g. Borderline States Robert P. Knight The term has achieved almost@iOTOMicialistatustin and conveys iagnostic illumination of a case other than’ i Gfanklypsychotic. In the few psychiatric textbooks wheretthejtetm is to be found at all in thelifdéx,it is used in the text togapplyjtoythoseyy as to whether the patients in (question are e(both neurotic and psychotic phenomena are @bserved|to \belipresent) The Feliictanee to make a (GiagnOsis\Of psychosisjon the one hand, in such cases, is usuallyibased G@iiithe clinical estimate that these patients havethotyet!broken with) en ity); on the other hand th id the: diagnosis of ajpsychoneurosisy Thus the label © used as a diagnosis, conveys more information about the dicertainty) @andjindecisionyofytheypsychiatrisy than it does about the condition of the patient. Indeed, ¢helterm and its equivalents have been frequently(attacked i iatri Rickman (1928) wrote: “It is not uncommon in the lax phraseology of a Mental O.P. Department to hear of a case in which LEE! have used the term myself, but with inward misgiving. There should be no talk of masks if a case is fully understood and certainly not if the case has not received a tireless examination—except, of course, as a brief descriptive term comparable to ‘shut-in’ or ‘apprehensive’ which carry our understanding of the case no further.”’ Similarly, (1932) . If a psychotic mechanism is present at all, it should be given a definite label. If we merely Guspect the possibility) this can be indicated in thettermy'poten=) GaP PSYEHSE More accurately a ‘potentially clinical’ psychosis). As for larval psychoses, we are all larval psychotics and have been such160 1950s AND 1960s since the age of two.”’ Again) ZilbO0rg (1941) wrote: “‘Theless advanced cases (of schizophrenia) have been Hoted, but hdt/seriously Considered) When of recent years such cases engaged the attention of the clinician, they were usually approached with the euphemistic labels of borderline cases, incipient Schizophrenias, (Schizoid personalities, mixed manic- ‘depressive psychoses, schizoid manics, or psychopathic personalities, Such an attitude is untestable either logically or clinically...” Zi. boorg goes on to declare that schizophrenia should be recognized and diagnosed when its characteristic psychopathology is present, and sug- gestsythesterm “‘ambulatory schizophrenia’ for that type of schizo- phrenia in which the individual/is’able for the»mostparts to conceal his pathology from the general public. Ihave no wish to defend the term “borderline state’’ as a diagnosis, I do wish, however, to discuss the clinical conditions usually connoted by this term, and especially to call attention to the diagnostic, psycho- pathological, and therapeutic problems involved in these conditions, I shall limit my discussion to the functional psychiatric conditions where the term is usually applied, and more particularly to those conditions which involve schizophrenic tendencies of some degree. I believe it is the common experience of psychiatrists and psychoan- alysts\icurrently(1o\\see|and|itreat, in open sanitaria or even in office practice, a rather high percentage Of patients Whommthey regard, in a general sense//as borderline cases) Often) these patients have been, referred ascases of psychoneuroses Of SeVeredegree, who have not responded to treatment according to the usual expectations associated with the supposed diagnosis. Most often, perhaps (they Have been called severe obsessive-compulsive cases; sometimes an intractable phobia has been the outstanding symptom; occasionally an apparent (major hysterical'symptom or an ‘anorexia hervosa dominates the clinical pic- ture; and at times ‘it is a question of thé Gegreeof depression, or of the extent and ominousness of paranoid! trends, or of the severity of a character disorder. The unsatisfactory state of our nosology contributes to our difficulties in classifying these patients diagnostically, and we legitimately wonder at a ‘“‘touch of schizophrenia” is of the same order as a ‘touch of syphilis or a “‘touch of pregnancy.” So we fall back on such qualifying terms as latent or incipient (or ambulatory) schizophrenia, or@mphasize that it is a severe obsessive-compulsive neurosis or depression, adding,BORDERLINE STATES 161 “for full coverage, “‘with paranoid trends” or ‘with schizoid manifes- @ations)Certainly, for the most part, we are quite familiar with the “necessity of recognizing the primary symptoms of schizophrenia and not waiting for the secondary ones of hallucinations, delusions, stupor, and the like. (@FFEUAN1913) made us alert t ing: ‘‘Often enough, when one sees a case of neurosis with hysterical sessional symptoms, mild in character and of short duration (just the type of case, that is, which one would regard as suitable for the treatment) a doubt which must not be overlooked arises whether the case may not be one of incipient dementia praecox, so-called (schizophrenia, according to Bleuler; paraphrenia, as