnings of object constancy are laid down with a strong therapeutic alliance, the patient will be more receptive to role-identification with the treater or treatment team.


The emphasis here is placed on the good enough treater rather then the perfect role model. From a supportive stance the treater can share experiences so the patient can identify and relate to the treater’s success and failures, along with his good days and bad days. Through repetition the patient can see how the treater (or group) handles the vicissitudes of anger, irritations and confusion and thus give some measure as how the patient sees herself. This measure may serve as an indicator to mark areas for improvement or for validation of adequate conflict handling giving rise to the patient’s self-esteem. It would not be realistic, nor therapeutic for the treater to try and present himself as perfect. More advantageous and in line with reality, the treater should present as a mature and decent human being, genuinely interested in the patient’s improvement. In time the patient may identify and co-op the treater’s conflict resolution skills through role-identification as a template to form her own new coping and resolution strategies.

Hold and Contain the Patient.

For this explanation, holding and containment are essentially the same. Wilfred Bion used this model for his contribution to object relations of the mother-infant dyad. He felt the good enough mother though reverie with her infant, would accept (contain) the infant’s overwhelming anxieties. In essence, the mother would contain and detoxify the projected badness and give it back in a less harmful form. As a container, the mother would also accept appreciation from her infant and mirror a positive durable relationship forming the infants personality. Bion saw the process as containment by the mother. Perhaps one could think of the mother as a filter that filters out unwanted contamination while adding healthy ingredients before returning the product.

To hold and contain the patient it would be required to identify the patient’s feelings that lead to maladaptive behaviors and events. Gunderson (2000) stated, “The primary therapeutic techniques that make a relational alliance possible involve showing interest, conveying feasible expectations, showing resilience in the face of opposition, and above all, as emphasized by Adler (1985) and demonstrated by Stevenson and Meares (1992), deploying empathy and validation.


An 18-year-old girl recently unemployed due to her first hospitalization was hospitalized again one month later after calling a crisis line for suicidal ideation. Her childhood is marked by abandonment and rejection. Her father deserted the family at birth and her mother was a chronic drug user who intermittently put her through a string of foster homes. She reports sexual abuse from one foster home and has discussed early memories of her mother taking her to satanic cults. Has history of self-mutilation. Currently, she is living with three families in a 3-bedroom house and sleeps on the couch. She reports household members are in constant conflict and turmoil. Axis one depression, rule out borderline personality disorder.

During this hospitalization one of her peers acting in her support worked out an alliance with her. Her peer encouraged her to seek help if she became overwhelmed and would begin to act out with self-harm. Later, reacting to her peer’s support, she revealed skin abrasions from scratching herself. With her permission, the peer notified staff requesting a forum for a more appropriate release of her disturbed feelings. Later that afternoon she entered the room that she shared with her peer. Her mood was depressed with flat affect. When the peer noticed her bandaged arm, the peer validated her efforts to seek help and encouraged her to continue to find more appropriate coping strategies to resolve her inner conflicts.

During this interaction between peers a staffer entered the room and stated the following, “Nancy, if you are going to have to be on a one-to-one, then you are not going to just lay there in bed. I’ve got things to do and I’ve got to be on the unit. I’m not just going to sit here and watch you. You are going to have to get up and come with me. I’m not just going to sit here on my butt…” Nancy quietly kept to herself and followed the staffer.

Even though the patient was able to interact and receive positive peer support, staff had confirmed her internalized belief of the rejected self. Based on the patient’s childhood, her internal objects consisted of abandonment; rejection and a sense of getting in the way by being passed off though foster homes. In this instance staff had the opportunity to modify the patient’s internal objects with a new model. But because the staff had impulsed into countertransference reaction, she failed the patient. In this case, a new positive modified object was not available to the patient, but instead, the staff’s tone, attitude and needs concreted the patient’s maladaptive beliefs of the rejecting caregiver.

