EBSCOhost Full Display Result 20  [Go To Full Text] [Tips]Title: Developmental formulation and psychotherapy of borderline adolescents.Subject(s): BORDERLINE personality disorder in adolescence -- Treatment -- United States; PSYCHOTHERAPY -- United StatesSource: American Journal of Psychotherapy, Winter94, Vol. 48 Issue 1, p5, 25p, 2 chartsAuthor(s): Beresin, Eugene V.Abstract: Describes the process of arriving at a developmental formulation and psychotherapeutic technique for the borderline adolescent. Discussion of theoretical models of etiology and treatment; Choice of conflicting models; Description of the potential risks and benefits of altering the therapeutic models.AN: 9410250984ISSN: 0002-9564Note: This title is not held locallyFull Text Word Count: 9981Database: Academic Search Premier Print: Click here to mark for print.View Item: Full Page Image XML Full Text  [Go To Citation]

 


Select Language
inglés/espaÅ„ol
anglais/français
Englisch/Deutsch




 


Section: SPECIAL SECTION: Adolescent Pyschotherapy[*] DEVELOPMENTAL FORMULATION AND PSYCHOTHERAPY OF BORDERLINE ADOLESCENTS The author describes the process of arriving at a developmental formulation and psychotherapeutic technique for the borderline adolescent. A variety of theoretical models of etiology and treatment are discussed, many of which conflict. The author points out that therapists must choose among conflicting models and, at times, mix or change therapeutic models during the course of treatment. The potential risks and benefits of altering therapeutic models is described in detail. A case example in which the developmental formulation and therapeutic model changed during the course of therapy is presented. INTRODUCTION Borderline adolescents are among the most difficult patients to treat in psychotherapy. This is, in part, due to their intrinsic psychopathology which often involves mistrust, affective instability and dangerous impulsive behavior, significant family psychopathology, and intense transference and countertransference phenomena.[1] The purpose of this paper is to present an overview of the diagnosis, developmental formulation, and psychotherapy of the borderline adolescent. For all psychotherapy, treatment ideally derives from formulation. Moreover, therapists must have theoretical treatment models which are applied to case formulations. Compounding difficulties in the treatment of the borderline adolescent is the fact that many theoretical models of etiology and psychotherapy conflict. The thrust of this paper is to help therapists clarify their psychodynamic formulations and distinguish between models. In addition, the author will try to help therapists choose between differing models and, at times if necessary, combine or shift models, although, as will be noted below, the latter options pose some very significant difficulties.[2] DIAGNOSIS OF BORDERLINE PERSONALITY DISORDER The clinical diagnosis of Borderline Personality Disorder is the same in the DSM-III-R[3] for both adolescents and adults (see Table I). Weston and Ludolph, et al., have shown that borderline adolescents can be reliably discriminated from nonborderline psychiatric patients and from normal adolescents.[4] The authors found that the borderline adolescents, compared with nonborderline psychiatric patients, demonstrated more malevolent representations; a lower capacity for emotional investment in people, relationships, and moral values; less accurate, complex, and logical attributes of causality and understanding of interpersonal interactions; and poorly differentiated representation of people.[4] ETIOLOGY: DEVELOPMENTAL THEORIES There are a multitude of developmental theories postulating the causes of borderline psychopathology. All of the theories postulate disturbed early parent-child relationships. The specific theories proposed in the body of this paper should not be seen as mutually exclusive, and it is perhaps best to consider etiology as multidetermined. Let us first consider some variables that have been implicated in the development of borderline psychopathology in adolescence. BIOLOGICAL FACTORS A number of authors have proposed biological underpinnings of borderline psychopathology. Some authors have focused on tempermental or constitutional factors such as excessive innate aggression,[5,6] or decreased rhythmicity and increased separation anxiety. Others have looked at low anxiety tolerance in borderline patients. Some theorists have postulated limbic instability. They hold that there may be a low threshold for excitability of the limbic system in these patients.[5] Still other theorists have indicated the possible relationship with Attention Deficit Hyperactivity Disorder and learning disorders and imply that these deficits may contribute to borderline psychopathology.[5,7] Finally, some theorists have indicated the possibility of deficient central serotonin metabolism associated with impulsive and hostile behavior.[8] This might explain the association between Borderline Personality Disorder, Mood, and Conduct Disorders. FAMILIAL FACTORS Studies have reported that in the families of borderline adolescents, there is a cluster of familial personality disorders including antisocial, narcissistic, histrionic, and borderline personality disorders.[9] There appears to be an increased frequency of early parental losses and/or traumatic separations.[5] Many theorists have noted a hostile and conflictual relationship between the parents.[5] Additionally, there is an increased frequency of familial violence, incest, and alcoholism.[5] In a recent study, Weston, Ludolph, et al. have demonstrated that there is a high incidence of physical and sexual abuse, along with maternal rejection and neglect in borderline-personality-disordered adolescent girls compared with controls.[10] It should be noted that these were highly correlated results and causal relationships could not be made in the study. The findings suggest, however, that there may be a significant contributary role for childhood abuse, particularly sexual abuse, in the etiology of borderline personality disorder in adolescents. Most of the abuse in this study took place in latency. The authors wonder to what extent a posttraumatic stress disorder had become chronic and was integrated into a victim's personality structure. They conclude that abuse during latency is likely to have a permanent influence on personality structure, e.g., on self-esteem, identity, the capacity to regulate affects, reality testing, expectations in relationships and trust, and strategies for achieving personal goals.[10] The above study indicates problems with making causal statements in delineating the etiology of borderline personality and psychiatric disturbances in general. Not all sexually and physically abused children become borderline, and not all borderline-personality-disordered people have been sexually and physically abused. The authors note that in the same sample of subjects, there is a history of multiple caretakers and this differentiated borderlines from controls. Moreover, they indicated multiple other family disturbances in these subjects. This, according to the authors, corroborates the psychoanalytic hypotheses of interference in attachment relationships in the etiology of Borderline Personality Disorder yet such disturbances did not uniformly predict the diagnosis. A provisional conclusion could be that interpersonal problems and vulnerable individual constitutional factors in parent and child synergize in the psychopathology of early parent-child interactions. Continued grossly inappropriate or neglectful parenting and manifestly traumatic experiences are implicated in the etiology of borderline personality disorder. However, since much of the disturbances occurred in latency, many theories of borderline personality disorder (see below) that implicate early parental neglect may be too narrowly focused and stagespecific. The authors conclude that a history of physical, expecially sexual abuse, is associated with serious psychological disturbances, e.g., borderline personality disorder. This and other studies[9] lend serious doubt to stagespecific, single-causation theories of borderline personality disorder that focus on difficulties in separation-individuation in the preoedipal years,[11] since traumatic events are probably cumulative from early childhood onward through adolescence. However, it is not inconsistent with earlier interpersonal traumas or biological abnormalities as well.