BPO
When Ms. M presented for treatment, she was 30 years old, single, and unemployed. She had
recently moved back to her mother's home from out of state, having been fired from her job as a
waitress. She had become embroiled in an argument with a customer whom she felt had
"disrespected" her, and she had ultimately threatened to throw a steaming-hot pizza pie in his face.
Socially isolated, Ms. M had had no long-term relationships outside her immediate family. She
described a series of either superficial or short-lived stormy friendships with men and women, and
had no history of dating or intimate relations. She was referred by her mother, who made being in
treatment a condition for her living in her home.
Ms. M was a large, overweight, and overbearing woman, overtly hostile, rarely making eye contact
except to glare at Dr. C. Her responses to Dr. C's efforts to obtain a history were curt and
incomplete, nonverbally communicating that Dr. C's questions were alternatingly intrusive or
idiotic. At the same time, Ms. M managed to communicate that she saw herself as "a useless,
hopeless piece of shit."
After seeing the patient in consultation, Dr. C made the diagnosis of borderline personality disorder
with paranoid and narcissistic features, organized at a middle borderline level.
Strategy 1: Defining the Dominant Object Relations
Although Ms. M initially agreed to the treatment contract, including twice-weekly sessions, she
quickly experienced difficulty complying with the treatment frame. The trip to Dr. C's office was
objectively inconvenient, but also, complying with the treatment frame that Ms. M felt Dr. C
imposed upon her left Ms. M feeling quite paranoid. Ms. M was often late for sessions, at times
stormed out early, and often sat in silence; she was "on strike." She would glare at Dr. C in silence
or complain about how self-serving and unfeeling Dr. C was to insist that Ms. M come in twice a
week; Ms. M accused Dr. C of caring only about rigidly sticking to the treatment model while
caring nothing about how difficult all this was for Ms. M.
Often, when Dr. C attempted to speak, Ms. M would cut her off, interrupting her, arguing with her,
or simply sitting forward in her chair, opening and closing her fists and glaring. In the countertransference, Dr. C felt frustrated, controlled, helpless, and at times also frightened.
1a: Identifying the Dominant Object Relations
This process helps the therapist to better contain her own affects while narrowing the clinical focus
to an area of conflict. Making use of her countertransference and Ms. M's verbal and nonverbal
communications, Dr. C pulled together in her own mind a hypothesis about the dominant object
relation organizing Ms. M's experience of the relationship in the moment (Strategy la). Dr. C
imagined an object relation of a controlling, aggressive bully in relation to someone who is
enraged, rebellious, and helpless, with the entire relationship colored by hostility and fear.
In her countertransference, Dr. C was aware of feeling controlled by Ms. M, at times victimized
and at time helpless and afraid. In her behavior, Ms. M acted the bully; however, as Dr. C reflected
on Ms. M's accusations and protestations, it seemed that the patient herself felt bullied and
controlled by Dr. C, and it was not clear if Ms. M was aware of the impact of her own behavior.
Thus, dr. C formulated in her mind the dominant object relation of a helpless and rebellions patientself, controlled by a bullying and aggressive therapist-other.
1b: Describing the Dominant Object Relations in Words
This process supports the patient’s capacity for self-observation and provides
containment of highly charged affect states. In a particular session, Ms. M arrived 10
minutes late and then went on a rant about the inconvenience of the commute to Dr. C's
office. She commented that Dr. C clearly didn't "give a shit" about Ms. M's time or
convenience. Ms. M was quite agitated and was looking to Dr. C for a response. Dr. C
used this opportunity to describe the dominant object relations in words (Strategy 1),
with the hope that this might provide some degree of affect containment and begin to
stimulate a process of self-observation on Ms. M's part. Dr. C attempted to put Ms. M's
dominant conscious experience, as she understood it, into words:
I hear you. I am controlling and selfish, rigidly adhering to the treatment frame to
meet my own needs, caring nothing about how difficult this is for you while you
feel controlled, helpless, and frustrated; I can understand that this leaves you
feeling very angry." Ms. M responded, "Yes, of course this is how I feel! How else
could I feel?" At the same time, she seemed less agitated and afraid.