Mish (2000) states the concepts of holding and containing beautifully, “The concepts of holding and containing refer to a therapist’s attempts to be a good parent by providing empathy, understanding, and verbal soothing; modulating affect; restricting self-defeating impulsivity or acting out; and generally setting limits appropriate limits.” Had the staffer in the vignette above presented her needs in a different format, both objectives could have been met. “Nancy (the patient), I understand you have some troubling thoughts right now [validation]. Because you are having trouble staying in control, I need to watch you [intervention]. Your safety is important to us [empathic, non-rejecting modified object]. Because we are a little short on staff, I need you to come with me so you can be safe [structure].”

The second response to this example would have modified the patient’s beliefs, provided therapeutic intervention, strengthened the therapeutic alliance, served as an extended ‘observing ego’ and met the required impending duties of the staff. The end result: effective treatment.

This next vignette is a paradigm for ineffective treatment when steaming from staff’s attitude rather then the use of effective therapeutic tools.


A 45 year-old woman with chronic depression was admitted after an automobile accident. Her previous hospitalization was 18 months ago for suicidal ideation. This was her third night on the unit with no prior problems other then her impression of the MD assessment. While in her room after lights-out, she isolated herself in the corner and cried as she reflected on the MD assessment and flashbacks from prior treatment in a county hospital 2 years ago. At this point the staff entered the room and asked,

“Ann, where are you?”

When staff noticed the patient crying in the corner, staff responded with irritation, “Ann, I don’t have time for this. Don’t be acting out at the end of my shift.”

“Acting out at the end of your shift? This is about your needs not mine. Why are you here? Get away from me and leave me alone.”

“Ann, I didn’t say that.”

“Yes you did say that, I just now heard you said that and you meant it. I heard it in your voice. Go, leave me alone, please.”

“Okay Ann, I did say it, but I didn’t mean it.”

“You say that now, but I know you meant every word of it. I saw how you treated Nancy today when she was so sad. You don’t care, why are you here? It’s just about you and your needs. Just go away.”

At this time staff had brought her initial irritation under control. She looked calm as she looked into the patient’s eyes. However, the patient was suspicious from her verbal attack when entering the room and her earlier treatment of her roommate, Nancy. The patient was resistant and in this instance, staff had failed the patient due to lack of observation and use of the available therapeutic tools. This interaction caused a lag or a stall in the development of the alliance and unfortunately these types of incidents are not isolated. In a progressive market-driven economy such failures are costly and the survival of this agency may eventually have to yield to a competitive agency that is more effective and competent.

Understanding the Ego

What are the Id, Ego and Superego?

Freud theorized that the mind works from a system governed by an executive agency, the ego. The other two agencies are the id (infant) and the superego (parent). Some researchers claim that 50% of the personality’s temperament forms from the biological givens. For our purposes 50% of the ego is predefined from a person’s hereditary genetic lines while the environment forms the remaining 50%. Our discussion will revolve around the environments that influence the ego system.

The Id

The id’s sole function is to immediately discharge excitation of anxiety or tension from any source of internal or external stimulation. Freud hypnotized that the id is similar to a biological organism that activates a reflex apparatus to discharge excitation to a quiescent state. Think of frustrations, discomforts and impulsiveness as originating from the id. The id remains infantile in character throughout life with traits that are demanding, irrational, asocial, selfish and pleasure-loving. The id is helpless to rid itself of it’s excitations. Out of the id comes the primary process of psych energy and instincts that are closer to the body process then to the external world. The id lacks organization compared to the ego and superego, and does not change with time. More interesting, the id cannot be modified be experience since it has no contact with the external world. The id therefore develops and co-ops the ego to perform its functions. In order to communicate with the ego, the id must develop a communication link. The id does this through memory traces of perception and memory images. Perception of an object is marked when first experienced through the senses and then a memory image takes form perception. For example, when the infant cried and the mother produced her breast, a memory trace of the objective object was formed as a memory image. This brings us to what is called the primary process. Later, when the infant was hungry (tension), a memory image of the objective object, the breast, was recalled from a memory trace to reduce tension (wish-fulfillment). In other words, the primary process, a function of the id, brings to mind its needs through memory traces. The id is governed by the Pleasure Principle.

