Knowing What To Do,When, and How: An Integrative Approach to the Use of Psychoanalytic Play Therapy with Children Affected by Cancer

This article delineates a comprehensive approach to play therapy in work with children with cancer. It considers different psychological needs experienced by the patient in connection with significant moments related to cancer treatment and the psychological tasks it involves. Different therapeutic aims are presented, and the therapeutic components related to each are described in detail. The therapeutic aims approached by play therapy are reality testing and ego strengthening, unveiling and working through of unconscious conflicts related to disease, and defense maturation. Therapeutic components leading to the attainment of those aims include the provision of realistic information about diagnosis and treatment by means of play, the use of play as a space for containment, the detection and interpretation of unconscious anxieties and defenses within play, and the exploration and trial of adaptive defenses in the face of illness-related anxiety. Implications of this approach in terms of the precision and flexibility of therapeutic actions and the diversity of roles played by the therapist are discussed.     

Abusive families and character formation

Family research studies confirm that abusive parents tend to be undifferentiated partners who compete with each other and with their children for attention and nurturance. More or less healthy parents make demands on children to counteract their own injured narcissism, but they do so largely without devaluation and the sadistic use of projective identification. Under sufficient stress abusive parents attack the child who fails to gratify their needs, thereby giving vent to longstanding frustrations and feelings of being threatened by the child's individuation and competency. The emotional atmosphere in such families facilitates ego deficits like those of the borderline personality as it molds the child's efforts to avoid anxiety. Devaluation, loss, and defenses against mourning partially account for depression and paranoid traits in abused youngsters. Early neglect and abuse exposes them to influential models who act out rage and primitive defenses. Some abused individuals project their rage and later become paranoid or antisocial, whereas others fragment or retain infantile defenses. The destructiveness of severe psychological abuse lies in the constriction of the experiencing self and healthy character development, together with the conditioning to repeat abusive relationships and to avoid intimacy. Achieving individuation under these circumstances entails overcoming the internalized abusive relationships and relinquishing the unconscious wish to be transformed from the abused into the abuser.     

Treatment of oral character neurosis in group psychotherapy

Summary In summary, orally regressed neurotic characters are generally regarded as extremely resistive and discouraging patients because of their excessive narcissism, weak, unadaptable ego, clinging passive dependency, intense infantile rage, strong psychic masochism, and intense need to provoke aggression. This author has found, however, that patients in this category are more likely to respond to treatment when it is provided in a group setting.This hard core of oral character neurotics who frequently resemble borderline psychotics because of their tenacious masochistic defenses often find it easier to recognize the rigid and inappropriate defenses they habitually employ after they have seen similar defenses enacted by their group peers. Watching others play out their various senseless and stubborn delaying tactics stimulates such patients to question their own inflexible behavior when it is challenged or interpreted. Moreover, in the group setting, they are made aware of the fact that the acknowledgment of anxiety by their peers does not demean them; nor do they become passive and vulnerable objects for annihilation as a result. They find instead that the uncovering of conflicts evokes sympathy, and produces tangible help by all the members of the group, including the unconsciously feared therapist who is perceived as the bad mother.Reprinted with permission from Sager, C. J. and Kaplan, H. S. (Eds.)Progress in Group and Family Therapy. New York: Brunner/Mazel, 1972.     

Deutende Interventionstechniken bei Patienten mit schweren Persönlichkeitsstörungen

The growing influence of ego-psychology, self psychology, object relations theory, and interpersonal concepts on the psychoanalytic psychotherapy of patients with personality disorders is reflected in a preference of relational therapeutic strategies and in a controversial discussion of interpretative techniques. It is shown that interpretative strategies are of invaluable importance in many patients with personality disorders. However, modifications of technique necessary for this group of patients should be considered. Especially, transference interpretation in the here and now can be of great use even in the treatment of patients with severe personality disorders. It is of outstanding relevance for the therapist to understand the interactional message a patients infers from his interpretation and to take into account the patient's reaction to the interpretation.     

Defenses, Personality Structure, and Development: Integrating Psychodynamic Theory Into a Typological Approach to Personality

Psychodynamic theory does not conceptualize motivated unconscious defenses primarily in terms of individual traits. Rather, a person's mechanisms of defense are understood in terms of his or her personality structure and level of psychological development. This paper outlines the way in which this perspective has been integrated into a configural approach to personality assessment. The six-group typology based on the Weinberger Adjustment Inventory (WAI) identifies higher-order personality organization through the intersection of self-reported high/low distress and high/moderate/low self-restraint. The framework incorporates a developmental perspective by assessing affect regulation in conjunction with the internalization of self-regulatory controls. The primary defenses of prototypic members of each of the six groups are highlighted, and hypothesized links to personality traits, stages of ego development, attachment styles, and proneness to specific personality disorders are discussed.     

