(1989). Contemp. Psychoanal.

, (25):393-411

Borderline Children and the Dilemma of Therapeutic Efficacy

Gerard Donnellan Ph.D. 

THE CLINICAL PERCEPTION AND understanding of borderline children is

circumscribed by the models we employ (Sandler & Rosenblatt, 1962). Many
clinicians find theoretical models useful which resonate with their experience,
and clinical descriptions helpful in the conduct of analytic child psychotherapy
(Rosenfeld & Sprince, 1965) ; (Ekstein, 1980) ; (Logan, 1985). The paucity of
relevant literature, coupled with one's need to conceptually attend to one's
clinical work, pushes clinicians to fabricate make-shift theoretical constructions,
borrowing a little here, a little there. Such borrowing leaves one theoretically
adrift, despite one's conviction of the significance of the treatment.

This paper aims to highlight and outline some of the fundamental clinical
implications raised by conceptual formulations on borderline children, while
offering alternative views which appear in tune with their developmental
realities and clinical presentations.

One-Person and Two-Person Models

Pine (1985) recently delineated a comprehensive and clinically-attuned

conceptual structure within which so-called "borderline children" might be
considered. He suggests two major developmental impairments which
distinguish borderline children from others: disturbances in ego functions and
in object relations. The sense of reality, reality testing and the signal function of
anxiety generally show major dysfunction (Fairbairn, 1941) ; (A. Freud, 1957) ;

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Contemporary Psychoanalysis, Vol. 25, No. 3 (1989)

393

(Chethik & Fast, 1970). Fluidity and instability of the ego and poorly articulated
ego functions seem to predominate (Weil, 1953) ; (P. Kernberg, 1983).

Developmental failures in object relations manifest in shifting levels of object

relations, great dependence on object contact, and regression to primary
identifications (Rinsley, 1980). In relation to others there seems to be loss of the
sense of self (Fast & Chethik, 1972) and a slip into an undifferentiated self-other
duo", which Masterson (1972) speaks of. This tendency to regress in the face,
perhaps, of intense affect or overwhelming situational factors, appears central
to many descriptive approaches to these children (Ekstein, 1980) ; (Anthony,
1983) ; (Pine, 1985).

The concept "borderline" is a spatial metaphor, as Pine (1985) notes, and

derives from a drive/structure model, a model which speaks of energy, drives,
transformations of energy, the development and articulation of boundaries and
structures, ego functions and identificatory processes (Greenberg & Mitchell,
1983). For diagnostic and evaluative purposes, such categories prove useful.
The frustration one eventually faces, however, is that such perspectives do not
capture the living reality of the child one treats by describing impairments in
ego functions: the sum of the psychic/anatomic parts does not equal the living,
breathing child with whom we work.

Yet, we must communicate with others and order our observations. And we
may have to make do with the compromises that we have available at present.
However, this bears further consideration.

While continued attention to the borderline concept has clarified many areas
regarding the borderline adult, similar attention is needed regarding children
(Shapiro, 1983) ; (Vela, et al, 1983). The choice of the lens with which we focus
our attention is consequential. If we consider the experience and
communication of affect, so central to any consideration of such children, we
have some choices. Affective life may be considered as an intrapsychic
experience which the person regulates and has some relation to, i.e. it is a
function of the ego. Affective life may also be viewed with an interpersonal lens,
i.e. as Modell (1984) puts it, affects are always "object-seeking". These divergent

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views on intrapsychic life vs. interpersonal life, one-person and two-person
models, may consider

394

the same clinical reality while filtering and delimiting our perceptions and
formulations.

To return to the consideration of affect, if one posits that affects are object-
seeking, as does Modell, then the communication from the child, via affective
interchange, is real communication to us: about themselves, us and the
situation. Thus, when a child expresses anger at me for not understanding, the
anger is a real statement about his relationship with me: it is perhaps distorted
and overdetermined, yes, but is it is also an attempt to make me real, to have
me understand him. Just as the little boy in a popular children's story makes the
velveteen rabbit real, in communicating his anger the child is trying to make me
real, as his need to be understood becomes real to him. He is not just suffering
from a broken ego function.

