PSYCHODYNAMIC COUNSELLING 6.

1 FEBRUARY 2000

Psychodynamic counselling for the borderline personality disordered client

A case study
ANDREW R. ARTHUR

ABSTRACT Psychodynamic counselling for clients with borderline personality disorder is dif cult and challenging because there are problems with the validity of the concept, diagnosing the disorder, managing disturbed behaviour and maintaining the treatment to successful completion. Nevertheless, counsellors are frequently called upon to provide assessment, management and treatment for this group. This article explores the application of psychodynamic principles of counselling to clients with borderline personality disorder, examines the history of the concept, the diagnostic process, and employs a case presentation to help describe aspects of character structure and treatment. KEYWORDS Borderline personality disorder, history, diagnosis, psychodynamic counselling

Psychodynamic Counselling ISSN 1353-3339 2000 Taylor & Francis Ltd

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INTRODUCTION Psychodynamically orientated counsellors, clinical psychologists, psychotherapists, community psychiatric nurses and mental health professionals frequently treat clients who could be described as borderline personality disordered. However, the process of diagnosis, treatment and theoretical conceptualization of this client group is controversial, subject to different interpretations by other professions (e.g. clinical psychology, nursing, psychiatry) and theoretical models (e.g. psychoanalytic, cognitive-behavioural, psycho-social, cognitiveanalytic). This article presents an overview of the history of the diagnosis, the contribution of different models and presents a case study that illustrates issues frequently raised in psychodynamic counselling with this group. HISTORY OF THE DIAGNOSIS The history of the diagnosis of borderline personality disorder began when clinicians in the late-nineteenth century noted that there was a group of chronically, mentally ill patients who were not mad, occupied the territory between psychosis and neurosis, but never, in their opinion, approached normality. Reviewing the clinical descriptions of these groups of patients, Stone (1986) suggests that they were probably suffering from borderline personality disorder. Early accounts of this borderline patient group were published by Lombroso in 1870, Falret in 1890 and Kraeplin in 1905, who diagnosed a milder form of dementia praecox and manic depression that he believed were borderline to the major psychosis. Likewise, Stone thinks the so-called schizophrenic patients that the psychoanalysts Maeder, Bjerre and Coriat successfully treated during the 1910s, and Janets hysterical, obsessional and anorectic patients described in 1903/1911, would probably be diagnosed as borderline personality disorder today. Nothing much was heard of borderline personality disorder until the seminal paper on the concept was published by Stern in 1938. This article rst used the term borderline in the sense it is understood today, and set in motion the process that has led to its inclusion and de nition in the psychiatric classi cation system DSM IV (APA 1994). Stern described a group of patients he observed who were neither psychotic nor neurotic, and did not respond to his psychoanalytic treatment. Stern reported that this group of patients showed a fairly de nite clinical picture and cluster of symptoms. These
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symptoms included: disturbances of the self, affective dif culties (depression, anger, discouragement and anxiousness), rigidity, inferiority, masochism, the frequent use of projection and problems with reality testing. He described certain modi cations of psychoanalytic technique that resulted in a better therapeutic response and improved prognosis in this patient group. In his classic paper on borderline personality disorder, Kernberg (1967) describes two uses of the term borderline, (1) the transitory manifestation of patients moving from neurotic symptomatology to psychotic and (2) patients who chronically function in a stable way on a borderline between neurosis and psychosis. It is his opinion, subsequently accepted generally, that the term should be reserved for (2). These individuals show evidence of a chronic disorder of personality characterized by typical symptoms and patterns of behaviour, but their capacity to test reality is preserved in contrast to psychotic patients. Kernbergs article described the characteristic borderline personality disorder pathology, observed its differentiation from other psychiatric disorders and noted the typical history and psychodynamic structure. An important paper in the history of borderline personality disorder was the Grinkler Study (Grinkler et al. 1968). This was the rst systemic empirical investigation to describe and de ne borderline personality disorder through the clinical investigation of fty-one patients. The authors investigated borderline personality disorder because they thought the term had been used as a