Integrative Therapie von narzisstisch gestörten Patienten

The psychotherapy of patients with a narcissistic personality disorder continues to be a psychotherapeutic challenge. There is still no psychotherapeutic program for the treatment of these patients which integrates different psychotherapeutic methods and strategies. Therefore the therapy of narcissistic patients remains difficult and only few psychotherapists voluntarily meet the challenge of treating such patients. In this article an integrative psychotherapeutic concept for the treatment of narcissistic patients using psychotherapeutic methods of different psychotherapeutic schools is presented. This integrative concept includes basic strategies such as working with the therapeutic alliance, schema work and activation of resources. On the other hand specific modules for different core symptoms of these patients are proposed. With this article the authors hope to contribute to a new conceptualization of the psychotherapy of narcissistic patients.     

Isolation

This paper reflects upon Winnicott’s term “the isolate” or “incommunicado self,” which must remain hidden for personality development to proceed satisfactorily. Paradoxically, the (of necessity) concealed isolate or True Self accedes to the personality’s dependence on an object for this development to take place. The impact of trauma on the isolate and the formation of pathological isolation are considered. The outcome of analysis with a traumatized person is contingent upon the type of narcissistic defenses employed to protect the isolate that has experienced impingement and exposure, with the adverse consequences for personality development this entails. A particular form of narcissistic withdrawal into what Green terms “deobjectalization” and “negative narcissism” is examined as a way in which the death instinct can infuse the personality’s defense of the isolate, limiting radically what may be analyzed. A clinical example is given.     

Intersubjectivity and narcissism in group psychotherapy: how feedback works

In group psychotherapy, inter-subjectivity is complicated by the number and quality of therapist-member, member-member, and member-group relations. Inter-member feedback structures the relational process. However, fears of narcissistic injury engender resistance to this form of engagement. The nature of the narcissistic belief system that motivates such resistance is discussed. Then, two models of feedback are presented: the cybernetic and the inter-subjective. In the cybernetic model, feedback is intended to inform recipients about themselves and to change their behavior accordingly. As such, this model is consistent with narcissistic beliefs in the power of others' perceptions to control one's being, identity, or value. The inter-subjective model focuses, instead, on what feedback tells recipients about their donors' worlds. This model and some of its parameters are exemplified clinically.     

Contempt and self-contempt

Clinical material characterized by devaluation of the analyst will be used to illustrate the classical narcissistic mechanism: grandiosity and contempt as a defense against feelings of inferiority, shame and dependency. The analysand's asocial behavior is related to this narcissistic dynamics and to the question of relative degree of split-off guilt and structural deficit. Technical problems connected to asocial behavior will also be considered. Finally, the holding function of the analytic setting and its importance to mental growth is dealt with.     

Addiction, helplessness, and narcissistic rage

In many cases addictive behavior serves to ward off a sense of helplessness or powerlessness via controlling and regulating one's affective state. Addicts have a vulnerability to feelings of powerlessness, which reflects a specific narcissistic impairment. The drive in addiction to re-establish a sense of power is, correspondingly, impelled by narcissistic rage. This rage gives to addiction some of its distinctive clinical properties. The narcissistic vulnerability in addicts is discussed. Several brief clinical cases are provided, and the view proposed is correlated with other psychoanalytic perspectives.     

Fear of humiliation

This paper explores the ontogeny of fear of humiliation, conceived of as an important organizing affect-laden fantasy in certain narcissistic personality disorders. The influence of the pleasure of the parental object in sadistically humiliating is emphasized in the overdetermined genesis of this fear. While, in elaboration of Loewenstein's (1957) and Eidelberg's (1959) contributions, "seduction of the humiliator" is a fundamental defensive process observed in masochistic characters, identification with the humiliator is a sadonarcissistic defense observed in work with certain narcissistic personality disorders. The countertransference potential to enjoy humiliating such analysands, as well as the defensive functions of fear to humiliation, are noted.     

