The interpersonal dynamics consultation in a therapeutic community for borderline patients: containing relationships at the coal face

Abstract

The Interpersonal Dynamics (ID) consultation is a structured method of group reflective practice which helps staff mentalize transference and countertransference dynamics with patients. We present a detailed ID consultation of a female patient in an inpatient therapeutic community for people with severe personality disorders and demonstrate how this method sheds light on this patient’s internal world as externalised interpersonally with staff in the treatment setting. The resulting enactments are discussed in relation to several psychoanalytic theories and concepts, including Bion’s theory of containment and Ogden’s interpersonal definition of projective identification. We conceptualise our population of patients based on their use of primitive psychological defences such as splitting and projective identification and on the idea that they live at the border between what Klein described as the paranoid-schizoid and the depressive positions. We argue that the ID consultation functions as a container for staff and patients by bringing together and integrating the parts of the patient which are split off and projected into different staff members. Furthermore, the ID consultation is an invaluable triangular space that facilitates the move from difficult dyadic subjective experiences with patients to triadic objective perspectives and from passive reactions to responsive thinking and understanding.

Keywords:

• interpersonal dynamics
• reflective practice
• therapeutic community
• personality disorders
• transference-countertransference enactments

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1. For more details about the theoretical and empirical background underpinning the development of ID consultation model see, Reiss and Kirtchuk (2009), and/or Gordon et al. (2017a).

2. As described for example, by Gordon et al. (2017b) and Li et al. (2019), the process of facilitating the ID consultation and formulating core relationship patterns can be learnt in a few sessions, without needing a psychoanalytic/psychodynamic training (even if the latter would certainly be of benefit for ID consultants).

3. Knowledge of the ID consultation and of psychoanalytic concepts varied amongst our participants, and these follow-up meetings offered the opportunity for staff to learn more about the ID consultation and basic psychoanalytic concepts (e.g., transference, countertransference, enactments) underpinning the interpersonal dynamics unraveled during the ID consultation. Most staff with no prior knowledge of the ID consultation were able to familiarise well with it during this pilot process (as evidenced by written feedbacks), without having had a formal training.

4. This process of object integration is paralleled in the self.

5. However, the projector’s primary aim may be to aggressively rid the self of frightening or otherwise unwanted aspects and to control the recipient both in phantasy and in external reality by unconsciously recruiting the object to feel that he or she is what has been projectively identified into him/her.

6. This third facet of Ogden’s description of projective identification, particularly the projector’s response to the attempted return of the understood (contained) material, is not at all straightforward when the main function of the original projective identification is aggressive and controlling (Klein, 1946). In this case the processed re-projection will be experienced not as understanding but as retaliatory counter-aggression in order to force the unwanted projected aspects back into the self/patient.

7. As Main highlighted: ‘The sufferer who frustrates a keen therapist by failing to improve is always in danger of meeting primitive human behaviour disguised as treatment.’ (Main, 1957, p. 13).

8. ‘Both staff and patients are implicated in a collusion, and inter-group exchange of personality characteristics: what patients lose of their healthy side accumulates in the staff; and what the staff get rid of in terms of their more negative attributes resurfaces within the patients.’ (Hinshelwood, 1998, p. 18).

9. When choosing the following interpersonal items in perspective A, there is a focus on gathering evidence to support them based on (second and third person) statements that the patient has actually made, as opposed to inferring them based on the patient’s behaviours or the staff’ s assumptions that that is how the patient must be perceiving others. This equally applies to perspective B, where (first person) statements are sought for evidencing items describing the way the patient experiences herself in response to others. We’ll give one example of patient’s statement per item.

10. Main (1957) draws a parallel with his clinical experience by quoting Balint (1952) who described the infant’s need for her mother ‘to be at one with him in feeling, and to have no other wishes’ but ‘the impossibility of these requirements, except for the shortest periods, leads not only to a disconsolate, forlorn longing for this state, but to a fear of the impotent, helpless dependence on the object. Defences therefore arise against the state and its pain in the shape of denial of dependence, by omnipotence and by treating the object as a mere thing. The pain of not being efficiently loved by a needed object is thus defended against by independence’ (Main, 1957, p. 32).

11. These findings were replicated across other ID consultations in our setting, and are consistent with the literature specific to the inpatient therapeutic community developed by Main (Bell, 1997; Main, 1957), and other psychoanalytically-informed hospitals (Gabbard, 1989; Kernberg, 1973).

12. Hinshelwood (1991) describes how a ‘point of maximum pain’ and the attendant defensive relationships can be hypothesised by identifying a common pattern amongst three areas of object-relations: the current life situation, the early infantile relationships and the transference.

13. In this classic paper, Main explained how several staff developed an ‘ailment’ whilst caring for ‘special patients’ as they were drawn into anti-therapeutic enactments driven by pathological splits and projective identifications. It was only when a reflective space in the form of a staff group was put in place that these interpersonal dynamics could be metabolised and contained: ‘only a group could achieve the capacity to recall past events with the merciless honesty for detail and corrections of evasions and distortions that this one required from and tolerated in its members.’ (Main, 1957, p. 17).

14. The whole ID consultation process can be thought of as an exercise in mentalizing: staff attempt to put themselves in the shoes of the patient and also to elaborate their own mental/emotional states. More generally, as further highlighted by participants of our ID consultations, these ID consultations can help with ‘thinking in detail, and in different ways, about a patient you do not necessarily know as well as you thought’, and also in ‘gaining the views of others on a patient’.

15. The ID consultation aims at eliminating any hierarchy among different MDT professionals as each of them is seen as carrying equally important information about the patient which needs to be brought together.