depository for clinical uncertainty for too long without a clear de nition (1968: 346). They criticized previous research as being based upon the observations of a few patients, skimpy data, metapsychological theory, psychoanalytic interpretations and conclusions that were inferences rather than descriptions of processes. Grinkler et al. found, from a cluster analysis of their data, that borderline personality disorder is a speci c clinical syndrome with a considerable degree of internal consistency and stability, characterized by the arrest of psychological development in the patient. A comprehensive review of the literature on borderline personality disorder was published by Gunderson and Singer in 1975. They were concerned that borderline personality disorder was becoming a wastebasket diagnosis, with an expanding literature that was contributing to diagnostic confusion. The purpose of Gunderson and Singers review of eighty-one articles was to arrive at a de nition to delineate the clinical syndrome and make it distinguishable, with
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reasonable reliability, from psychoneurosis and schizophrenia. From their evaluation, they derived six diagnostic features that they hoped would form the basis for a reliable system of diagnosis. Examination of these shows they bear a remarkable resemblance to DSM III, DSM IIIR and DSM IV criteria for borderline personality disorder diagnosis. In a meta-review of borderline personality disorder, Stone (1986) suggests there is evidence to support the presence of a chronic characterological defect that is between neurosis and psychosis, has a reliable and consistent cluster of symptoms, responds to certain forms of psychotherapy and has a speci c developmental aetiology. However, Stone is concerned that the subject of borderline personality disorder has gotten out of hand. The borderline literature has swollen to a size too vast to be digested by one anthologist (1986: 432). The validity of borderline personality disorder as a diagnostic entity is challenged by Akiskal et al. (1985). They studied one hundred borderline patients from phenomenologic, developmental and family history perspectives. They found these patients to be an enormously heterogeneous group that shows evidence of a wide range of psychopathology. The authors conclude that borderlines do not seem to represent a de nable personality type and that the concept covers a large group of chronically and seriously ill dif cult patients outside the area of classical psychoses and neuroses (1985: 566). In their opinion the borderline personality disorder is a borderline diagnosis. Millon (1996) also criticizes the term and argues for a more clearly descriptive designation consistent with the observed distinctive syndromal trait constellations. He notes that the borderline label was used when a clinician was uncertain about diagnosis, but suggests it presently describes an actual discrete syndromal entity characterized by a disturbance in depth and variability of moods. Millon concludes that most of the models used to understand borderline personality disorder are psychoanalytic and biological, and proposes his own sociogenic model (see later) that emphasizes the role of sociocultural factors as indirectly in uencing the pathogenesis of the borderline disorder. The essential features of borderline personality disorder are summarized by Roth and Fonagy as a pervasive pattern of instability of self-image, interpersonal relationships and mood (1996: 198). They also describe the uncertain sense of identity, unstable interpersonal relationships, terror of being alone, impulsivity, anger and self-harming behaviour that characterize the borderline personality disordered patient. Roth and Fonagy report that controversy
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still exists over the de nition and description of personality disorders in general, the degree to which accurate diagnosis is possible and the overlap that exists between the different syndromes within DSM IV. They quote a large-scale study of the relationship between personality and symptoms (Tyrer et al. 1990) which, in their opinion, failed to show a predictive relationship between personality disorder and response to a variety of treatments, and suggests classi cation is erring towards over-re ning personality disorder description, with few practical bene ts. Roth and Fonagy (1996) believe that many practitioners take issue with the phenomenological approach that de nitions of personality disorder are based upon, and they prefer a model in which personality is measured within domains (e.g. work, relationship and self-care) and the accumulation of life choices to speci c experiences in the course of development. They conclude by saying that, although they do not regard the diagnosis and de nition of personality disorder as the most appropriate way of designing and assessing psychotherapeutic treatment intervention, they recognize it is the most common heuristic device for assessing treatment outcome studies. This is a pragmatic conclusion