In another view, there is no ego without the other. The ego of the borderline
child needs another ego in order to change. This is an affective tie, and it is this
affective tie to us which allows the child to step into the unknown and risk
finding something new—a scary prospect. There may be another way, then, to
think about these children—as children whose affective life is confused, murky
and terrifying to them. The other, the therapist, throws the child a life-line to the
real world—the world the child has escaped. If we place the understanding of
the child's experience of and communication of affect central to our
consideration of these children, we may feel more for them and, consequently,
understand more about what we can provide in treatment.

Modell (1984) offers a bipartisan compromise to the dilemma of which lens to

use in our considerations of these children. He suggests that neither a one-
person psychology nor a two-person psychology stands alone, and that each
offers a singular view of the person as a relational being or as a solitary entity.

Choice of Model

With its roots in drive/structure approaches, the concept of "borderline

children" may be limited in its usefulness for a treatment which focuses on
intrapsychic change through symbolic transformations in the child's inner
representational world (Sandler, 1983). A melding of the two views, the one-

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person and two-person psychologies, is a clash of sensibilities, leading
nowhere,

395

I believe, but to a blurring of the contributions of each (Greenberg, 1986)

(1986b). Each view is intrinsically irreducible and irreconcilable with the other.
Symbolic play, countertransference, dreams and fantasies in child analytic
therapy all occur in a dyadic meeting place of child and analyst. The analytic
posture requires of both child and therapist a mutual disregard for reality, as
the playroom becomes the shared world of the two actors in the drama. Such a
view of the therapeutic experience does not easily transliterate into the
metaphor of drive. And, as some would argue, it is impossible for it to do so
(Modell, 1984) ; (Greenberg & Mitchell, 1983).

And, this may be where Modell's thoughts may be of assistance; the drive/
structure view appears useful when we consider the person after
internalization has occurred; the model may more aptly apply to more
"structured" individuals. Partial or incomplete internalization more closely
describes the state of affairs of borderline children: internalization as a
developmental process has been interferred with. And the process has been
tampered with by others—the important objects in the child's life. Here, we are
drawn into the interpersonal sphere.

In the view of a one-person psychology, internalized ego structures are ill-

defined and incomplete; clinically, the child appears "stunted" in many areas of
ego development. The therapist, within this model, believes he can get the child
back on the developmental track if he provides the child with the corrective
experience of the therapist's own good reality testing, judgment, modulation
and control of drives, and understanding through interpretation of the
transference.

Already, however, the therapist has shifted from a focus on the debilitating
intrasystemic ego deficiencies of the one-person model to what the therapeutic
situation is, two people attempting to understand the confusion and pain of the
child. This shift derives from the therapist's belief that he can provide what is
needed to correct the developmental deficiency, even when this belief is
unarticulated by the therapist. The therapist focuses on understanding the
nuances of the interaction with the patient. Even when relying on drive/
structure formulations, there tends to be this move on the therapist's part
toward understanding the nature of the interaction with the patient, with less
emphasis on the structural

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 396

deformities of the patient, for it is within the therapeutic two-person interaction

that the developmental unevenness takes form.

The therapist wonders about the nature of the affective ties between himself
and the young patient, again representing a shift in the mode of internal
discourse on the part of the therapist. Guided by the shifting of the child's
affect and the structural and symbolic transitions of the play, the therapist
infers something about the child's experience with him in the consulting room.

For many of us, understanding and thinking is limited by the vocabulary

available to use from our metaphorical models. More descriptive, imaginative,
allegorical formulations about the patient may add substance, texture and life
to our wonderings about these particularly troubling children. Such
formulations may sharpen the focus of the interchange, highlighting the
therapists affective experience and, perhaps, enhancing his effectiveness.