Pleasure Principle = Aim to rid and reduce tension to a low level. Tension may be experienced as pain or discomfort. Relief is experienced as pleasure of satisfaction. In succinct, the id avoids pain and seeks pleasure.

Wish-fulfillment = The id seeks to discharge its tension by the formation of an image of the tension reducing object though fantasy or dreams. An example here would be a man stranded in the desert with great thirst and then imagines a water hole that is in reality only dust.

This brings us to two issues for any id process. To discharge tension thought Wish-fulfillment or succumb to the influence of the ego which bounds the energy of the id temperately until an appropriate release can be discovered.

The Ego

The ego is the decision maker, making transactions between the self and cultural reality, controlling and governing the id and the superego while maintaining socially accepted behavior with the external world.

The function of the ego operates through thinking and reasoning which leads to the secondary process. The id generates a memory image of an object, the primary process and then the ego thinks of a plan to retrieve the object, the secondary process. To satisfy the id the ego must negotiate between the psychosocial demands of reality and the demands of the id, and then comprise. It is this compromise which society judges weather or not a person is normally adjusted. For example, the id that demands the immediate release of urine must subject itself to the regulation of the ego which delays the release until the person has arrived at a socially accepted area to discharge the substance. Transactions between the self and reality are controlled by the ego, the executive branch of the personality that controls and governs the id and the superego while maintaining a compromise with the external world. Disharmony and maladjustment results when the ego relinquishes too much power to the id, superego or to the external world. The ego is governed by the Reality Principle.

Reality Principle = Aim to postpone to discharge of energy until actual object that will satisfy the need has been discovered or produced. In other words, the ego tolerates tension until discharged by appropriate form of behavior. The Reality Principle only suspends the Pleasure Principle in the interest of reality. When the id is governed by the Reality Principle, a by law of the ego, the id’s energy is said to be bound until eventual discharge, while holding the id’s Pleasure Principle in abeyance.

To recap, the Secondary Process of the Ego is governed by the Reality Principle. The Primary Process belongs to the id that pictures a need for an object through memory traces. Then the Secondary Process of the Ego sets about getting the object or brings it into existence through cognition and rules of the Reality Principle. The ego is basically an executive agency of the system dedicated to thinking and problem solving. The infant ego will continue to grow though the Reality Principle by reality testing, meaning setting a plan into action and judging what works and what does not work. The psychological growth stimulated from reality testing improves perception, thinking, memory and action. As the psychological function of the ego develops it can appreciate a perceptual system that perceives the external world with greater precision and accuracy. This growth will vacillate more effective plans when scanning the environment though experienced filters to enable quicker solutions.


The superego is the ideal agency of the mind. It is the moral or judicial branch of the personality, the inner critic. It seeks unrealistic perfection rather then pleasure or reality. The superego develops its moral code out the ego though assimilation of discipline from parents, schoolteachers, religious agents and authority figures. Consequences from discipline give rise to the formation and incorporation for what is bad, good, moral, immoral, sinful and virtuous. Through repeated assimilations from authority, the superego forms a subjective impression that develops the inner critic to keep the personality inline with the wishes of authority figures. Its main rule of function is to secure their pleasure and avoid their displeasure. I should mention here that the superego is divided up into two sub-systems;

  1. The ego-ideal is formed out of rewards based on what the child perceives from parents to be morally good. Good = Rewards. Some examples of physical rewards would be toys and food. Psychological rewards would be cuddling, love, affection, and approved expressions.
  2. The conscience is formed out of punishments and discipline on what the child perceives from the parents to be morally bad. Bad = Punishments. Some examples of physical punishments are corporal punishments, and isolation. Psychological rewards would be scorn or disapproving facial expressions.

The ego-ideal and the conscience are at opposite poles of the continuum and both exert demands on the ego. The superego formed out of the child’s wishes for love. Not being loved means an unloving mother who creates painful states of tension by withholding food, emotional soothing and other vital life necessities. For the superego to be effective it must exercise the same power as the parents. Like the parents and authority figures, the superego implements rules and regulations by rewards and punishments.