employed by other authors for the treatment and assessment of borderline personality disorder (e.g. Millon 1996; Ryle 1997). Clinicians are aware that more patients with borderline personality disorder are being identi ed as requiring help and treatment. Is this because of re ned diagnostics and increased mental health expectations, or could it re ect developments in society? According to Millon (1987), social factors affect the development of the borderline personality disorder. He believes pervasive sociocultural forces in Western society play a signi cant role in its development. He describes Western societies as uid and inconsistent, amorphous, ambiguous and as experiencing increased and rapid social change, immigration, mobility, technology and mass communication. This results in an erosion of traditional standards and values and, as a consequence, children are faced with constantly shifting and changing norms, values, practices and beliefs. Lacking a coherent view of life, Millon observes children groping with a bewildering, unstable ux of principles and models. Unable to turn to a stable and secure system of extended families, schools, religion or neighbours, the child has no back up or insurance to turn to if its own parents or families are dysfunctional. Millon believes that, under these conditions, vulnerable children are left to their own devices to cope with psychic trauma and they become
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scattered, unguided and discordant. These children are able neither to master the complexities of their varied and changing world nor to contain the intense aggressive and sexual urges that develop nor to channel fantasy and achieve their goals in a coherent fashion. In effect, Millon suggests, social factors play a signi cant role in the development of the borderline personality disorder. A single case study that employs psychodynamically orientated counselling is presented to describe and illustrate the process of diagnosis, personality structure and treatment of a client with borderline personality disorder. CASE STUDY Ms Jones, a single woman in her mid-thirties with children, was referred for counselling because she was experiencing a multitude of symptoms: anxiety, depression, confusion, inability to work, mood swings, relationship problems and dif culty in thinking clearly. In her words, she was a mess. She had previously been in contact with psychiatric services, received medication, sought help from her GP, attended various counsellors and therapists, and experienced an episode of psychiatric hospitalization. At her initial consultation, Ms Jones presented an alarming picture. There were a range of signs and symptoms present that suggested someone on the borders of severe psychiatric disturbance. Consequently, there was a temptation to have recourse to a purely clinical perspective and view her as a psychiatric-diagnostic and management problem. Assessment of her mental state, cognitive functioning, depressive-suicidal ideation, dangerousness and current needs further con rmed this. She increased my concern by recounting a traumatic history of incest and other sexual abuse. Although Ms Jones attempted to persuade me that she was potentially extremely disturbed, it was unlikely she was consciously exaggerating her symptoms, but rather her fear of falling apart and disintegrating was affecting her presentation. She also seemed to be testing my therapeutic skills and ability to contain her panic, which was probably a desperate re-creation of past attempts to get people to help her. Only by getting others to panic at her distress, it seemed, could she convey the urgency of her needs. It was important to help her contain her own fear of herself, and resist the temptation to decide she was far too disturbed for psychodynamic counselling and refer her to psychiatric colleagues. As the
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session wore on and more dramatic material emerged, this became increasingly dif cult. It was as if she desperately needed a panic response as a sign of empathic contact with her. At the end of her consultation, I said she had revealed a great deal about herself, and that we both needed time to re ect and could meet again to consider how to proceed. Her failure to panic and alarm me had not produced the desired reaction, and the offer of a further session was therefore reluctantly accepted because it was perceived to be better than nothing but also, I think, because it suggested the possibility of therapeutic containment. Millon warns of the dangers of overreacting to the symptomatic presentation of clients with these types of dif culties: Some therapists may overreact to a borderline patients tendency toward psychotic-like experiences or actual breaks with reality (1996: 690). At the next consultation, she again renewed her attempts to concern and alarm me with accounts of an inability to look after her children, an imminent separation with her partner, more accounts of the sexual abuse she had experienced as a child and pleas for something