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.     

Commentary: “A Fundamental Polarity in Psychoanalysis: Implications for Personality Development,Psychopathology, and the Therapeutic Process” by Sidney J. Blatt

A commentary on Dr. Sidney J. Blatt's article, “A Fundamental Polarity in Psychoanalysis: Implications for Personality Development, Psycho-pathology, and the Therapeutic Process” is presented by articulating Dr. Blatt's significant contribution to psychoanalysis, developmental and attachment theory, and therapeutic process research. According to Blatt's theory, normal maturation involves a complex reciprocal transaction between two developmental lines throughout the life cycle: (a) the establishment of stable, enduring, mutually satisfying interpersonal relationships and (b) the achievement of a differentiated, stable, and cohesive identity. He has applied this theory to understand both normal and pathological psychological phenomena, the latter resulting from disruptions in these developmental lines, resulting in an overemphasis on relational (anaclitic) or self-definitional (introjective) issues. Further, Dr. Blatt has evaluated his theoretical model through empirical study and demonstrated that relationally oriented and self-definitionally oriented persons have differential responses to psychotherapy. Finally, areas of question and potential for future research are outlined. Specifically, it is argued that although anaclitic and introjective configurations are easy to discuss as distinct types, relevant evidence from attachment theory raises the issue of whether these types may be better conceptualized as dimensions, with different configurations located within two-dimensional space. Further, findings of a group evidencing mixed anaclitic and introjective features raise additional questions about how these configurations relate to one another, and evidence from the attachment literature is used to shed light on this issue.     

Attachment Theory,Psychoanalysis, Personality Development,and Psychopathology

Blatt and Levy place attachment theory and research in a broad theoretical matrix by considering the relationship of attachment patterns to personality development and to different types of psychopathology in adults. Thus Blatt and Levy construct conceptual bridges between the two configurations of personality development and psychopathology that Blatt and colleagues have developed over the past quarter century (e.g., Behrends and Blatt, 1985; Blatt, 1974, 1995; Blatt and Behrends, 1987; Blatt and Blass, 1990, 1996; Blatt and Shichman, 1983) and attachment theory and research. Blatt and Levy identify a polarity that is central to attachment theory and research, the polarity of attachment and separation, and they note that this polarity has also been central in much of classic psychoanalytic theory (e.g., Freud, 1930; Loewald, 1962). This polarity is expressed in attachment theory and research in the differences between avoidant and anxious-preoccupied insecure attachment patterns as well in the distinction between two types of disorganized attachment, helpless-withdrawn and negative intrusive, identified by Lyons-Ruth (1999, 2001).

This polarity of attachment and separation, or relatedness and self-definition is also fundamental to personality development that occurs in the hierarchical dialectic transaction of two basic developmental lines—interpersonal relatedness and self-definition (Blatt and Blass, 1990, 1996). This polarity is also inherent in the conception of two fundamental configurations of psychopathology—anaclitic psychopathology, the dependent (or infantile) and hysterical personality disorders—that are preoccupied with issues of interpersonal relatedness, and introjective psychopathology, the paranoid, obsessive-compulsive and depressive personality disorders, in which issues of self-definition and self-worth are dominant (Blatt, 1974, 1995; Blatt and Shichman, 1983). Thus, the identification of this fundamental polarity provides the basis for establishing links between attachment patterns, personality development, and adult psychopathology. Blatt and Levy also attempt to integrate psychoanalytic concepts of the representational world (e.g., Sandler and Rosenblatt, 1965)—the development of concepts of self and significant others—with the internal working models (IWMs) of attachment relationships. This integration enabled Blatt and Levy to bring a fuller developmental perspective to the IWMs of attachment theory and to note that, based on differences in the content and structural organization of the IWMs or mental representation of self and significant others, several developmental levels can be identified in both avoidant and anxious preoccupied attachment. These developmental levels within each attachment style also identifies less and more adaptive forms of both types of insecure attachment. Thus, the integration of the psychoanalytic concepts of mental representation with concepts of the IWM of attachment theory and research enables Blatt and Levy to create a fuller developmental perspective in the study of insecure attachment patterns.     

Research on the Impact of Military Trauma: Current Status and Future Directions

The wars in Afghanistan and Iraq have absorbed our attention both as citizens and professionals. A new generation of veterans may be at risk for life course disturbances implicated by exposure to war-zone stressors and adversities. I describe these new conflicts and use this as a backdrop to review the state of the field with respect to military trauma and posttraumatic stress disorder, early intervention, and risk and resilience research. Throughout, I offer recommendations for future research.     