Fragmentation and Narcissism

The paper focuses on the articulation of two areas of theory: that of development of the self through fragmentation and differentiation and that of narcissism in early psychological development, and its pathology later in life. Jungian ideas concerning the self and individuation (including those developed by Fordham) are linked with psychoanalytic ideas, notably Kohut's, and related to the concepts of narcissism and ego-development. In this the focus is on a revaluation of the negative overtones of 'fragmentation' and 'narcissism' and an indication of their place in the process of individuation. It is pointed out that a varying emphasis in the analyst on what are called the biological and ethological aspects of these theories will have important implications for the treatment of patients. The theoretical position is illustrated by a lengthy clinical example involving a case of early injury to the self which suggests the pathology of narcissistic character disorder. But the case also illustrates the contribution to development of fragmentation and narcissism, which are revalued here as the 'part-for-the-whole' and as one of the 'motors' of individuation. Working within a perspective that prioritizes the importance of the drive towards relationship, it is recommended that the analyst learns to respect and value phenomenologically the contribution of fragmentation and narcissism to normal development, if true healing is to occur.     

Sibling differentiation, identity development, and the lateral dimension of psychic life

The lateral dimension of psychic life, lived through relationships with siblings and their substitutes, is structured around a distinct psychic challenge: to find one's unique place in a world of similar others. Like the challenge that structures the vertical parent-child dimension, the lateral challenge is fraught with conflict and ambivalence; its resolution imbues psychic structure. That resolution may be accomplished through a process of differentiation, an active and unconscious process of identity development by which a child amplifies differences with siblings and minimizes similarities. Differentiation from siblings serves to mitigate interpersonal rivalry with them and to ease internal conflict associated with the lateral dimension. Three clinical examples are offered to illustrate the operation of sibling differentiation and its costs, particularly in terms of constricted identity and attenuated relationships with siblings and peers. Differentiation as a process of becoming what the other is not has been eclipsed by identification in psychoanalytic theories of identity development. Yet differentiation is a common strategy for resolving the primary rivalries and conflicts of the lateral dimension, and has unique developmental and clinical implications.     

Narcissism, variability in self-concept, and well-being

The present research examined whether narcissism is related to higher variability in self-concept across roles and time points. Three indices of self-concept variability across roles were formulated based on the participants’ self-ratings for personality attributes. A probabilistic sample in Study 1 as well as a student sample in Study 2 revealed that the narcissistic personality inventory (NPI) positively correlated with the variability indices, except for the self-concept differentiation (SCD), while well-being measures were only related to SCD. The student sample also showed a significant correlation between NPI and longitudinal variability in self-concept within a month-long interval. Implications for the instability of the narcissistic self-concept and its relationship with psychological well-being are discussed.     

Omnipotence in the transference and in the countertransference

The concept of omnipotence refers to a primitive fantasy, a mechanism of defense, and a pathological psychic structure. Omnipotence and its derivative defensive operation, omnipotent control, are highly prevalent in borderline personality organization. Three clinical vignettes illustrate these mechanisms in the treatment of patients with borderline, narcissistic, and obsessive personality disorders, respectively. These vignettes illustrate the transference developments when omnipotence and omnipotence control are dominant, and the therapeutic approach to these conditions.     

Transference Focused Psychotherapy for Patients with Comorbid Narcissistic and Borderline Personality Disorder

Clinical experience involving the treatment of patients with comorbid borderline and narcissistic personality disorders suggests that this patient population is among the more difficult to treat within the personality disorder spectrum. In this article, we present refinements of Transference Focused Psychotherapy (TFP) based on our clinical experience with and research data on patients with comorbid narcissistic personality disorder/borderline personality disorder (NPD/BPD). We briefly review object relations formulations of severe narcissistic pathology, as well as recent research in attachment and the allied concept of mentalization, which have provided a new lens through which to view narcissistic disorders. The research findings from two randomized clinical trials demonstrating the efficacy and effectiveness of TFP are presented. The data from the two Randomized Clinical Trials (RCT) allowed for the study of the characteristics of the subgroup of borderline personality disorder patients who have comorbid NPD/BPD. Findings on comorbidity, attachment status, capacity for mentalization, and level of personality organization of borderline patients with comorbid NPD/BPD, compared with borderline patients without comorbid narcissistic pathology (BPD), are presented. Clinical implications of the observed group differences are discussed, with a focus on refinements in the technique of TFP. Clinical case material is presented to illustrate the specific challenges posed by narcissistic patients to carrying out TFP in each phase of treatment.     