The Id, Ego and Superego as an Operative System

The formation of the superego reflects how a person reacts to authority figures, since it is a template of earlier experiences with parents. The superego holds the traditional values and the ideals of cultural and society handed down from primary caretakers that influenced the child. The superego serves the function to bear pressure on the ego to maintain order and moral character in accordance to societal norms. The superego is not able to comprise but demands perfection and places restraints on the table of the ego.

The id however is not concerned with perfection but to rid itself imminently of anxiety, apprehension and discomfort. In the wake of id would be lawlessness, immoral sex acts, unregulated emotions and affect, fulminate explosions of impulsiveness, lack of personal regard toward others and any impulse that would serve to rid itself of tension.

Caught between these two relentless forces of the id and superego is the ego that acts as a referee while consulting the objective world, reality. It is for this reason that the ego must be able to tolerate ambivalence and conflict from all three opposing forces. It could be said that the id aligns itself with the biological instinctual demands of the self while the superego aligns itself with moral code of societal pressure to preserve harmony in the external world. The ego seeks to be a ‘good-enough’ executive agent by repeating tests to make comprise for the needs of each force, the id, superego and external world. This is called reality testing. The goal of the ego system is to think more effectively, and effective thinking will arrive at the truth more quickly. Reality = Truth. It is here, in the ego, that the personality draws on ego-strength to combat stress from the opposing forces.

It should be noted that the ego forms out of the id, and the superego forms out of the ego. These three agencies make up part of the personality and are in themselves without sharp boundaries. We use these terms to describe their function in a linier fashion to help the reader understand the conceptualization and flow of this psychodynamic.

Understanding Defense Mechanisms

As the newly formed ego takes shape out of the id, it develops defense mechanisms to rid itself of conflict or anxiety. Early primitive defenses form out of instinctual reaction since abstract thinking is not available and infantile cognition functions only from concrete images. As the infant matures, he develops age appropriate defenses that are more adaptive and suitable for his environment. For example, a person is regressed developmentally when he predominately operates from primitive defenses that no longer serve him. His defenses are maladaptive if they cause interpersonal problems in relationships or cause chronic friction among peers in the work place or in social circles.

Lets take a look at our previous defense, splitting, and see how it may affect more mature relationships. Recall that splitting is a primitive defense used in the earliest stages of life to ward off the infant’s anxieties. Since the infant cannot conceptualize that the person who loves him can also be disapproving, the infant reacts to his affect. If the infant is in rage, his hates mother since he does not have the cognition or developmental progress for reflective thought to resolve his internal conflict that he also loves his mother at the same time and that she is a whole continuous person. Such thought would cause unwanted ambivalence increasing his anxieties to higher levels.

Now lets examine the effect splitting would have in an intimate adult relationship. A woman using this defense would view her target on a pedestal or with utter contempt. Accompanying her distorted view of the object (her partner) are the inappropriate affects. For example, if she becomes irritated, it may progress into rage since the defended person (her) cannot reflect on the goodness of her target. The target now becomes the devil and can’t do anything right, and along with this distorted view is rage, the affect. To the target, it appears she is moody with highs and lows to match her distorted views. If she were able to master the ability to view her target as both good and bad, her mood would have been more appropriate given situation. As you can see, the personality using splitting as a defense can cause havoc when engaging with others.

It might be helpful to think of defense mechanisms as coping strategies. Defenses are adaptive or maladaptive. Maladaptive defenses such as splitting, denial, projection identification and psychotic transferences are to be discouraged while encouraging adaptive defenses of humor, intellectualization, altruism and rationalization. Think of a defense as an aid to help the defended adjust to existing anxiety and tension. Certainly, treatment goals include age appropriate functioning but first the patient must be receptive in the frame of a strong therapeutic alliance.


I find the title of this section fitting since I have received letters from frustrated treaters claiming all treatment options have been exhausted, and they are now grasping for straws though the Internet. It is simply not enough to understand that a child went though abuse since this information will not provide clues of the patient’s intrapsychic roadmaps. Treaters have tried enormous empathic holding in carefully framed environments with heroic support and than it is a mystery to the treater that the patient does not improve and in some cases appears to become more abusive. The question is why? This section will center on this puzzlement.