Psychotherapeutischer Prozess und Persönlichkeitsstörungen

This paper begins with a cursory overview of psychotherapy outcome research for personality disorders; however, relatively little is known about process research or process outcome relationships. It then focuses on relevant patient and therapist variables. Significant controversies in personality disorder treatment techniques are examined. Initially, studies generally associated transference interpretation with less favorable therapy outcomes. Recent work supports the possibility of differentiated correlations. There is increasing evidence that a moderate amount of transference interpretation and perhaps even a therapeutic alliance that is not so good, maybe indicative of an inner conflict with the therapist relationship, could ultimately be beneficial. This association most probably does not exist in cluster C personality disorders. A problem with this type of research is that clear definitions are often lacking. This complicates comparisons between studies and the influence of other mediating variables remains vague.     

Fantasy or structural defect? The borderline dilemma as viewed from analysis of an experience of nonhumanness

The experience of nonhumanness, a crucial aspect of the phenomenal self of borderline states, is studied in two cases to test assumptions concerning the application of the classic ego-psychological or object-relations and self-psychological models. Are these experiences to be seen as fantasy and treated as manifest content, with dynamically active unconscious conflict and meaning, requiring interpretation, or as a developmental arrest in which structural disturbances are ameliorated through clarifying and empathic interventions? The first case is of a patient with a neurotic depression and hysterical and obsessional character traits, treated in a classic psychoanalysis. Even though dyadic oral and anal fantasies were strongly in evidence, the ego was well integrated. The second case is of a severe borderline patient who showed depressive panic and agoraphobia. Her major ego disturbances, poorly integrated and differentiated self- and object representations, and primitive defenses prevented effective psychoanalytically oriented treatment. Interventions were used to consolidate self-representations, internalize tension-regulating structures, promote adaptive ego functions and reality testing. These clarifications were necessary to move the patient to where she could tolerate facing unconscious dynamic conflicts. Only at that point could repression be lifted, memory emerge, and interpretation be utilized.     

Ethical considerations in the use of nonerotic touch in psychotherapy with children

Although touch frequently occurs in psychotherapy with children, there is little written on the ethical considerations of therapeutic touch. Because physical contact does occur, therapists must consider if, how, and when it is used, for both their clients' safety and their own. In this review, I further develop the issues suggested by Aquino and Lee (2000) in the use of nurturing touch in therapy by considering many types of touch that occur in psychotherapy with children; the possible positive role of touch; clients' perception of touch in therapy; considerations related to the therapist, the child's safety, and any history of abuse in the child's and family's background; and other practical considerations. I list guidelines.     

The evolution of culture and cohesion in the group treatment of ego impaired children.

The challenge of group treatment with ego impaired children is to provide a situation in which their maladaptive efforts to organize volatile affects and impulses can be tolerated and structured. This article addresses the process of culture building in group and how it can provide a cohesive structure for affective expression that is acceptable and tolerable to the defensive, resistant child. In particular, the author will argue that it is through the sense of normality and commonality engendered by indigenous peer culture that the members initially develop a structure and language for affiliation, play, and mutual identification. By facilitating the cohesion of indigenous peer culture, the therapist creates a sufficient holding environment to begin a dialogue involving both verbal and nonverbal communication. For children who are difficult to engage in discussion, let alone treatment, this dialogue is the essential process for creating a corrective emotional experience. Through a concise case study, the author describes the process by which the children's efforts to express and create their own culture are cultivated, managed, and understood.     

Differentiating Ego Functions of Borderline and Narcissistic Personalities

This study investigated differences in ego functions of borderline and narcissistic personality disorders through examining responses to Rorschach structural and content variables. Reality testing, thought process, affective regulation, impulse control, and the defenses of splitting and grandiosity were examined from Rorschach protocols of 50 borderlines and 26 narcissists. The borderlines produced greater distortion in reality testing, p < .05; the narcissists produced more insidious thought process disturbance, p < .05; and higher functioning groups demonstrated greater control of impulses, p < .05. Borderlines in this sample demonstrated more affective constriction than the narcissists and used more splitting, p < .05; narcissists used more grandiosity, p < .05. Implications of this study are (a) ego functions mature inconsistently, (b) affective responsivity influences ego disorganization, and (c) level of functioning and IQ are related to the production of Rorschach variables.     