[9] INTERPERSONAL RELATIONSHIPS AND INTRAPSYCHIC CONFLICTS Most psychodynamic theorists have postulated significant deficits in the realm of interpersonal relationships,il particularly in separation-individuation. Unable to internalize basic mother-child caring due to postulated difficulties in normal separation-individuation,[12] the borderline adolescent feels empty, anxious, and isolated, without a stable sense of self to provide comfort. The core of the patient's disturbance lies in a pervasive feeling of aloneness with the ongoing belief he/she is or will be abandoned.[11,13] Many theorists posit that as the child gradually separates from his/her parents, he or she is faced with a crisis of ambivalence and guilt. The child's aggression threatens loss of a love object, and yet the child needs mechanisms for tolerating this aggression without undue guilt, separating from the parent, owning instinctual aggression as well as libidinal desires, and realizing that this crisis will not result in really losing the object, disavowal of feelings or impaired self-esteem. The mechanisms for successfully working through this process, as we will see, vary from theorist to theorist. In general, however, it is obvious how this normative process can be disrupted or significantly handicapped if there are excessive biological or familial deviations. For example, the above-noted problems inherent in separation-individuation and dealing with aggression are seriously compounded in children who have an excessive amount of aggression temperamentally.[6] In other cases, it becomes significantly more difficult for the child who lives in a family in which parents are hostile, neglectful or intolerant of aggression. For example, if a parent deals with the process of separation and individuation or rage with betrayal and abandonment, the child may develop interpersonal distrust, an inability to use others as whole objects (good and bad)[6] and develop intense anxiety and primitive guilt regarding separation. Kernberg notes the use of denial and splitting to preserve and protect the "good" object.[6] An additional consequence may be deficiency in the development of evocative memory which results in an inability to soothe oneself when alone.[13] The child may develop impaired empathy, a lack of concern for others and low self-esteem.[14] In general pathologic defenses may develop including splitting, idealization, devaluation, denial, projection, and projective identification in order to preserve the integrity of the individual.[6] There may be a clear inability to take responsibility for one's feelings, thoughts, and actions. Serious pathological consequences may occur if a child grows up in an environment in which (1) healthy maturation is not furthered[15]; (2)separation and individuation is viewed as betrayal and abandonment; (3)the child's attempts to grow and separate are met by overt aggression or abuse on the part of the parents[14]; (4a) there are few opportunities for making reparations and owning one's own aggression[16]; (4b) and/or the parent is viewed as not surviving the child's aggression.[6,11,14-17] These problems in development can result in the psychodynamic profile of the borderline patient. The borderline adolescent will fear abandonment and live with pervasive feelings of aloneness. He or she will search for an all-nurturing, protecting object, using splitting as a primary defense to ensure survival of the all-good object.[6] However, since no one can fulfill the adolescent's desire for an ideal object, there will remain chronic feelings of failure and disappointment in relationships, which will result in regression. Regressions may involve the dissolution of evocative memory, transient psychotic thinking, primitive defenses, feelings of rage, guilt, and worthlessness, and acting out in self-destructive behavior. There may be feelings of infantile entitlement and pervasive victimization. Normal Adolescence Many theorists and therapists have noted the importance of adolescence as a period of reworking earlier conflicts and healing earlier deficits in relationships,[18] often through regression. Moreover, they note the potential (though not universal) for extreme lability of affects, emotional turmoil, limit testing, experimentation, and identity crises. According to Meissner, a successful adolescent yields an integrated self-concept, sexual identity, loosened parental ties with increased autonomy, the approach of more adult social roles and relationships, and a mature, adaptive, flexible superego.[19] CATEGORIES OF THE BORDERLINE ADOLESCENT: MICHAEL GOLDSTEIN AND JAMES JONES Goldstein and Jones[20] have categorized four groups of adolescents based on behavioral manifestations. While their categorization is not all inclusive or perfectly delineated, it provides a framework for noting the behavioral, intrapsychic and interpersonal heterogeneity of this disorder. Table II presents an outline of the Goldstein and Jones groupings of the borderline adolescent and can help in our awareness of the variety of patients who present with borderline psychopathology. A Note on Theory and Technique Before discussing specific etiologic theories and techniques for the treatment of the borderline adolescent, it is imperative that we consider the relationship between theoretical models of psychopathology and therapeutic technique. Therapists should be cautioned that while, ideally, theory and therapeutic formulation should go hand in hand, many cases are not perfectly amenable to this ideal and that one must approximate the best theoretical framework to fit a formulation from which technique derives. Additionally, many cases require mixing or modifying therapeutic models at the outset of therapy or during the course of treatment, particularly as the adolescent and family change or, perhaps, when more data are available to the therapist. There are inherent difficulties in such an approach, which may be required by a particular case. Borderline patients of all ages are exquisitely sensitive to ambiguity and inconsistency, common outcomes of careless mixing of therapeutic models. This can cause regression and acting out.[2] The case example at the end of this paper will note some potential problems with mixing models but, nevertheless, underscore the necessity of changing models during the course of therapy. There are a number of common situations in which models of theory and therapy, which may be quite contradictory, are mixed. The most common situation of this sort occurs when a patient enters an inpatient treatment setting in which the therapeutic framework is in stark contrast with outpatient treatment. An example of this is a patient in outpatient exploratory insight-oriented psychotherapy who enters a short-term behaviorally oriented inpatient unit. The borderline patient faces two different conceptual frameworks. The outpatient therapist, for example, believes that insight, interpretation, and controlled regression are the route toward repairing pathological object relations, while the inpatient structure is organized around purely behavioral management of symptoms and shoring up pathological defenses to meet reality. The patient, unfortunately, is faced with outright conflicting models and tends to regress.[2] This instance is one of many other causes of regression in borderline adolescents. Others are severe intrinsic psychopathology, transference, and countertransference reactions, regression inherent in interpretive psychodynamic psychotherapy and conflict between staff members on inpatient units.[2] The following sections will briefly describe a number of theoretical and therapeutic models for the diagnosis and psychotherapy of borderline adolescents. It should be emphasized that this is a highly condensed version of a very complex subject matter and that the reader should recognize that only the essential theoretical features of the theories described will be provided. Much greater depth of understanding is necessary to implement these theories and techniques in practice. THE ADOLESCENT BORDERLINE PATIENT: SPECIFIC THEORIES OF ETIOLOGY AND THERAPEUTIC TECHNIQUES Otto Kernberg Kernberg applies his concept of borderline personality organization equally to adults and adolescents. His emphasis in understanding and treating the borderline adolescent is on defensive splitting and identity diffusion.[21, 22] The focus of Kernberg's theory is on the lack of integration of both "good" and "bad" self and object respresentations resulting in failure to have a satisfactory love relationship with an object that can be trusted and relied upon despite one's aggression towards it.6 Kernberg notes that the dissociation of primitive, contradictory, and anxiety-raising object relations is reenacted in the tranference with therapist. Therefore, the major work is diagnosis, interpretation, and resolution of primitive transference patterns.