to be done. A response was necessary but not one that conveyed a premature reaction. Still unclear as to whether she would require a psychiatric evaluation, I validated her feelings by carefully telling her that I recognized her experience of panic, confusion and despair. I also suggested that, in her desperation, she wanted someone to take care of her, and that, though she felt she might need this, it might also be an unhelpful pattern of obtaining help in her life. I suggested that, though it might be frustrating for her, it was best not to jump to diagnostic conclusions as a result of her distress and recommended prolonging the consultation phase to try to be clearer about what was happening. She appeared to accept this but then carried on in her attempts to alarm and concern me with talk of distressed feelings. Again I recommended continuing the assessment phase and, again reluctantly, she agreed. My containing response aroused hatred and envy in this client, which led to attack and criticism during assessment and treatment. She insisted, like a male patient Bion describes, that I must go through it with him, but was lled with hate when he felt I was able to do so without breakdown (1990: 105). This, according to Bion, is an attack on linking: the capacity to introject and contain projective identi cation that forms a link between patient and analyst, or infant and breast. This process contains risks because the therapists peace of mind, Bion notes, is perceived by the patient as hostile
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indifference, and problems arise because there is a wish to destroy it through acting out, delinquent acts and threats of suicide. Diagnostic formulation The initial assessment and consultation phase lasted an unusually long two months. During this time she would use the sessions to describe, in great detail, her desperation and despair at the many relationship breakdowns she experienced, her self-disgust, swings of mood from excitement to depression and sexual impulses. I considered the diagnosis of borderline personality disorder because she showed evidence of the essential feature of the disorder mentioned by DSM IV which is a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity that begins by early adulthood and is present in a variety of contexts (APA 1994: 650). The central dif culty is that the person with borderline personality disorder will resort to impulsive and frantic efforts to avoid real or imagined abandonment. This makes relationships problematical and leads to very strong ambivalent reactions (Gallahorn 1981; APA 1994; Millon 1996). Other features described by DSM IV include an unstable self-image, suicidal behaviour, marked affective instability, chronic feelings of emptiness, dif culty controlling anger and paranoid ideation with dissociative symptoms. DSM IV describes these symptoms as nine separate criteria, ve or more of which are required to be present to justify the diagnosis. During the consultation phase, this client showed evidence of all the nine DSM IV1 symptomatic criteria, strongly suggesting she was suffering from this disorder. Further, her descriptions of her life and her behaviours also met those criteria described by Gallahorn (1981), Stone (1986), Millon (1996), Roth and Fonagy (1996) and Ryle (1997). Psychodynamic counselling Reviewing the research on psychotherapy with borderline personality disordered patients, Roth and Fonagy (1996) found two types of studies: those without a control group (uncontrolled) and those with (controlled). Uncontrolled studies involved treating borderline disordered patients primarily with psychodynamic psychotherapy and evaluating improvement. Of the twelve studies evaluated by Roth and Fonagy, eleven employed psychodynamic psychotherapeutic methods and one employed cognitive-behavioural psychotherapy
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(Turkat and Maisto 1985). The majority of psychodynamic psychotherapy studies assessed suggested improvement with this treatment. Higgit and Fonagy (1993) reviewed the results of follow-up and outcome studies of psychotherapy with borderline personality disordered patients and concluded that this form of therapy is more effective with less severe borderline patients who are depressed, psychologically minded, have good social support, low impulsivity and are not substance abusers. Other psychotherapeutic approaches to understanding and treatment include cognitive behaviour therapy (Beck and Freeman 1990), cognitive analytic therapy (Ryle 1997), dialectical behaviour therapy (Linehan 1987) and the psychobiological perspective (Siever and Davis 1991). Controlled studies are rare: Roth and Fonagy (1996) review only one and mention two that are in progress. They conclude their review by suggesting psychodynamic and interpersonal approaches may be helpful, but the ndings should be interpreted cautiously and in the context of these patients tendency to improve with time and of the relatively small gain achieved for the long-term intervention required. Based upon the diagnostic