Let me turn to the nature of the tie which grows between patient and therapist.

The Tie between the Child and the Therapist

More than anything, these children demand from their therapists. In one way
or another, they seek answers about why the object world is the way it is and
why they are the way they are. The formidable denial of these children, in its
varied guises, assaults our sensibilities about who we are, how we construct the
world the way we do, and what we believe to be true about object relatedness.
The assaults may be direct and palpable, or only inferred from the child's
distancing from objects, withdrawal or more regressive behavior.

It may be that the therapist's toleration for and understanding of these assaults
reflects the depth and pervasiveness of the child's confused denial of reality. By
playing dead or hiding in a cocoon, the child reveals that he is not really dead,
but hiding.1 The child living in the cocoon has the opportunity to emerge into
the safe atmosphere of the consulting room. It is the therapist who
communicates

1Certainly, this contrasts with the psychotically depressed child who feels dead at

heart, whose self may, in fact be dying, suffering the torture of living in a world
he feels so apart from, which he feels cannot understand him.
397

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through the membraneous wall; who interprets the world to the child,
describing what it is like in the sun, what if feels like to be separate and what is
possible when one emerges from the cocoon (Donnellan, 1989).

The child's life in the cocoon, in the presence of the interested, patient
therapist, is not too bad. It is comfortable and safe, although the child feels
cramped after a while; he is self-sufficient, or at least appears so. The therapist
waits and reveals his presence to the child, without demanding. The demands
or wishes of the child, in this way, are enacted in the transference: the child
wishes the therapist to be there without doing anything the child does not
want, nor making demands on the child. The patients discussed by Chused
(1982) highlight the transference re-enactment clearly: these children feared
the overwhelming intrusion of the other person, and when in the analytic
situation, attempted to control the analyst.

The patient attunement of the therapist outside the cocoon creates an

ambience surrounding the child—the child feels something, apparently
emanating from the space between patient and therapist. What the child feels,
at first vaguely, is the quiet caring of the therapist/mother who makes no self-
serving demands on the child. In such an atmosphere the transference
flourishes, buds and blooms. At some level the child responds to the mutually
created, illusory and shared environment—for this is what the child yearns for
and fears.

The yearning for that early closeness and the fear of engulfment has paralyzed
the child in the past. This terrifying ambivalence leaves the child being torn
between the disparate internal representational constellations around the
yearning and the fear. The cocoon allows the child to experience, slowly and
deliberately, the curious, inevitable pull toward the object and the fear of his
being overtaken. What allows the child to tolerate this heartfelt struggle is the
perception of the therapist as dependable, interested and, most importantly,
not seeking self-gratification through the child. If the child perceives the
therapist as seeking self-gratification, e.g. by controlling the child in some way
(other than for safety reasons), making the child behave as a "good boy", the
yearning and fear will never emerge fully nor be experienced by the child in any
way other than as confusion and destructive rage.

398

The therapist, if he seeks self-gratification through the child, colludes with the
child in denying reality, does not truly permit the child to begin to separate, and
ultimately, while attempting to be a newly-experienced object to the child, is, in
actuality, an old object in newer clothes. Still recognizable to the child as an old

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object, and not really new, the child remains unconnected to the newer aspects
of the therapist. He feels unsafe, remains defensive and denies reality; he
changes little, essentially. His stance, undoubtedly frustrating to the well-
meaning therapist, is, however, in keeping with the demands of the situation:
he is responding as he has learned to respond, for the primary pathologic
situation has been re-created, is real and the child must now protect himself
from danger.

In every sense, this is the real situation of the treatment as I have described it
and it is hopelessly deadlocked unless the therapist can allow the child to use
him as a representational figure in his inner world in a safe way (Sandler &
Rosenblatt, 1962). "Safety", in this sense, means at least not creating a collusive
environment which denies reality, i.e. that the therapist is driven to collude by
his own self-interest, although this is denied to the child and, perhaps, to the
therapist himself, but creating an atmosphere in which the therapist truly wants
nothing from the child, allowing the child to use him to turn to while both
wander through the encrusted, archaic civilization of the primary pathologic
situation (Sandler, 1960) ; (Winnicott, 1965).

