Avoiding unbearable pain

This presentation describes the way in which defence mechanisms and resistance manifested themselves in the analysis of a man with a narcissistic personality disorder. In the course of the analysis, there were changes in the forms taken by the defence and the resistance, signalling important genetic and dynamic conditions in his life. Both represented desperate attempts to avoid the unbearably painful feelings and affects which he had experienced in his childhood, and bore witness to early and primitive defence mechanisms such as denial, splitting and projective identification. The defence can also be seen as an expression of an unconscious fear of being re-traumatised. The idealisation of the analyst in the first years of the analysis can therefore be understood as a precondition for entering into this kind of process. It also represented a defence against aggressive and homosexual feelings in the transference which first became clear during the final phase of the analysis and could then be worked through. At this point, the analyst's reactions to his own unconscious countertransference were of help in understanding what was actually going on. This analysis may also suggest that defects and trauma in the earliest years may be conducive to alexithymia, deficient contact between feelings and words, linked to the risk of developing serious psychosomatic illnesses. This may be a consequence of the fact that the child's feelings and affects were neither accepted, understood nor affirmed in words, or they may even have been met with rejection or ridicule. A connection between narcissistic personality disorders and alexithymia can possibly be seen here.     

An Island Entire of Itself: Narcissism in Anorexia Nervosa

ABSTRACT

This article explores the idea of anorexia nervosa as a narcissistic disorder, in which the denial of the need for food symbolically represents a denial of the need for relatedness and dependence. Narcissism is a state in which self and object are undifferentiated and all objects are felt to be within the individual’s omnipotent control. Primary narcissism occurs when the capacity for object relations has never developed and secondary narcissism develops as a defense against dependence which is associated with overwhelming anxiety, envy, or fear of disappointment. Both processes can occur in anorexia nervosa, which provides a cognitive and behavioral framework for the expression and maintenance of the narcissistic position. Narcissistic anorexia is a state of omnipotent isolation in which the patient denies one of her most basic needs and rejects a powerful source of connection with the outside world. An important aim of therapy is to help the patient to develop a capacity for object relations and to be able to acknowledge dependence. This is achieved through coming to experience the therapist as separate and real and requires the therapist to resist being taken over by the patient’s projections.     

The unreachable object? Difficulties and paradoxes in the analytical relationship with borderline patients

The author investigates the main difficulties the analyst encounters in borderline patient analysis, focusing on the specific way in which such patients put the analyst's mental functioning to the test and highlighting the most salient elements of the transference-countertransference dynamic. The author picks out several of the paradoxes that characterize the analytical relationship with these patients, who are constantly seeking contact with the object, which is inevitably traumatic for them. On the basis of highly detailed clinical material, the author demonstrates how - no matter which theoretical-clinical model is adopted - a specific technical problem with these patients is how to manage their intense destructiveness. With these patients, countertransferential difficulties are inevitably predominant because of the looming threat of the destruction of the analytical relationship. Maintaining a balance between the recognition-legitimization of primary narcissistic mirroring needs and the recognition-control of narcissistic demands and attacks on the analytical link is as crucial as it is complex. The paper examines the most important therapeutic and anti-therapeutic factors, highlighting the importance of countertransference analysis and self-analysis as ways of accessing as yet unrepresented elements of the patient and analyst respectively. Particular attention is given to the role played by the analyst's subjectivity and to the enactment.     