Strategy 2: Calling Attention to the Repetitive, Rigid, and/or Contradictory Nature of the
Patient's Experience and Behavior The second TFP-E strategy in the treatment of BPO
patients is conceptualized in terms of three generally sequential steps that build on one
another:
• First, the therapist calls attention to repetition in the clinical process of a single dominant object
relation that organizes the patient's experience and communications in session, and often across
multiple sessions, inside and outside the transference.
• Next, the therapist focuses on role reversals within the previously defined object relation,
highlighting how the patient is identified at different times with sides of the object relation, or
identified with one side while simultaneously enacting the other.
•Finally, the therapist invites the patient to attend to the dissociated quality of his experience
across separate, idealized, and persecutory object relations and across time.
Each of these strategies calls on the patient to step out of his immediate affective experience
first, to become aware of the rigid, repetitive, and predictable nature of his experience (Strategy
2a); next, to see contradictions between his current experience and his current behavior (Strategy
2b); and finally, to note contradictions between his current dominant experience and experiences
he has had at other times (Strategy 2c).'
Over the next sessions, Dr. C called Ms. M's attention to how Ms. M frequently found herself
feeling bullied, controlled, and angry (Strategy 2a). Ms. M agreed; she described feeling
controlled and bullied in virtually all her encounters with others, but especially with her mother
and with Dr. C. Ms. M said, "Of course I'm enraged. Who wouldn't feel this way if constantly
treated as I am?" Dr. C and Ms. M began to identify the different ways in which Ms. M felt
controlled, as well as the powerful negative emotions that accompanied seeing herself in that
position. In relation to Dr. C, issues of control were organized around ongoing struggles in
relation to the treatment frame: the inconvenience of transportation to Dr. C's office, the
imposition of twice-weekly sessions, the request that sessions begin and end on time, and even
the expectation that Ms. M speak in session all left Ms. M feeling bullied, controlled, hostile, and
rebellious, with Dr. C cast as rigid, controlling, and self-serving. Similar difficulties emerged
repeatedly in Ms. M's interactions with her mother as well.
2a: Calling Attention to the Repetitive Nature of the Patient's Experience and Behavior as
a Single Object Relation Predictably Organizes the Clinical Material under the Impact of
Splitting-Based Defenses
This process promotes self-observation and reflection.
Ms. M walked into a session 15 minutes late, ranting angrily about how she despised her
mother. She went on to describe what she perceived as her mother's cruelty to her cat,
whom her mother typically locked out of the living room before leaving for work; her
mother didn't care about the cat, only about her own convenience. When Dr. C began to
speak, Ms. M sat forward in her chair and glared at Dr. C in a threatening fashion, opening
and closing her fists. Dr. C contained her own anxiety. She then shared with Ms. M that
she had a thought and wondered if Ms. M would like her to share it. Ms. M considered
and then acknowledged that she did. Dr. C went on to say, "You know, this experience
you describe of watching your mother control the cat, and her selfishly caring only
about her living room and nothing about the cat's comfort, reminds me of how you
feel in relation to your mother's insistence that you come to therapy when you don't
want to, and when it's so difficult for you to be here" (Strategy 2a). Ms. M did not
acknowledge Dr. C's comment but instead complained about the traffic when coming to
the office and the imposition of twice-weekly sessions. At this point, Dr. C went back to
this pattern in the transference, commenting, "Your current complaints make me
wonder if you're not having the same experience here with me now that you
describe with your mother. This is a pattern we've observed many times between
us; I seem controlling and selfish, and you are left feeling bullied and controlled"
(Strategy 2a).
