Paranoia and narcissism in psychoanalytic theory. Contributions of self psychology to the theory and therapy of the paranoid disorders

Many factors go into a choice of a therapeutic focus: the patient's psychopathology; the therapist's training, countertransference reactions, and ideological beliefs; and, importantly, a decision about what seems most amenable to treatment and change. As a theory, self psychology describes one aspect of the paranoid process; as such, it is an incomplete theory that complements rather than invalidates more classical theories. As a technique, however, it suggests a style and focus conducive to working with paranoid patients, one that is markedly supportive, nonconfrontational, yet also interpretive. In this context, it must be remembered how difficult it is to treat paranoid patients psychotherapeutically, much less to keep them in treatment. The strategies discussed above do not wholly replace other dynamic approaches (e.g., counterprojective techniques), nor are they universally applicable. Some patients may be more amenable than others. However, the techniques provide a very supportive framework that may help the therapist to be more available to and in contact with the paranoid patient. More broadly, this paper's application of self psychology to the theory and therapy of the paranoid disorders further illustrates the practical utility of this approach. Attention to the narcissistic developmental line, interpersonal selfobject relationships, intrapsychic conflicts and deficits, and empathic immersion in the patients's world are important adjuncts to the psychotherapy of paranoid patients. Rather than an either/or dichotomy, the principle of overdetermination suggests a both/and relationship between self psychology and traditional theory, such that the self psychological approach complements rather than contradicts the classical psychoanalytic theory. The vicissitudes of the self simply add another perspective or vantage point from which to understand and respond to the patient, one which has perhaps more applicability for preoedipally disordered patients.     

Reactions of Outpatient Schizophrenics to Group Psychotherapy

Preoedipal patients present a special problem in group treatment. This is because their difficulties arose largely before they learned to use words. Such patients are prone to act. rather than talk. They do not respond well to interpretation. They must be approached and influenced through feelings. We can utilize the group to provide them with maturational experiences, helping them reach a more adult level of mental functioning so that our usual technical interventions can be brought into play. The paper discusses methods for enhancing this process, including reflection, emotional communication, using reconstruction to close developmental gaps, and immunization.     

Treating Patients with Symptoms—and Symptoms with Patience: Reflections on Shame,Dissociation, and Eating Disorders

I offer the view that the symptom picture found in most patients with eating disorders, as well as in the symptomatology of many other so-called difficult patients, is the end result of prolonged necessity in infancy to control traumatic dysregulation of affect. I propose that the central issue for an eating-disordered patient is that she is at the mercy of her own physiologic and affective states because she lacks an experience of human relatedness and its potential for reparation that mediates self-regulation. She is enslaved by her felt inability to contain desire as a regulatable affect and is thus unable to hold desire long enough to make choices without the loss of the thing not chosen leading to a dread of self-annihilation. Trauma compromises trust in the reparability of relationship, and for symptoms to be surrendered, trust in reparability must be simultaneously restored. Because felt desire is the mortal enemy of an eating-disordered patient, this fact becomes a central dynamic in the analytic field, leading analyst and patient into a struggle over who shall hold the desire and whether the issue of control over food is allowed to become a subject for negotiation. I discuss the inevitability of the analyst's own dissociative reactions in response to the patient's internal war over desire and control, and the different types of interpersonal enactments into which an analyst is drawn. In this tension, as illustrated through clinical vignettes, analyst and patient slip in and out of a constantly shifting array of self-states and thereby have an opportunity to coconstruct a transitional reality within which the patient's impaired faith in the reliability of human relatedness can be restored, and eating can become linked to appetite rather than to self-protection.     

Practical Wisdom: Aristotle meets Positive Psychology

The strengths and virtues identified by positive psychology are treated as logically independent, and it is recommended that people identify their “signature” strengths and cultivate them, because more of a strength is better [Peterson and Seligman: 2004, Character Strengths and Virtues: A Handbook and Classification (Oxford University Press, New York); Seligman: 2002, Authentic Happiness (Free Press, New York)]. The present paper contrasts that view with the Aristotelian view that virtues are interdependent, that happiness (eudaimonia) requires all the virtues, and that more of a virtue is not always better than less. We argue that practical wisdom is the master virtue essential to solving problems of specificity, relevance, and conflict that inevitably arise whenever character strengths must be translated into action in concrete situations. We also argue that practical wisdom is becoming increasingly difficult to nurture and display in modern society, so that attention must be paid to reshaping social institutions to encourage the use of practical wisdom rather than inhibiting it.     