The psychoanalytic treatment of a preschool boy with a gender identity disorder

A three-year, nine-month-old boy began analysis by wishing he was a girl and pretending he was a superheroine. Over the course of almost five years, the cross-gender defense against fear of loss of the object, anal loss, and castration by the object reorganized in all libidinal phases through early latency. Developmental arrests seemed to occur during the anal rapprochement and oedipal phases that led to observable cross-gender strivings by two and a half years of age. The role of early childhood illness, narcissistic vulnerability, mother's childhood wish for a sister, the mother's adult wish for a daughter, a shared fantasy between mother and child, identification with the perceived power and beauty of mother and grandmother, pathological sibling rivalry that influenced identification with his sister, were demonstrated in his play during sessions. Interwoven in the background was the impact of an emotionally absent father, a dying grandfather, and an accident-prone uncle. This paternal matrix seemed to discourage budding masculinity and encourage feminine identifications. The analyst's approach and the child's responses to interpretation of the transference manifestations, cross-gender behavior, fantasies, and play are presented. Finally, the gradual resolution of the conflicted wish to be a girl was supplanted by the emergence of appropriate gender identification. A two-year followup appeared to confirm his postanalytic gender stance and continuing consolidation of stable gender development.     

On the connection between physical defects and the character type of the "exception"

A clinical and theoretical study is presented of the effects of physical defects on character structure, especially on its narcissistic aspects. The basic thesis of this paper is that there are two differentiable responses to awareness of a physical disability: various forms of denial, and a clinging to narcissistic overgratifications as a compensation for negative feelings about the self. The first response, of overusing denial, is universal, and of course leaves its mark on a person's character. However, only the second sort of response, of clinging to overgratifications, leads to the character type of the "exception" (Freud 1916). The distinction between moral ideals, embodied in the ego ideal narrowly defined, and nonmoral ideals, embodied especially in the wishful self-image, is presented as a useful tool in understanding various psychological effects of physical disabilities.     

Life-threatening illness in the analyst

The literature on practicing throughout a life-threatening illness is reviewed and important differences about attitudes toward self-disclosure are understood by noting a division between two perspectives on transference: "one-body" and "two-body" views. The analyst's use of self-disclosure is informed by the prominence given the interpretation of transference as against that given the patient's needs in the collaborative relatedness supporting the therapeutic alliance. Themes and illustrative clinical vignettes are presented from the author's own experience practicing during such an illness. Three phases of working during illness are delineated, each somewhat different regarding the analyst's state, and hence patients' needs and reactions. Recommendations are made regarding conditions that make it possible to work effectively during a life-threatening illness. The analyst needs help from his or her own analyst to make the clinically and sometimes ethically appropriate decisions about practice; while this is important in instances in which the analyst recovers, it is essential should the analyst become terminal and face more certain death.     

Countertransference evolution in theory and practice

A framework is suggested for conceptualizing countertransference, based on expansion of the concept emerging subsequent to Freud's original view of the phenomenon: from Ucs to Cs, from reactions to transference to all reactions, from the analyst's neurosis to the analyst's functioning, from self-analysis to self-scrutiny, from obstacle to contribution. Particular attention is called to the advantages of maintaining the distinction between the patient's transference and the analyst's countertransference; the importance for successful psychoanalytic work of being aware of the subtleties of countertransference in work with neurotic patients, especially in contrast to the blatant countertransference experiences more disturbed patients thrust upon the analyst; the need for further investigation of the relations between the analyst's empathy, regression, and countertransference; the lack of understanding of and information about the homosexual countertransference, based on insufficient knowledge of the mechanisms of resistance to self-analysis, among other reasons; and the need for more reliable information about the limits of and indications for using countertransference responses in particular kinds of clinical situations, whether for informing the patient as to the analyst's responses to him, for informing the analyst in the interpretive process, or in formulating reconstructions. A clinical example provides an illustration of the complexity of countertransference-transference interaction and of the impact of countertransference on the transference.     

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.     

Narcissism and Grace: Inherent Incompatibility

Narcissistic conditions are highly prevalent in clinical treatment settings. However, most developmental theories include only maturational and interpersonal aspects of functioning without including spiritual and Christian-based factors. In working with narcissistic disorders, it is necessary for the patient to incorporate grace and forgiveness into their sense of self, through the transmuting internalization of vicarious introspection of the therapist. This paper asserts that grace is a necessary and vital prerequisite for developmental and spiritual growth. Specific examples are included to help therapists identify and work within the therapeutic transference to help the patient integrate grace into their identity.     

