See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/287659679

Psychotherapy for Borderline Personality: Focusing on Object Relationsby John

F. Clarkin, Ph.D., Frank E. Yeomans, M.D., Ph.D., Otto F. Kernberg, M.D.
Washington, DC, American Psyc...

Article in American Journal of Psychiatry · May 2006

DOI: 10.1176/ajp.2006.163.5.944

CITATIONS READS

0 1,377

1 author:

Mardi Horowitz
UCSF University of California, San Francisco
57 PUBLICATIONS 3,378 CITATIONS

SEE PROFILE

All content following this page was uploaded by Mardi Horowitz on 05 January 2016.

The user has requested enhancement of the downloaded file.

BOOK FORUM
represents yet another clear indication that the interdiscipli-
nary field of philosophy of psychiatry has been flourishing
lately. Perhaps the most distinctive mark of the recent work in
this area is aiming not just at illuminating the intricate philo-
sophical problems inevitably faced by psychiatry but also at
doing something about it. In other words, philosophical ana-
lytical rigor has been put to the service of building a more so-
phisticated conceptual framework for psychiatry, which is
much needed as ever, in order to keep pace with the myriad of
scientific and humanistic developments of such discipline.
Values and Psychiatric Diagnosis by John Z. Sadler is an im-
portant and remarkable book for several reasons. First, it ad-
dresses a number of thorny and controversial issues regard-
ing the many roles played by values in the classification of
psychopathology (and correlate issues) in a thoughtful, bal-
anced, and nonpolemic manner, as Sadler truly seeks to en-
gage the reader in a constructive dialogue. Second, even
though the scope of the book is broad, the scholarship dis-
played is impressive, as the work is richly referenced and an-
notated and the author strives to be as fair-minded as possi-
ble with respect to the conflicting viewpoints discussed. This
does not prevent him, however, from presenting his own per-
spectives. Third, despite the fact that treating values in the ag-
gregate is a very tall order, Sadler’s analytical skills allow him
to move swiftly in the messy world of psychiatric classifica-
tion; diagnostic finesse always pays off.
The main thrust of the book is to identify and unpack the val-
ues-commitments of the profession (enshrined in the diagnos-
tic manuals, arguably its benchmarks), which according to him
remain largely unrecognized as such. By values, Sadler means
the concepts that we use to guide our actions and lead us to be
deserving of praise or blame, but also and mainly the concepts
we use to describe blame/praiseworthy and action-guiding ac-
tivities (value-language as description). In a systematic fash-
ion, the author applies throughout the book the distinctions
between value-terms (encompassing both thick and thin
ones), value-semantics, value-commitments, value-entail-
ments, and value-consequences. A heuristic typology of values,
comprising aesthetic, ethical, pragmatic, epistemic, and onto-
logical values, is prolifically used as well. Furthermore, the
scrutiny of the six ontological assumptions underlying the
DSM effort—namely, empiricism, hyponarrativity, individual-
ism, naturalism, pragmatism, and traditionalism—renders
more understandable several key nosological controversies.
Drawing on the analogy between the social features of sci-
ence (openness, equality of opportunity, peer review, epistemic
freedom, and criticism) and democratic values, Sadler ad-
vances a forceful argument for good politics for psychiatric
classification, politics taken in the sense of seeking and main-
taining a moral vision of aiding the mentally ill. Accordingly, a
strong case is made in favor of a broadly based diagnostic prac-
tice. In sum, by offering a tentative road map for conceptual
challenges and value-inquiries that are likely to play a promi-