The role of the analyst in the analytic cure during times of chronic crises

The role of the analyst in psychoanalytic treatment during periods of chronic crises is illustrated with material from two case studies. The first clinical vignette shows an analyst able to stay with fears evoked in the patient by the traumatic external reality, even as the analyst tried to explore with the patient an inner universe that handled this reality in unique ways. The second case study focuses on how the analyst's countertransference during this period of chronic crises, which she was experiencing along with the patient, made it difficult for her to contain the patient's fears and anxieties, because of the threat to her own existence, as well as to her identity as an analyst. In this second case the analyst, out of denial of the external situation, focused blindly on the patient's internal reality in order to counteract her own sense of passivity and helplessness in the confrontation with death and destruction. She clung to "classical" analysis by trying to analyze the patient's defenses, work them through, etc., thus making so-called analytic interpretations rather than staying with the patient's fear, as well as her own, and helping the patient more directly. A turning point came with the birth of the analyst's granddaughter; fear for the new arrival's safety made the analyst sharply aware that it is impossible to ignore external reality, that it must be given a place both in everyday life and in analysis. This awareness enabled the analyst to contain the patients' fears, which helped him feel more supported and facilitated change.     

Imagining what might be: why children underestimate uncertainty

Children’s well-documented tendency to behave as if they know more than they do about uncertain events is reduced under two conditions: when the outcome of a chance event has yet to be determined and when one unknown outcome has occurred but is difficult to imagine. In Experiment 1, in line with published findings, 5- and 6-year-olds (N = 61) preferred to guess the unknown location of a known object when the object was in place rather than before its location had been determined. There was no such preference when the object’s identity was unknown. In Experiment 2, 29 5- and 6-year-olds were more likely to correctly mark both possible locations when an already hidden object’s identity was unknown rather than known. We conclude that children’s vivid imaginations can lead them to underestimate uncertainty in a similar way to imagination inflation or fluency effects in adults.     

Moral psychology of nursing robots: Exploring the role of robots in dilemmas of patient autonomy

Artificial intelligences (AIs) are widely used in tasks ranging from transportation to healthcare and military, but it is not yet known how people prefer them to act in ethically difficult situations. In five studies (an anthropological field study, n = 30, and four experiments, total n = 2150), we presented people with vignettes where a human or an advanced robot nurse is ordered by a doctor to forcefully medicate an unwilling patient. Participants were more accepting of a human nurse's than a robot nurse's forceful medication of the patient, and more accepting of (human or robot) nurses who respected patient autonomy rather than those that followed the orders to forcefully medicate (Study 2). The findings were robust against the perceived competence of the robot (Study 3), moral luck (whether the patient lived or died afterwards; Study 4), and command chain effects (Study 5; fully automated supervision or not). Thus, people prefer robots capable of disobeying orders in favour of abstract moral principles like valuing personal autonomy. Our studies fit in a new era in research, where moral psychological phenomena no longer reflect only interactions between people, but between people and autonomous AIs.     

The trial period and the creation of analytic patients

Just as there are many roads to Rome, the trial period may be considered one of many opening moves in psychotherapy or psychoanalysis. The responsive – and responsible – therapist must be many things to many patients, some of whom know nothing about the psychotherapeutic/analytic process. Freud advocated the trial period to help him take a “sounding” when he knew little about the patient and when the patient knew little about psychoanalysis. R.I.P.? This brief communication laments the apparent demise of this promising procedure and makes an effort at resurrection by describing the hitherto unmapped latent structure of the trial period. Even if there are fewer patients in psychoanalysis today, there may be a number of reasons to recommend a trial period, no matter what we name this period of optimistic uncertainty at the beginning of every treatment. Even if “consultation” is the term de jour, the psychoanalytic psychotherapist cannot escape certain role responsibilities at the beginning of every treatment, which has been made clear in the ethical principles of the American Psychoanalytic Association. What we will learn about the trial period should serve our understanding of what must also occur in the beginning of every psychotherapy or psychoanalysis. Conceptually, I propose that a trial analysis (1) will serve as a discriminative stimulus, signaling, to the patient, the unique nature of the analytic conversation; (2) will permit an in vivo assessment of the patient's suitability for psychoanalysis, and, more importantly, the fit between analyst and patient; (3) will provide anticipatory socialization for the unfamiliar and difficult roles of patient and therapist within the analytic process; (4) will offer true informed consent about the task facing therapist and patient; and (5) will facilitate an opportunity for therapeutic assessment, all of which will help the naive patient acquire the skills and lived experience to become an analytic patient. The trial period is the perfect host for all that must happen – and what we can do– to help naive patients become analytic patients.     