2b: Focusing on Role Reversals
This process introduces alternative perspectives, promoting reflection and selfawareness by focusing on the impact of projective identification on the patient’s subjective
experience and behavior. In response to Dr. C's comment, Ms. M seemed calmer, more
contained, and somewhat reflective. Dr. C felt that Ms. M might be at that moment in a
frame of mind to be able to broaden her view to take into account her own behavior and
her dissociated identification with the controlling bully that she had so frequently
associated with Dr. C. At this point, Dr. C decided to attempt to call Ms. M's attention to
the role reversal enacted in the clinical process. Accordingly, Dr. C said that while she
understood Ms. M's feeling of being controlled and bullied, she also wondered whether
Ms. M could see the ways in which Ms. M herself was at times behaving in a controlling
or bullying fashion in relation to Dr. C-for example, by cutting off Dr. C when she attempted
to say something, or by sitting forward in her chair and glaring at Dr. C while opening and
closing her fists. "At the same time that you feel I control you, you also are controlling
me; and at the same time that you experience me as bullying you, in the same way,
you can bully me" (Strategy 2c). Over the ensuing months. Dr. C worked with Ms. M
to identify the repetitive enactment of core dominant object relations in the transference,
inviting Ms. M to join with her in noticing the impact of role reversals on the clinical
process.
2c: Focusing on Dissociation of Idealized and Persecutory Object Relations
This process promotes reflection on internal states by highlighting the impact of splitting
on the patient's subjective experience and behavior while inviting the patient to
contextualize idealized and paranoid experiences across time.
Despite ongoing difficulty with the frame and intermittently stormy sessions characterized
by Ms. M's hostile accusations and paranoia, Ms. M did stick with the treatment and
started to make gains. Overall, she was less aggressive in sessions, and role reversals
were less confusing and disruptive to the clinical process. She found steady employment,
and things seemed to be less rocky at home. At the same time, she rarely let on that she
was doing better and continued to complain (albeit not entirely enthusiastically) about Dr.
C. Nevertheless, Ms. M would at times very tentatively acknowledge a positive view of
the treatment or of her circumstances outside the treatment. She would then quickly
return to her usual hostile, paranoid stance. These developments enabled Dr. C not only
to articulate the familiar paranoid object relations that predictably organized the clinical
process, but also to capture more hidden, idealized views of the relationship, in which Ms.
M anticipated that Dr. C would solve all Ms. M's problems Having described and examined
with Ms. M both the paranoid and newly evident idealized view of their relationship, Dr. C
began to invite Ms. M to bridge contradictory and dissociated views of the relationship
activated across time. For example, in a session 6 months into the treatment, in response
to a return of Ms. M's paranoid agitation, Dr. C commented, "You feel angry and afraid
that I am trying to control you and have no interest in helping you. This is different
from what you were saying in our last session, when you acknowledged that you
are doing better and that the treatment may have something to do with that"
(Strategy 2c). Dr. C could see that Ms. M was listening and that she had experienced
this intervention as a "bid for reflection."2 Sensing curiosity on Ms. M's part in relation to
the contradictions to which Dr. C had called her attention, Dr. C proceeded to move on to
Strategy 3 -that is, to offer a possible explanation of why Ms. M might shift between
dissociated, persecutory, and idealized views of the relationship.
Strategy 3: Exploring the Anxieties and Conflicts Motivating Splitting and
Organizing the Dominant Object Relations, and Introducing Hypotheses about
Underlying Wishes and Fears
This process promotes the capacity to tolerate awareness of anxieties driving the mutual
dissociation of idealized and paranoid object relations, introducing greater flexibility into
defensive functioning; this process also broadens the patient's perspective to appreciate
the constructed, symbolic nature of subjectivity and, ultimately, the impact of
psychological conflicts on his experience and behavior.
The impact of TFP-E Strategy 2 is that the patient has a developing awareness that the
experiences he is exploring in treatment are reflections of his internal life, that his
subjective experience is distinct from external reality that is, the patient's perspective
becomes less concrete and more flexible. This perspective is typically fleeting at first, but
becomes more stable over time with ongoing clinical attention to role reversals and
splitting. At those times that the BPO patient does have an awareness of the internal and
subjective nature of his experience, the therapist can capitalize on moments of
reflectiveness to initiate exploration of the anxieties and conflicts embedded in the
dominant object relations. Here the therapist builds on earlier interventions, now focusing
attention on the mutual dissociation of idealized and paranoid object relations to highlight
how these defend against one another and to explore the anxieties motivating splitting.
