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This here-and-now transference experience (see chapter 7) allows the patient to experience in the moment the splitting that is so prevalent in his life experience. The therapist’s office becomes a kind of laboratory, in which the patient can examine his feelings in a safe, protected environment, and then extend his understanding to the outside world. The combination of intellectual understanding and the emotional experience in working with the therapist can lead to the healthy integration of identity and perceptions of others.

Comparing Treatments

A vignette may help demonstrate how therapists utilizing these various approaches might handle the same situation in therapy:

Judy, a twenty-nine-year-old single accountant, arrived at her therapist’s office quite upset, after having an intense argument with her father, during which he called her a “slut.” When her doctor inquired about what prompted his slur, Judy became more upset, accusing the therapist of taking her father’s side and throwing a box of tissues across the room.

A DBT therapist might focus on Judy’s anger and physical outburst. He might empathize with her frustration, accept her impulsive gesture, and then work with her to vent her frustration without becoming violent. He might also discuss ways to deal with her frustration with her father.

The SFT therapist might first try to correct Judy’s misperception of him and reassure her that he is not angry at her and is totally on her side.

In MBT, the doctor may try to get Judy to relate what she is feeling and thinking at this moment. He may also attempt to direct her to thinking (mentalizing) about what she supposed her father was reacting to during their conversation.

The TFP therapist may explore how Judy is comparing him to her father. He might focus on her severely changing feelings about him at that moment in therapy.

Other Therapies

A number of other therapy approaches, less studied, have also been described. Robert Gregory and his group at the State University of New York in Syracuse have developed a manual-based protocol, Dynamic Deconstructive Psychotherapy (DDP), specifically directed toward borderline patients who are more challenging or have complicating disorders such as substance abuse.13 Weekly individual, psychodynamically oriented sessions are directed toward activating impaired cognitive perceptions and helping the patient develop a more coherent, consistent sense of self and others.

Alliance-Based Therapy (ABT) developed at Austen Riggs Center in Stockbridge, Massachusetts, is a psychodynamic approach that focuses specifically on suicidal and self-destructive behaviors. 14 Much like TFP, the emphasis is on the therapeutic relationship and how it impacts the borderline’s self-harming actions.

Intensive Short-Term Dynamic Psychotherapy (ISTDP), designed for the treatment of patients with borderline and other personality disorders, has been elaborated by a Canadian group.15 Weekly individual sessions concentrate on unconscious emotions that are responsible for defenses and the connections between these feelings and past traumas. Treatment is generally expected to continue for a period of around six months.

Practitioners from Chile, recognizing the difficulty of providing intensive individual care for borderline patients, developed a group therapy system, Intermittent-Continuous Eclectic Therapy (ICE).16 Weekly ninety-minute group therapy sessions are conducted in ten-session cycles. Patients may continue with further rounds, as they and their therapists choose. A psychodynamic viewpoint guides understanding of the patient, but interpretations are minimized. The first part of each session is an open, supportive period in which unstructured discussion is encouraged; the second half is arranged like a classroom, in which skills are taught to handle difficult emotions (as in DBT and STEPPS).

Which Therapy Is Best?

All of these “alphabet-soup” treatment designs endeavor to standardize the therapy, most utilizing manual-based programs, and have attempted to develop controlled studies