Theoretical Groundwork
The primary target in the psychodynamic treatment of patients with borderline personality organization is to address the patient's internalized, constantly repeating, morbid behavioral pathologies and object relations that lead to chronic mood and cognitive pathologies. includes replacement. From the perspective of object relations psychoanalysis, this process can be described as follows: Rejective and primitive internalized object relations are healed from a state divided only into "good" and "bad" into a mature, integrated and more flexible form. This process takes place by studying the transference and the resistance to the interpretation of tendencies towards this division. Here, interpretation makes it possible to integrate and (re)internalize the divided good and bad parts.
According to Waldinger (1987), psychodynamic psychotherapy applied to Borderline patients is based on the following principles:
1.Treatment. It is necessary to bring up the stability of the conditions/frame from time to time
2. It is necessary to make therapeutic coping more active in the context of borderline patients' reflection mechanisms, distortions and problems in evaluating reality. This means that in borderline patients, compared to neurotic patients, the psychodynamic therapist must use more language and encourage the patient to participate more verbally.
3. The psychodynamic therapist must deal with the patient's "hostile" maladaptive behaviors and attitudes with a tolerant approach. and negative transferences must be disclosed and work on them.
4. The patient's self-harming behavior must be made increasingly impossible through explanations and confrontations, and this state of harm must now become ego-dyston. Thus, the secondary gains of the disease should gradually disappear.
5. Comments should be used to build a bridge between the patient's emotions and behaviors and to help the patient.
6. (depending on the fifth article) In this way, it is possible for the patient to live based only on his emotions and impulses and to stop the patient from harming himself, others and the therapy.
7. At the beginning of the therapy, especially NOW Comments based on I and HERE should be more prominent, and comments based on the patient's biographical history and THERE AND THEN should be made less.
8. Psychodynamic The psychotherapist should carefully monitor countertransference feelings.
Transference-Focused Psychotherapy (AOP) is based on Otto Kernberg's object relations theory. This approach, based on the British tradition of object relations theory (Fairbairn and Guntrip) and, first of all, the tradition of impulse and then Ego psychology, was developed in the 60s and 70s in the studies on the treatment of severe personality disorders at the Menninger Clinic in America. Particularly through his study of the concept of the "splitting" defense mechanism, Kernberg made a significant contribution to the fundamentals of understanding severe personality disorders. Object- and self-representations that cannot be integrated or distanced as moods are either overly idealized or devalued in order to protect the patient's self, and the patient attributes this idealization or devaluation either to his own self or to other people. This explains many of the clinically salient symptoms in patients with personality disorders (e.g., discontinuity in emotional and interpersonal relationships).
The starting point here is that the patient maintains pathological, internalized relationships from the past that he maintains in the here and now. It is an idea that is repeated unconsciously. These unconscious conflicts are anchored in the patient's personality in the context of object relations. These object relations not only affect the present but also impose themselves on the reality experienced by the patient (compulsion to repeat relations). Although internalized object relations in healthy and neurotic individuals show a certain continuity and generally include both positive and negative aspects (partial object relations), a splitting phenomenon stands at the center of the patient's object representations and self-representations. The difficulty in the therapy of these patients is the rapid changes that occur from one end to the other in the form of partial object relations, and these are often not perceived by the patient.
Basic Components of AOP
Therapeutic Entry 'Channels'
There are three entry styles that allow the therapist to reach the patient in an intellectual and empathic way, and these are called channels. To truly open these channels, an open, unprejudiced and accepting stance/attitude is required and is close to a classic 'free-floating attention'. Channels:
1. Verbal Communication (what is the patient telling?, associations, dreams, etc.)
2. Patient's actions and emotions (how is he telling? facial expressions, etc.)
3. The therapist's countertransference feelings (what feelings does the patient evoke in me?)
Verbal communication alone (channel 1) is often not sufficient, especially in severely disturbed borderline patients who are still suitable for outpatient treatment, because the central material may be split. and therefore the channel near consciousness may not emerge.
The excessive openness of some borderline patients may paradoxically mean resistance and indicate a lack of confidentiality based on trust.