Recall that interjects are received and assimilated by the patient in the projective identification tripartite. Now I will focus on earlier developmental interjects the patient experienced as an abused child that are termed pathogenic interjects. Meissner (1976, 1980) viewed these interjects as introjective constellations with polarized caps. One pole represents the victim’s characteristics (child) and at the opposite pole, the victimizer characteristics (parent). When the child takes in the introjected dyad, the victim resides in her ego and the victimizer resides in her superego (conscience). Recall the conscience portion of the superego is formed out of punishment and belongs to the child’s inner critic of a lawful, moral sociality. To an observer it appears this is a paraxial complex, meaning the bad object (abusive parent) resides in the superego, the system that strives for perfection. Since the child internalizes the bad object in a realm of perfection (superego), she cannot let go and separate, but rather remains in some type of symbiosis with the bad object. Recall during the subphases of separation-individualization, a child gains mastery of her new budding world. Through mirroring and taking back, though the positive introjects she experiences world as relatively safe, through shadowing and darting away she begins to separate, as she needs her parent less and less. The child’s internalized good parent that performed from good intent allowed the child to separate into an individual.

Through repetition the child interacts with the abusive parent. The child internalizes a negative interactional dynamic that shapes her mental structures of relating. The bad object is taken in, assimilated and becomes part of the child’s internal world. Even though the bad object resides in the superego, it remains elusive, never mastered as the negative dynamic is played out over and over again. This dynamic becomes a template for distorting when taking in new experiences. Stark (1994) reaffirms the patient’s resistance to change, “Intrinsic to the patient’s relentless pursuit to infantile gratification is a wish to be stopped. Intrinsic to the patient’s compulsive reenactments of his internal dramas is also a wish to be contained.”

So what would take the place of the patient’s bad object if it vanished from her internal world of object relations? Emptiness, a black hole. The patient’s primitive defensive mechanisms are familiar and compulsive. Her internal world is reenacted in the here-and-now from her unconscious in an attempt to grant her infantile wishes for a different outcome. With compulsiveness, she keeps everything as it is and resistant to change. Through transference she co-op’s treaters to play out the past with her compulsive drives, that which is known, even if it is pathological. This phenomena lies at the heart of resistant patients.

Building Ego Strength

I have thus far explained the dynamics of the ego and it’s defense mechanisms. I have described their effect on the personality and the external world this matrix relates to. I titled this section building ego strength since I will address psychoeducational treatment in skills training, and the modification of a closed-system of introjects, or what I can refer to as the pathogenetics to change structure.

Structure Modification Vs Dialectical Behavioral Treatment

Modifying the patient’s internal structure has several advantages, the maximum of which mitigates the genesis of the deep buried pain and introduces a new modified world for the patient. To help put this into perspective, think of a patient’s source of pain deriving from earlier structures developed from experiencing sexual, verbal or physical abuse. These earlier structures shaped from abuse continue to unconsciously play-out through obsessive compulsiveness as a maladaptive defense hoping for a better ending. Since these earlier structures are a closed-system and only apparently semi-available to a trained professional, the patient’s repeated defenses are doomed to failure. That is until now, but first we will review a fairly new established complex theory before exploring this concept of exciting structure modification further.

Positioned at the opposite end of the structured spectrum is Linehan’s empirically successful Dialectical Behavioral Treatment for Borderline Personality Disorder (DBT). Linehan’s concept is Zen spirituality combined with western psychological theory. The concept is inviting since the emphasis is to accept the patient at her current level while introducing change. This becomes a mutual commitment that seems almost a paradox, but is defined as Dialectical because when two opposites exist to create the synthesis, a process of change takes place. Yet this dialectical change takes place as micro-formations, once one change is formed at each end, reality has evolved altering the properties, and again another synthesis is required, but with each synthesis less is geometrically required in the advancement toward the final goal. In other words, we accept you as you are as long as you commit to dialectical change.