[23,24] Kernberg notes that there is possibly an excess of innate aggression that can interfere with normal development of healthy object relations. In this instance, he is referring to a biological underpinning in borderline personality, though he writes definitively about the abnormalities in object relationships in the growing and developing child. Given the above conception of the borderline adolescent, Kernberg requires the following techniques. The therapist needs to organize, absorb, transform, and integrate the patient's chaotic, intrapsychic experience. Thus, the therapist serves an ancillary, cognitive ego function. Interpretation of splitting in this framework is stabilizing.[6,21,24] The therapist is empathic, but the work is rational, cognitive, and almost ascetic. This relationship clearly differentiates the therapist-patient relationship from that of the infant-mother. Kernberg notes that the therapist should accept the reality of the patient's aggression without being overwhelmed. He also notes that interpretation of the negative transference in the "here and now" is essential and genetic interpretations should be avoided if at all possible.[24] The therapist must trust in some loving potential in the borderline patient despite the patient's limitations in expressing it. The therapist must maintain a hope for positive change and accept his or her own aggression and countertransference reactions. There must be the implicit reassurance that the therapist will not be destroyed by aggression; not by falling apart or retaliating.[23] The therapist should avoid giving in to the demands of the transference, set limits when necessary, and provide the critical, technical neutrality for interpretation of transference themes. This is absolutely essential and compatible with the "holding" necessary in the therapy. Provisions of the "holding" environment described by Winnicott[16,17] are essential in Kernberg's therapy, both within the therapeutic relationship and outside by the utilization of multiple ancillary support structures, e.g., social service, hospital, day treatment, group therapy, etc. Crucial problems here, not addressed by Kernberg however, are the realities of economic constraints in health care, e.g., the decreased manpower and limited services in the current climate of managed care. Finally, Kernberg notes that family psychopathology may derive from the borderline adolescent's pathological behavior rather than the family pathology causing it.[22] James Masterson Masterson postulates the concept of a "developmental arrest" during the rapproachment subphase of separation-individuation.[25] He theorizes that the mother encourages and rewards attachment and thwarts autonomy. This behavior could have a wide variety of causes, e.g., the mother herself frequently has a borderline personality disorder, which leads her to regressive behavior and withdraws from the adolescent's separation-individuation in order to maintain her own intrapsychic equilibrium. The mother, according to this theory, cannot tolerate separation and her own abandonment fears, anxiety, and narcissistic rage. She transmits to the child that if not symbiotically attached, she will die. Masterson postulates other pathogenic conditions in the maternal-child relationship, e.g., a long physical separation from mother; a mother who is psychotic, depressed, or emotionally empty; or one who dies. Thus, the mother need not be a borderline personality, but merely be exquisitely sensitive to abandonment and anxiety, and intolerant of separation.[26, 27] Clinically, in Masterson's theory, one sees the borderline adolescent presenting with a number of features. Acting-out behaviors such as antisocial activity, drug abuse, and sexual promiscuity are viewed by Masterson as a defense against abandonment depression. Difficulties in separation will result in a family process which promotes prolonged pathological symbiotic attachment to mother. He also notes that there is deviant communication within the family due largely to the fact that the parents may have borderline or other pathological personality structures. Masterson also is consistent with Kernberg on the central role of splitting to provide for the ongoing life of the critically needed attachment to the mother.[26] The key in Masterson's model to psychotherapeutic work with the borderline adolescent is identification, tracking, and making the patient conscious that the "Borderline Triad"[28]--separation, individuation, and self-activation--leads to anxiety and depression, which summons a defense. Confrontation of the defense promotes awareness of the underlying abandonment depression which then can be worked through by resolving pathological intrapsychic conflicts.[27] Masterson notes the importance of repairing the faulty separation-individuation process through intensive psychoanalytic psychotherapy. Some critical features of Masterson's therapy are: Advancement of the separation-individuation process while protecting the patients from self-destructive actions that are aimed at maintaining pathological symbiosis; removal from the home and hospitalization in a structured, closed inpatient unit with clear behavioral expectations.[29] The therapist invokes strict control of acting out by clear limit setting, and explicit confrontations in order to reduce splitting and projection and elicit, over time, appropriate "abandonment depression." The focus on eliciting "abandonment depression" vs. acting out is critical because it thwarts the process that would previously have promoted symbiosis. The key is that acting out is seen as a symbiosis-prompting process and the role of the therapist is to thwart this, since such symbiosis prevents normal separation individuation. In Masterson's model, the parents are treated separately.[29] Masterson poses three primary phases of therapy.[29] In phase one, the "testing phase," the therapist establishes a therapeutic alliance by confronting the patient's defense against his/her "abandonment depression," in other words, by interpretation of acting out. In the second or "engagement phase," the patient deals with and works through his/her feelings of hopelessness and helplessness regarding the wish for unconditional love and the feeling that if he/she separates, he/she and mother will die. Finally, in the third or "resolution" phase, depression decreases, reality perception improves, and individuation flowers. The key to Masterson's model and, perhaps, the most striking and controversial aspect of this model is that the adolescent does not return home.[28,29] James Egan In concert with the above theorists, James Egan also emphasizes developmental origins for borderline psychopathology in adolescents. He indicates that the mother is only partially available for nurturing. She is sufficiently gratified by the child becoming attached, yet creates too much frustration for enhancing optimal development in the child. This frustration derives from: inconsistent care, multiple caregivers, and/or lack of maternal availability, e.g., due to depression, substance abuse, etc.[7] The early frustrations in the child's development generates rage, depression, separation anxiety, clinging behaviors, and splitting. A stable sense of self and others fails to develop. Egan also considers possible biological factors, i.e., mood disorders, attention deficit hyperactivity disorder, and conduct disorder in these children.[7] The therapeutic model of James Egan has two major aims: strengthening the ego and conflict resolution.[7] Strengthening the ego consists of: increasing frustration tolerance, the capacity to delay gratification, the capacity to resist "regressive tugs," and the capacity to tolerate and bear painful affective states. In addition, an aim of strengthening the ego is increasing the capacity to inhibit impulses. It also implies reducing the tendency to impulsive action, cognitive distortions and failures in reality testing, and producing euthymia.[7] The primary aim of conflict resolution centers around the themes of loss and abandonment vs. union and merger, including issues of idealization, devaluation, and the need to maintain splitting. Early efforts in therapy are directed at forming a therapeutic alliance. Treatment, according to Egan, is best handled in a warm, open, direct exchange between the therapist and patient. He is close to Kernberg in his efforts to interpret events in the "here and now" rather than providing genetic reconstructions. Moreover, the positive transference is not assiduously analyzed. However, a thorough interpretation of the negative transference is advocated.[7] Egan notes, as Kernberg does, that the management of transference and countertransference is important. In addition, he advocates management of "the negative therapeutic reaction."