The recreation of that lost civilization reflects the child's wish to change the
past, change himself and become a separate, individuated person. The affective
tie to the therapist becomes stronger and clearer as the child experiments with
the new feelings of being separate. The cocoon becomes the experimental
chamber within the analytic laboratory. The senior scientist allows the junior to
learn from the explosions and tests. The child learns that he does not have to
take care of the therapist—for the therapist does not need him for that; he
does not have to protect the therapist, for the therapist can do that for himself.

And, for the longest time, the therapist will be the willing dupe, the object of
the hatred, anger, desire and yearning. He will act in the child's play and not
change the lines, nor attempt to re-write the play, unless perhaps he is invited
to do so; he knows it is the

399

child's play and that he is only a visiting bard, permitted in the theater and on
the stage at the child's discretion (and sometimes whim).

Interpreting within the Child's Metaphor

What I am here describing is a phase of treatment with these children which

focuses on the therapist's attending to what the child is recreating in the

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transference, while the therapist uses interpretation to structure the affective
experience of the child. During this phase the therapist listens, observes and
interacts in a manner which is consistent with the associations embedded
within the play of the child. This does not mean that the therapist is mute and
uninvolved; rather, he acts consistently in a manner to establish himself as a
new object within the child's representational world, while allowing the child to
transferentially re-invent the primary pathologic situation with the therapist as
"something like" the old object, and "something like" the longed-for new object
(Greenberg, 1986b).

The ambiguity and complexity of the therapeutic situation affords the child the
opportunity to experience the therapist as the hated, devouring or suffocating
partner of that primary pathologic situation, while sumultaneously beginning
to experience the therapist as a benign, caring, interested person who attempts
to give meaning to the child's affective experience within this newly created
situation.

What Racker (1968) calls the "myth of the analytic situation" is that analysis
consists of the interaction of a healthy person with a sick one. In my view of this
phase of the treatment with these children, in order for the child to trust and
reveal his perceptions of the therapist, the internal world of the child must be
made real in the consulting room with the therapist, such that the child
experiences the therapist as somehow sick, or depriving or disgusting, or
whatever, and himself as the actor who perceives that in therapist (Searles,
1975).

As Benedek (1953) observes of the patient who "bores his way into the
preconscious mind of the therapist" (p. 203), so too, the child "bores" his way
into the internal world of the therapist, disturbing things a bit. This internal
disturbance unsettles the therapist who may be well-defended in other aspects
of his life, for the child, somehow, has managed to get inside and confront
some of

400

the characters on the therapist's internal stage. Yet, it is precisely this

infringement on the therapist's affective experience which allows the therapist
to begin to understand the child before him. The therapy and the child become
real for the therapist—and shouldn't this be so?

This intrusion by the child into the therapist's inner world accomplishes several
things for both child and therapist.

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First, it allows the therapist, as I've said, to understand the child, i.e., to
empathize with the child's experience of the world, of what he has experienced
passively.

Second, his affectively-rooted experience of the child allows the therapist to

interpret for the child, what that experience has done to the child, how he has
had to defend himself from it, how he has maintained the defenses which he
may begin to find out may no longer serve him, etc., in a manner which the
child can take in: the interpretation derives from the shared, though not fully
articulated, experience of child and therapist. Thus, the therapist understands,
because he knows it from the interactions with this child, thereby disallowing
diffuse or countertransferentially-based interpretations resulting from the
unexamined emotional reaction of the therapist to the child.

Third, the therapist, aware of what the child effects in him and aware that his
thoughtful understanding of his personal reactions to the child can be useful to
his work with the child, finds interpretations of the transference to be a more
natural part of their relationship, for it forges a meaning in the child's
experience, while avoiding objectification of the child's intrapsychic state.