I prefer to call it), and may not sooner or later develop well marked signs of this disease.” Many authors in recent years, among them Hoch and Polatin (1949), Stern (1945), Miller (1940), Pious (1950), Melitta Schmideberg (1947), Fenichel (1945), H. Deutsch (1942), Stengel (1945), and others, have called attention to types of cases which belong in the borderline band of the psychopathological spectrum, and have com- mented on the diagnostic and psychotherapeutic problems associated with these cases. SOME DIAGNOSTIC CONSIDERATIONS In attempting to make the precise diagnosis in a borderline case there are three often used criteria, or frames of reference, which are apt to lead to errors if they are used exclusively or uncritically. One of these, which stems from traditional psychiatry, is the question of whether or not there has been a “‘break with reality’’; the second is the assumption that neurosis is neurosis, psychosis is psychosis, and never the twain shall meet; a third, contributed by psychoanalysis, is the series of stages of development of the libido, with the conceptions of fixation, regres- sion, and typical defense mechanisms for each stage. No psychiatrist has any difficulty in diagnosing a psychosis when he finds definite evidence of falsification of reality in the form of halluci- nations and delusions, or evidence of implicit loss of reality sense in the form of self-mutilation, mutism, stupor, stereotypies, flight of ideas, incoherence, homicidal mania, and the like. But these are all signs of advanced psychosis, and no present-day psychiatrist of standing would162 1950s AND 1960s be unaware of the fact that each patient with one or more of these psychotic manifestations had carried on for some previous years as q supposedly normal individual, albeit with concealed potentialities for a psychotic outbreak, and that there must have been warning signs, var. ious stages of development, and a gradually increasing degree of overt- ness of these gross expressions of psychotic illness. All science aims at the capacity to predict, and psychiatry will become a science the more it can detect the evidences of strain, the small premonitory signs of a psychotic process, so that it can then introduce the kinds of therapeutic measures which have the best chance of aborting the psychotic devel- opment. The break with reality, which is an ego alteration, must be thought of not as a sudden and unexpected snapping, as of a twig, but as the gradual bending as well, which preceded the snapping, and sound prognosis must inevitably take into account those ego factors which correspond to the tensile strength of the twig, as well as the kinds and degree of disruptive forces which are being applied. A second conception which leads to misdiagnosis is that neurosis and psychosis are mutually exclusive, that neurosis never develops into psychosis, and that neurotics are “‘loyal to reality” while psychotics are ‘‘disloyal to reality.” It is, to be sure, one of the contributions of psychoanalysis that neurotic mechanisms are different from psychotic mechanisms and that psychosis is not simply a more severe degree of neurosis. However, it is quite possible for both psychotic and neurotic mechanisms to have developed in the same individual, and this is the crux of the problem in many borderline cases. Furthermore, there isa sense in which there is a loss of reality even in neurosis. As Freud (1924) pointed out: ‘‘The difference at the beginning comes to expres- sion at the end in this way: in neurosis a part of reality is avoided by a sort of flight, but in psychosis it is remodeled. Or one may say that in psychosis, flight at the beginning is succeeded by an active phase of reconstruction, while in neurosis obedience at the beginning is followed by a subsequent attempt at flight. Or, to express it in yet another way, neurosis does not deny the existence of reality, it merely tries to ignore it; psychosis denies it and tries to substitute something else for it. A reaction which combines features of both these is the one we call normal or ‘healthy’; it denies reality as little as neurosis, but then, like a psychosis, is concerned with effecting a change in it. This expedient normal attitude leads naturally to some active achievement in the outerBORDERLINE STATES 163 world and is not content, like a psychosis, with establishing the alter- ation within itself; it is no longer autoplastic but alloplastic.” Again, on the point of gradations in loss of reality, Freud (1922) discussed normal jealousy, projected jealousy, and delusional jealousy, pointing out their transitions from one to the other, and describing how an individual may “for a time maintain his critical judgement over paranoid ideas which are already present but do not yet have the strength of conviction of delusions. Anna Freud (1936) describes how children can use the defense of denial—denial in fantasy and denial in word and act—in ways which represent temporary breaking with reality while retaining an unimpaired faculty of reality testing. However, if adolescents and adults persist in, or resume, this kind of denial after the normal development of ego synthesis has taken place ‘‘the relation to reality has been gravely disturbed and the function of reality-testing suspended.”’ The varieties of channeling psychotic (usually paranoid) tendencies in eccentric or fanatical ways—even to the point of developing a following of many _ people—and the various degrees of inappropriate emotions seen in ‘many individuals further highlight the vagueness of the criterion of reality testing, and of the distinction between neurotic and psychotic. Also, we are well aware that in these and other borderline conditions the movernent in the case may be toward or away from further psychotic development. The third frame of reference, that of the levels of psychosexual development—oral sucking, oral biting, anal expulsive, anal retentive, _ phallic, and genital—and of the attempts to build a classification of mental disorders by linking a certain clinical condition to each level of libidinal fixation, has presented a one-sided, libidinal theory of human functioning. This psychoanalytic contribution has been of major value, but it needs to be supplemented extensively with the findings of ego psychology which have not, as yet, been sufficiently integrated with the libido theory. Reliance on the “‘ladder”’ of psychosexual development, _ with the line of reality testing drawn between the two anal substages, has resulted in many blunders in diagnosis—especially in the failure to _ perceive the psychosis underlying a hysterical, phobic, or obsessive- compulsive clinical picture. I believe it was Freud who used the metaphor of a retreating army to illuminate the mixed clinical picture in libidinal regression. I should like164 1950s AND 1960s to borrow the metaphor and elaborate it for the purpose of illuminating ego-defensive operations. Various segments or detachments of the re. treating army may make a stand and conduct holding or delaying op erations at various points where the terrain lends itself to such opera- tions, while the main retreating forces may have retired much farther to the rear. The defensive operations of the more forward detachments _ would, thus, actually protect the bulk of the army from disaster; but these forward detachments may not be able to hold their positions, and may have to retreat at any time in the face of superior might. On the other hand, the main army may be able to regroup itself, receive rein- forcements or gain new leadership, and recapture its morale. In that event, the forward positions may hold long enough for the main forces to move forward to, or even well beyond, the stubbornly defended outposts. I believe this metaphor conceptualizes in an important way the psy- choeconomy and the indicated therapy in the borderline cases. The superficial clinical picture—hysteria, phobia, obsessions, compulsive rituals—may represent a holding operation in a forward position, while the major portion of the ego has regressed far behind this in varying degrees of disorder. For the sake of accurate diagnosis, realistic prog- nosis, and appropriate therapy, therefore, the clinician must be able to locate the position, movement, and possibilities of resynthesis of the main ego forces and functions, and not be misled by all the shooting in the forward holding point. An important corollary of this conception is that the therapy should not attempt to attack and demolish the forward defensive operations when to do so would mean disaster for the main ego operations. Some forward defensive operations are a matter of life and death. Without defending the term ‘‘borderline state”’ as a diagnostic label, Ihave thus far developed the argument to show that there is a borderline strip in psychopathology where accurate diagnosis is difficult, I have tried to show the general characteristics of such borderline conditions, and to point out why the often used diagnostic criteria of break with reality mutual exclusiveness of neurosis and psychosis, and the libido theory is insufficient and misleading in reaching accurate diagnosis, prognosis and appropriate therapeutic recommendations for such cases. What, then, are the more reliable methods of evaluating these cases so that one will not have to be content with using as a diagnosis theBORDERLINE STATES 165 unspecific term ‘‘borderline state’’? The attempt to answer this question will involve a discussion of certain dynamic considerations as they relate to the diagnostic techniques available to us—the psychiatric interview, the free-association interview, and the use of psychological diagnostic tests. SOME DYNAMIC CONSIDERATIONS We conceptualize the borderline case as one in which normal ego functions of secondary-process thinking, integration, realistic planning adaptation to the environment, maintenance of object relationships, and defenses against