[7] In this situation, the patient gets worse the more the therapist works to help him or her. In this case, there is the necessity of interpreting a sadistic impulse or the projective-identification process. One of Egan's major contributions to the therapy of the borderline adolescent is understanding suicidal behavior in these patients. He notes that it is imperative to determine the extent to which depression vs. narcissistic disappointment and rage are operative.[7] Depression, in Egan's framework, necessitates creating a warm "holding" stance and, possibly, medications. Narcissistic rage, on the other hand, demands assisting the patient to see the extent of disappointment and retaliatory or manipulative intent of the suicidal ideation. This is managed by interpretation of the rage. In Egan's framework, wrist slashing is seen often not as a wish to die but as a maladaptive effort of obtaining selfhood, feeling alive, and attacking an external object or introject.[7] A critical part of Egan's theory that separates him from Kernberg and Masterson, among others, is the necessity of mobilizing families and schools in the treatment process.[7] Family treatment, in Egan's framework, derives from a social-learning model. This is in opposition to an object relations, psychodynamic model as will be noted below in Zinner and Shapiro's approach. In Egan's social-learning model, the goal is to treat the destructive behavior, i.e., impulsive, provocative, or noncompliant behaviors. Much of these behaviors are secondary to separation problems and manifest as running away or persistent defiant behaviors that the patient knows will result in parental reinvolvement.[7] In this sense, Egan is close to Masterson in interpreting acting-out behaviors as bringing the parents closer. It also is consistent with Winnicott's theory of antisocial behavior. The social-learning model in family treatment, according to Egan, has a number of elements[7]: the therapist teaches the parents how to attend to the adolescent without giving directions, asking questions or guiding his/her behavior when the adolescent is behaving well. The therapist teaches parents how to reward. Rewards may be seen as social rewards, i.e., hugs, praise, or doing things together, or nonsocial rewards for good behavior, i.e., providing money, gifts, or special privileges. The rewards, of course, depend on a number of factors including the adolescents capacities, i.e., intelligence, needs, and capabilities. In the social-learning family-treatment model of Egan, the therapist will teach the parents how to ignore unwanted behaviors that are not clear violations of commands. He or she will train the parents in giving instructions and also train them in appropriate contingent responses or consequences to the unacceptable adolescent's behavior.[7] In contrast to Masterson's view, the adolescent in Egan's model remains at home in the family and is not removed except for necessary hospitalizations. A Family Therapy Approach: John Zinner and Edward Shapiro Zinner and Shapiro have developed a psychodynamic theory of borderline psychopathology in adolescence and a treatment approach that includes family therapy as an essential ingredient.[30-32] They note that families of adolescents who exhibit splitting demonstrate a tendency toward splitting that parallels the borderline adolescent. Their focus is on the family process. In their theory, the internalized split object relations, as defined by Kernberg, derive significantly from actual interpersonal events in the individual's relation within the family.[30] Lack of parental empathic sensitivity to the adolescent's developmental needs is determined by a shared family regression.[30] The family, in this model, shares unconscious fantasies, drama, and assumptions. Each family member is unconsciously assigned a role. The primary mechanism for this role is projective identification. Members, particularly the parents, will split off disavowed or cherished aspects of themselves and project them onto others within the family group. These split-off aspects are typically acted out. This model explains why one vulnerable individual child may be borderline and not another.[30] Regarding ego identity in the developing child, the family as a group must provide a "holding" environment in which the group itself survives the instinctual demands and angry assaults of the child without retaliation or cutting off sources of gratification. Failure to do so prevents developing a capacity for ego autonomy, ambivalence, mourning, concern, and authentic guilt, all of which are contingent on the integration of "good" and "bad" object relations. This becomes especially difficult when unconscious, disavowed aspects of parents are projected onto the child and the child acts them out unconsciously.[30-32] Zinner and Shapiro posit a relationship between the severity of the adolescent psychopathology and certain attributes of projective identification. They include the following: the capacity of parents to experience themselves as separate from the offspring, the dependence of parental defensive organization of transpersonal defenses such as projective identifications which require the adolescent's collusion, and the content of the parental projections, i.e., whole or part objects, elements of the superego, etc. The severity of any of these variables parallel the severity of the borderline adolescent's psychopathology.[30] The common denominator in this theory is that there is a shared unconscious fantasy that hostile feelings will destroy the loved anaclitic object, and the parent(s) needs the child to stay close to participate in the projective identification. Therefore, separation and individuation is seen as a family betrayal and a life-threatening act. Loyalty to the family's unconscious fantasy is of paramount importance. Zinner and Shapiro acknowledge that there is wide variability in levels of functioning of family members, e.g., with people outside the family and with certain family members. However, a particular adolescent's threats at separation and autonomy may result in regression, splitting, projective identification and primitive defenses depending on the role that the adolescent plays in the family, the particular vulnerabilities of that adolescent, and the relationship of that adolescent to other members of the family. For example, one adolescent may be at risk for projective identification because a parent unconsciously identifies with that adolescent. The therapeutic technique of Zinner and Shapiro,[30] Shapiro, Shapiro, Zinner, and Berkowitz[31] is quite unique. They combine individual psychoanalytic psychotherapy of the adolescent with a particular form of family therapy. In their model, two therapists are required. One therapist will see the adolescent in exploratory, psychoanalytically oriented psychotherapy sessions, from one to three sessions per week. There is frequently couple's therapy in addition, with a separate therapist. This therapist will, of necessity, be the family therapist, whether or not couple's therapy is provided. There will be conjoint family therapy in which the family therapist (couple's therapist) and the adolescent therapist meet together in the family sessions. The authors note that it is inadvisable for one therapist to see the adolescent and couple and that two therapists are ideal. They hold that the whole family must attend the meetings or the meetings are cancelled. It is critical that both therapists, if at all possible, should attend. Therapists must work with resistances and require a need for collaboration with the entire family. Each member of the family is seen and experienced as a patient. The therapists must receive, contain, and metabolize the patient's interactional behavior and provide feedback. They must bear the painful affects of the family and be aware of negative countertransference responses. Moreover, they must consistently thwart induction into the family system and the pressure to utilize projective identification. Finally, they must set appropriate limits. It is of greatest importance that there be two therapists in this process, since the borderline adolescent needs an ally and a figure to help interpret the projective identification process as it occurs in the family. The therapist meeting with the family can work with the adolescent's therapist to facilitate this process. Gerald Adler and Dan Buie Although Adler and Buie did not speak in many of their papers about borderline adolescents, their theory is worthy of inclusion here to contrast it with Kernberg, Masterson, and Egan and serve as a bridge between object relations theory and self psychology. Whereas Kernberg considers the quality and organization of object relations as central to borderline psychopathology, Adler and Buie see it as deriving from a deficiency and instability of the specific kind of introject--the "holding" introject for self-soothing, resulting in intense separation anxiety and threats of annihilation[14] In their theory, they draw from Winnicott the importance of introjecting the soothing "good-enough" mother[15,16] and the inadequacy of evocative memory and "holding introjects" in the borderline patient.