Hoffman (1983), in commenting on Racker's "myth of the analytic situation",

emphasizes the view that the analyst reacts to the patient emotionally, perhaps
an obvious point. He adds, "what is more, every patient senses this, consciously
or unconsciously." (p. 408). The child patient perceives his effect on the
therapist—at some level. And the child senses some reaction on the therapist's
part, if the situation is to be in any way real, i.e. if the child is to experience
himself as real with the therapist. This preconscious knowing by the child
becomes the arc to the child's experience and understanding of himself as real
or not. For the child who relies heavily on defensive denial, the demarcation
between what is real and what is not is crucial if there is to be any therapeutic
headway.

Oftimes these children are uncannily adept at assessing and

401

tuning into the idiosyncratic vulnerabilities of the therapist. For example, the
tidiness of the therapist's office may be the cue to the child to "mess up" and
"gross out" the therapist with anal talk and references. In such instances it may
not be the astuteness of the therapist's observations or the incisiveness of his
comments which strike a responsive chord in the child, as much as the fact that
the child effects a reaction in the therapist. A sense of efficacy and personal
influence on another fosters within the child a more active, separate self.

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Just commenting, "You seem to want to make a mess today", first of all
communicates to the child that the therapist is observant and attentive to the
child. Secondly, the child, over time, responds to the non-judgmental attitude of
the therapist reflected in such a comment. The mere statement of the
observation tells the child that the therapist willingly sits with him without
judging. And, thirdly, the neutrality of the statement leaves the door open for
both child and therapist to wonder about the messiness, without accusation or
alarm. As Chused (1982) notes in the discussion of her cases, "But it was the
experience with the neutral analyst that permitted the child to reclaim, as it
were, his own drive to mastery." (p. 25).

Clearly, the response, "You seem to want to make a mess today, " may not
suffice for the child who seeks to re-create a demeaning, humiliating or hostile
atmosphere. And so, he ups the ante to create the personally-specific
transferential scene. The transition after the therapist's comment will tell the
tale of what the child attempts to re-enact.

The continual replay of the eliciting behavior on the child's part (breaking the
therapist's favorite toy, for example), the therapist's responsive commentary,
and the transitional developments that ensue, reveal the associative links of the
child's internal dialogue. Thus, the therapist's response, in whatever form,
including silence, is crucial to the unfolding of the child's associations. And
central to that response of the therapist is the therapist's affective experience
(Greenberg, 1986c).

Something is "in the air", as Hoffman (1983) refers to it, between patient and
therapist. It is the growing connection between patient and therapist which
emerges from the experience of their separateness—each of the other. The
child, many times in pain and confusion, gradually experiences his
separateness from the

402

therapist; the therapist, sometimes with anguish and frustration, sometimes

with joy, experiences the child's growing separateness as a loss and as a move
toward a newly emerging wholeness on the child's part.

Each brings something to the interaction which is unique and flawlessly clear: a
willingness to experience in the presence of the other. The therapist attempts to
foster an "atmosphere of safety" (Sandler, 1960) ; (Schafer, 1983), allowing the
child to recreate elements of the primary pathologic situation with someone
who permits the child to reveal his internal story.

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The initial phases of treatment, perhaps of several years duration, require
continued patience, self-monitoring and understanding on the therapist's part
that the correctness of one's interpretation alone is not therapeutically
efficacious. The interpretation must be coupled, I believe, with the child's
perception that he has effected something in the therapist, that the therapist
has felt. I believe it is the strength of the affective tie, particularly with children
who are damaged early in their lives, that allows the child to test himself
against the therapist, to find out who he is in relationship to the therapist, and,
ultimately, to listen to what the therapist has to say—how the therapist makes
sense of the child's internal world.

