Personality & Long-Standing Patterns
Reese, 31, non-binary, barista and part-time artist
Fictional teaching case
Compare the formulations ↓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.
Read the full case history and clinical context
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.
Compare how approaches understand this case
Two approaches to begin with; change them below. These are starting examples, not a clinical ranking.
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Showing 2 of 8 formulations.
DBT
Biosocial model: biological emotional vulnerability (high sensitivity, high reactivity, slow return to baseline) transacting with an invalidating environment (foster care, abuse, disbelief). The result is pervasive emotion dysregulation. Self-harm is an emotion regulation strategy that works. The idealizing-devaluing cycle is that dysregulation inside a relationship: the affect swings and takes the appraisal with it, and Reese has never had the interpersonal skills to stay in the room while feeling that much.
Stage 1, target hierarchy: life-threatening behaviors first (suicidal gestures, cutting), then therapy-interfering behaviors (missing sessions, firing therapists), then quality of life. Weekly individual therapy + skills group. Diary card tracking urges, behaviors, and emotions. Phone coaching for crisis. Consultation team for therapist.
"Cutting works. It brings the emotional pain down fast. I'm not going to pretend it doesn't. But it's also putting you in the hospital, and it's keeping you from building the life you want. Can we find other ways to get through those moments?"
Schema Therapy
Early maladaptive schemas from childhood deprivation: Abandonment (everyone leaves), Mistrust/Abuse (people will hurt me), Defectiveness (I'm too damaged to love), Emotional Deprivation (no one will meet my needs). Four schema modes cycle: Abandoned Child (terrified, desperate), Angry Child (raging, self-destructive), Detached Protector (numb, pushing people away), and Punitive Parent (you deserve this: the internalized abuser).
Limited reparenting within the therapeutic relationship: the therapist provides what the early environment didn't. Mode work: identify which mode is active, empathize with the Abandoned Child, set limits with the Angry Child, bypass the Detached Protector, fight the Punitive Parent. Experiential techniques (chair work, imagery rescripting).
"Right now I think the Abandoned Child is here: the part that's terrified everyone will leave. That part learned something true when you were four years old. But I want you to look at me: I'm not leaving. Even when things get hard in here."
IFS
Reese's system is in emergency mode. Firefighter parts (cutting, raging, sabotaging relationships) are desperately protecting Exiles carrying the foster care abandonment, the sexual abuse, and the disbelief. Manager parts, the one that fires therapists before they can leave and the one that tests every new person early, work to keep the Exiles from surfacing at all. The Self is there but almost completely blended with protective parts.
Slow, patient work. Build trust with protective parts before trying to access Exiles: these parts have been protecting a severely wounded system for 27 years. Don't rush unburdening. The therapy relationship itself will activate parts that test, push away, and idealize.
"The part that pushes people away: it's been working overtime since you were four. It learned something real: people leave, people hurt you. Can you tell that part that I see how hard it's been working? We're not trying to get rid of it. We're trying to understand what it's protecting."
ISTDP
Massive defense structure protecting against core affect: grief and rage about abandonment and abuse. The self-harm is a defense, aggression turned against the self rather than felt toward the people it belongs to. The relationship pattern (idealize, rage, abandon) is the repetition, driven by unconscious anxiety about closeness. The question the first hour has to answer is where that anxiety goes when the feeling starts to rise, and with a history like Reese's the likely answer is cognitive-perceptual disruption rather than tension in the striated muscle.
Trial therapy to establish the anxiety pathway before deciding how hard to work. Striated muscle would mean the intensive format is tolerable. Cognitive-perceptual disruption means the graded format instead: build anxiety tolerance and restructure defenses first, because pressure on a fragile character produces more disruption rather than breakthrough. Identify the triangle of conflict in real time. The eventual aim is that the grief and rage about what happened are experienced rather than acted out.
"Right now, as you talk about what happened in foster care, what do you notice in your body? ... That tightness in your chest: if you didn't push it away, if you let it come, what feeling would be there?"
Mentalization-Based Tx (MBT)
Mentalizing failure: under attachment stress, Reese loses the capacity to represent their own and others' mental states. They switch to psychic equivalence (what I feel IS reality, 'you don't care'), teleological mode (only actions count, 'prove you care by calling me back immediately'), or pretend mode (intellectualizing without feeling). The self-harm restores a felt sense of reality when mentalizing has collapsed.
Not-knowing stance. Therapist models curiosity about mental states rather than claiming to understand. Slow down interactions to rebuild mentalizing capacity. When Reese says 'you don't care,' explore: 'What happened inside you that made it feel that way?' Group MBT provides social mentalizing practice.
"I notice something shifted just now. A moment ago we were connecting, and then your face changed. I'm not sure what happened. Can we rewind? What went through your mind when I said that?"
Relational Psychoanalysis
Reese is organized around dissociated self-states: the desperate child, the enraged avenger, the one who tests whether you will stay, the numb survivor. These are not deficits but creative solutions to an impossible developmental environment. The therapeutic relationship will be the site where these self-states are enacted and recognized, and the aim is standing in the spaces between them rather than fusing them into one. The therapist's countertransference is data, not interference.
Long-term, relationally intensive work. Attend closely to what is happening between therapist and client: the enactments are the treatment, not obstacles to it. The therapist must tolerate being cast in multiple roles (rescuer, abuser, abandoner) without acting them out or withdrawing.
"I notice I'm feeling pulled to reassure you right now: to tell you I won't leave. I want to be honest about that pull, because I think something important is happening between us. What are you needing from me in this moment?"
Transference-Focused (TFP)
Identity diffusion: Reese's internal world is organized by split object relations: idealized all-good representations alternate with persecutory all-bad representations, with no integration. The self-harm and relationship instability reflect the structural instability of split internal objects projected onto external relationships. The therapeutic relationship will inevitably become the arena where these splits are enacted.
Twice-weekly individual sessions. Establish a treatment contract (conditions under which therapy continues). Clarify, confront, and interpret the transference as it unfolds. Name the splitting as it happens in real time. The goal is integration of split representations into whole-object relating.
"You said last week I was the first therapist who really understood you. Today you're saying I don't care and you want to quit. I wonder if we can look at both of those together, because I think both are real to you, and that's the problem."
NARM
Attunement and Trust carry most of this. Attunement: three placements by age ten taught Reese that nobody tracks what you need, so needs are hard to locate from the inside and humiliating to say out loud. Trust, in Heller's sense, is about the danger of depending on someone, and a disclosure that was not believed settled that question at twelve. Love-Sexuality shows in the split between wanting closeness and what closeness came to mean after the abuse. What gets diagnosed as a disorder is a survival structure that once fit its conditions exactly.
Identify the survival style adaptations that organize Reese's current experience. Work at the intersection of identity, emotion, and body. The NARM model is relational and doesn't require cathartic processing: it works with the adaptive patterns as they show up in the present, including in the therapeutic relationship.
"You said everyone leaves and you make sure of it. There's something honest in that: part of you is choosing the rejection before it chooses you. What would it be like to notice that pattern happening in real time, right here between us?"
Where Approaches Genuinely Disagree
The patient needs to see their distortions in real time. Interpreting transference, including aggression, is the work.
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.
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.
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.
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.