[14] The therapy of the borderline personality in Adler and Buie's model has as its core the formation of a "holding selfobject" as a primary task of the therapist. It should be noted that a selfobject, in self-psychological terms, is an object (person) who provides functions for another person that he/she cannot perform. The therapist, in forming the "holding selfobject" relationship, helps the borderline patient develop evocative memory by forming an empathic "good-enough" relationship which survives. The therapist endures aggression and is seen as an indestructible good object.[14] The latter part of this theory, of course, is consistent with Kernberg and Winnicott's model, as will be described in the following section. Adler and Buie posit the necessity of dealing with rage and the "need-fear dilemma."[31] The "need-fear dilemma" is characterized by a situation in which the greater the perceived felt need on the part of the patient for the therapist, the greater the fear of abandonment, retaliation, and/or destruction of the therapist. They also posit that therapists must deal with primitive guilt by clarification, confrontation, interpretation, and/or the use of transitional objects, i.e., extra appointments, postcards on vacation, and phone contacts, all serving to demonstrate the therapists ongoing existence, commitment, and availability.[14] This is in stark contrast to Kernberg, who would interpret this a gross departure from technical neutrality and consider it transference gratification. So, too, would Masterson and Egan. However, Adler and Buie would argue that the true borderline patient has deficient evocative memory and does not trust in the ongoing existence of the therapist in the context of his/her destructive rage. Hence, building an alliance may take an exceedingly long time,[33] and it is of the utmost importance to convince the patient of the therapist's ongoing existence and alliance in the therapy. They also focus, in this initial period, which may take up to two years, on the positive transference in alliance building and noninterpretation of the negative transference. This, of course, departs sharply from Kernberg who sees interpretation of the negative transference as stabilizing. Adler and Buie see it, at least in the initial phases, as being destabilizing to the borderline patient. In their view, the healing of splitting must await the formation of stable, holding introjects. This, clearly, cannot take place early on in therapy. However, once a stable alliance is built, the clarification and interpretation of negative transference can begin. Donald Winnicott and Self Psychology Winnicott's theory of early emotional development is unique in bridging a gap between object relations theory, ego psychology, and also with self-psychological theories of developmental psychopathology. His theory adds a comprehensive overview to the theory of borderline psychopathology. Winnicott, like Mahler, notes that personality psychopathology, particularly of a borderline variety, is highly sensitive during the period of separation individuation in the second year of life.[11] Winnicott indicates that cognitive advances during this period enable the child to realize that the object of libidinal drives is the same as the object of aggressive drives. The child realizes that his or her own aggression can, potentially, destroy the object needed for survival. This realization, which may be largely unconscious, presents the child with a crisis in development, namely dealing with ambivalence and a profound sense of primitive guilt.[15,16] How does the child learn to tolerate this crisis in development? In Winnicott's framework, the child has developed the use of evocative memory by this time and can use transitional objects to soothe him or herself when alone, feeling that the libidinal object is present.[16] Winnicott also noted the early need of the child for omnipotence, and this is implemented by parental admiration and mirroring.[17] When the reality principle is consciously recognized, resulting in a narcissistic injury, the new cognitive capacities will convert omnipotence to the use of illusion. The first use of illusion is in the transitional object. This process fosters the belief and confidence that what is needed and wanted can be provided in the world. By using transitional objects, the child can see his or her creativity, needs, and individuality reflected in the world. This, according to Winnicott, is vital for positive self-esteem, confidence and hope.[17] Another crucial part of the tolerance of ambivalence and primitive guilt in Winnicott's framework is the need of the child to make reparations for one's own aggression.[15] It is postulated that as the child feels aggression, hatred, and, subsequently, guilt toward the libidinal object, the process of reparation and, most importantly, the parents receiving reparation allows the child to tolerate guilt and ambivalence and realize that one can own instinctive destructiveness and aggression.[17] This, according to Winnicott and other object relation theorists, is the seed of morality, social consciousness, productivity, and altruism. In Winnicott's framework, it provides a basis for developing what he designated as the capacity for concern.[15] The beauty of Winnicott's theoretical construction is that, through the process of tolerating the attendant affects, making reparations for the child's aggressive impulses, and realizing that the parent can accept the reparations and survive, the child is able to own his or her instinctive aggression without undue guilt and lowered self-esteem. This, in turn, helps the child develop a capacity of concern in others and is the heart and soul of the development of empathy. In Winnicott's framework, the role of the parent is to provide a "holding environment" that allows separation yet requires that the parents remain attuned and available, survive destructive rage, receive reparation, do not retaliate, and do not deal with separation as a betrayal, abandonment, nor with engulfment.[16,17] Winnicott coined the phrase "good-enough mother" in the sense that parental mistakes are inevitable. In fact, Winnicott noted the necessity of failures in parenting. Failures are viewed as a necessity because mending empathic failures provides the child with a realistic view that parents are neither all good nor all bad, that mistakes can be made, and that there can be reparations for mistakes. This enables the child to grow seeing people in terms of their limitations and yet able to provide what is wanted and needed throughout development. The child is capable of living with and tolerating imperfections and disappointments in others. This entire process results in faith in others and a decreased tendency for self-blame.[15] Winnicott pointed out that the acting-out and antisocial behaviors on the part of many adolescents may not be an indication of an early sociopathic personality. Antisocial behavior may be seen to be a cry for the environment to become instrumental in their care and development. Winnicott saw antisocial behavior in adolescence as resulting from a period of privation. Two manifestations of antisocial behavior on the part of adolescents are stealing and destructiveness. Both of these are viewed as a self-corrective function of the adolescent environment into a position of "holding" and caring rather than one of abandonment and retribution.[16] The therapeutic technique with borderline adolescents, in Winnicott's view, is provision of a therapeutic holding environment. He and the self psychologists focus on reworking early dyadic failures.[15,16] Therapy involves empathy, survival of the therapist, the role of playing and working together, and creating a facilitating environment for transference interpretation. They emphasize the adolescent's needs for admiration, validation, and mirroring, which was somehow lacking during development within the family. It is also critical that emphatic failures are acknowledged and interpreted. According to the self-psychological literature, progressive empathic failures are necessary to create internal structures by subsequent transmuting internalization. Kohut noted that internal structures are created by the environment and interactions and that they are not innate.