The point of view taken here is consistent with Hoffman's (1983) discussion of
the "patient as interpreter of the analyst's experience". His fascinating and rich
paper suggests, among other things, that the consulting room is not a sterile
surgical field, nor is the analyst the blank screen or container for the patient's
split-off part-objects. Rather, within the social paradigm which Hoffman
elaborates, the experience of patient and therapist in the consulting room, or
playroom in our case, is layered by "reciprocal conscious, preconscious and
unconscious responses in each of the participants." (p. 412–413).

Hoffman's point in this regard, although a substantive departure from more

classical views, finds its roots in the work of other theorists. Strachey's (1934)
remarkable early paper, for example, contains the seeds of a point of view
which allows for the "mutative interpretation" being tied to the patient's
affective experience of the analyst. Greenberg (1986c) contends that the social
view of transference "is an invevitable counterpart of the theoretical emphasis
on the situational side fo the [Freud's] 1926 model." (p. 19). Indeed,

403

the thread linking commentators on this subject is the relative emphasis placed
on the analyst's experience of and reflections on his experience with the patient
as valuable and necessary tools if the patient is to feel understood by the
analyst, and, thereby, be willing to consider the interpretative comments made
by the analyst.

In line with this thinking, these children, so given to denial and regression, do
make observations of the therapist and do have impressions of the therapist. If
the correctness of the child's observations of us is never addressed, the child is
left confused and unable to separate out his observations from the distorted
impressions of those observations. The sorting out of the observations from
the transference distortions is central for a child whose perceptions are so
heavily blurred by intrapsychic factors. The social paradigm suggests that

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transference is rooted in the observations by the child of something which is
real and that realness is embodied in the transference (Greenberg, 1986, c).
Thus, these children wish to make us real as they wish to make themselves real.

Being real, on the therapist's side, does not mean being "nice", not confronting
the child with his distortions, or behavior, nor relying on the therapist's self-
revelation to have the child comprehend what is real and what is not. It means,
rather, believing that the therapy with the child is a shared enterprise in which
the transference is part of the relationship between the two, while the child is
permitted to explore, along with the therapist, the meaning of the relationship
in the present and the roots of the relationship in the past. The attitude of the
therapist allows the child to "muck around" with what was unsafe in the past:
his own impulses, his desire for or rage at the object, his fears and his yearning.

One's promotion of the child's risk-taking entails an inevitable self-exposure for

the therapist. If the therapist retreats to a self-protective stance, in the name of
analytic neutrality, he will have missed the opportunity to allow the child to
"find out" through him. Neutrality, as it translates in the work with these
children, does not mean being grey or affectless, but being real without being
the self-absorbed or punitive old object.

What Sandler (1976) refers to as the "intrapsychic role relationship which each
party tries to impose on the other", is revealed in the preconscious responses
of the therapist to the child. When we

404

notice these responses they are usually bits of our behavior which strike us as
different from what we ordinarily might do. A clinical vignette illustrates this
point.

In the course of treatment with a latency-age boy much of the fantasy play
centered on the child inhabiting a cave. The cave consisted of two tub chairs
overturned to form an enclosure. At various times he would be a baby bear, a
boy or some dangerous animal. I was to sit outside the cave and try to
communicate with him, inside the cave. It struck me several times over the
years that this fantasy had to be enacted according to the child's directions, and
that I wasn't allowed to change the play or decide to be another character.
Indeed, I was cast in a role. After some time I could wonder with the child why I
was cast in this role, what meaning it carried for him, etc.

The fact that I remained in my assigned role allowed me to wonder and analyze
its meaning. Initially, I had little clue as to the personal meaning this enactment

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had to the boy; with time, the meaning emerged: I was to be the interested,
concerned, non-intrusive mother who hoped that the child was OK inside the
cave, but who would rather see the child outside, when he was ready. My
boredom, frustration and fascination with these enactments suggested
something to me about the child's experience of being the pawn of others,
having no say about his role, how he felt excluded from real contact with people
and how he felt alone with chaotic, intense feelings. (Myerson, 1981a), (1981b).