nent role in the forthcoming revisions of ICD and DSM, this is
a timely contribution to the further development of a sensible
and pluralistic psychiatry.
CLAUDIO E.M. BANZATO, M.D., Ph.D.
Campinas, Brazil
944 ajp.psychiatryonline.org
Psychotherapy for Borderline Personality: Focusing
on Object Relations, by John F. Clarkin, Ph.D., Frank E. Yeo-
mans, M.D., Ph.D., Otto F. Kernberg, M.D. Washington, DC,
American Psychiatric Publishing, 2006, 397 pp, $55.00.
The science of psychotherapy is supported by public fund-
ing in large measure. In the NIMH study sections that guide,
and also limit, psychotherapy research it has been a virtual re-
quirement that all investigators who submit applications pro-
vide treatments manuals for the specific population to be
studied. The concept is that these pamphlets or little books
have enough specific detail that clinicians can conform to the
set of techniques provided if and when the investigators’
demonstrate that a treatment is efficacious.
Most clinicians not involved in psychotherapy research dis-
like these manuals because the details provided, although
concrete, do not well fit their own inferences about their pa-
tients. The authors have labored in this vineyard, and here
provide more than a treatment manual with concrete and
specific techniques. Lucid examples allow a clinician to imag-
ine actual situations. Their book will therefore be of greater
use to many clinicians.
The longer the psychotherapeutic treatment is needed, the
less the treatment manuals seem to fit individual cases. What
works better for clinicians is to know enough relevant theory of
explanation and processes of change that they can infer how an
individual case might work out. With objective theory they can
make better subjective judgments and individualize phase-
specific treatment plans. That is, they can make inferences
about what to do at any phase of the individual treatment.
Such theory can be linked to practice using systems of case for-
mulation. The authors provide such theory of etiology and formu-
lation. Starting with the first chapter, they define what they mean
by “borderline” by outlining the context of both normal personal-
ity and the range of other, related, and sometimes overlapping
personality disorders. Their system of formulation is both like and
unlike other systems such as configurational analysis (Horowitz,
2005). Their principles of treatment are both like and unlike those
advocated in cognitive-behavioral approaches for borderline per-
sonality disorder, such as dialectical behavior therapy.
The big difference is in the therapist’s attitude toward the util-
ity of activation of the patient’s irrational schemas of self and
other, including scenarios for intense feelings, within the rela-
tionship of the therapy itself (patient with therapist). In their
transference-based approach, communications in the session
area are used to analyze and clarify irrational projections. A firm
structure of boundaries and transactions within the therapy is
established to keep negative emotions such as rage from de-
stroying a working alliance. Within this structure, and once it is
established, the authors advocate close observation for transfer-
ences and countertransferences with interpretation of transfer-
ences as a vehicle for insight. The newly emerging therapeutic-
alliance relationship between therapist and patient becomes a
key opportunity for schematic change in operative role-relation-
ship models, as a kind of corrective relational experience.
In contrast, cognitive-behavioral approaches use educative
means to both contain and ward off this potential for transfer-
ences. As one might expect, a related difference with cogni-
tive-behavioral techniques for psychotherapy of borderline
personality disorder concerns active analysis of a patient’s de-
fenses. Transference-based therapy tunes into analysis of de-
Am J Psychiatry 163:5, May 2006