A Structural Analysis of the Obsessional Character: A Fairbairnian Perspective

This paper reviews the object relations model of W.R.D. Fairbairn and applies it to the understanding of the obsessional personality. Fairbairn's model sees attachment to good objects as the immutable component of normal development. Parental failures are seen as intolerable to the child and trigger the splitting defense that isolates (via repression) the frustrating aspects of the object along with the part of the child's ego that relates only to that part-object. This fundamental defense protects the child from the knowledge that he is dependent on indifferent objects and preserves his attachment. The split-off part-self and part-object structures are too disruptive to remain conscious, yet despite being repressed make themselves known through repetition compulsions and transference. The specific characteristics of families that produce obsessional children impact the child's developing ego structures in similar ways. This style of developmental history creates predictable self and object configurations in the inner world, which then translate via repetition compulsion into obsessional behavior in adulthood.     

Differentiating ego functions of borderline and narcissistic personalities

This study investigated differences in ego functions of borderline and narcissistic personality disorders through examining responses to Rorschach structural and content variables. Reality testing, thought process, affective regulation, impulse control, and the defenses of splitting and grandiosity were examined from Rorschach protocols of 50 borderlines and 26 narcissists. The borderlines produced greater distortion in reality testing, p less than .05; the narcissists produced more insidious thought process disturbance, p less than .05; and higher functioning groups demonstrated greater control of impulses, p less than .05. Borderlines in this sample demonstrated more affective constriction than the narcissists and used more splitting, p less than .05; narcissists used more grandiosity, p less than .05. Implications of this study are (a) ego functions mature inconsistently, (b) affective responsivity influences ego disorganization, and (c) level of functioning and IQ are related to the production of Rorschach variables.     

Verbal Participation and Improvement in Group Therapy

The challenge of group treatment with ego impaired children is to provide a situation in which their maladaptive efforts to organize volatile affects and impulses can be tolerated and structured. This article addresses the process of culture building in group and how it can provide a cohesive structure for affective expression that is acceptable and tolerable to the defensive, resistant child. In particular, the author will argue that it is through the sense of normality and commonality engendered by indigenous peer culture that the members initially develop a structure and language for affiliation, play, and mutual identification. By facilitating the cohesion of indigenous peer culture, the therapist creates a sufficient holding environment to begin a dialogue involving both verbal and nonverbal communication. For children who are difficult to engage in discussion, let alone treatment, this dialogue is the essential process for creating a corrective emotional experience. Through a concise case study, the author describes the process by which the children's efforts to express and create their own culture are cultivated, managed, and understood.     

Changeover of a Mental Hospital Unit into a Therapeutic Community

This paper explores some clinical implications of combining individual and group psychotherapy for children functioning at different levels of ego development. More highly structured children are able to observe the continuity and discontinuity that inevitably exist between the two modalities. Bridging of the two therapeutic contexts—integrating split off object representations—enriches the transference and strengthens the therapeutic alliance. In working with ego impaired children the goal in combining treatment modalities is to provide a therapeutic structure capable of containing unintegrated affects and perceptions. The therapist's challenge is to provide the opportunity to regulate emotional distance while at the same time maintaining the experience of a nurturing relationship. While potential hazards exist, with proper precautions taken, combined treatment can provide significant opportunities to establish or strengthen a therapeutic alliance with children, particularly those most in need and yet most resistant to treatment.     

Emotionally disturbed, adopted adolescents: early patterns of family adaptation

This article focuses on the development of compatibility or goodness-of-fit within adoptive families and on the possible contribution of such problems to emotional disturbance of adolescents. Subjects included 50 adopted adolescents in residential treatment (mean age = 14.96) and their families, and 50 nonadopted adolescents in treatment (mean age = 14.90) and their families. The child, both parents, and the child's caseworker were interviewed. Three distinctive interactional patterns presenting adaptational challenges are discussed: the family's adaptation to the child's hyperactivity, the family's adaptation to the child's avoidance of contact and cuddling from early infancy, and perceived incompatibility between the child's personality and the parents' style. Results are discussed in terms of behavioral and attributional contributions of both the child and parents to the development of compatibility. Implications for clinicians are discussed.     