The dead donor rule: lessons from linguistics?

American society traditionally has assumed a univocal notion of "death," largely because we have only one word for it and, until recently, have not needed a more nuanced notion. The reality of death-processes does not preclude the reality of death events. Linguistically, "death" can be understood only as an event; there are other words for the process. Our death vocabulary should expand to reflect multiple events along the process from sickness to decomposition. Depending on context, some death-related events may constitute a more obvious discontinuity than others and more justifiably may be considered "death" within that context. There is no reason to assume a priori that there must be an overarching, unitary concept of death from which all diagnostic criteria must derive. Regarding organ transplantation, the relevant question is not "Is the patient dead?" but rather "Can organs X, Y, Z ... be removed without causing or hastening death or harming the patient?"     

On ethics in personal construct theory

Abstract

In personal construct theory, people interpret the world in unique ways. Constructions are subjective representations rather than objective truths. This means that our ethical constructions are (a) potentially wrong, if there is an external moral reality we cannot access, or (b) no more inherently defensible than others’ ethical constructions, if all notions of “right” and “wrong” are personally constructed. Constructions promoting violence, hatred, and intolerance are as viable as those promoting peace, love, and acceptance. To overcome this ethical quandary individuals must create meaningful ethical constructions and have faith in them. This is difficult because, as constructivists, we see each person's constructions as legitimate and our own world views as merely constructions, themselves. Implications for moral righteousness are discussed.     

Researcher and clinician: Role conflict and resolution

Group therapy investigations are often conducted by researchers rather than by experienced clinicians who also possess research expertise. Given the fact that doctorally prepared clinicians must demonstrate research competence in their education programs, it is surprising that there is not more research on group therapy. The literature indicates that research and group psychotherapy practice are considered quite separate entities. However, there is much that both processes have in common. The principal investigator's experience during a group psychotherapy research project suggested that the conflict between the roles of researcher and clinician may not be due to differences in the external processes but rather to difficulties in trying to combine them within one person. The value of the researcher-clinician is elaborated, and recommendations are offered.This paper was supported by a grant from the Group Psychotherapy Foundation.     

Power and formation: New Foundations for a radical concept of Power

A radical concept of power identifies social processes which (whether as ‘ideology’, ‘false consciousness’, or ‘the spectacle') influence people's actions by moulding their beliefs or desires. However, seeing people as deluded is to risk treating them as less than fully autonomous beings. Despite his libertarian intentions, Lukes fails to guard against this paternalistic implication. His view still implies that it is the social critic who is in the best position to identify the real interests of an oppressed group. Here it is argued that power should be conceived as an intrusion on the ‘formative practices’ of people. It is possible to identify power as an unwanted influence on the processes in which people ‘form and discover’ interests, while maintaining that interests can only be self‐ascribed. This solution requires a concept of formation as both irreducibly social and yet potentially free. Neither Foucault nor Habermas can provide such a solution, despite some valuable insights. In the end, we must look at the influences of power on formative practices which are actual rather than idealized, productive rather than reflective, and which involve the whole person rather than merely the intellect.     

Assessing the Ethics of Medical Research in Emergency Settings: How Do International Regulations Work in Practice?