Thus, my reflections on the context of the play, my own affective responses and
my hunches about the nature of the boy's internal drama led me to conclude
that I was participating in the reenactment of an interaction. If my interpretive
comments had focused on the projective elements of what the boy enacted, I
suspect he would have felt misunderstood, put down, angry, confused and
alone. My more usual approach to interpretations with neurotic adults and
more developmentally advanced children might well have focused on the
projective elements of the interaction—an interpretation more utilizable to the
person who has achieved some degree of ego-autonomy and toleration for
separateness.

But my comments stayed within the metaphor of the play: "I wonder if the baby
bear is OK in there? It's kind of dark and I hear him moving around. Hey, he
stuck his paw out! Maybe he's

405

saying hello to me." Comments along these lines would elicit further
elaboration of the baby bear's needs, wants and fears. The child's further
elaboration suggested to me that I was getting to understand my role and how
he wanted me to be. Over time, the baby bear told more about himself,
allowing me, eventually, to interpret particular transferential elements as they
appeared in the play.

Following Sandler's (1976) observation that the patient attempts to impose an

interaction with the analyst, the child elicited in me "useful"
countertransferential feelings, which could be utilized to further the work of the
therapy. My response to his petulance and feckless abandon, or my sadness
when considering the links in the play to his early, severe deprivations, found
their way into my comments and observations about the play.

This situation, that the analyst's felt experience finds its way into interactions
and interpretations is expectable and unavoidable. It may be regarded as the
compromise between the demands of the child to reenact earlier interactions,

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the affective response of the therapist to the child, and the thoughtful,
considered analytic stance with the child.

Child As Agent

The interaction which the child imposes on the therapist has its developmental
beginnings in experiences of having been left alone with confusing, chaotic or
overwhelming affect. Passively experienced, unarticulated situations of
abandonment, rejection, violence and powerlessness have a certain
developmental outcome: the child cannot separate his own from another's
responsibility for situations; he has little sense of himself as agent acting on his
own behalf.

Myerson (1981, a), (1981b) suggests that feelings of desire and anger,
particularly, are unarticulated, and, thus, remain hazy, diffuse and unsafe.
These unarticulated affective experiences remain unintegrated into any
coherent sense of self, fostering a sense of powerlessness, ineffectiveness and
confusion regarding the emotional intricacies of human relatedness.

Central to this confusion is the child's experience of having been left alone with
distressing, chaotic affective situations. The situation was not made
comprehensible by the parents, such that the child could not hook his affective
experience onto any articulated meaning. Thus, events were not causally linked,
but began to appear

406

as discrete, floating happenings, related neither to each other nor to any other
continuous internal or external process.

Adult patients, in describing this experience of causal irrationality and affective

disconnectedness, portray a feeling of being invisible, ineffectual, incompetent
and powerless. Children reveal this in their affect storms, bland withdrawal and
their lack of "being in tune" with another's affective experience. Thus, the child
who feels less than an active agent has not been helped in the past with
distressing affect—he has had no one to shape that experience into meaningful
feelings of desire or anger.

Myerson (1981, b) sums up the child's predicament:

By and large they have not been helped to accept responsibility for
their desire and their anger. They have not been helped to mitigate the

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 kind of magical thinking where they feel they have caused harm to
befall themselves or others. In fact, their notions of the causal
relationship between events is quite confused, blurred and magical.
They have limited potential for making realistic discriminations
between alternative causes of or alternative results from the events of
desire or anger. Their difficulty in accepting responsibility for their own
desires and anger goes along with a strong tendency to account for
these events as caused by someone or something external to
themselves (p. 177).

This developmental lag, in another view, has consequences in terms of the

child's sense of self and his experience of the world. The tendency to denial and
externalization reflects the child's experience of confused powerlessness.
Experience is not internalized, since no one has helped the child "bring it in"
and master it. A less articulated sense of self, or agency as Myerson prefers it,
results in this tendency toward defensive denial, externalization and
withdrawal.