Linehan explains that DBT is useful to modulate affect and control emotional dysregulation. The DBT model provides once weekly group ‘skills’ meetings and once weekly individual therapy sessions. The weekly skills groups are divided up into four 8-week skills training modules, which could be taken twice each over the year-required period. The target is to replace maladaptive, ineffective behavior with trained skilled responses.

Weekly Skills Group

Weekly Therapy Session

1.      Core mindfulness skills

2.      Interpersonal effectiveness skills

3.      Emotional regulations skills

4.      Distress tolerance skills, respectfully

1.      Suicidal behaviors

2.      Therapy-Interfering behaviors

3.      Behaviors that interfere with the quality of life

4.      Behavioral skill acquisition

5.      Posttraumatic stress behaviors

6.      Self-respect behaviors


To Linehan’s credit, she makes it absolutely clear the consequences concerning the invalidating environment toward the child. This is important because an invalidated child secures the child’s emotional reaction to her interpersonal world, or lack of it. See this example:

Child: ”Mom, I’m thirsty”

Mom: ”No, you just had a drink of water, you are not thirsty.”

Adult Version –

Patient: ”I’m hurting inside and I don’t know what to do”

Therapist: “I don’t know why you are hurting so much, I just went over my time limit with you for 30 minutes.”

The patient now reacts with emotional sensitivity and as the evening approaches her emotions become intense and she has patterns of perceiving herself as invalidated. She escalates her behavior toward suicidal ideation in frantic attempts for validation, which are now confused and uncontrolled.

As Linehan echoes throughout her work, a child that grows up in an invalidating environment will have poor reality testing skills as to what works and what does not work. (Linehan) “The invalidating environment contributes to emotions dysregulation by failing to teach the child to label and modulate arousal, to tolerate distress, or to trust her own emotional responses as valid interpretations of events.” Also, linked to poor reality testing is a confused identity of self, since a consistent validated mirror or feedback of self was unavailable. On moment the child is bright like her mother and the next instant, stupid, dirty and ugly like her drunken father, who in objective reality is not even a shadow of this biting description.

As you can see from this material, it generates incentive to accept and validate a patient’s current position when entering the DBT program, to break the invalidating cycle, and second, to apply the skills training modules beginning with Core Mindfulness to address emotional dysregulation and modulate affect and other therapy interfering behaviors. DBT also stress cheerleading, coaching, problem solving and homework though handouts. Below is an example of Mindfulness Handout #1, one of DBT’s capital declarations.

DBT illustrates three states of the mind.

  1. The Reasonable Mind (This is the logical part of the mind that takes cakes care of the day-to-day tasks)
  2. The Emotional Mind (This part of the mind bases it decisions on reactions rather then response, or in other words decisions from feelings of the ‘heart’)
  3. The Wise Mind (This part of the mind is a combination of the Reasonable Mind and the Emotional Mind, able to take appropriate actions based on good insight and good judgment)

When analyzing DBT as a treatment program and its functions to create self-regulatory repertoires to tolerate stress, impulsiveness, modulate affect; regulate emotional arousal and cognitive skills management to act as an internal gage, and all of its related functions, the operator of this system must be constantly alert and aware of impending movements of measurements, comparing, looking for signals, guidelines, sign-posts and warnings. This patient must be as the operator of a lighthouse, keeping the light burning in the night least the ships crash against the hidden rocks in the harbor. Measuring, monitoring and attempting to self-validate through weekly sessions. At a glance it seems a daunting, relentless task that would consume vast amounts of emotional energy. Through cogitation and skills training, it appears to be a single source to control pain. To quote Linehan (1993), “The distress tolerance module assumes that even though there may be a lot of pain, it can be tolerated, and life can be accepted and lived in spite of pain.” In our next section, I hope to illustrate another possibility, structure modification reducing pain without the consuming energy of cognitive measuring and monitoring.