A Framework of Statistical Tests For Comparing Mean and Covariance Structure Models

Temporal patterning in blood glucose (BG) consistent with fractals—how BG follows a repetitive pattern through resolutions of time—was used to examine 2 different samples of adolescents with Type 1 diabetes (10–14 years). Sample 1 contained 10 adolescents with longtime series for accurate estimations of long-term dependencies associated with fractals. The second contained 94 adolescents measured multiple times daily over a 2-week period corresponding to psychosocial measures. In both samples, temporal dependencies in BG showed patterns consistent with fractals. In the second sample, temporal dependencies were associated with indicators of vigilant regulation including adolescents' higher anxiety, mothers' higher monitoring, and intrusive support. The existence of temporal dependencies in BG moderated the relationship between glycosylated hemoglobin (Hb_A1c) and indicators of low BG risk but not the relationship between Hb_A1c and high BG risk. These results show how a biomedical indicator may be susceptible to metric issues associated with fractals.     

‘Be careful,or you'll act corruptly and make a carved image for yourselves,in the form of a figure,the likeness male or female’ (Deut. 4:16): A commentary on Norenzayan's Big Gods: How Religion Transformed Cooperation and Conflict (2013)

Norenzayan's book is an ambitious attempt to integrate recent research from behavioral economics and social psychology, particularly priming studies, into a book about religion. If the account is meant as an explanation of religion or big religion, it does not succeed. If it has more modest aims, namely to describe how surveillance institutions, of which big religion is one important class, can sometimes lead to cooperation and conflict, then it is quite successful in doing so.     

Men’s strategies for preserving emotional well-being in advanced prostate cancer: An interpretative phenomenological analysis

Objective: This study explores men with advanced prostate cancers’ own practices for promoting and maintaining emotional well-being using Interpretative Phenomenological Analysis.

Design: Five men with advanced prostate cancer participated in face-to-face, semi-structured, in-depth interviews.

Results: Within rich narratives of lost and regained well-being, two super-ordinate themes emerged – ‘living with an imminent and uncertain death’ and ‘holding on to life.’ Well-being was threatened by reduced sense of the future, isolation and uncertainty. Yet, the men pursued well-being by managing their emotions, striving for the future whilst enjoying life in the present, taking care of their families and renegotiating purpose. Running through participant’s accounts was a preference for taking action and problem-solving. Sense of purpose, social connectedness, and life engagement were revealed as concepts central to improving well-being, indicating areas which practitioners could explore with men to help them re-establish personal goals and life purpose.

Conclusions: The findings also add weight to the evidence base for the potential value of psychological interventions such as cognitive behaviour therapy and mindfulness in men with prostate cancer.     

The role of positive thinking in social perceptions of cancer outcomes

Pressure for ‘positive thinking’ (PT; i.e. focusing on positive thoughts/suppressing negative thoughts to ‘fight’ cancer) burdens cancer patients facing health deterioration. It was determined whether PT exposure enhanced effort, control and responsibility attributions assigned to an individual for his/her cancer trajectory. Within an online blog a hypothetical same-gender person describes a personal cancer experience. 482 participants were assigned to one of six experimental conditions in which we manipulated PT exposure (blogger learns about ‘power of PT’ but does not try it, blogger tries PT, control/no PT) and cancer outcome (successful/unsuccessful treatment). A 3?×?2?×?2 multivariate analysis of covariance (with personal cancer experience covariates) tested PT exposure?×?cancer outcome?×?gender effects on attributions for the blogger's cancer outcome. Results indicate that PT exposure enhanced effort and responsibility attributions assigned to individuals for their cancer outcomes and that responsibility attributions differed as a function of gender. Findings suggest that exposure to the idea of PT may lead to cancer patients being perceived as culpable if they do not recover from the disease.     

What,and Where,Luck is: A Response to Jennifer Lackey

In ‘What Luck Is Not’, Lackey presents counterexamples to the two most prominent accounts of luck: the absence of control account and the modal account. I offer an account of luck that conjoins absence of control to a modal condition. I then show that Lackey's counterexamples mislocate the luck: the agents in her cases are lucky, but the luck precedes the event upon which Lackey focuses, and that event is itself only fortunate, not lucky. Finally I offer an account of fortune. Fortune is luck-involving, and therefore easily confused with luck, but it is not itself lucky.     

How Best to Treat Deployment-Related Guilt and Shame: Commentary on Smith,Duax, and Rauch (2013)

We comment on Smith, Duax, and Rauch’s (2013--this issue) explication of their approach to treating perpetration-related guilt and shame using prolonged exposure (PE) therapy, with the aim of promoting a discourse about the mechanisms, techniques, and assumptions that underlie the treatment of moral injury in veterans and service members. We first discuss the theoretical foundation underlying PE and consider the extent to which it accounts for the phenomenology of moral injury. We then examine the treatment strategies used in the PE approach and the mechanisms by which these techniques ameliorate perpetration-related guilt and shame. We also briefly highlight points of similarity and contrast between PE and adaptive disclosure, a brief cognitive behavioral intervention targeting combat-related moral injury and traumatic loss.