The difficulty of understanding a borderline patient

SUMMARY

For much of the time during my work with Mr A, a borderline patient whom I saw for twice-weekly psychotherapy over a period of one year. I had difficulty understanding and communicating with him. I felt despairing and impotent and that therapy was not progressing at all. A few weeks prior to termination a shift occurred and I realised that there had been some improvement in Mr A's functioning. Although I was aware that behind the polite façade was an angry, disturbed man, I felt that he was a little more in touch with reality than he had been at the beginning of the treatment.

In this paper I will focus on the factors that contributed to my difficulty in understanding and communicating with Mr A. I will also attempt to account for his apparent improvement.     

Catch 22: the inflammatory nature of insight

I will describe a man I saw in psychoanalytic psychotherapy with a history of serious drug abuse and violent psychotic episodes. At the start of therapy my patient had little capacity to tolerate the anxiety, depression or the inevitable frustrations involved in facing reality. Over time and with the support of the therapy he was able to increase his capacity for self observation noticing the way he withdrew from the world of shared reality into psychotic states of mind in order to avoid painful feelings of rage, humiliation and shame. In the book ‘Catch 22?, Joseph Heller described the paradox of pilots who wish to claim insanity in order to avoid fatal flying missions, while the authorities maintain that in claiming insanity to avoid suicidal missions the individual demonstrates a sane awareness of the insanity of the missions! This insight is deemed to be evidence of the individual’s sanity and consequently their plea of insanity is denied. In this paper, I will show how Mr. A’s developing capacity for reflective functioning lead to a ‘Catch 22’ as the insight he needed as part of the process of recovery threatened to overwhelm him with depressing realities about the extent of his illness.     

Can You Help Me Be? Commentary on Mr. Mikulka’s Paper “Surviving Destruction and Finding Connection: Play Therapy with an 11 Year Old Boy”

ABSTRACT

In his paper “Surviving Destruction and Finding Connection: Play Therapy with an 11 year Old Boy” Mr. Mikulka describes the treatment of a difficult boy who presented a very contrasting picture – deeply connected to Mr. Mikulka and yet highly provocative and offensive. Mr. Mikulka describes his efforts to make sense of the boy’s acts and to establish limits. In reading his case, one can marvel at his ability to go on despite his provocative statements and sometimes offensive acts to become a steadying presence for the boy, someone who made him feel not just tolerated, but also valued and seen.     

An Integrated Treatment Program for Psychogenic Pain

The family characteristics associated with the presence of recurrent abdominal pain are identified. The involvement on the pediatrician and the effects of this involvement on the patient, family, and perpetuation of the symptoms are described. A successful therapeutic program combining behavior modification and family therapy is elaborated. Changes in the structure and functioning of the family are vital to the outcome of therapy and the prevention of recurrence of symptoms.     

Psychodynamische Zusammenh?nge zwischen Psychose und Lebensgeschichte

Using two cases as examples it is shown how psychotic experiences and behaviour are psychodynamically associated with the biography of affected patients and can be beneficially used in therapy. Based on the historic pioneer work of Sigmund Freud who, with his psychoanalytical interpretation of Daniel Paul Schreber??s autobiography Memoirs of my nervous illness (Denkwürdigkeiten eines Nervenkranken) from 1903 shortly after his death 100 years ago, was the first to attempt to construct an association between Schreber??s delusional symptoms and his past history, this approach will be extensively discussed for patients with schizophrenia and similar psychoses. Particular attention is paid to trigger situations for the occurrence of psychotic conditions and the interpretation of certain delusional symptoms with respect to conflictual subjects from the past. In patients suffering from monopolar or bipolar affective disorders or psychoses, the symptoms are generally less exaggerated and extravagant than in schizophrenic psychoses. However, in such cases it can also be beneficial for the therapy in depressive or manic episodes to follow up the long-lasting conflicts which existed prior to the psychosis, where they either experience an escalation or describe an attempt to free themselves from previous pathogenic settings.     