MODES OF IDENTIFICATION: FREUD'S CONCEPTS REORGANIZED

The author examines Freud's conceptualizations of identification, Melanie Klein's projective identification, and Anna Freud's identification with the aggressor and altruistic surrender of one's own instinctual impulses. After demonstrating that Freud's concept primary identification refers not to a process but to the state of being identified, he suggests the substitution of it with Sandler's term “oneness”. He notes that hysterical identification, narcissistic identification, and introjection are unconscious processes that lead to a state of oneness and that they can be distinguished clinically in terms of the emotional meaning that an object holds for the individual. Furthermore, it is shown that the concept of identification with the aggressor represents a defense mechanism of its own and a specific mode of narcissistic identification, which together with projections and hysterical re-identification play a decisive rôle in projective identification and altruistic surrender of one's own instinctual impulses.     

The Group Psychotherapy Literature 1958

This study applies Kohut's self-psychology toward an understanding of the self-functions that membership in a religious cult group (Divine Light Mission) provides for the narcissistic personality. It is proposed that there exists a psychosocial fit between the appeal of the cult group's structure and process and the needs of the narcissistic personality. The cult group offers reparative and substitutive functions to the follower who seeks an idealized selfobject to stabilize a defective sense of self. The special relationship of the follower to the Guru bears a close resemblance to the “idealizing transference” which arises between certain narcissistic patients and their group therapist. The therapeutic use and misuse of the “idealizing transference” in group therapy is explored and suggestions are made for its appropriate clinical management.     

A Modern Instrument for Evaluating Psychopathology--The Personality Assessment Inventory (Book)

The Splitting Index (SI), a self-report scale based on the writings of Kernberg (e.g., 1976) on self and object representations and the defense mechanism of splitting, was constructed. After development over the course of 6 pilot studies, the SI was validated through 2 further studies. FacTor analyses revealed a 24-item scale with three 8-item subscales, measuring the splitting of self, family, and others' images. The SI and its subscales were demonstrated to be internally consistent and stable over a 4-week period. Convergent validity was supported by significant correlations with measures of borderline and narcissistic personality disorders, self-image stability, self-esteem, depression, and negative affectivity. Discriminant validity was demonstrated by near-zero correlations with two measures of cognitive complexity. Contrary to predictions, the SI was significantly correlated with the Dogmatism Scale (Rokeach, 1960), a third measure of cognitive complexity. Research and clinical applications of the SI are discussed.     

Defense Mechanisms in Mania,Bipolar Depression and Unipolar Depression

The present study compared the use of defense mechanisms in ten bipolar manic, ten bipolar depressed and ten unipolar depressed patients. The defense mechanisms were assessed by two methods: TAT stories scored by Defense Mechanism Manual and Defense Mechanism Rating Scale ratings of psychodynamic interviews. The severity of symptoms was assessed by Beck Depression Inventory for depressed patients and Young’s Manic Rating Scale for manic patients. Both bipolar manic and depressed groups used the defense mechanism of denial, borderline level defenses and immature defenses significantly more than the unipolar depression group. The manic group showed greater dependence on narcissistic level defenses as compared to the other two groups. Positive relationships were found between severity of manic symptoms and the defense mechanisms of denial as well as the narcissistic level defenses. The bipolar depression group also used more action level defenses as compared to the unipolar depression group. The unipolar depression group scored higher on the defense mechanism of identification and adaptive level defenses as compared to the manic group. A negative correlation was found between the severity of depressive symptoms for unipolar depression group and the defense mechanism of identification. The neurotic level defenses were used most frequently by unipolar depression group, followed by the bipolar depression group and manic group. Some of these findings are in consonance with the psychoanalytic understanding of mania and depression.     