[34] THE USE OF HOSPITALIZATION The above models of borderline psychopathology in adolescents and psychotherapeutic techniques are oriented toward outpatient treatment. There are times when the adolescent must be hospitalized during the course of psychotherapy, but hospitalization should only be considered in the presence of certain emergency criteria.[36] In addition to emergency criteria directly dealing with borderline psychopathology, the possibility of severe abuse or abandonment by the often dysfunctional families of these adolescents must be taken into account when deciding on hospitalization for their protection. In these times of managed care and short-term hospitalizations, one should not only consider criteria for hospitalization but, also, consider the importance of the therapeutic environment following hospitalization. Since hospitalization will, of necessity, be short, provisions should be made for ancillary therapeutic environments, i.e., day treatment, half-way and quarter-way houses, after-school programs, and other "holding environments" for the adolescent outside of the hospital. PHARMACOTHERAPY IN THE CONTEXT OF PSYCHOTHERAPY At times, the use of psychopharmacology is necessary in the treatment of the borderline adolescent. Another paper (p. 60) in this issue considers details of medicating the borderline adolescent. It should be noted, however, that there are some inherent problems medicating these patients, particularly in the context of psychotherapy. Numerous difficulties can ensue in medicating borderline adolescents. While, on the positive side, medications can effectively treat dual diagnoses and can also potentially quell impulsive dysphoric affective states or psychotic disorganization, they can be valuable psychologically as a transitional object and a symbol of caring. Conversely, medicating a borderline adolescent can psychologically increase omnipotent and omniscient fantasies about the doctor. Medications can also increase ways of potentially acting out dangerously. Finally, medications may be seen as an alternative to the painful vicissitudes of psychotherapy. Thus, one must weigh the pros and cons of medicating borderline adolescents and, at all times, be judicious in the use of medications, prescribing them in small quantities and with close monitoring. This concludes a review of the major theories of developmental psychopathology and psychotherapy of the borderline adolescent. It is fitting to close this review with the presentation of a case example that exemplifies the use of a developmental formulation, the modification of the formulation during the course of therapy, and the changing of a treatment model in accordance. Of course, changing models during the course of therapy has its hazards, but can be achieved with success, if the therapist is aware of the growth and development of the adolescent and family, including their changing needs and the impact of modifying a model on the treatment technique. The following case serves to demonstrate how a model is chosen based on a psychodynamic formulation. The model is, of necessity, multimodal and finally required shifting in response to two factors: the patient and family developed and changed; the therapist had not considered certain important data in his initial formulation, which required modification at a clinical impasse through the use of a consultant. The clinical impasse points out the therapist's need to reformulate the case on the basis of understanding the environment in its ethnic, cultural, sociocultural, and religious context, i.e., in terms of a set of belief systems maintained by each family. CASE EXAMPLE Identifying Information Karen, a 21-year-old female with borderline personality disorder, anorexia and bulimia nervosa, and dysthymia, has been treated in multimodal therapy for seven years. History of Present Illness When Karen was 14 years old, she came for treatment with symptoms of anorexia nervosa after the sudden death of her father on Christmas Eve. The anorexia nervosa progressed to bulimia nervosa when she was approximately 18. At that time, she also developed symptoms of dysthymia. Borderline personality disorder has been the most prominent aspect of her diagnostic formulation, in addition to her eating disorder. Her borderline characteristics include intense, unstable interpersonal relationships, impulsivity affective instability ranging from severe, angry temper tantrums to depression. suicidal ideation and gestures, an identity disturbance and confusion over her goals, ideals, career interests, loyalties, and friendships, chronic feelings of emptiness and boredom, intolerance of being alone, and frantic attempts to avoid being alone. Developmental History Karen is the younger of two girls. Her sister Margaret, two and one half years older, had early separation anxiety and was significantly attached to the mother for five years. Father had been an investment banker who was frequently away. There was a strong identification that Karen developed with him in fantasy and she learned through this identification to be self-sufficient and compliant. She clearly idealized her father. Karen did well academically, socially, and emotionally, until the sixth or seventh grade when, even before her father's death, she developed low self-esteem, profound feelings of inferiority, increased self-consciousness, problems with identity, and overattachment to two idealized friends. She was utterly unable to negotiate the stresses of adolescence. Family History The family are devout Catholics. Mother is quiet and saintly, but very isolated from others except her daughters and her family of origin. She thwarts separation at all costs, is overprotective, yet there is unconscious collusion with her daughter's illness. She is intolerant of affect and demonstrates a striking lack of empathy in the guise of caring. For example, when Karen, who is 5'7", weighed 68 lbs and was threatening suicide, mother refused to bring her to the emergency ward despite the therapist's demands. It was only when the therapist threatened commitment that mother decided not to "let God take her" and conceded to the therapist's recommendation. Thus, mother demonstrated overprotection, denial of her daughter's suicidality, denial of her own hostility, and rage toward her daughter's threatening behavior, but could not admit how angry she was toward the patient. PHASES IN THERAPY AND PSYCHODYNAMIC DIAGNOSTIC FORMULATION Phase I: Years 1-2 (ages 14-15) When I began seeing Karen, she weighed 105 lbs. I saw her twice weekly in psychotherapy. There was increased resistance to therapy with a great deal of distrust, anger, and devaluing of me, especially during her two pediatric hospitalizations. For example, when I approached her for a therapy session, she would hold a math book in front of her face and not even look at me except to occasionally scowl. I sat with her despite the resistance. She was rigid and demonstrated little affect except anger and silence. Her most prominent defenses were denial, projection, projective identification and severe distrust. My initial formulation was that Karen demonstrated borderline psychopathology and a false self-structure as described by Winnicott.[15,16] I also postulated that mother projected her anger at loss of father on Karen, particularly in light of Karen's identification with him. Mother and Karen also demonstrated projective identification consistent with Zinner and Shapiro's model in Karen's appropriating mother's split-off affect of rage. This was fiercely denied by mother. Karen was convinced that separation from mother would kill her and, therefore, she could not tolerate automony. This is consistent with the theories of Masterson, Kernberg, Adler and Buie, Egan, Zinner and Schapiro, and Winnicott. Karen's rage toward her mother initially was acted out by her anorexia nervosa. Mother could not separate from Karen because she had no other close attachments in her everyday life and also was insecure and fearful of extrafamilial relationships. By this time, Margaret had emotionally separated from mother and gained a boyfriend, father had died, and mother's siblings were not in close proximity. Mother's emotional ties were exclusively linked to Karen. Given this formulation, I elected to use a self-psychological approach. As exemplified by the models of Adler and Buie and Winnicott, I was extremely empathic, attempted to survive the patient's rage, and emphasized the positive transference. I made no attempt at interpreting negative transferential issues. There was medical monitoring and nutritional monitoring that caused frequent no-show visits, two pediatric hospitalizations, and a separate family therapy in which the sister never came. The family therapy proved to be unsuccessful in alliance building. Phase