In discussing the concept of defense, Stolorow and Lachmann (1980) make

what they consider a crucial distinction between "defense" and "prestages of
defense". Put succinctly, defenses ward off components of structural conflict,
whereas "prestages of defense" speak to developmental arrest rooted in
incomplete self-other differentiation. These "prestages of defense" are
precursors to defenses, prior to the consolidation of self and object
representations. The structuralization of self and object representations allows
for the experience of structural conflict, thereby necessitating defensive activity.

Before structuralization of self and object representations, there

407

is a diffuse, global flavor to the child's experience. Structuralization of internal

representations occurs within a social context, i.e. with another person. If, as
I've described, the child lacks an interpreter for his experience, he is left without
the tools to organize experience, other than in a global, diffuse manner. The
frustration one often experiences with these children, I believe, derives most
times not from our ineptness as therapists, nor from the intractability of the
child's patholgy. Rather, the frustration many times reflects the "lack of fit"
between what we believe to be therapeutically mutative, and the
developmental needs of the child (Sandler, 1983).

A resonating, empathic response to the child's distress seems insufficient, as

does the correctness of the transference interpretation, to account for

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therapeutic change. The child must experience with the therapist that whatever
happens, he, the child, is not the sole mover of the world, i.e. that events occur
in relation to other events, as one's affective experience occurs in relation to
other people. For example, if the therapist is notably distressed in an hour,
denial of the upset, or asking for the child's thoughts about the therapist's
upset will only further confuse and disturb the child. A simple
acknowledgement of the correctness of the child's perception, without undue
self-revelation, will allow the child to explore his own upset, what it is like for
him, what it means to be upset, the different kinds of upset, etc. The
withdrawal, anger, denial and externalization we sometimes see in response to
our interventions, in this context, is appropriate and indicative of the child's
inability to discriminate affects and really understand what we say. They must
feel listened to, yes, but more importantly, they must feel that we will help them
make sense of the distressing affect.

In the above example, if one is distressed, or whatever, the child looks to us to

see how we make sense of the distress, leading him by example to learn how to
make sense of his distress. The child will never be able to articulate his internal
distress, much less understand it, if he does not experience the therapist as not
only caring, but experiences the therapist as an active agent, working on the
child's behalf.

The apparent dissonance between being an active agent for the child and
remaining neutral is disspelled if one maintains, as Chused (1982) calls it, "A
non-judgmental willingness to listen and

408

learn." And, as Myerson (1981) says, "The analyst will have offered him the kind
of help he [the child] originally needed from his parents to become a more
active agent." (p. 179).

Strivings for mastery, competence and agency unfold within a child in the
context of a relationship with another person who allows the child to
experience desire or anger, without intruding, coopting the child's experience
or denying the reality of the child's experience.

The child's experience of un-understood feelings and fantasies of himself, his

expression of them, and eventual acknowledgement of them and
understanding of them, is the aim of analytic psychotherapy with these
children. We may tend to rush toward the understanding, leaving the child in
dusty confusion. If, as therapists we can tolerate the child's struggle to
experience and express hitherto unarticulated feelings and fantasies, the

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understanding of them and integration of them by the child will stand as
testimony to our collaborative efforts.

Conclusion

This line of reasoning suggests several fundamental concerns about the

implications of our psychodynamic formulations for psychoanalytic
psychotherapy with children we call "borderline":

1. Is this a useful term at all for analytic therapists attempting to understand

the nature, function and aim of the interactions with these children?

2. An emphasis on ego functioning leads to very different ways of thinking

about and treating such children, in contrast to the view presented here, which
emphasizes the interactional aspects of their development and presentation in
treatment.

3. Treatment, at least for some time, might well be geared toward

understanding the nature and aim of the enacted interactions or the function
of the imposition of roles in the therapeutic encounter, rather than focusing on
the dysfunctional components of the child's ego development or the drive-
dominated wishes of the child re the analyst.

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