?Omnipr?senz��

Excessive urge for free individual development even beyond moral law and social rules is discussed as part of the aftermath of severe political repression and traumatization. It is proposed to describe these phenomena which have not yet been sufficiently considered in the scientific literature as ??omnipresence??. In terms of psychoanalytic understanding these mechanisms result from specific unconscious defense activities. The relationship to other defense mechanisms, e.?g. of anal, phobic, paranoid and manic nature, is outlined, and illustrated by a short case vignette. The article ends with a differentiation between omnipresence as described above on the one hand and the phenomena of media-moderated expansion of individual development and acceleration typically and generally found in postmodern societies, on the other hand.     

Interpersonal Psychoanalysis: The Selected Papers of Clara M. Thompson Edited by Maurice Green

The aging process presents a challenge to the narcissism of the individual due to physical, social, and psychological changes and losses. There is a danger that mental health professionals may add to narcissistic trauma by underestimating the elderly patient's potential for change. An older adults group established on a short-term psychiatric unit is presented. Therapeutic principles and strategies are discussed which are aimed at helping the aged patients make restitution for losses and regain self-esteem through renewed engagement with their environment. The importance of cohesion and inclusion in the group is examined, with attention given to the particular needs and conflicts experienced by the older adult population. The use of techniques to promote the experience of mastery is also discussed.     

The cross-culturally disordered self: A self-psychological study and treatment

The psychotherapeutic treatment of a young woman whose development was thwarted by patriarchal, sexist, familial, and cultural contexts is presented and discussed. The history, dream material, and symptomotology indicate developmental deficits from which derived a lack of cohesive, individual selfhood as well as narcissistic vulnerabilities manifested by a high propensity for shame. The author posits a view of patriarchy as acculturating women subjectively to experience themselves on an unconscious fantasy level as appendages of men, thus depriving them of genuine and authentic selfhood. This perspective is used as a lens through which this woman's experience in two patriarchal cultures can be empathically understood. The case enables us to examine how the process of acculturation in patriarchal contexts can interfere with women's capacity to develop a strong sense of self and allows us to consider whether and how human development is culturally determined.     

Comparing a narcissistic and an autistic retreat: 'looking through or at the window'

In this paper I discuss two different forms of psychic retreats that I encountered in the treatment of a patient who suffered from two traumatic experiences: the loss of his mother when he was 2 years old and his 'near-death' experience when he was five. In the parasitic narcissistic retreat, using intensive projective identification enabled him to create an impasse in the form of a 'high tide - low tide' scenario in which alternating hope and disappointment kept the process going, yet paralyzed development. The autistic retreat, for its part, led to the collapse of projective identification mechanisms, dismantling and disrupting the transference/countertransference negotiations. The emerging state of non-communication and 'near death' seemed to act as a protection against the unbearable pain of abandonment and desolation.     

A Rorschach Study of Narcissism Defense,and Aggression in Borderline,Narcissistic, and Cluster C Personality Disorders

We examined the differences between narcissism, mode of defense, and level of aggression on the Rorschach. We also investigated differences in borderline, narcissistic, and Cluster C personality disorders by examining responses to Rorschach content variables. The Lerner Defense Scale (P. Lerner & H. Lerner, 1980), the aggressive content section of the Holt (1977) method for assessing primary process manifestations, a modified version of Exner's (1986a) Egocentricity Index, Wagner's (1965) exhibitionistic M score, and grandiosity were scored on the Rorschach protocols of 17 borderline, I7 narcissistic, and 17 Cluster C personality disorders. Borderlines were found to employ primitive defensive structures to a greater degree and severity, show more intense and overall aggression as welt as more responses on the three forms of aggression in the Holt method, and have higher levels of grandiosity. Narcissists evinced significantly higher levels of egocentricity than borderlines and higher levels of idealization than the Cluster C group. Convergent validity was found on the measures of defense and aggression, which showed a strong relationship between primitive aggression and primitive defense.