Meeting of the New York Psychoanalytic Society

October 11, 1960. THE DEVELOPMENT OF THE THERAPEUTIC ALLIANCE IN BORDERLINE PATIENTS. Walter A. Stewart, M.D.

The borderline patient is described as having an impairment in reality testing, poor judgment, intolerance of frustration, and as showing rapid regression, primitive object relations, and a tendency toward primary process thinking. Real and traumatic deprivations are major etiological factors, often occurring as a consequence of distorted and unsatisfying relationship to a disturbed mother. The case of a homosexual girl with a doll phobia, who had been severely deprived in the early months of her life, was presented. Prominent among her symptoms were periods of derealization and depersonalization. Dynamics of the therapeutic alliance were discussed. Drawing on the dynamics described by Freud in Group Psychology and the Analysis of the Ego, it is suggested that the 'analytic ideal' which the analyst offers to the patient, if accepted, allows the formation of a dedicated 'group of two', which is the therapeutic alliance. The dynamic and technical problems in the creation of the therapeutic alliance are those presented by the object relations, the primitive drives, and the analytic setting.

The primitive object relations are discussed in terms of the function of the transitional object, which is viewed as protecting the mother from unfused and relatively unneutralized drive discharge and the consequences of object inconstancy. Hartmann's and Piaget's concept of preobjectivation as an aid to the understanding of the distorted object relations—distinguishing the earlier cathexis of the drive toward the object and the later cathexis of the object representation—is used. Generally the development of object relations can be viewed in terms of a progressive shift in the balance of cathexis in favor of the importance of the object as compared to that of the drives. In the borderline patient the need satisfying object relationship yields easily to the stage of