formulation and the evidence to suggest the probability of a positive response to psychodynamic approaches, I decided upon a trial of psychodynamic counselling and offered Ms Jones twice weekly counselling sessions for a period of three months. Initially, she used the sessions to express her anxiety but then began to describe previous psychotherapeutic treatments with therapists who had offered her personal advice and appeared to intervene in her life directly with their own opinions. She appeared to be inviting a repeat of that pattern of treatment to help contain her anxieties and it was easy to imagine how others had been tempted to intervene in that manner. Her descriptions of the psychotherapeutic and psychiatric attention she had received led me to speculate that she had an ability to get professionals to act outside their parameters. Those who did not act in this way, she perceived as unhelpful and unresponsive and she attempted even more desperately to goad them into action of some sort. However, while her feeling of desperation demanded some sort of action, I felt it more important to try to understand the feeling itself. Ms Jones was furious with my attempts to encourage this type of exploration and, partly in order to evoke some response, became involved with a most unsuitable and dangerous man. She found it dif cult to believe that this involvement could be related to her anger with me, and that it was a
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repetition of attempts to relieve abandonment feelings with excited sexuality. Periods of impulsive and dangerous behaviour, often sexual, are part of the symptomatology of borderline personality disorder (Millon 1996). Kernberg (1976) emphasizes the importance, in the treatment of borderline patients, of the psychotherapists neutrality, abstinence in the transference, restraint from acting-out, preservation of the freedom to examine, internally, the countertransference and introspective awareness of emotional reactions. Gallahorn says the therapeutic treatment of borderline personality disorder requires much self-awareness on the part of the therapist to survive the onslaught of these transference feelings and strike the right balance between empathy and detachment, between limit setting and nondirectiveness (1981: 83). Millon (1996) also emphasizes the need to monitor transference reactions that often consist of intensely negative as well as positive reactions towards the therapist. These must be properly handled, he points out, otherwise they will disrupt the therapy. The concept of borderline personality diagnosis, he says, also acts as a container for the therapists anxieties and provides a model and reference for the treatment (1996: 689). Because, due to her negative reactions to me anger, disappointment and fear of abandonment the counselling could not contain her impulses, Ms Jones temporarily left counselling and became involved with the aforementioned unsuitable man. Their relationship became physically and sexually dangerous, broke down and she returned to counselling feeling in an even worse state. However, this became an opportunity for much further exploration of her problems. She said she had been keeping secret her almost constant state of excited sexuality that led to compulsive masturbation, erotic fantasy and inappropriate sexual contacts with men and women. She blamed her childhood sexual abuse as being entirely responsible for this and accepted no responsibility for her subsequent sexual behaviour. I commented that, whereas her childhood powerlessness and ambivalence regarding the early sexual abuse was understandable, it now seemed she was actually perpetuating the abuse upon herself. Millon notes that there have been persuasive reports suggesting a high incidence of abuse during childhood in the history of borderline patients. . . . Although sexual abuse appears the most prominent of the abusive triad, both verbal and physical abuse may play a role as well (1996: 680). Millon also reports family studies that show faulty family boundaries and capricious relationships among family
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members that at times become sexual. In a review of empirical studies, the role of childhood trauma and abuse is perceptively described by Perry and Herman (1993). They believe that many of the troubling features of borderline personality disorder are more comprehensible in the light of a history of early, prolonged and severe childhood trauma. The psychopathology is an understandable reaction to a familial environment of fear, secrecy and betrayal, rather than an innate defect of the self. They point out that childhood abuse occurs in a familial climate of terror, but the abused child cannot turn to the parents either because they are the perpetrators or because they have succeeded in alienating the child from them. A link between impulsive sexuality and the intolerance of aloneness has also been noted in borderline personality disorder (e.g. Stone 1986; Millon 1996). As a sexually abused child living in a dysfunctional