Addressing Structure Modification – A Closed System

As we have coved earlier, projective identification and its three levers work together to modify the patient’s interpersonal world. Wallersten (1989) concluded that both supportive and interpretive interventions are often mixed together, and both can lead to structural change, that is, improvement in the basic underlying personality structure.” Yet, Gabbard (2000) found that “..Interpretations were high-risk, high-gain..” In other words, unless undergoing long-term psychoanalysis, interpretations by a therapist of early transferences through exploration could hinder progress. So in this case, the third lever, introjective identification is our immediate access to what would otherwise be a closed system.

Let’s review introjective identification briefly through the writings of a different author, Martha Stark (1994) who states it this lever beautifully, “Structural change involves the modification of existent pathological structure and is accomplished by way of working through negative transference [or assimilation of positive introjects from the treater]. In other words, if something good is missing inside, then the goal is to add it. Alternatively, if something bad is already there inside, then the goal is to change it.”

This is where disappointment seems to set-in for most inpatient mental health workers. Constantly, they are exasperated, looking for change. “I am the treatment team leader. We have tried everything, and nothing works. I have been assigned to look for other avenues…” But the fundamental key is not change but modification, to ameliorate, to grow better, to improve. Often when I ask a mental health worker for the definition of therapeutic, I usually get a lengthy response. In essence, therapeutic simply means, “to grow better.” That’s it. If through positive introjects, accepted and assimilated by the patient, then her closed system of personality structures have been modified, and the treater has in effect been therapeutic.


This is a case of a 45-year-old female hospitalized for acute suicidal ideation and attempt by wrist slashing. She was progressively becoming detached and withdrawing due to her belief that she was untreatable from many prior hospitalizations. Supported by her caseworker and friends to be honest about her beliefs, she expressed her wish to die rather then be gamy to escape the court.

The night before her court appearance, her friends came by to wish her well with sad affect. She felt crestfallen when they departed that evening. Filled with self-loathing for putting her friends though such misery, she became tormented with semi-psychosis as she flung her fists into her head. She claimed she hated herself and the blows could not come hard or quick enough. The staff prevented her from self-harm and held her arms. Unusual, since this patient reported that usually staff immediately reacted using restraints.

The patient’s one-to-one took action and called for assistance. The patient failed to respond to staff instruction or intervention. In this instance, the patient was now using the primitive defensive mechanism, projective identification. She was projecting her bad-self. [Her hated, self-loathed object] Staff on the other hand, had wonderful countertransference management, and in this case, the countertransference hook needed to create the ‘fit’ for projective counteridentification was almost non-existent. The patient was attempting to control the staff by unconsciously projecting the bad-self, then identifying with the bad-self in the staff, and then attempting to control the bad-self, in effect hoping to be punished by staff by some punitive measure of restraints or withholding of empathic nurturing. Now we will examine the third lever, introjective identification.


Staff continued to restrain the patient until she seemed under control. In intervals her intrapsychic stimuli aroused and the patient began striking her face, screaming she did not deserve comfort, and should be hated for putting her friends and family through this. Staff maintained a calm affect with firm, non-punitive restraint. Brad, a staffer intermittently interjected in soft tones,

“Ann, when you are ready, let me know, I would like to say something.”

“Not now Brad, I can’t think. I need quiet, I need to focus.”

“Ann, are you ready now?”

“Yes, Brad, I am ready now.”

“Ann, you are a beautiful child of God.”

Brad repeated this phrase over and over, until Ann got it. Like the line in the movie, “Good Will Hunting” ‘It wasn’t your fault.’ Brad knew she needed spiritual substance from earlier conversations.

Brad and staff allowed the patient that time. Staff used the third lever, introjective identification, detoxified and contained the bad-self, then introjected the modified bad-self object that the patient accepted and assimilated. In this instance the patient’s closed system was modified in structural personality growth. Because her closed system had become hot, it could be reworked more effectively. Martha Stark (1994) writes, “When the patient delivers [her] pathology into the transference by way of projection [identification], we have a recapitulation in the here and now of the negative interactional dynamic characterizing the early-on traumatic failure situation between parent [therapist] and child [patient].”