Goals
Four central goals, which build on each other, have been defined so that the patient can integrate transference-based interpretations into his own internal system and how he tries to avoid anxiety experiences through splitting can be demonstrated within the self-therapy process. These goals accompany the whole therapy as an "internal lasso".
Goal 1: Identification of Dominant Object Relations
The problems that arise in the transference relationship between the patient and the therapist. Metaphorically interpreting examples of dominant (primitive partial) object relations behavior and showing them to the patient.
First Step: Learning and Tolerating Disorganization
Therapist working with a borderline patient , often at the beginning of therapy, the borderline patient must have learned that he/she may be dragged into a spiritual and mental confusion. Although the patient comes to therapy to get help, the therapist experiences behavioral patterns as if this therapy were a hostile situation, a threat, or a process with an uncertain beginning and end, that is messy and will not benefit him. The therapist must have the experience to tolerate this mess, because these motifs contain a lot of information and The therapist must be able to confront the patient's negative emotions.
Second Step: Diagnosing Dominant Object Relations
Always rely on representations of the patient's inner world that can only be observed indirectly. The best way to approach it is to capture and grasp the various roles it plays. Over time, the therapist must become able to identify a number of typical roles played by the patient in a sequence or order and to name them for himself and describe them with adjectives. To better understand the emergence of these roles, the therapist needs information about the emotions, desires, and issues in the patient's life about which he or she fears or worries. The therapist expands his observation by directing his attention to internal states that relate to the patient. Examples of this are emotional states or intense emotional states that seem foreign to the patient, the emergence of self-imposed needs or fantasies to take on or abandon a role. With these, dominant object relations become increasingly clear or visible. The important thing here is to pay attention to areas where agreement can be reached with the patient.
Third Step: Naming the Roles
Once the roles are clear enough, the therapist defines these roles in a way that is expressive and enriches the relationship. should name it. What is meaningful here is that the therapist waits for the right moment, which should be the moment when the patient's stormy emotional state related to that role decreases or softens, so that the patient can gain some distance regarding that role. The therapist should explain this naming not in a general way, but on the contrary, based on individual differences specific to the patient. For example, it can do this by explaining the emergence of the patient's beliefs and acceptances regarding that role. As a form of approach, it can connect the patient's emotion and the self and object representations in the formation of that role. Sometimes, in this way, the patient and therapist can find an increasingly close and common therapeutic language through the metaphorical naming of these roles. What is important here is that the therapist conveys a hypothesis to the patient, not a definitive reality. This should also be explained to the patient. Even if this hypothesis is wrong or does not fit, the patient should be told "yes, you are right" in this very accepting way.
Fourth Name m: Paying Attention to the Patient's Reactions
Regardless of the patient's acceptance or rejection of these active role pairs shown to the patient, from that moment on, it is a matter of focusing on what associations begin to emerge in the patient or the changes in his interaction with the therapist. is the next important step. The precise identification of the patient's previous dominant object relations either leads to a further strengthening of those roles or, with a sharp turn, to gaining distance from them, which the therapist sees. By reflecting this on the patient in depth, the patient feels that his emotional state is correctly recognized and defined, and this leads the patient to the association of new examples in this behavioral lane. Accurate naming also makes it possible to bring new therapy topics or associations that have not been expressed until now into therapy. In this way, the groundwork is prepared for remembering completely new and other object relations in the following hours of therapy.
Purpose 2: Observation and Interpretation of the Patient's Role Changes
The patient's response to himself or his therapist. Unconscious and disturbed self and object representations must be diagnosed and analyzed: The therapist defines role pairs. For example, the Victim-Perpetrator role. These role pairs are often the duality of self and object that remains active in the patient's role reversal, whereby these roles are displaced in both the self and the object through the processes of projection and absorption. Such a role reversal is often behind a sudden feeling in the therapist ("I've missed the connection" or "I can't understand this patient anymore")
As the therapy progresses, it becomes clear that the Self-Object duality does not just exist in the inner psychic system as completely independent, divided, fragmented components; On the contrary, it becomes clear to the patient that it continues to exist in connection with other unconscious dualities. These dualities, which become more clear in therapy, can be interpreted from the perspective of drive theory as different poles of intrapsychic conflicts revolving around libidinous and aggressive attributions. S
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