Different ethical principles conflict in research conducted in emergency research. Clinical care and its development should be based on research. Patients in critical clinical condition are in the greatest need of better medicines. The critical condition of the patient and the absence of a patient representative at the critical time period make it difficult and sometimes impossible to request an informed consent before the beginning of the trial. In an emergency, care decisions must be made in a short period of time, and the more time is wasted, the more the risk of death or severe tissue damage and incapacity increases. Consent requests take time, and so the time period before treatment might put the patient’s life in jeopardy. Not requesting consent before a trial is also contradictory. A person should not be forced to participate in a trial against his or her will. Due to the dark history of medical research previously, international declarations and conventions have set up ethical principles for medical research. They emphasize the autonomy of the research participant—or his or her legal representative—to give a free and informed consent prior to the initiation of research. In the case of a critical emergency, the unconscious state of the patient, the emotional stress of family members or the lack of time to start life-sustaining measures may often restrict the possibilities of communicating with the patient or his/her representative. Therefore, written informed consent is difficult to achieve, and its voluntariness in emergency situations is, at best, open to question. The mortality of patients is high without clinical interventions in emergency research. Random selection of patients is difficult and requires extra work from personnel in the emergency rooms. Recruitment, information and asking for consent may also take time, postpone the initiation of treatment and increase the risk of death and irreversible tissue and organ damage, and therefore be risky for the patient. It is therefore essential that the health care professionals recruiting suitable research participants are well motivated and well trained. Medical research in an emergency setting should always be regarded as an exceptional situation requiring special provisions. Only such research should be done as cannot be done in other conditions. An independent body must approve the research protocol and the ways in which the consent of the participant or proxy are to be sought. In addition, the trial must be expected to result in direct and significant benefit for the research participants. If research without prior consent is not approved, the development of emergency care is threatened. On the other hand, if prior consent is not required, a person could be recruited into a clinical trial against his or her will. Doing good and avoiding harm, and respecting the autonomy of the patient are in conflict in the context of emergency medical research. To develop better medicines for patients experiencing acute medical emergencies, research into such conditions should be allowed. Research participants should have the possibility to participate or refuse to participate in research that may benefit them and other patients. The risk of irreversible damage occurring as the consequence of time delays for seeking consent is unacceptable. A prior wish about participation in clinical trials should be respected, if known. The conditions under which medical research in emergencies can be considered acceptable can be determined and agreed upon nationally and internationally. An earlier version of this paper was presented at The 7th International Conference on Bioethics on “The Ethics of Research in Emergency Medicine”, held on June 2, 2006, Warsaw, Poland.     

What is Literature? Revisited: Sartre on the Language of Literature

This article argues that Sartre's distinction in What Is Literature? between prose and poetry should be understood in the light of his earlier distinction in The Imaginary between two kinds of meaning. Sartre argues against the “Cartesian picture” of consciousness in The Imaginary, specifically concerning our experience of images. Not only is a mental image not an “inner object” mediating between consciousness and the world, even a picture drawn on paper should not be understood as an object standing between the viewer and what this picture represents. Our experience, Sartre argues, is that of seeing things in a picture rather than seeing through it, such that the meaning of pictures and images in general is embodied in them and cannot be separated from them. He then goes on to contrast this kind of embodied meaning (which he calls “sense”) with a kind of meaning that can be completely grasped independently of its expression (which he calls “signification”) and identify the two with painting and language respectively. It is for this reason, this article argues, that Sartre later sees poetry as a deviation from language's proper function. This rigid distinction is maintained by Sartre until the end of his career, and the change that some commentators found in him are its outcome rather than a revolt against it. In contrast, Merleau-Ponty has demonstrated more convincingly that sense and signification are both essential aspects of linguistic meaning, and their relation is much more dynamic and complimentary than Sartre would have allowed.     

Decision-Making in Mental Healthcare: A Phenomenological Investigation of Service User Perspectives

As Victorian asylums closed down in the United Kingdom, community mental health services were set up to support patients in exercising choice and freedom; in finding a place in society. The success of these services has been questioned, so further policies have been introduced in an effort to protect rights and improve social inclusion. However, capacity to make decisions has been interpreted as no more than a process of rational mental calculation. This article reports on a phenomenological study that explores the decision-making experiences of three men who have endured psychosis. It is not only associated with choice and freedom but also with responsibility, blame, and social exclusion. These men appear to have faced common existential dilemmas, but have sought to express emotional will in conflict with other people and have, perhaps, been placed under more social pressure and become more isolated as individuals, while enduring experiences that are difficult to make meaningful for others. It seems that, paradoxically, efforts have been made to empower these men by controlling them, and medication has been imposed on them so as to regulate thoughts and moods, in attempts to serve their best interests.     