family, this client experienced isolation and self-disgust. As an adult, her sexuality was still being employed to distract her from feelings of aloneness and abandonment, although paradoxically it also increased them. I attempted to help her see how she employed exciting, sexual feeling to keep her from an abandoned, empty and lonely self but she did not like to hear these sorts of interpretations. Nevertheless, by confessing to and describing what sexually excited her, she was anticipating and encouraging some sexual response from me. She was attempting to recreate her sexual solution within the therapeutic relationship. When I suggested this to her, she agreed she had been aware that revealing such material could have such an effect and had been ambivalent about a response. At one session, her self-view was summarized by saying that, basically, she thought she was a dirty, sick and bad little girl who was unlovable. This comment affected her very much. She appeared to hesitate, stop her stream of monologue and simply said, Yes. Really. Thats what it feels like, and cried. There are four conditions that Malan (1982) believes must be satis ed in order to judge that a given psychodynamic explanation for a particular symptom is correct. Malans conditions are employed here to examine this interpretation of her excited sexuality. First, the four requirements are: (1) That events in the patients life, and particularly precipitating factors, suggest the nature of the con ict underlying the symptom. (2) That a detailed mechanism can be clearly formulated whereby the symptoms represents or expresses the con ict.
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(3) That interpretation of this mechanism to the patient brings the con ict clearly into consciousness. And nally, the most important: (4) This results in the disappearance of the symptoms. (Malan 1982: 107) Next, these conditions (shown in parenthesis) are employed to support the psychodynamic interpretation of the clients sexuality. Ms Joness early, premature sexual development (an event) had become established as a method to avoid the aloneness that resulted from early attachment problems between mother and daughter (precipitating factor). The excited sexuality was a repetition of the short-lived distraction from her real need for maternal intimacy (the symptom representing the con ict). The interpretation of this con ict allowed her to understand its current effect in her life and in the therapeutic relationship (brings the con ict into consciousness). Consequently, she had less recourse to exciting impulsive sexuality (the disappearance of the symptom). As a result of expressing her lonely, abandoned and unlovable self, Ms Jones now felt she could disclose even more disturbing sexual material but, interestingly, this appeared less designed to convince me of her potential serious psychiatric disturbance and more to gain a genuine understanding of what was wrong. She admitted to, in her own words, perverse sexual thoughts and feelings. These were interpreted psychologically as attempts to ll a serious void in herself (she did not know who she was and sought to distract herself in this sexual manner). This seemed con rmed when she said that what therapy represented was a dull, empty, boring, nothingness, and that she could experience something else much better through her excited sexuality. Millon notes that borderline patients frequently experience emptiness, boredom and deadness. He reports childhood studies which suggest that, as youngsters, these patients are characterised by vague feelings of apathy and boredom, an inability to see any meaning or purpose to life other than momentary grati cations (1996: 666). At this point in counselling, she began to experiment with being alone more, trying to be with her children and leaving the potentially exciting sexuality alone. This was very dif cult because the capacity to be alone is, according to Winnicott one of the most important signs of maturity in emotional development (1958: 29) and implies that the individual has had the chance through good-enough mothering to build up a belief
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in a benign environment (1958: 32). Consequently, this was a frustrating period for her. The process was supported though by drawing an analogy with coming off a drug (sexuality) and being faced with what one had desperately been trying to escape from (herself). Gradually she began to tolerate some periods of what she called boring nothingness. It was dif cult and there were many relapses, frustrations and attempts to get me to act in various ways. However, there was a beginning of an understanding of what had happened to her development, and what she was re-enacting in the transference. This helped considerably because she now had a model with which to understand herself. The model was of a child who had developed no meaningful idea of herself through relationships with parents, and was further entrapped by a guilty disturbing premature development of sexuality. Her parents were too