fense mechanisms such as splitting self-other schemas into
all-good and all-bad segregations of self and other person
schemas, what I like to call role relationship models. This
analysis can lead to interpretation of emotional beliefs that
are projected onto others, and why for example blame is dis-
located from self to others. In comparison, cognitive and be-
havior therapies tend to tune in on obstacles and resistances
without as much specific work on pathogenic defenses, with-
out clarifying what is projected, what is dissociated, and why.
In cognitive behavioral approaches as in this transference-
based approach there is attention to hatred as a way of feeling
strong, and revenge as a way of controlling a person who might
otherwise make the self feel so weak that loss of identity coher-
ence would be a feared result. More than in cognitive behavior
therapy, the transference-based approach in this book regards ac-
tivation of such hate as a defense to be interpreted as such. Usu-
ally the rage is a defense against fear of personality disintegration.
As one might expect, this kind of approach takes years of con-
tinuous therapy sessions to achieve maximum positive effects.
As some may not realize, some cognitive behavior therapy ap-
proaches also assume the necessity of such durations of psy-
chotherapy. Unfortunately, NIMH has been reluctant to fund
long-term treatment research although the nature of severe
psychopathologies requires centers for such empirical work.
Step one, in both this transference-based approach and
cognitive behavior therapy approaches involves work on ex-
periencing and tolerating confused states and explosive state
cycles. The goal in the first phase of both approaches is to in-
crease state stability, and this is a first step in supportive ther-
apy and pharmacologic approaches as well. The authors have
a good understanding of this and take a step toward where we
have to go (psychotherapy integration) by a capable compar-
ison of their transference focused psychotherapy with three
other current therapy brand names: cognitive therapy, dialec-
tical behavior therapy, and mentalization-based treatment.
Using case examples, the authors tell readers how to under-
stand and intervene in short segments, considering the “here-
and-now” few minutes, the present moments in a therapy
session. This will help therapists to understand on the spot
their otherwise often confusing or glossed-over moment-by-
moment countertransferences.
Is this perhaps too psychoanalytically deep for the non-an-
alytically trained clinician? I think not. First of all, the book is
written in lucid prose without much jargon. Second, the
depth is warranted by the complexity and nonhomogeneity of
borderline personality disorder. Third, the authors give spe-
cial care to informing clinicians how to protect the bound-
aries that establish a sense of the safety of therapy sessions.
This includes establishing clear contracts, choosing current
topics of concern that have priority and sage advice on how to
handle the many specific threats to the treatment.
These threats are seen as both symptoms and signs of psy-
chopathology and as tests of the integrity and skill of the ther-
apist made by the patient to see if he or she can safely go on. I
refer to such signs and symptoms (and tests) as suicidality,
homicidal impulses, substance abuse, dishonesty, and exces-
sive and provocative passivity.
There are too many worthy scientific articles and books for
every clinician to read everything. Even in the area of border-
line personality disorder, these authors do not quote all the
relevant literature, and if they did, the book might have be-
Am J Psychiatry 163:5, May 2006
View publication stats
BOOK FORUM
come unreadable. So who is the ideal reader of this work other
than a borderline personality disorder psychotherapy re-
search specialist? I think it would be the psychotherapist who
has completed his basic training and is perhaps 3–4 years af-
ter graduation. He or she will find many epiphanies and gain
the acumen of the highly experienced authors.
References
1. Horowitz M: Understanding Psychotherapy Change. Washing-
ton, DC, American Psychological Association, 2005.
MARDI J. HOROWITZ, M.D.
San Francisco, Calif.
Pathological Gambling: Etiology, Comorbidity, and
Treatment, by Nancy M. Petry. Washington, DC, American
Psychological Association, 2005, 415 pp, $59.95.
Although the field of systematic study of pathological gam-
bling is relatively young, spanning a little more than two de-
cades, Dr. Nancy Petry, herself quite young, has provided in
this book a sophisticated and scholarly review on the etiology,
comorbidity, and treatment of pathological gambling. Dr.
Petry presents an exhaustive review of the empirical literature
on problem gambling that will serve the novice, advanced
student, and researcher well in documenting what is known
about problem gambling and what is needed in future stud-
ies. The empirical data compiled is enriched by compelling
and telling case examples throughout the text.
After describing the classification system [levels 0-3], preva-
lence, and types of gambling, Dr. Petry draws on the case exam-
ples to describe the dimensions and experience of pathological
gambling and the often tragic consequence in a person’s life as
he/she becomes progressively involved with the process. She
starts with the more concealed and subtle manifestations, then
“comments,” and then “continues” her case examples. As Petry
indicates, there is a “dynamic” and progressive process with
problem gambling, which her case reports amply reveal. In a
number of instances the case examples are continued in subse-
quent chapters to demonstrate assessment and treatment is-
sues. The reader also benefits by her clear definitions, includ-
ing levels of gambling, and how such variables interact with life
changes which in turn determine the level of severity of gam-
bling behaviors. For instance, $20 per week for scratch tickets
might be harmless, but in the context of job loss or a new baby
it could become a hardship and the basis of marital conflict.
The author supplies a detailed citation and interesting reviews
of the existing studies on prevalence rates of gambling patterns.
When lifetime prevalence rates for problem gambling (level 2)
are combined with lifetime prevalence rates of pathological
gambling (level 3), the worldwide rate ranges between approxi-
mately 2%–6%, a little more than one in 20 individuals having a
gambling problem at some time in their life (the past-year rates
are in the range of 40%–60% of lifetime rates). Prevalence issues
are made more interesting when rates in special populations are
examined such as among substance abusers (significantly
higher), the elderly (in some studies comparable to the general
population and as tragic), and gaming patrons (not surprisingly,
higher). Petry also examines rates of different types of gambling
to determine if some are more addictive than others. Although
inconclusive, she speculates how internet and electronic ma-
chines might be the most addictive and why this might be so. Dr.
Petry provides data indicating that there have been modest but
ajp.psychiatryonline.org 945