Personality & Long-Standing Patterns

Reese, 31, non-binary, barista and part-time artist

Presentation

Referred after third psychiatric hospitalization in two years for suicidal gestures following relationship breakups. Intense, unstable relationships — idealizes new partners, then rages when they disappoint. Self-harm (cutting) since adolescence, currently 1-2x/month. Says: 'Everyone leaves. I make sure of it.' Diagnosed BPD at 25.

History

Foster care from age 4 after parental neglect. Three foster placements by age 10. Sexual abuse by foster sibling at 12, disclosed but not believed. Adopted at 13 by a well-meaning but emotionally distant couple. Multiple therapists — fired or quit on most of them. Currently on sertraline and low-dose quetiapine.

Clinical note: Reese's presentation has more high-quality treatment evidence behind it than almost any personality disorder. DBT has the most RCTs (Storebø et al., 2020 Cochrane review), with strong evidence for reducing self-harm and hospitalization — critical given Reese's three hospitalizations. Schema Therapy showed large effects in the Giesen-Bloo et al. (2006) RCT, outperforming TFP on several measures. MBT (Bateman & Fonagy, 2009) showed sustained improvement over structured clinical management. TFP (Clarkin et al., 2007) showed comparable outcomes to DBT with additional gains in reflective functioning and attachment organization. The clinical question for Reese isn't which treatment works best — all four have evidence — but which fits: DBT for acute risk stabilization, Schema for the reparenting Reese's foster care history denied, TFP if Reese can tolerate interpretive challenge, MBT for rebuilding the mentalizing capacity that early abuse disrupted. In practice, the therapist's ability to survive Reese's rage and testing — without retaliating, withdrawing, or rescuing — matters more than any protocol. Reese's non-binary identity adds a dimension most BPD manuals don't address: the intersection of identity instability with gender identity exploration requires careful clinical discernment about what is 'pathological' diffusion versus healthy development.

Where Approaches Genuinely Disagree

How much confrontation is therapeutic?

Transference-Focused (TFP)

The patient needs to see their distortions in real time. Interpreting transference — including aggression — is the work.

vs.

DBT

Confrontation without validation is retraumatizing. The relationship must be safe before it can be challenging.

Philosophical Lenses

These are not treatment plans. They are ways of seeing — philosophical perspectives that illuminate aspects of this case that clinical modalities may not address directly.

Jean-Paul Sartre

Reese's pattern — idealization, rage, self-harm, hospitalization — looks like repetition compulsion from a psychoanalytic frame. Sartre would see it as bad faith: the refusal to acknowledge freedom. Each cycle begins with the other being made into the guarantor of meaning ('this person will save me') and ends with the discovery that no other person can bear that weight. The rage is not at the partner but at the impossibility of the project. Reese is attempting what Sartre called the fundamental project of being — trying to become an object (solid, certain, defined by the other's love) while remaining a subject. This is impossible. Therapy is the confrontation with that impossibility and the anguish of freedom it reveals.

Emmanuel Levinas

Reese's relational pattern is a form of what Levinas would call totalization — the reduction of the Other to a category within the self's economy of need. In the idealizing phase, the partner is consumed as an object of absolute need: not encountered as Other but incorporated as the missing ground of the self. In the rageful phase, the partner who fails this impossible function is expelled — but what is expelled is still not the Other as Other, only the failed need-object. Levinas's ethics demands something Reese has never experienced: letting the Other be genuinely other, irreducible to what I need them to be. This is not a relational skill to be learned. It is an ethical orientation that presupposes a subject who can bear the infinite demand of a face that will never be 'enough' because it was never supposed to be.

8 Formulations

Select 2–3 modalities to compare side by side:

Sources & Method

This is a composite fictional case — no real client is depicted. Formulations represent how each modality would typically conceptualize and approach a case with this presentation, based on published clinical literature and training materials. Each formulation draws on the modality's own theoretical framework, key texts, and clinical principles as documented on its modality page. Full source citations for every modality are available on the Sources page.