儿童功能性躯体化症状研究述评

功能性躯体化症状(Functional-somatic Symptoms, FSS)是指无法用医学知识解释, 或经医学治疗后无改善的躯体不适症状, 多发于儿童和青少年群体, 常伴随焦虑、抑郁等心理障碍共同发生。儿童FSS的发病受多方因素的影响, 包括社会文化、年龄、性别、家庭环境、生理易感性等。各个心理学流派从不同视角提出了儿童FSS的心理理论模型。心理干预, 尤其是认知行为疗法和放松–生物反馈疗法对治疗儿童FSS有较好的效果。     

Recommending Interventions for a Borderline Personality Disorder Patient

Borderline personality disorder (BPD) is a severe personality disorder leading to unstable emotional state, impulsivity, disturbed relationships and personal distress. This paper suggests a 12-step intervention plan including Dialectical Behavior Therapy (DBT) to Mr. X, a 21 year old male psychiatric inpatient having BPD, to promote his mental health. Therapy could not be conducted as the patient dropped out of treatment and got himself discharged from the hospital. This paper outlines implications for treatment on the basis of the clinical presentation of Mr. X. Mr. X presents himself with the BPD features showing suicidal tendencies, substance abuse and disturbed emotions. In depth interview of the patient showed extreme emotional disturbance and difficulty in controlling emotions and suicidal ideations. He was admitted at the Nur Manzil Psychiatric Centre, Lucknow, India and was kept under close observation because of being obsessed with suicidal thoughts; he also tried to kill himself. The DBT skills training and problem solving approach along with contingency management and behavioral chain analysis are suggested according to the clinical profile of Mr. X in order to reduce his self mutilating acts and substance abuse. Thus a general feeling of personal well being can be achieved thereby reducing personal distress.     

Effect of Diagnosis and Personality on Impression Formation1

Nurses were asked to rate patients differing in diagnosis and personality type. Two diagnosis conditions (psychogenic or physiogenic) were compared across two personality conditions: Mr. Cummings, a hypothetical patient presented to nurse/subjects via audiotape, willingly disclosed information about his illness in a nonemotional manner; while Mr. Lockwood, the second “patient”, disclosed less and was more emotional. Two control conditions were also included: One measured subjects' reactions to the personality type independent of diagnostic label; the second determined nurses' stereotypic reactions to the two diagnostic labels alone. Subjects reacted more favorably to Mr. Cummings than to Mr. Lockwood regardless of Cummings' diagnosis. Nurses' impressions of Mr. Lockwood, on the other hand, varied as a function of his diagnosis.     

Art therapy in transcultural family therapy

The increased existence of foreign culture patterns in the child population calls for transcultural comprehension in child psychiatry. This case report describes transcultural aspects in the therapy of an 11 year-old Moslem girl admitted to a child psychiatric department. Her symptoms were abdominal pain, headache, anxiety, and pretended fever. A family therapeutic approach was used together with elements of art therapy and individual therapy in a successful treatment. The family therapeutic approach was based on art therapy as a part of the communication where cultural symbols were an important part. An interpreter was not used. The cultural context where it is acceptable to overstep the borderline between reality and fantasy is seen as an important healing capacity.I would like to acknowledge my debt and my appreciation to Ebba Ernst, psychologist of the department and supervisor in the therapy of the S. family. I would also like to thank professor Kai Tolstrup and child psychiatrist Torben Marner for stimulating support in the process of writing the article. A grant from Enkefrue Hermansens Mindelegat made the participation in the Krakow Congress possible.     

A Single Intervention: A Visit to the Family

The following letter is reported unchanged except for disguised names. Concern with repairing disrupted relationships of adult members of a family with their own parents has been a matter of growing interest to a number of family therapists; Bowen (1), Boszormenyi-Nagy (2), and Framo (3), among others have stressed the importance of sending family members back to their families of origin. This report makes no effort to formulate the process in any particular theoretical framework (i.e., as reestablishing connectedness after an “emotional cut-off” or rebalancing a ledger of fairness, or whatever) but is intended only to illustrate the kind of outcome one may hope for in prescribing such a maneuver. It is offered simply as a clinical note. The letter needs little prefatory explication. Mr. Jack Newburgher had been a patient in psychoanalytic treatment for four years, with a quite successful outcome. On two occasions in the course of his therapy a joint session had been held with Mr. Newburgher and his wife, Muriel, when changes in his behavior had precipitated crises in the marital relationship. His therapy had terminated about two years before the visit referred to in the letter. Mr. Newburgher had called and asked for a joint consultation with Muriel about an acute family problem they were experiencing. Some — not all — of the background material was described, not nearly as coherently as it is reported in Muriel's letter, but in sufficient detail to make it plain that she was in distress about having to withdraw completely from her parents and that their family was in disarray as a consequence of her distress. The acuteness of the emotional disturbance, against a background of a lifelong adversary relationship between Muriel and her father and a history of ten years of illness on her fathers' part, suggested that the distress was the product of Muriel's anxiety and guilt over a decision to cut herself off completely from her parents. As a consequence, Muriel was urged to visit her family of origin, with the caveat that she might indeed discover them to be malignantly self-centered people indifferent to their effect on her and her family, but that she would at least have the gratification of having tried. The reference to “speaking French” was to the therapist having suggested that, on the other hand, she might find that her parents expressed their feelings in a different modality from her definitions of how feelings should be expressed, much as though their native tongue were French and she were insisting that they must speak to her in English.     