Summery of Structure Modification Vs Dialectical Behavioral Treatment

Dialectical Behavioral Treatment (DBT), a cognitive behavior model we have a one-person theory of therapeutic action, the therapist, in order to correct the patient’s distortion, offers validation and directs the patient’s attention cognitively, directing her to observe her internal process and the fact of her unconscious repetitions, and emotion dysregulation.

Structure Modification (introjective identification)…. we have a two-person theory of therapeutic action, (Martha Stark) a corrective experience is thought to be what ultimately heals.

Both theories are seen as useful and have their proposes and each are positioned at opposite ends of the spectrum. To help illustrate this point I find it helpful to use the following analogy:


Considering this analogy, one clinical psychologist at the Adventist Portland Medical Center remarked, “If I had my choice, I would rather cut the fire then live with the pain.” Which makes perfect sense. But when entering into a burning kitchen, the operator would cut the flame and release the steam simultaneously. While grief does have its place in the healing process, certainly whenever possible the patient’s pain should be mitigated through creative empathic methods and the treatment team must be sensitive to opportunities to rework, and add the missing links to what would otherwise be a closed system of the patient’s personality structure.

Commitment to Excellence.

Considering the enormous detailed work of multidisciplinary treatment notes, doctors orders, progress notes, head counts, medication records and the treatment team’s intervention strategies, staff should take great care to be aware of their impending countertransference. Countertransference reaction can disrupt progress leading to resistive and non-responsive patients that would risk expensive work. On this basis, professional staff working with patients should be committed to self-exanimation.

Follow up letter from a helping professional

January 12, 2002

Hello Kathi,

I found your response extremely useful. As I said in my original letter, I'd found a great deal of information regarding diagnosis and the characteristics of BPD but very little regarding treatment. Following your response, I was able to put a pack together to distribute to my team and then use this as a base line when we came to care-planning our client. This helped in a number of ways.

Possibly the most significant impact or your work was that it helped my team to understand that it was our client's condition that was making her so difficult to be with at times - and not her.

As professional as my team are, they were finding themselves drawn into petty and destructive arguments, responding negatively to personal insults and generally finding our client difficult to like. This was despite the fact that she was clearly reaching out to them for help and desperately confused by her mixed emotions.

After I introduced your work to them and the BPD pack that I'd put together, the heavy atmosphere in the unit just seemed to lift. The team were able to objectify the condition and this stopped them taking my client's behavior and attitude towards them personally.

The work that had been exhausting and mentally draining before became understandable and stimulating now because we had something with a name, recognizable criteria and also strategies for dealing with it.

The impact for our client was immediate. Because the team felt more confident they responded more positively towards her. Because my client felt less rejected and more accepted, her confidence grew and she was able to develop more positive relationships with each of her team.

This young woman is sixteen next week and we're throwing a surprise party for her. Many of the staff that have worked with her across the years will be there and this is because they have a genuine affection for her.

Prior to her diagnosis we were looking at long term care in a therapeutic setting for this client. Now, because of the work we've been able to do with her, we're moving her towards independence.

Finally, I have been able to pass on the pack I put together, including your response, to other team leaders who have begun working with BPD young people. So, your work has impacted across our organization and on the lives of a number of young people.

Thanks once again for all that you do.



Judith Teich: Characteristics of Managed Behavioral Health Care Organizations in 1996 p.1422-1427 / Psychiatric Service – Nov 2000

Edited by Gabbard (1999): Countertransference Issues in Psychiatric Treatment / Review of Psychiatry Volume 18 / APA

Edited by Gunderson & Gabbard (2000): Psychotherapy for Personality Disorders / Review of Psychiatry Volume 19 / APA

Martha Stark (1994) Working With Resistance

Joel Paris (1994) Borderline Personality Disorder / A Multidimensional Approach

Perry & Bond (2000) p, 22

Applegate & Bonovitz (1995) p, 54

Misch (Fall-2000) p, 178 / The Journal Of Psychotherapy Practice and Research

Scharff & Scharff (1992) The Primer of Object Relations Therapy p, 53

Linehan (1993) Cognitive-Behavioral Treatment of Borderline Personality Disorder

Linehan (1993) Skills Training Manual for Treating Borderline Personality Disorder