primitive unconscious impulses are severely weak- ened. As a result of various combinations of the factors of constitutional tendencies, predisposition based on traumatic events and disturbed human relationships, and more recent precipitating stress, the ego of the borderline patient is laboring badly. Some ego functions have been severely impaired—especially, in most cases, integration, concept for- mation, judgment, realistic planning, and defending against eruption into conscious thinking of id impulses and their fantasy elaborations. Other ego functions, such as conventional (but superficial) adaptation to the environment and superficial maintenance of object relationships may exhibit varying degrees of intactness. And still others, such as memory, calculation, and certain habitual performances, may seem unimpaired. Also, the clinical picture may be dominated by hysterical, phobic, obsessive-compulsive, or psychosomatic symptoms, to which neurotic disabilities and distress the patient attributes his inability to carry on the usual ego functions. During the psychiatric interview the neurotic defenses and the rela- tively intact adaptive ego functions may enable the borderline patient to present a deceptive, superficially conventional, although neurotic, front, depending on how thoroughgoing and comprehensive the psy- chiatric investigation is with respect to the patient’s total ego function- ing. The face-to-face psychiatric interview provides a relatively struc- tured situation in which the conventional protective devices of avoidance, evasion, denial, minimization, changing the subject, and other cover-up methods can be used—even by patients who are genu- inely seeking help but who dare not yet communicate their awareness166 1950s AND 1960s of lost affect, reality misinterpretations, autistic preoccupations, and the like. Several interviews may be necessary to provide the psychiatrist with a sufficiently comprehensive appraisal of the total ego functioning, and to provide the patient with enough sense of security to permit him to verbalize his more disturbing self-observations. In spite of the patient’s automatic attempts at concealment, the presence of pathology of psy- chotic degree will usually manifest itself to the experienced clinician, Occasional blocking, peculiarities of word usage, obliviousness to ob- vious implications, contaminations of idioms, arbitrary inferences, in- appropriate affect and suspicion-laden behavior and questions are a few possible examples of such unwitting betrayals of ego impairment of psychotic degree. In regard to such manifestations the appraisal of total ego functioning can be more precise if the psychiatrist takes careful note of the degree of ego-syntonicity associated with them. Momentary halting, signs of embarrassment, and attempts at correction of the peculiarity of. expres- sion are evidences of a sufficient degree of ego intactness for such psychotic intrusions to be recognized and repudiated as ego-alien; whereas unnoticed and repeated peculiarities and contaminations pro- vide evidence that the ego has been overwhelmed or pervaded by them and has lost its power to regard them as bizarre. Likewise the expression of suspicions accompanied by embarrassed apologies or. ‘joking indicates preservation of the ego’s critical function with respect to paranoid mistrust; whereas unqualified suspiciousness indicates the loss of that important ego function. Sometimes this capacity for taking distance from these psychotic productions has to be tested by questions from the psychiatrist which call attention to the production and request comments from the patient about them. Obviously such confrontations should be made sparingly and supportively. In addition to these microscopic evidences of ego weakness in respect to id eruptions in borderline cases, there are more macroscopic mani- festations which may be either frankly stated by the patient or may be implicit in his attitudes and productions. Lack of concern about the realities of his life predicament, usually associated with low voltage wishes for help or grossly inappropriate treatment proposals of his own, is one such macroscopic sign. Others are the fact that the illness de-BORDERLINE STATES 167 yeloped in the absence of observable precipitating stress, or under the relatively minor stress which was inevitable for the point where this patient was in his life course; the presence of multiple symptoms and disabilities, especially if these are regarded with an acceptance that seems ego-syntonic, or are viewed as being due to malevolent external influence; lack of achievement over a relatively long period, indicating achronic and severe failure of the ego to channelize energies construc- tively, especially if this lack of achievement has been accompanied by some degree of disintegration of the ordinary routines of looking after ‘one’s self; vagueness or unrealism in planning for the future with respect to