Introducing the living with illness group: A specialized treatment for patients with chronic schizophrenic conditions

This paper introduces a specialized psychotherapy/psychoeducational group treatment for patients with chronic psychotic symptoms who receive only partial benefit from psychotropic medications, psychotherapy, and milieu/activities therapy. The goal of the group is to assist patients to accurately identify the feelings, thoughts, and behaviors that are dysfunctional symptoms of their disability and then use the functional aspects of their brain as well as learned coping strategies to compensate for their disability. The group format, philosophy, procedures, and typical topics of discussion are detailed.The authors would like to thank Bruce Levine, Ph.D., and Terry Fujeoko, Ph.D., for their assistance with the initial formation of the group. Mr. Howe and Dr. Fujeoko originated the Living with Illness group and began the first group in 1985 at Waterbury Hospital Health Center, Waterbury, CT.     

The Man of the House: Commentary on Thomas Burkhalter’s “Foregrounding Masculinities in Psychoanalytic Psychotherapy”

Thomas Burkhalter is complemented on so vividly bringing the reader into his personal struggles to find a true masculinity in the unforgiving context of contemporary South Africa where White masculinity is associated with apartheid. The struggle to be free of old identifications with the patriarchal order and gender binaries saturate the paper, and attention is drawn to the lingering presence of older conceptions of masculinity as a monolithic concept that leaves women as victims and nurturers and the male as dominant. Burkhalter’s clinical vignette is examined and found to illustrate well his struggle and to capture the vulnerability to genderized enactments and the enduring presence of the old order manifested by a reliance on defense analysis that constrains his construal of Mr. Jones’s statement that he is “after all the man in the house.” Potential alternative meanings of this phrase that foreground grief, hope, and a plea for companioning in pain are offered and a deeper engagement with Mr. and Mrs. Jones’s conscious and unconscious worlds is encouraged.     

抽动症儿童的箱庭治疗个案研究

探讨箱庭治疗对抽动症儿童的有效性和作用机制。对一名抽动症儿童进行15次箱庭治疗,综合使用作品分析、访谈法和问卷法对治疗的过程及效果进行评估,结果发现个案的变化经过问题呈现、转变和自性三个阶段,箱庭治疗所提供的自由受保护的空间、矫正性的情绪体验以及良好的咨访关系等能够帮助个案减少抽动症状,提高情绪调节能力和人际交往能力。     

Fairy-tales in psychotherapy

Fairy-tales, like mythologies, can be found all over the world containing the same motif and chains of motifs. In this paper I have presented some theories on the occurrence of this archetypal phenomenon ranging from the old migration theory to Sheldrake's theory of morphogenetic fields. I have then tried to show how fairy-tale-motifs can appear in various ways in analytical therapy, often in hidden forms. We find them in patients' dreams as well as in their fantasies and associations. If the therapist is open to them they will also appear in his or her amplifications. He or she might then take note of the fairy-tale or point it out to the patient; in the latter case it might provide better access to the patient's problems and complexes as fairy-tales have an emotional completeness because of their pictorial character. Finally I have described the favourite fairy-tale of one of my patients and related it to his symptoms, his central complex and his personal ways of experiencing and behaving. This survey of how fairy-tales can be used in therapy with children and with adults far from exhaustive.     

Kohut's case of Mr Z: overcoming countertransference in self psychology

This paper has attempted to discover if the two analyses of Mr. Z by Kohut do in fact substantiate the clinical efficacy of his theoretical model. A brief overview was presented, as were critical assessments. The major point was developed, that a creative working-through of a complementary countertransference was largely responsible for the success of a second analysis after a first phase was seriously undercut by interfering material which rigidified the therapist's interpretation. It was concluded by noting how Kohut's need to overcome the countertransference played a vital role in catalyzing the evolution of his new theory.     