Amie Thomasson's Easy Approach to Ontology

Philosophers have long debated whether abstract objects such as numbers and properties exist, but in recent years philosophical debate about what things exist has been ratcheted up more than a notch to question whether even ordinary objects such as pineapples and tables exist. One view has it that all existence questions are difficult questions whose answers hang on achieving an ontological theory that succeeds in carving nature at its joints. Some proponents of this view further claim to have succeeded in that carving, even without the benefit of any instrument sharper than the a priori arguments conjured in their armchairs, and to have discovered, alas, that no ordinary concrete objects exist. Naturally, many of us have been made to wonder what premise in the argument for that conclusion enjoys a plausibility greater than that of the negation of the argument's conclusion. In her remarkable new book, Ontology Made Easy, Amie Thomasson strives to do much more than that in defense of common‐sense ontology. But not only for common‐sense ontology. She propounds a unified approach to all existence questions—whether about the existence of dogs, shoes or tables, or about the existence of numbers, propositions or fictional characters—according to which existence questions “are not deep and difficult subjects for metaphysical dispute, but rather questions to be resolved straightforwardly by employing our conceptual competence, often combining this with empirical investigations” (20). Thomasson calls her way of resolving existence questions the easy approach to ontology, and to that I now turn.     

Integrating Care for Persons, Not Only Diseases

Integrated care is geared toward enhancing usual care and decision-making for common combinations of medical and mental health conditions, including the behavioral health and behavioral change aspects. Yet even with comprehensive and well-integrated care for health conditions and well-coordinated teamwork in place, some patients do not engage or respond to care in the way clinicians would like or predict. This troubles patients and clinicians alike and may be chalked up informally to things like medical complexity (multiple co-existing conditions), mental health conditions (that complicate care), or simply the case being considered complex or difficult. It also raises the question of how to address person-specific factors that interfere with care of whatever conditions the patient may have, and invites behavioral health clinicians in medical settings to look beyond care of conditions to the care of persons, and to look beyond disease-specific care management protocols to master generic practices of care management across whatever conditions the person may have. This person-centered emphasis is intrinsic to the concept of the “patient-centered medical home” which has burst into animated discussion and demonstration among providers, health plans, government plans, employer purchasers, and professional associations across public and private entities. This represents an opportunity for collaborative care clinicians to help shape the national state of the art in medical home and includes a range of person-oriented (rather than disease-oriented) practices for care management, including working systematically with complex patients and difficult patient–clinician relationships.     

How to Begin A Therapy Group: Six Approaches

Japanese “groupism,” or the tendency to emphasize groups rather than individuals, often favors the use of group psychotherapy with Japanese patients. However, the author recommends that the clinician should be sensitive to other cultural phenomena, which are thought to be related to groupism that will influence the nature of group treatments. For example, the traditional Japanese relationship to authority may make it difficult for many patients to express negative attitudes and to share intimate material. Differences regarding confidentiality and gender, distinction between “miuchi” (families) and “tanin” (strangers), and attitudes toward silence may also influence the nature of group therapy. The author discusses these and related cultural differences and highlights implications for the therapist's style of intervention. Finally, the amount of influence that groupism has on group psychotherapy must be considered. The author suggests that it is greater for patients with mild neurosis than severe psychosis.     

Care versus treatment at the end of life for profoundly disabled persons

Individuals who are profoundly mentally handicapped do not have the capacity to make their own decisions and also do not have a past record of decisions, from when they had capacity, to guide us in making decisions for them. They represent a difficult group, ethically, for surrogate decision making. Here I propose some guidelines, distinguishing between these patients and patients in a persistent vegetative state (PVS). As the life span of patients becomes shorter, or their level of consciousness becomes permanently impaired, the presumption for comfort care should become an imperative, and the standard of evidence to justify any invasive intervention should become higher. For members of this population, who have no more ability to refuse treatment than to consent to it, protection of the vulnerable must mean allowing a peaceful death as well as a comfortable life. Reasonable legal safeguards are also proposed to allow improved end-of-life decisions to be made for this population.     

What causes failure to apply the Pigeonhole Principle in simple reasoning problems?

The Pigeonhole Principle states that if n items are sorted into m categories and if n > m, then at least one category must contain more than one item. For instance, if 22 pigeons are put into 17 pigeonholes, at least one pigeonhole must contain more than one pigeon. This principle seems intuitive, yet when told about a city with 220,000 inhabitants none of whom has more than 170,000 hairs on their head, many people think that it is merely likely that two inhabitants have the exact same number of hair. This failure to apply the Pigeonhole Principle might be due to the large numbers used, or to the cardinal rather than nominal presentation of these numbers. We show that performance improved both when the numbers are presented nominally, and when they are small, albeit less so. We discuss potential interpretations of these results in terms of intuition and reasoning.