Core Issues in the Treatment of Personality-Disordered Patients

by Dan H. Buie, MD

We all share in common our clinical experience with personality-disordered patients, and we note certain of their attributes. To a significant extent these patients are lost in terms of knowing who they are: they feel a dark aloneness; feel a grim sense of worthlessness; feel no warmth for themselves; and do not feel like a whole person with a genuine place with others. We could ascribe these attributes to their being deficient in five capacities basic to human stability, even viability. Because they are required for maintaining the self, I refer to them as self-maintenance capacities. They include (1) the capacity for self-realness, the experiential (not merely cognitive) knowledge that one’s qualities, and the relationships between oneself and others, exist as real, that is, as actual; (2) the capacity for self-security, the ability to provide oneself an ongoing experience of being secure, which is the heritage of having developed with secure, warm holding; (3) the capacity for self-worth, the experiential knowledge of one’s self-worth; (4) the capacity to experience love for oneself; and (5) the capacity to know one’s identity experientially. To boil this down, people need to experience that they are real, secure from aloneness, worthwhile, and deserving of their love, and that they possess an identity.

The major difference between neurotic and personality-disordered patients is that neurotic patients have the capacities to provide themselves these basic-self experiences. Personality-disordered patients do not. The aim of treatment with the latter, then, is to help them develop these capacities. Though I have listed these self-maintenance capacities as if they occur as distinct phenomena, in the clinical situation they do not present so neatly. They overlap and intertwine. I have listed them separately simply to help us think about them. <…>

Journal of the American Psychoanalytic Association, 61/1: 10-23, 2013.

Link to Online Publication


Previous Posts

Ana-María Rizzuto, MD (2013) Field Theory, the “Talking Cure,” and Metaphoric Processes. Psychoanalytic Inquiry, 33:3, 210-228, 2013

Phillip S. Freeman, MD (2012) The Resilience of Illusion. International Journal of Applied Psychoanalytic Studies (First Brief Communication, 9: 78-83; Second Brief Communication, 9: 344-349).

Paul Ornstein, MD (2012) The Novelist’s Craft: Reflections on The Brothers Karamazov. American Imago, 69/3, p. 295-316.

Stephanie R. Brody, PsyD (2013) Entering Night Country: Reflections on Self-Disclosure and Vulnerability. Psychoanalytic Dialogues, 23:1, p. 45-58.

Ellen Pinsky, PsyD (2012). PHYSIC HIMSELF MUST FADE: A View of the Therapeutic Offering through the Lens of Mortality. American Imago, Vol. 69, No. 1, 29-56.

All articles are available in the library.