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.     

Group psychotherapy of the characterologically difficult patient

A broad range of characterologically difficult patients present for treatment in psychotherapy groups. Despite different clinical presentations, including features of the schizoid, borderline, and narcissistic personality disorders, these patients share a common developmental failing. Specifically, these individuals have failed to attain object constancy and the associated stable internalization of tolerably ambivalent representations of the self, and of the other, in relationship with one another. Splitting mechanisms predominate over integrative ones, as primitive defenses are utilized to deal with the individual's powerful needs and fears related to engagement and intimacy. These maladaptive interpersonal styles are clearly illuminated in group therapy, but often to the exclusion of the latent, intrapsychic derivatives of this behavior, with detrimental effects. This paper examines the group therapy of such patients from the perspective of object relations and self psychology theories, models that provide the essential link between the interpersonal and the intrapsychic worlds.     

Dialogical Relationship Patterns in Narcissistic Personalities: Session Analysis and Treatment Implications

Patients with narcissistic features are difficult to treat in psychotherapy, in particular because of problems in building sound therapeutic relationships with them. Therapists can get easily involved in dysfunctional relationship patterns that have a negative impact on the therapeutic alliance. Tracing the typical patterns that can recur in persons with narcissistic features should, therefore, prove useful in helping therapists to recognize their involvement in them at an early treatment stage and to deal with them effectively. A dialogical theory of the self offers a promising perspective from which to recognize and describe these patterns. From this vantage point, we discuss the treatment of a client diagnosed as having a narcissistic personality. What occurred during this therapy lends support to the idea that there are typical dialogical relationship patterns in patients with narcissistic features and that knowing them might help therapists to make treatment effective, avoid early dropouts, and successfully manage the therapeutic relationship. In addition, we put forward the hypothesis that some of the therapeutic techniques described here also can be applied to other patients displaying similar narcissistic features.     

Falling off the couch

The patient's therapeutic regression intensifies certain unconscious meanings of the analytic couch. In addition to representing the analysis or the analyst in general, the couch can represent the unconscious, or it may take on the symbolic significance of the analyst's or mother's arms, lap, breasts, or womb. When the genetic roots of the patient's transference include substantial experiences of disappointment, narcissistic injury, and mistrust, the theme of falling from the couch may emerge as a dream, an association, or even an enactment. This theme usually implies the presence of a deepening but mistrustful transference, based on earlier disappointments by the patient's primary objects. Falling off the couch may be associated with being dropped as an infant, rolling out of bed as a child, birth, miscarriage, castration, death, termination, defending against passive wishes, punishment for sexual or aggressive transgressions, escaping an attack, descending into the unconscious, or wanting to be picked up and comforted.     

Discussion: The Narcissism of Small Differences — and Some Big Ones

A broad range of characterologically difficult patients present for treatment in psychotherapy groups. Despite different clinical presentations, including features of the schizoid, borderline, and narcissistic personality disorders, these patients share a common developmental failing. Specifically, these individuals have failed to attain object constancy and the associated stable internalization of tolerably ambivalent representations of the self, and of the other, in relationship with one another. Splitting mechanisms predominate over integrative ones, as primitive defenses are utilized to deal with the individual's powerful needs and fears related to engagement and intimacy. These maladaptive interpersonal styles are clearly illuminated in group therapy, but often to the exclusion of the latent, intrapsychic derivatives of this behavior, with detrimental effects. This paper examines the group therapy of such patients from the perspective of object relations and self psychology theories, models that provide the essential link between the interpersonal and the intrapsychic worlds.     

Transference-countertransference

This paper concerns the dynamics of transference-countertransference as they reveal themselves in object relations and specifically in the psychoanalytic process. It is postulated that transference and countertransference cannot be viewed separately, that both analyst and patient exhibit transference-countertransference reactions, and that they are normal ingredients of the psychoanalytic process. Brief clinical illustrations are provided. Attention is called to special problems when the patient's defenses are primitive, and to the therapeutic value of the analyst's countertransference.     