Revitalizing Oedipus

Abstract

Three steps are presented to revitalize the concept of the Oedipus complex and to apply this revitalized concept to clinical work. First, a comprehensive child developmental map is constructed of the road from the early infantile genital phase to the achievement of the full Oedipus stage, integrating the diverse components of self, gender, libido, aggression, ego, superego, object relationship and adaptation. Second, specific developmental lines (e.g., separation-individuation) are magnified in a given patient for close examination to explore the relationship to that patient's overall oedipal conflicts. Third, a reciprocal interaction is fostered between the evolving conceptual framework and the emerging clinical data. The paper contains two in-depth case examples to illustrate the clinical application of these ideas.     

Angstzustände bei Patienten mit schweren Persönlichkeitsstörungen

States of anxiety are very common problems in patients with severe personality disorders. All phenomena of anxiety can be observed. In this connection a continuum of the severity of impairment of structural personality organisation can be postulated. In many cases proper anxiety disorders exist as comorbid disorders. Anxiety is esteemed to be the central affective problem of borderline patients. In spite of these relations, states of anxiety in patients with personality disorders are often underdiagnosed or misdiagnosed. For the treatment of neurotic anxiety disorders (for example panic disorders), there exist disorder-specific therapy manuals that proceed from behavioural as well as psychodynamic perspectives. Nevertheless, for the treatment of anxiety states in personality disordered patients, the techniques that focus heavily on symptomatology appear often contraindicated. In our opinion, treatment of these typically severe anxieties must be contained within a therapeutic framework, which essentially takes into account the personality organisation of this group of patients. Such treatment makes special demands on the therapist for working with transference and countertransference processes. From a disorder-specific psychodynamic perspective recommendations are given for psychotherapy.     

Personality disorders and response to outpatient treatment of chronic pain

As part of a comprehensive interdisciplinary evaluation conducted prior to participation in an outpatient chronic pain treatment program, the psychological status of 101 persons was assessed. The majority of participants was found to have a form of personality disorder, determined by conservative cutoff scores applied to their Millon Clinical Multiaxial Inventory (MCMI) profiles. DSM-III-R Cluster C disorders (i.e., Avoidant, Dependent, Obsessive-Compulsive, and Passive-Aggressive) were overrepresented in this sample. Subsequent analyses revealed that personality disorders were related to higher levels of self-reported distress and pain at both the beginning and the end of outpatient treatment. Differential responses to treatment were observed on self-report measures; however, few relations were found between personality disorder and physical therapist ratings of impairment and improvement. Implications for the assessment of personality disorders in outpatient pain treatment programs are discussed and appropriate intervention strategies are considered.     

Regression in the service of the ego in young children.

Analysis of studies of primary process thinking as manifested in Rorschach and TAT production of young children (ages 6 to 10) indicate that children show approximately the same amount of primary process production as do young adults (48% vs 54%). However, this primary process does not appear to be clearly related to the child's creative, scholastic, or perceptual-motor development as measured by appropriate tests. High levels of primary process appear to be significantly related only to the negative qualities of the personality, that is, to high levels of tension, anxiety, and poor control of aggression. It is possible that young children have not yet learned to use it in the service of the ego, although they do not seem to be encumbered by its presence.     

A preliminary report on defenses and conflicts associated with borderline personality disorder

The authors present preliminary psychodynamic findings from a naturalistic study of borderline personality disorder compared to antisocial personality disorder and bipolar type II (depression with hypomania) affective disorder. An independent psychodynamic interview of each subject was videotaped from which ratings were made of the presence of 22 defense mechanisms and 11 psychodynamic conflicts. A factor analysis of ratings from 81 subjects supported the separation of borderline (splitting, projective identification) from narcissistic defenses (devaluation, omnipotence, idealization, mood-incongruent denial). While certain groups of defenses were associated with each diagnosis, defense ratings did not significantly discriminate the three diagnostic groups, suggesting a limit to their diagnostic value. Among 27 subjects rated, borderline personality was strongly associated with two conflicts: separation-abandonment, and a global conflict over the experience and expression of emotional needs and anger. Antisocial personality was psychodynamically distinct and more heterogeneous. Bipolar type II was associated with two hypothesized depressive conflicts: dominant other and dominant goal. Chronic depression, which was more common in both personality disorder groups than in bipolar type II, was associated with a third depressive conflict, overall gratification inhibition. Overall, conflicts were powerful discriminators of the three diagnostic groups. The heuristic value of these findings is discussed.