In work with borderline personality organization (BPD), we often encounter the same dramatic core:

a split dynamic in which constant shifts between polarized states (hatred and opposing affects) prevent the relationship from complete collapse.

The patient lives in an internal world where the “injured self” and a sadistic object endlessly pursue one another, exchanging places—the victim becomes the aggressor, and the aggressor experiences themselves as entirely vulnerable.

It is precisely from this point—from the inability to tolerate one’s own aggression without destroying either the self or the other—that the deeper therapeutic work begins. In Transference-Focused Psychotherapy (TFP), this process gradually leads to genuine structural personality change. 

This internal configuration does not remain static—it manifests in the specific dynamics of the patient’s psychic life. In addition, projection leads to corresponding fears of the object’s hatred toward the self. Interference with the experience of libidinal, affiliative, loving affects is clear. The process of overcoming the internal split and bringing affects of aggression and hatred into an integrated self includes the patient’s becoming aware that these affects are part of the human experience and that, if integrated and mastered, they do not destroy any possibility of experiencing oneself as a decent human being and experiencing gratifying relationships. Containment and tolerance of the awareness of aggressive and negative affects, in contrast to their expression by acting out, somatization, or destruction of the communication with the therapist, is a sign of an advanced stage of treatment.

The decrease of manifestations of aggression is seen in changes in its direct expression in sessions, in a decline in aggressive dismissals of whatever the therapist offers, and in the reduction in sadomasochistic transferences.

In TFP, this becomes particularly evident in the way the interaction within sessions changes: instead of immediate devaluation, rejection, or attacks on the therapist as a “bad object,” the patient gradually develops the capacity to hold tension within the relationship, explore their own reactions, and tolerate ambivalence—the simultaneous presence of aggression and the need for the other. 

In addition, negative therapeutic reactions as the expression of unconscious envy of the therapist (i.e., the need to defeat the therapist’s efforts) resolve, as do characterologically anchored self-directed manifestations of hatred, such as suicidal, parasuicidal, and self-injurious behaviors; substance abuse; eating disorders; severe self-destructive sexual behaviors; and/or relentless self-loathing.

At this stage of the treatment, the most destructive aspects of the patient’s sexual behavior should be under control or, in those cases characterized by an inhibition of sexuality, sexual feelings can now be experienced. In the early stages of the treatment, the dominance within some patients’sexual behavior of severe aggressive and self-aggressive trends interferes with all intimate love relationships. This could consist of promiscuous, unsafe sex; sadomasochistic sex; or, more subtly, serial affairs that are based on the quest for the ideal object and that destroy the possibility of any in-depth relationship. Alternatively, in some cases these patients present an absence of all sexual engagements. A general increase demonstrated in sessions of the patient’s concern for his or her love life and sexual interactions indicates an improvement in the patient’s functioning in the sense that sexuality is no longer dominated by aggression and libidinal desires are no longer overshadowed by paranoid fears. 

In TFP, these changes are understood as the result of the gradual integration of internal object relations: as representations of the “bad” and the idealized object are no longer split, the patient becomes able to experience the other as whole, and relationships as stable and capable of withstanding ambivalence.

A potential problem in the advanced stages of treatment, however, is that in cases of severe primary inhibition of the sexual response, such inhibition may increase as the patient’s general functioning improves and repressive mechanisms replace more primitive dissociative or splitting mechanisms. This is a complication that may require modification of the psychotherapeutic approach, such as combination with sex therapy once the patient’s severe inhibition of sexual desire has been sufficiently reduced to make the unconscious dynamics of this primary sexual inhibition clarified enough to permit an integration of psychodynamic psychotherapy and sex therapy.

It is precisely this capacity to tolerate and integrate aggression without разрушая relationships that defines deep structural personality change in the course of therapy. 

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(c) Yuliia Holopiorova,

Ukrainian Association of Transference-Focused Psychotherapy