Combined Therapy with Borderline and Narcissistic Inpatients at the Cassel Hospital

An account is given here of a rather unorthodox approach to psychodynamic therapy with Borderline patients in part of the therapeutic community at the Cassel Hospital. ‘Combined therapy’ here refers to the setting in which one therapist sees patients in groups and individual sessions concurrently. The paper demonstrates the manner in which this approach brings to the fore the massive destructiveness and rage which so often lies at the core of these patients’ difficulties. This is done by describing the development of the group over its first nine months. The therapist comes to be split in the patient's perception, the group sessions representing separation in all its most hated aspects rather than as a prerequisite for differentiation and growth. The resultant rage and destructiveness threaten to render the group unworkable and dangerous. The individual sessions, by contrast, represent a fantasy of being regressed and at one with the ideal mother. It is my belief that these difficulties can be contained only within a therapeutic community. The strength of this approach lies in the vivid reconstruction of a central conflict for these patients and corresponding potential for working through difficulties in the area of separation and individuation. It is also particularly effective in bringing the therapeutic community alive within the therapy. The discussion attempts to address some of the complex theoretical issues raised by the transformation of the transference in both settings which occurs when they are used together and with the same therapist.