disturbed and preoccupied to see what was happening, and the clients fearfulness prevented communication in any case. This pattern of determining identity through her sexuality persisted into adulthood. The objects of her sexual feeling were many. They could be herself, women, men - particularly those with problems or even her children (although she never interfered with them). The development of this shared understanding, informed by the literature, helped to contain and make sense of her dif culties and symptoms. Her progress also provided evidence for a therapeutic response to the treatment. With twice weekly psychodynamic counselling established, after a year she was more settled and able to tolerate sad feelings of loss, bereavement and despair. As a result, she returned to college and was able to embark on some studies that re ected her talents and skills. There were periodic regressions to early forms of sexually excited feeling as attempts to escape the desperately empty self. However, she was now able to use the sessions to talk about her thoughts, feelings and temptations to act. This was often suf cient to prevent dangerous action and she began to realize how her self-development had become frozen, and how a false-self identity based on excited sexuality and escape from lonely desperation had evolved. Containing and preventing this process enabled her undeveloped true self to emerge. This true self was hurt, abandoned, isolated and ill-formed, and therefore needed help, encouragement and support to sustain its growth. This concept of the true and false self is described by Winnicott. The false self is created, according to Winnicott, as a defence against distress in the childs environment. It is a method of denying that
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which is unthinkable (1960: 147), but it has one positive redeeming feature to hide the true self. Unfortunately, the adult identity often xates to the false self and this results in a rigidity of defensive structure, which prevents maturation. The experience of distress may indicate a fracturing of the false-self identity, and present a therapeutic opportunity to experience the pain of what is and was unbearable in the patients life. The client terminated her treatment after eighteen months and, although expressing feelings of loss, emptiness and abandonment (her real self), was no longer desperately attempting to panic herself and others nor impulsively seeking excited sexuality. Her mood swings had lessened and her self-esteem improved through her studies. She appeared more thoughtful, capable and began to grow concerned about the effect her dif culties had had on her children. To this end she sought psychological help for them. DISCUSSION Kernberg (1986) describes a spectrum of psychodynamically derived psychotherapies for the treatment of borderline personalities consisting of psychoanalysis, psychoanalytic psychotherapy and supportive psychotherapy. He rmly and consistently recommends the use of psychoanalytic (or what he calls expressive) techniques employing interpretation, maintenance of technical neutrality and transference analysis, and is critical of supportive techniques, even though widely used, claiming they eliminate the possibility of interpretation. Kernberg acknowledges that a supportive approach can be effective in the short term and notes some therapists employ these techniques for the initial stages of psychoanalytic psychotherapy, but he suggests that the approach becomes a long-term commitment without producing therapeutic change. The contrast between the two approaches expressive and supportive is apparent when Kernberg advises therapists to interpret primitive transferences in the here-and-now at the commencement of therapy, while Klein suggests that there are some patients (not necessarily borderline) for whom interpretation of unconscious material is inappropriate (1990: 38) and who need therapists that can value and maintain a holding function, allow a degree of therapeutic latitude, use non-interpretative interventions and facilitate ego development and trust. Ms Joness description of her previous therapists, and her initial expectations of me, suggested she had experience of
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supportive strategies that involved therapists intervening, taking action and giving advice. They apparently did not maintain the rm, consistent and stable reality boundaries that Kernberg believes are required to assist being ever on the alert to the possibility of being sucked into reactivation of the patients pathological primitive relations (1986: 102). Therefore, for this client, the failure of past supportive-based strategies suggested a classical approach with interpretation, therapist neutrality and transference analysis, even though, it might be argued, this resulted in her feeling frustrated and leaving prematurely, albeit temporarily, because interpretation may have been experienced as penetrative and exciting. That she was able to return and bene t from the approach I took, something she may