Dr. C sensed curiosity on Ms. M's part in relation to her previous intervention (Strategy
2c), in which Dr. C had called Ms. M's attention to the contradiction between her current
and familiar, paranoid view of her relationship with Dr. C and the idealized version Ms. M
had communicated in the previous session. With Ms. M seemingly attending closely, Dr.
C proceeded to offer a possible explanation of why Ms. M might shift between dissociated,
contradictory views of the relationship while focusing preferentially on the negative
(Strategy 3).
Dr. C suggested, "Perhaps you prefer to focus again on the negative relation
between us because to do so feels familiar and safe. Experiencing the positive
relation may feel good for a moment, but doing so is risky; the negative emotions
are so overwhelming that all the good feelings could at any moment easily
disappear. If you stick with the negative and keep the positive under wraps, it
protects the good feelings in a secret place."
Strategy 4: Working Through Identified Conflicts
4a: Working Through Identified Conflicts and Associated Anxieties as They Are
Enacted in Different Contexts across Time While Making Links to the Treatment
Goals and the Patient's Interpersonal Relationships
This process enables the patient to contain anxieties associated with the expression of
aggression and to relinquish splitting-based defenses, promoting integration of idealized
and persecutory internal object relations and leading to a gradual process of identity
consolidation while improving interpersonal functioning.
As part of the process of working through (Strategy 4a), during the middle phase of Ms.
M's treatment, Dr. C made use several times of the strategies we have described.
Working through allowed an exploration of the anxieties motivating Ms. M's use of
splitting-based defenses and ultimately came to focus on Ms. M's fears of allowing Dr. C
to be powerful: If the idealized version of Dr. C could help Ms. M, then Dr. C became
very powerful. If Dr. C was powerful, then she was also dangerous; after all, she could
at any moment turn on Ms. M and exploit or humiliate her, or she could decide to
interrupt the treatment or to raise her fee to a rate Ms. M could not afford.
In subsequent interventions, Dr. C also suggested that just as Ms. M experienced her
as an external enemy, she likewise struggled with an internal enemy: a powerful,
controlling tyrant within that wanted to destroy the possibility of her making gains in life.
Exploration of various anxieties underlying Ms. M's need to destroy her own possibilities
included fear of attack from an envious, cruel, and aggressive parental figure and fear of
her own intolerable disappointment and humiliation were she to allow herself to be
duped into feeling falsely hopeful. Ultimately, the fear of losing a deeply held hope of
attaining perfect love and care from a parental figure and the wish to hold on to the
possibility of attaining such love and security from Dr. C were seen as motivations for
maintaining a split view of the relationship.
As these anxieties were identified and explored, they became less concrete and less
credible to Ms. M: they came to feel like fears and fantasies rather than actual dangers.
In this setting, early depressive anxieties began to emerge, side by side with more
familiar paranoid concerns. These anxieties revolved around Ms. M's sense that she
was not deserving of Dr. C's help or of her mother's consideration, that she had been
aggressive and had enjoyed bullying and frightening them and as a result did not
deserve fair treatment from them.
In the later phases of treatment, Ms. M began to associate to early experiences with her
father before he left the family, recalling that he would bully and frighten her, pulling out
his belt and threatening to beat her if he thought she had not done as he asked. She
reflected on how she had hated and feared him, and how as an adolescent she had
been aware of her connection to him as she bullied her mother after her father left the
family (Strategy 46). Triangular and oedipal conflicts also emerged in later phases of
treatment in terms of guilty wishes to triumph over and humiliate a highly successful
younger brother whom their father manifestly preferred over the patient.
Toward the end of treatment, after Ms. M had begun working full-time and reconnecting
with some of her high school friends, exercising at a gym, and helping out at home, she
looked back on her earlier behavior, commenting on how angry and frightened she had
been when she began therapy, and how challenging her behavior must have seemed.
She commented that it had taken her a long time to be able to forgive herself. "I used to
hate myself.... I used to hate everybody," she said, and she wondered how Dr. C had
managed to put up with her. "A lot of other therapists would have run for the hills. But I
can see now that somehow you always believed in the therapy, maybe even saw
something in me ... that I could do better. I no longer need you to be perfect. But you're
okay. I guess I am, too."