education, vocation, marriage, parenthood, and the like; and the relating of bizarre dreams, or evidence of insufficient contrast between dream content and attitudes on the one hand and waking activities and attitudes on the other. All of these macroscopic manifestations will be observable, if they are present, only if the psychiatrist keeps as his frame of reference the patient’s total ego functioning, with appropriate allowances for the patient’s age, endowment, cultural background, pre- vious level of achievement, and the degree of severity of the recent or current life stresses. The question of using the free-association interview, with the patient on the couch, frequently comes up with borderline cases. The associ- ative anamnesis has been advocated by Felix Deutsch (1949) and many analysts use free-association interviews either as a limited diagnostic tool or as a more extended trial period of analytic therapy. This tech- nique changes the fairly well-structured situation of the face-to-face psychiatric interview into a relatively unstructured one, so that the patient cannot rely on his usual defensive and conventionally adaptive devices to maintain his front. Borderline patients are then likely to show in bolder relief the various microscopic and macroscopic signs of schiz- ophrenic illness. They may be unable to talk at all and may block completely, with evidence of mounting anxiety; or their verbalizations may show a high degree of autistic content, with many peculiarities of expression; or their inappropriate affect may become more obvious. The diagnosis is aided by the couch—free-association technique, but the experience may be definitely antitherapeutic for the patient. Defin- itive evidence of psychotic thinking may be produced at the expense of humiliating and disintegrating exposure of the patient’s naked pathol-168 1950s AND 19608 ogy. Clinical judgment must be used as to how far the psychiatrist should go in breaking through the defenses in his purpose of reaching: an accurate diagnosis. In the face-to-face psychiatric diagnostic interview the patient is ina fairly well-structured situation and is reacting to the interested listening and active questioning of a visible and supportive physician; in the couch—free-association interview the patient is ina relatively unstruc- tured situation, more or less abandoned to his own fantasies, and rela- tively unsupported by the shadowy and largely silent listener. Diagnos- — tic psychological tests combine the advantages of support from a visible — and interested professional listener, as in the face-to-face psychiatric interview, and the diagnostically significant unstructured situation of the couch—free-association interview. The various test stimuli are unusual and unconventional, and there are no “‘correct’’ answers, so that the patient does not know what he is revealing or concealing. The psychological tests also have one sig- nificant advantage over either of the two kinds of diagnostic interview. The tests have been standardized by trials on thousands of cases, so that objective scoring can be done and comparisons can be made of this patient’s responses to typical responses of many other patients with all — kinds of psychiatric illness, whereas even the experienced psychiatric interviewer must depend on impressions and comparisons of the pa- tient’s productions with those of other remembered patients in his particular experience. The psychologist can also determine the patient’s capacity to take critical distance from his more pathological responses, and thus assess the degree of ego-alienness or ego-syntonicity of the pathological material, by asking questions which elicit comments from the patient about certain of the unusual responses. As Rapaport, et al. (1945 and 1946), Schafer (1948), and others have pointed out, the interpretation of diagnostic psychological test results is far from being a mere matter of mathematical scoring followed by comparisons with standard tables. There is also required a high degree of clinical acumen, and it is just in the field of the borderline cases that expert interpretation of the test results is essential. The Rorschach is probably the most sensitive test for autisfic thinking, and the word association and sorting tests are most valuable for detecting the loos- ening of associations and disruption of concept formation. The The- matic Apperception Test is less sensitive to schizophrenic pathologyBORDERLINE STATES 169 but can give a sharply etched picture of the patient’s projected image of himself and of the significant people in his life, while describing what the patient feels he and these significant people are doing to each other. The Bellevue-Wechsler intelligence test may, on the other hand, espe- cially in borderline cases, show excellent Preservation of intellectual functioning. The relatively clean and orderly responses of the Bellevue- _ Wechsler do not cancel out the contaminated and disorderly responses of the other