The Borderline Ego and the Working Alliance: Indications for Family and Individual Treatment in Adolescence

The borderline patient is characterized by serious ego weakness with a pathological use of splitting as a defence. During his adolescence, the patient's difficulty in distinguishing the therapist from his projections of internalized (split) objects can be severely aggravated by concurrent regressive family interaction which repeatedly confirms these projections. Because of this family regression, there may be increased difficulty in sustaining a stable working alliance with the use of individual therapy alone despite the use of technical modifications (decreased frequency of sessions, limit-setting, manipulation, etc.)

The authors suggest that in the treatment of borderline adolescents, the presence of the individual therapist in concurrent family therapy can clarify the reality of the family's regressed behaviour for patient and therapist with the aid of the therapist's observing ego. In the individual transference, when the patient's regression evokes a re-enactment of these interactions with the therapist, this shared experience can be called upon to supplement and support the working alliance. The authors provide parallel excerpts from family and individual treatment to illustrate the use of this concurrent treatment approach.