The structure of psychosomatic symptoms

1. According to our findings, a psychosomatic structure is not an alternative to neurosis. The syndrome of alexithymia appears to be, in our cases, a transitional phase, the dynamics of which can be understood and treated by psychotherapy. In the course of psychotherapeutic treatment, alexithymia always disappears. 2. However, a special psychotherapeutic technique is advisable, one different from that applied in classical neurosis. 3. For this reason the term psychosomatic structure can be used as a way of expressing a variation of neurosis. 4. Modern concepts of psychosomatic disease describe pathological personalities that are different from the classic pseudoneurotic type because of their narcissistic and pregenital structures. These structures can be concealed underneath a facade of genital and psychoneurotic defense. 5. The old relationship between psychosomatosis and psychosis can be better understood on the basis of our findings, which reveal a borderline structure and splitting mechanisms in many psychosomatic patients. 6. Psychosomatic pathology can be better understood today by relating it to the structure of the psychosomatic family. 7. It appears that if, on the one hand, psychosomatic diseases of a more hysterical picture are frequent among preindustrial cultures and in low-income classes, on the other hand psychosomatic syndromes of a narcissistic and borderline type are characteristic for our civilization.     

Current developments in the practice of individual psychoanalytic psychodrama in France

The authors present the history of individual psychoanalytic psychodrama and its current developments as practised in France. They put forward the technique, objectives and rules, along with the indications, limits and risks that ensue from the specific nature of this therapeutic approach. Through its technical adjustments, individual psychoanalytic psychodrama provides a therapeutic option that is appropriate to the defences prevalent in many patients that cause classical psychotherapies to fail: massive inhibition, operative functioning far removed from affects or in false self mode; phobias, disavowal or splitting of the internal psychic life and emotions; prevalence of short discharge circuits in acted-out behaviours and bodily or visceral complaints and expressions. Psychodrama utilizes these defences not in order to eliminate them but to 'subvert' them so that they can continue to carry out their protective role, in particular ensuring narcissistic continuity. At the same time, psychodrama relaxes these defences and facilitates a possible filtering through of the repressed material. Through the number of actors and the diffraction of transference that this allows, psychodrama provides a possibility of adjusting the potentially traumatic effect of the encounter with the object and the instigation of the transference in the regressive dimension induced by any psychotherapeutic process.     

Transforming Disorganized Attachment Through Mentalization-Based Treatment

A disorganized attachment pattern is found among several mental disorders, most notably among severe personality disorders (PD). It is characterized by profound mentalizing deficits, which makes relations to self and others highly problematic. There is no evidence of any preferred mode of psychotherapy to heal this condition. In this article we describe the successful treatment of a female (28) with schizotypal and avoidant PD with additional borderline features as well as substance use dependency. She participated in the mentalization-based treatment project of the Bergen Clinic Foundation, Norway. We discuss the therapeutic strategies and interventions that most probably mediated the change for this patient, highlighting the mentalizing stance, working in the transference, managing countertransference and repairing alliance ruptures.     

Countertransference, conflictual listening, and the analytic object relationship

Analytic listening is an ongoing conflictual process, containing all the components of conflict and shaped in every moment by both the patient's and the analyst's conflicts. The mutual responsiveness that develops between analyst and patient stems from a complex conflictual object relationship, fundamentally no different from any other object relationship, in which countertransference at all times simultaneously facilitates and interferes with the analytic work. Detailed clinical process is used to illustrate these and related phenomena, including the use of signal conflict, the benign negative countertransference, the function of countertransference structures, and the analyst's use of projection. The analyst's affects, thoughts, and actions trace the shifting nature of the patient's transference and resistance, and the level of the object relationship continuously being created between patient and analyst.