tests and thus make the diagnosis doubtful. Instead, the _ former highlight the preservation of certain ego functions in the face of the impairment of other ego functions revealed by the latter, and thus provide a basis for critical appraisal of ego strengths in relation to _ threatening eruptions from the id. The Rorschach alone is often given asa test to check on possible schizophrenia, but only a balanced battery of tests can provide the range of responses which will permit accurate _ appraisal of total ego functioning. Tn all of these diagnostic methods, then, the aim should be to take a complete inventory of ego functioning in order to discover the kind of equilibrium which exists between ego controls on the one hand and threatening impulses on the other, and to learn whether the movement in this patient is toward less go control and poorer adaptation. The qualitative appraisal of ego functions is, if anything, even more impor- tant than the quantitative estimation of impulse-control balance. Even quite severely neurotic defenses may be capitalized, through therapy, and become reintegrating forces leading to a dynamic shift away, for example, from dereistic thinking to fairly well-organized compulsive Striving, with marked improvement in both the defensive and adaptive aspects of ego functioning. Some final comments are in order regarding the clinical picture in the borderline group of cases before turning to the therapeutic considera- tions. A useful distinction can be made between internalized or auto- ‘Plastic illnesses, such as schizophrenias, depressions, and clinical psy- choneuroses, and the externalized or alloplastic illnesses, such as the ‘Reurotic and psychotic characters. In the autoplastic conditions, the '€go, in various stages of enfeeblement, is attempting to hold out against 8 barrage of ego-alien impulses and their autistic elaborations; in the alloplastic conditions, or character disorders, the ego itself has been Molded and distorted by the gradual infiltration of pathogenic impulses and defenses, and the invasion of id impulses appears much more ego-170 1950s AND 1960s syntonic. In some respects the alloplastic conditions thus represent greater integration of the ego, but just because of this integrated inf. tration of pathogenic impulses into the ego these cases are more diff. cult to influence therapeutically. On the other hand, the autoplastic conditions may appear more severely ill than the alloplastic ones but the prognosis for therapy may be more favorable. Both the psychi. atric interview and the psychological test results can aid in estab. lishing whether the structure of the illness is primarily autoplastic or alloplastic. SOME THERAPEUTIC CONSIDERATIONS The ego of the borderline patient is a feeble and unreliable ally in therapy. In the incipient schizophrenias the ego is in danger of being — overwhelmed by the ego-alien pathogenic forces, and in the psychotic — character disorders the ego is already warped by more or less ego- syntonic pervasion by the same pathogenic forces. Yet a few adaptive functions remain, and certain psychoneurotic defense measures may still be in operation, even though the impulse-defense balance is pre- carious. In an environment which maintains its overtaxing demands on such patients, further regression is likely. If these patients are left to their own devices, in relative isolation, whether at home or in closed hospital, they tend toward further intensification of autistic thinking. Similarly, if they are encouraged to free-associate in the relative isola- tion of recumbency on the analytic couch, the autistic development is encouraged, and the necessary supportive factor of positive transfer- ence to an active, visible, responding therapist is unavailable. Thus even though a trial analysis may bring forth misleading “‘rich”’ material, and the analyst can make correspondingly rich formulations and inter- pretations, the patient’s ego often cannot make use of them, and they may only serve the purpose of stimulating further autistic elaborations. Psychoanalysis is, thus, contraindicated for the great majority of bor- derline cases, at least until after some months of successful analytic psychotherapy. Psychotherapists can take their cue from the much better front these patients are able to present and maintain in face-to-face psychiatric interviews, where the structured situation and the visible, personal, active therapist per se provides an integrating force to stimulate theBORDERLINE STATES 171 patient’s surviving adaptive, integrative, and reality-testing capacities. Our therapeutic objective, then, would be the strengthening of the patient's ego controls over instinctual impulses and educating him in the employment of new controls and new adaptive methods, through a kind of psychotherapeutic lend-lease. With our analytic knowledge we can see how he defends himself, and what he defends himself against, but we do not attack those defenses except as we