II: Years 3 - (Ages 16-17) This period was characterized by multiple hospitalizations after high school graduation. There were a few trials at separation, three involuntary escorts to the hospital, all resulting in voluntary, though resistant, hospitalizations. As noted above, in all three cases, mother initially refused to take the patient to the hospital despite one serious overdose of prescribed medications. It was only when I threatened involuntary commitment that mother complied. Three times, the patient was brought to the emergency ward for rehydration. At that time, her weight had dropped to 68-70 lbs. and, on one occasion, she increased the rate of IV fluids on her own, thus risking her life. Interestingly, once the patient entered the hospital, she settled in well, gained weight and, in fact, took a leadership role among her peers. There was more opening up in therapy during hospitalizations. During this period, she attempted to enter nursing school but dropped out after two months. In twice-weekly, self-psychologically oriented psychotherapy, Karen was a bit more open but still flip, scowling, often denying her problems, advocating rapid solutions and formulas. She consistently devalued me. She would often claim that "God and religion will save me, not you." As before, in the hospital the patient always did w elf, but rapidly deteriorated upon discharge to home. The hospital staff concluded that separation from mother was highly beneficial and advocated a halfway house, but both patient and mother adamantly refused. Family therapy, at this point, was also refused. As a last resort, I and hospital staff advocated day treatment and Karen and mother chose a day program 30 miles away from the site of Karen's individual psychotherapy. Phase III: Years (5 (Ages 18-19) The patient became more open in therapy during this period. There was more affect, fantasies, and longings shared with the therapist. The patient expressed issues of aloneness and yearning for a sense of identity and separation. Also during this period, there was prominent low self-esteem, self-blame, and expression of intolerance of her anger toward her mother. She longed for a boyfriend. Despite the increased openness, Karen became bulimic with excessive denial, especially of her vomiting, despite blood potassium levels of 1.7 meq per liter to 2.2 meq per 1. There was no history of laxative abuse. MODEL OF TREATMENT Individual psychotherapy was maintained twice weekly, but although empathic, there was more interpretation and confrontation of her defenses. Yet, I remained self-psychologically empathizing with her issues of aloneness, longing for a boyfriend, low self-esteem, self-consciousness, and intolerance of her emotions. I validated her with minimal confrontation, but as w e progressed during this phase, my confrontation of her denial and of her lying, especially her binging and vomiting, increased. She was able to tolerate this. Also, at times there were periods of increased self-esteem. She became more open in therapy and was more aware of her defenses and more in touch with her affect. During this period, I initiated Prozac, initially at 20 mg per day and then, after four months, increased this to 40 mg per day, and Ativan .5 mg b.i.d. for anxiety. There were two brief hospitalizations. The hospital staff was even more convinced separation from home was essential, especially in view of the fact that the patient consistently improved dramatically in the hospital and deteriorated upon discharge. Family therapy was still refused but medical and nutritional follow-ups were noteworthy for greater compliance. At this point, I concluded that there was a major point of impasse. I felt there was some progress in psychotherapy but, overall, we were not moving ahead. One breakthrough during this phase was a family-therapy-and-systems consultant. Upon reviewing all the treatment in a meeting with both inpatient and outpatient teams, the Director of Family Therapy of our department suggested a change in treatment orientation with a greater emphasis on the outpatient team as the locus of treatment and the use of the hospital in a consulting capacity and not as a perpetual refuge. The consultant suggested that we should not demand separation, especially given the deeply engrained ethnic, religious, and enmeshed family system. She emphasized the ethnicity and culture of the Irish Catholic family and noted that we had to consider this, particularly in the context of this family system. She recommended using a day program vs. a halfway house and also recommended a different form of family therapy using Catholicism and a father figure as a family therapist. Phase IV: Years 5-7 (Ages 20-21) During Phase IV, the patient gradually increased her weight to 100 lbs. She returned to school, not nursing school this time but a medical-assistant program. She was even more open in therapy and more assertive and rebellious, but the rebelliousness was seen in the service of her own ego. She would often reject the therapist's recommendations, e.g., refusing to attend school or outings when her weight was low and this gave her an increased sense of self-confidence. She began to engage in deeper explorations of therapy and also to joke with the therapist. We could often joust and play verbally during the sessions. There was greater perception of her inner states and no suicidal ideation. She became able to express anger toward her mother and sister. She began socializing. During this period, she utilized a day program quite effectively. Brief hospitalizations of less than 7-10 days were used only when requested by the patient or the outpatient team and a new form of family therapy was successful. In this model, the male therapist was an Irish Catholic who was a graduate of training in Christian theology and an expert in Christian mysticism. He represented the father who had been lost and had symbolically abandoned the family. In therapy, he emphasized the meaning of the loss of the father to the patient and the husband to the patient's mother. He also was adamantly against separation of mother and daughter. The patient's sister gradually reentered family therapy and eventually came in regularly. In individual psychotherapy, again twice weekly, the model changed. I utilized much more of an object relations approach as defined by Kernberg, Masterson, and Egan. In this model, I centered around themes of the loss and abandonment and made interpretations in the here and now. I did not analyze the positive transference but focused on the negative transference and how the patient "gives me the business." I interpreted the patient's self-destructive tendencies and the familial projective-identification process. I also interpreted her illness as a Nvay of keeping mother occupied, close to her daughter, and impeding Karen's own separation, as well as protecting mother from moving on in life and in the world. Karen acknowledged that she feared her rage and that her recovery would kill mother. A full-time day program was used for one-and-one-half years. As soon as she enrolled in the medical-assistant program, she took three classes and attended three half days in the day program. Medical and nutritional follow-up has been quite consistent. During this period, there were two brief hospitalizations each less than one week, each requested by the patient for weight gain and learning newer techniques to prevent binging and vomiting, that had become less and less frequent. I encouraged socializing and, in fact, coached her on methods of socializing and explored social interactions with her. SUMMARY Treatment of the borderline adolescent requires a highly sophisticated, multimodal treatment formulation that is based on a developmental, psychodynamic formulation of the patient and family system. The therapeutic model chosen must fit the case as well as possible, but, of necessity, may change as the patient grows and develops. It is of utmost importance to understand the patient's process of growth and development and the utilization of each particular model of psychotherapy chosen. Therapeutic techniques should derive from the model(s) of treatment and should constantly be analyzed during the course of psychotherapy with these very difficult patients. The case example illustrates the treatment of a borderline personality patient who, in Goldstein and Jones's model, initially was in Group IV, the withdrawn and socially isolated group, but as therapy developed, fell into Group II in her defiance, disrespectful stance toward her mother, belligerance, and antagonism both in the family and in therapy. She progressively was able to relinquish her defensive stance of denial, projection, and splitting, and became more aware of her