not have done if I had compromised with a supportive technique, suggests the decision to employ an interpretative analytic approach was correct. Although this case demonstrates a response to psychodynamically orientated counselling, and though studies and reviews of treatment with borderline personality disordered patients have suggested there is evidence to support the effectiveness of psychodynamic approaches (Stone 1986; Higgit and Fonagy 1993; Roth and Fonagy 1996; Chiesa et al. 1996; Millon 1996; Dolan et al. 1997; Ryle 1997), the evidence is not rm and conclusive. Roth and Fonagy in their metaanalysis of psychotherapy research note that the amount of data available for examining the ef cacy of psychodynamic treatment is very limited indeed (1996: 33). Counsellors, especially those in the public sector, who need to justify the time and costs of psychodynamic treatment, are hampered by this lack of research. Roth and Fonagys conclusion that this absence of studies does not necessarily constitute a case against the ef cacy of these therapies offers some reassurance, but it does not enable the psychodynamic counsellor to feel fully con dent he or she is operating from a soundly based theoretical and evidential model. Nevertheless, personality disordered individuals represent major costs to society (Roth and Fonagy 1996) and, as in the case presented here, experience considerable psychological distress. They require the regular support of social services, the NHS and the voluntary sector. Additionally, their ineffective work patterns, chaotic family lives, substance abuse, social and personal distress and disturbing effect on their own children, all result in further costs. Therefore, Roth and Fonagy suggest the cost-effectiveness of intensive long-term treatment approaches for severely dysfunctional, personality disordered individuals should be a focus of urgent scienti c inquiry (1996: 214).
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In response to the pressure of this challenge to show evidence of therapeutic and cost-effectiveness, two NHS psychotherapeutic treatment facilities for personality disordered patients recently published studies evaluating their ef cacy. One study was conducted at the Henderson Hospital, a national special in-patient unit that employs a therapeutic community approach (Dolan et al. 1997). The investigation compared treated versus non-treated patients on the Borderline Syndrome Index (BSI) (Conte et al. 1980) and found signi cantly greater reduction in BSI scores for the treated group. This study demonstrates the ef cacy of specialist in-patient psychotherapy in reducing borderline symptoms at one-year follow up, and that a substantial proportion make a return to normal functioning. The second study was conducted at the Cassel Hospital, a psychotherapeutic facility for personality disordered and psychoneurotic patients (Chiesa et al. 1996). The investigators compared pre-treatment and post-treatment groups of patients on measures of health service utilization (medical, surgical and psychiatric), medication, cigarette and alcohol consumption and employment rate. Their results showed a substantial decrease in ve dimensions of health service utilization and related services, a substantial decrease in prescribed medication and an increase in employment rate. The authors estimate the provision of in-patient psychotherapeutic treatment makes a total of 7,423 saved per treated patient. Although both of the studies had methodological limitations, signi cantly concerning generalizability due to relatively small sample sizes and under-representativeness, they do illustrate how it is possible to confront the issues of evidence-based practice and cost-effectiveness in psychotherapy research and practice. CONCLUSION With informed diagnosis, good supervision and psychological understanding, the borderline personality disordered client can bene t from psychodynamically orientated counselling. The disorder does not need to be a wastebasket diagnosis (Gunderson and Singer 1975) and considered beyond the reach of the psychodynamic counsellor. Although the diagnosis has been subject to abuse and controversy, this case illustrates how the conceptualization of the clients dif culties as a borderline personality disorder phenomenon aided the counselling and understanding of this client.
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ACKNOWLEDGEMENTS Professor Robert Bor, City University, London, and Ms Doreen Carter for their help in the preparation of this paper. Andrew R. Arthur, D.Psy, Clinical Director, Corecare Ltd, 7th Floor, New Zealand House, 80 Haymarket, London SW1Y 4TE NOTE
1 DSM IV notes that borderline personality disorder is diagnosed predominantly (about 75 per cent) in females, and the prevalence is estimated to be about 2 per cent of the general population, 10 per cent of psychiatric out-patients, 20 per cent among psychiatric in-patients and comprises from 30 per cent to 60 per cent of clinical populations with personality disorder.

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