Psychotherapy of the quiet borderline patient

Psychotherapy of the Quiet Borderline Patient is the first book-length study of the as-if personality, also referred to as the quiet borderline patient. This book offers the most detailed exposition of etiology in the literature, tracing as-if development first from an object relations standpoint and then from a family interaction perspective. In addition, this is the first work to propose a specific treatment approach for the quiet borderline patient.

Half a century has passed since Deutsch's famous paper introduced the as-if category. In spite of the popularity and influence of that paper, there has been little development of the concept, apparently because subsequent writers felt there were few as-if patients. Psychotherapy of the Quiet Borderline Patient, however, suggests that there is no shortage of as-if individuals in contemporary society.

The authors demonstrate that such cultural factors as changing conceptions of childrearing, emphasis on rapid adaptation to change, and an intolerance of any process requiring an investment of time are likely to promote the as-if style.

As-if pathology is essentially imitative. These individuals are skilled at sensing what roles others might want them to play and matching up with those roles. The as-if individual has no stable underlying identity, and the as-if personality consists of an endless series of transient identifications with very little that stably carries over from one situation to another. That part of the personality generally called the self seems to be deficient.

In therapy, as-if patients try to sense what the therapist expects of them. If they glean enough clues about how the therapist thinks a productive patient should act, they can play that role for prolonged periods of time. The therapist may have the uneasy intuition that something is wrong, without knowing what. The patient is acting as if he or she is in treatment, but therapy is actually having little impact.

The as-if patient very often comes to treatment at the behest of someone else, or comes with only the vaguest sense that something is wrong, hence, the patient does not usually notice that nothing is happening in therapy.

The therapist's task, after spotting as-if pathology, is to induce some sort of sustained, genuine interaction. If the therapist succeeds, the as-if patient will begin to feel dependent on the therapist, which will be a confusing, disorganizing experience. If this part of treatment can be safely negotiated, the patient can use the therapist as an object for identification, beginning to replace the earlier system of transient identifications with a basis for identity formation.