may modify them or educatively introduce better substitutes for them. Our formulations will be in terms of his ego operations rather than of his id content, and will be calculated to improve and strengthen the ego operations. The psychoneurotic defenses and symptoms especially are not at- tacked, for just these ego operations protect the patient from further psychotic disorganization. Particularly the obsessive-compulsive de- fense line is left untouched, except as it can be modified educatively. To return for the moment to the metaphor of the retreating army, our therapy should bypass the outposts of neurotic defenses and symptom formation, and should act as a rescue force for the main army of ego functions to the rear, helping to regroup them, restore their morale, and provide leadership for them. Then we might hepe te bring them forward to or beyond the neurotic outpost which we by-passed. We may even take our cues for morale building and leadership from the kind of neurotic outpost we observed. If it was primarily obsessive-compulsive we might strive therapeutically for a reintegration based on strength- ened compulsive trends. If it was phobic we could attempt to build counterphobic defenses. Not only do we try to consolidate the more neurotic defenses avail- able, but we also attempt to convert autoplastic (self-crippling) defenses into alloplastic (externally adaptive) ones. This attempt will often re- quire considerably more therapeutic impact than can be provided in an hour a day of modified analytic psychotherapy. Both the motivation and the specific opportunities for alloplastic adaptation can be provided through group dynamics measures—group discussions, group projects, and initiative-stimulating group and individual activities. In a compre- hensive attempt at providing such a setting in which to conduct the individual psychotherapy of these cases, we have discovered that many such patients can be carried on a voluntary basis and in an open hospital facility, thus avoiding the encouragement toward isolation, regression, and inertia which closed hospital care sometimes introduces.172 1950s AND 1960s { SUMMARY Borderline cases have been discussed in'their diagnostic, dynamic, an therapeutic aspects. The term borderline case is not recommended a diagnostic term, for a much more precise diagnosis should be mad which identifies the type and degree of psychotic pathology. Far mo important, however, than arriving at a diagnostic label is the achieve. ment of a comprehensive psychodynamic appraisal of the balance in each patient between the ego’s defensive and adaptive measures on th one hand, and the pathogenic instinctual and ego-disintegrating forces on the other, so that therapy can be planned and conducted for the purpose of conserving, strengthening, and improving the defensive an i adaptive functions of the ego. BIBLIOGRAPHY Deutsh, F. (1949), Applied Psychoanalysis; Selected Objectives of Psychotherapy. New York: Grune & Stratton. Deutsch, H. (1942), Some Forms of Emotional Disturbance and Their Relationship to Schizophrenia. Psychoanalytic Quarterly, 11:301-321. Fenichel, O. (1945), The Psychoanalytic Theory of Neurosis. New York: Norton. Freud, A. (1936), The Ego and the Mechanisms of Defence. New York: International Universities Press, 1946. Freud, S., (1913), Further Recommendations in the Technique of Psycho-Analysis, On Beginning the Treatment. The Question of the First Communication. The Dy- | namics of the Cure. Collected Papers, 2:342-365. London: Hogarth Press, 1946. — (1922), Certain Neurotic Mechanisms in Jealousy, Paranoia and Homosexuality. Collected Papers, 2:232-243. London: Hogarth Press, 1946. —— (1924), The Loss of Reality in Neurosis and Psychosis. Collected Papers, 2:277- 282. London: Hogarth Press, 1946. Glover, E. (1932), A Psycho-Analytical Approach to the Classification of Mental Disorders. Journal of Mental Science, 78:819-842. Hoch, P. and Polatin, P. (1949), Pseudoneurotic Forms of Schizophrenia. Psychiatric Quarterly, 23:248-276. Miller, W. R. (1940), The Relationship Between Early Schizophrenia and the Neu- roses. American Journal of Psychiatry, 96:889-896. Pious, W. L. (1950), Obsessive-Compulsive Symptoms in an Incipient Schizophrenic. Psychoanalytic Quarterly, 19:327-351. Rapaport, D., Gill, M., and Schafer, R. (1945 and 1946), Diagnostic Psychological Testing, 2 Vols. Chicago: Yearbook Publishers. Rickman, J. (1928), The Development of the Psycho-Analytical Theory of the Psychoses, 1893-1926. London: Baillidre, Tindall & Cox for the Institute of Psycho-Analysis. — Schafer, R. (1948), The Clinical Application of Psychological Tests. New York, Interna-_ tional Universities Press.BORDERLINE STATES 173 Schmideberg, M. (1947), The Treatment of Psychopaths and Borderline Patients. Journal of Psychotherapy, 1:45-70. el, E. (1945), A Study on Some Clinical Aspects of the Relationship Between 166-187. A. (1945), Psychoanalytic Therapy in the Borderline Neuroses. Psychoanalytic