When a patient with borderline personality organization enters therapy, we as psychotherapists step into a space where emotional turbulence is the norm rather than the exception. It is in this phase that a distinctive type of therapeutic bond begins to emerge — one capable of containing anger, anxiety, disappointment, and at times, the intense urge to withdraw.

You have already completed the diagnostic phase, discussed diagnostic impressions and reached a mutual understanding, discussed the proposed type of therapy and its inner-research paradigm, clarified therapeutic goals, framework, and the ways you will limit the patient’s acting-out behavior. You have also discussed the principle of free association and explained your own responsibilities in detail. What comes next? Only after all this does the therapy itself begin.

The goals and related tasks of the early treatment phase reflect the nature of borderline pathology and the manner in which psychodynamic treatment begins to shape the interaction. 

The therapist begins to apply the treatment strategies. However, the goal of beginning to identify the internal object representations can take place only in a context that is not excessively disrupted by the patient’s acting out. 

Therefore, paying attention to adherence to the treatment contract, as well as focusing attention on deviations from it, is especially important in this phase of therapy. 

Acting out in this phase often takes the form of challenging or testing the frame of treatment that was established in the contracting phase. 

Another common early type of acting out comes in the form of the patient’s impulses to leave the therapy as attention to the patient’s intense affects and internal world provoke anxiety. 

If the early phase of treatment goes well, the patient begins to demonstrate increased control over impulsive and self-destructive behaviors in conjunction with an increased ability to experience intense affects. This progression is also in response to the elimination of secondary gain from acting out, as established in the treatment contract. 

As the patient’s impulse control is strengthened, his or her chaotic and socially inappropriate behavior is reduced—although not necessarily eliminated—outside the treatment setting. 

Limit setting tends to shift the experience of affect into the therapeutic relationship, where the underlying object relations dyads are activated in the transference. 

Limit setting and the decrease in acting out allow the therapist to begin to use the analytic techniques of TFP. 

Intense affects tend to become concentrated in the treatment situation, which has been defined as a space where all affects can be tolerated. 

The therapist has the opportunity to link the patient’s impulses to act and symptoms such as anxiety, rage, emptiness, or depressed mood to vicissitudes in the relationship with the therapist that reflect the dominant, underlying object relations in the patient’s inner world as they are activated in the transference. 

As the patient becomes more confident in the possibility of expressing intense affects in the treatment setting, the therapeutic alliance increases even as the therapeutic relation may be stormy at times.

The ability of the patient to experience and express intense affects in relation to the therapist and to come back to the next session reflects a strong alliance.

Even so, the patient’s urges to drop out may occur in response to a number of possible developments: 

1) the anxiety of reflecting on uncomfortable aspects of the patient’s internal world, 

2) increasing attachment to the therapist that may be threatened by the anxiety of attachment itself and by related fears of abandonment, 

3) initial glimpses of awareness of dissociated or projected aggression, with paradoxical increases in paranoid reactions in the transference.

At this stage, the therapist’s primary tasks are to:

• maintain the continuity of the process,
  
  
• refrain from premature interpretations, and
  
  
• tolerate confusion and the tension necessary for the development of therapeutic relationships.
  
  

It is precisely within these moments that the true therapeutic alliance begins to take shape — one that does not avoid emotional storms but learns to navigate through them.

(c) Yuliia Holopiorova,

Ukrainian Association of Transference-Focused Psychotherapy

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