Illegality 1988

The author presents how the Holocaust appears symbolically in an obsessive-compulsive neurosis in 1988 in Budapest, through the therapy of a 16-year-old boy and his family. The behavior therapy that was first applied made the symptoms even more serious, supposedly because the index patient interpreted it as pursuit. The hypothesis supposed the appearance of the Holocaust in the third generation—as a family myth—and intervention based on this hypothesis brought an end to the neurotic symptoms. The knowledge of historical processes is very important in psychotherapeutic treatment.I would like to acknowledge my debt and my appreciation to Valeria Kiss, occupational therapist, Central National Institute, Budapest, who has had a major role in creating therapy, as co-therapist. I would like to thank Beata Susansky and Gareth Dewar for helping in translation and Andras Posman for helping with the figures of the genogram.     

薛学潜易统计方程式推导存在的问题探讨

民国薛学潜先生作为科学易学的代表人物,打通了传统易学与西方现代科学的隔阂,建立了一个相对缜密的薛氏科学易体系。但由于受诸多因素制约,其推导仍有许多不足,甚至有对物理模型的模糊认识,导致了一些结论不能令人信服。本文以易统计方程式为例进行探讨,发现易统计方程式总摄三种物理统计有些牵强,其推导过程也颇有缺陷。     

Developing the therapeutic relationship: from 'expert' professional to 'expert' person who stutters

This article looks back over the years and identifies some of the most influential thinkers, writers, and researchers who have had a profound effect on the way the therapy at the Michael Palin Centre for Stammering Children in London has evolved. It tracks the changes that have occurred in theoretical perspective, treatments offered, and the delivery of therapy. In particular this author is interested in the changing nature of the therapeutic relationship between professionals and people who stutter (PWS), and describes the way it has developed from the “expert professional” towards a more collaborative relationship that recognises the “expert patient”. It was inspired by a book written in 1902 by Mr Beasley, a person who stammered. After several unsuccessful attempts to find a ‘cure’ he found his own solution to his stuttering and then used what he had learned to help many others. Much of what he wrote was well ahead of his time and reminds us, the professionals, of the importance of listening to and taking account of the views of PWS in therapy and designing treatment that meets the needs of the individual. This article also looks briefly at evidence based practice (EBP) and the issues involved in measuring outcomes that reflect the complex and individual nature of the problem. Finally the importance of the research in developing the knowledge and skill base of clinicians as well as PWS is acknowledged and discussed and the way ahead signposted.Educational objectives: The reader will learn about (1) the early history and development of stuttering therapy, (2) the influence of a variety of psychotherapeutic approaches, (3) the relevance of designing therapy to meet the needs of the PWS, and (4) discuss the role of ‘common’ factors in EBP.     

The Relationships of Stress to Angioneurotic Edema:

Hereditary angioneurotic edema is a disease characterized by attacks of swelling of the extremities, face, and airways, frequently accompanied by abdominal pain and gastrointestinal symptoms such as vomiting and nausea. The possibility of improving the management of hereditary angioneurotic edema through psychological interventions was raised by the fact that stress has been implicated as a potential precipitant for acute attacks as well as a common psychological sequala to them. The current case evaluates efficacy of Psychological interventions in reducing the frequency and intensity of symptoms associated with this disorder in a 16-year-old white female. The combination of family therapy and behavior management was more successful than an initial effort utilizing stress management techniques in combination with positive reinforcement alone.     

Prediction of treatment outcome among patients with irritable bowel syndrome treated with group cognitive therapy

Using a sample of over 125 patients with irritable bowel syndrome (IBS) who were treated with cognitive therapy administered in small groups, we sought to predict end of treatment and 3-month follow-up improvement in two changes indices of gastrointestinal (GI) symptoms (Pain/Discomfort Index which assessed change in abdominal pain, abdominal tenderness and bloating and Bowel Regularity Index which assessed change in diarrhea and constipation). We also sought to predict scores on IBS specific quality of life (QOL) and overall level of psychological distress using the Global Severity Index (GSI) of the Brief Symptom Inventory (BSI). Significant, but modest, levels of prediction were found for prediction of improvement in GI symptoms (4-15% of variance). Stronger significant prediction was obtained for the QOL and global psychological distress measure with R(2)'s ranging from 0.36 to 0.50. A wide variety of demographic, GI symptom, psychological status and psychiatric status variables entered the final prediction equations.