affect. As she progressed in therapy, her mood shifted from states of anger to states of depression and self-consciousness and her treatment was facilitated by use of pharmacotherapeutic agents and a very close-knit outpatient team. It is important to emphasize the value of a close-knit working outpatient team in the psychotherapy. [*] The first part of this section appeared in Volume 47, No. 3, Summer 1993. [**] Assistant Professor in Psychiatry, Harvard Medical School; Director, Child and Adolescent Psychiatry Residency Training, Massachusetts General Hospital, Department of Psychiatry and McLean Hospital, Department of Psychiatry Mailing address: Massachusetts General Hospital, Department of Psychiatry, Bulfinch 449, Boston, MA 02114. Table I BORDERLINE PERSONALITY DISORDER: DSM-III-R DIAGNOSTIC CRITERIA[3] 1. A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of overidealization and devaluation; 2. Impulsivity in at least two areas that are potentially self-damaging, e.g. spending, sex, substance use, shoplifting, reckless driving, binge eating; 3. Affective instability marked shifts from baseline mood to depression, irritability, or anxiety, usually lasting a few hours and only rarely more than a few days; 4. Inappropriate, intense anger or lack of control of anger, e.g. frequent displays of temper, constant anger, recurrent physical fights; 5. Recurrent suicidal threats, gestures or behavior, or self-mutilating behavior; 6. Marked and persistent identity disturbance manifested by uncertainty about at least two of the following: self-image, sexual orientation, long-term goals or career choice, type of friends desired, preferred values; 7. Chronic feelings of emptiness or boredom; 8. Frantic efforts to avoid real or imagined abandonment. Table II CATEGORIES OF THE BORDERLINE ADOLESCENT: BASED ON GOLDSTEIN AND JONES[20] 1. Group I: Aggressive-Antisocial a. Poorly controlled, impulsive, acting-out behavior b. Aggressive patterns appear in many areas of functioning, i.e., school, family, peer relations, the law 2. Group II: Active Family Conflict a. Defiant, disrespectful stance toward parents b. Belligerence, antagonism in family setting c. Signs of distress and turmoil, e.g., tension, anxiety, somatic complaints d. Few manifestations of aggression or rebelliousness outside the family 3. Group III: Passive-Negative a. Negativism, sulleness, indirect forms of hostility or defiance toward parents and other authorities b. vs. Group II, infrequent overt defiance and temper outbursts; superficial compliance with adult wishes c. School difficulties, e.g., underachievement, not disruptive behavior 4. Group IV: Withdrawn-Socially Isolated (e.g., Eating Disorders) a. Marked isolation, generally poor communication skills b. Few, if any friends and excessive dependence on one or both parents c. Gross fears or signs of marked anxiety d. Unstructured time spent in solitary pursuits REFERENCES [1.] Esman, A. H. (1989). Borderline personality disorder in adolescence Adolescent Psychiatry, 16 319-336. [2.] Gordon, C., & Beresin, E. (1983). Conflicting treatment models for the inpatient management of borderline patients. American Journal of Psychiatry, 140, 579-583. [3.] APA (1987). Diagnostic and Statistical Manual of Mental Disorders 711 (Revised). Washington, DC., American Psychiatric Association. [4.] Weston, D., Ludolph, P. S., Lerner, H., et al (1990). Object relations in borderline adolescents. Journal of, the American Academy of Child and Adolescent Psychiatry 29 338 348. [5.] Gunderson; J. G. (1989). Borderline personality disorder. In H. S. Kapian and B. J. Sadock (Eds.) Comprehensive Textbook of Psychiatry, Vol. 5. Baltimore: Williams and Wilkins. [6.] Kemberg O. (1975). Borderline conditions and pathological narcissim. New York: Jason Aronson. [7.] Egan, J. (1988). Treatment of borderline conditions in adolescence. Journal of Clinical Psychiatry, 49, 32-35. [8.] Gunderson, J. G.. & Phillip, K. (1991). A current view of the interface between borderline personality and depression. American Journal of Psychiatry, 148, 967-975 [9.] Ludolph, P. S., Weston, D., Misle, B., et al (1990). The borderline diagnosis in adolescents: symptoms and developmental history. American Journal of Psychiatry, 147 470-476. [10.] Weston. D., Ludolph. P., Misle, B.. et al (1990). Physical and sexual abuse in adolescent girls with borderline personality disorder. American Journal of Psychiatry, 60 55-66. [11.] Shapiro, E. R. (1978). The psychodynamics and developmental psychology of the borderline patient: a review of the literature. American Journal of Psychiatry, 135, 1305-1315. [12.] Blanck, G., & Blank, R. (1974). Ego psychology: Theory and practice New York: Columbia University Press. [13.] Adler, G. & Buie, D. H. Jr. (1979). Aloneness and borderline psychopathology: the possible relevance of child developmental issues. International Journal of Psychoanalysis, 60, 83-96. [14.] Buie, D. H., & Adler, G. (1982). Definitive treatment of the borderline personality. International Journal of Psychoanalytic Psychotherapy; 9, 51-87. [15.] Winnicott, D. W. (1965). The maturational processes and the facilitating environment. New York: International Universities Press. [16.] Winnicott, D. W. (1975). Through pediatrics to psychoanalysis. New York: Basic Books. [17.] Winnicott, D. W. (1971). Playing and reality London: Tavistock Publications. [18.] Blos, P. (1962). On adolescence A psychoanalytic interpretation New York: The Free Press. [19.] Meissner, W. W. (1984). The borderline spectrum: Differential diagnosis and developmental issues New York: Jason Aronson. [20.] Goldstein, M. J., & Jones, J. E. (1977). Adolescent and family precursers of borderline and schizophrenic conditions. In: P. Horticoelis (Ed.), Borderline personality disorder The concept, the syndrome, the patient New York: International Universities Press. [21.] Kemberg, O. (1978). The diagnosis of borderline conditions in adolescence. Adolescent Psychiatry, 6, 298-319. [22.] Kemberg, O. (1979). Psychoanaltic psychotherapy with borderline adolescents. Adolescent Psychiatry. 7, 294 521. [23.] Kernberg. O. F. (1976). Technical considerations in the treatment of borderline personality organization. Journal of the American Psychoanalytic Association. 24, 795-829. [24.] Kernberg, O. F. (1977). Structural change and its impediments. In: P. Horticoellis (Ed.), Borderline personality disorders: The concept, the syndrome, the patient New York: International Universities Press. [25.] Masterson. J. (1975). The splitting defense mechanism of the borderline adolescent: developmental and clinical aspects In: J. E. Ivlack (Ed.), Borderline states in psychiatry New York: Grune & Stratton. [26.] Masterson. J. (1972). Treatment of the borderline adolescent: A developmental approach. New York: York: Wiley. [27.] Masterson. J. (1973). The borderline adolescent. Adolescent Psychiatry, 2, 240-268. [28.] Masterson. J. F. (1986). Tracking the borderline triad. Adolescent Psychiatry, 13, 467-79. [29.] Masterson. J. Ludlow. W. & Costellov, J. (1982). The test of time: borderline adolescent to functioning adult. Adolescent Psychiatry, 10, 492-522. [30.] Zinner, J . 5: Shapiro. E. R. (1975). Splitting in families of borderline adolescents. ln: J. E. Mack (ed.). Borderline states in psychiatry. New York: Grune and Stratton. [31.] Shapiro, E. R., Shapiro, R. L., Zinner, J., Berkowitz, D. A. (1977). The borderline ego and the working alliance: indications for family and individual treatment in adolescence. International Journal of Psychoanalysis. 58. 77-87. [32.] Zinner, J. (1978). Combined individual and family therapy of borderline adolescents: rationale and management of the early phase. Adolescent Psychiatry, 6, 420-433. [33.] Adler. G. (1970). The myth of the alliance with borderline patients. American Journal of Psychiatry, 136, 642-645. [34.] Kobut H. (1977). The restoration of the self. New York: International Universities Press, inc. [35.] Cowdry, R. W., & Gardner, D. L. (1988). Pharmacotherapy of borderline personality disorder: Alprazolam. Carbamazepine. Trifluoperazine and Tranylcypromine. Archives of General Psychiatry 45, 111-119. [36.] Beresin E. V., Falk, W. E., 6: Gordon, C. Borderline and other personality disorders. In S. E. Hyman & G. E. Tesar (Eds.)..Manual of psychiatric emergencies, Chap.21, pp. 178-193. Boston, MA: Little Broston, ~~~~~~~~ By EUGENE V. BERESIN, M.D.[**] Copyright of American Journal of Psychotherapy is the property of Association for the Advancement of Psychotherapy and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.Source: American Journal of Psychotherapy, Winter94, Vol. 48 Issue 1, p5, 25p, 2 charts.Item Number: 9410250984  Result 20  [Go To Full Text] [Tips]© 2002 EBSCO Publishing. Privacy Policy - Terms of Use