“One Never Knows,Do One?”: Commentary on Paper by the Boston Change Process Study Group

I discuss the work of the Boston Change Process Study Group, focusing on the paper in this issue of Psychoanalytic Dialogues, but also addressing broader issues across the range of their work. After describing the considerable similarities between their views and mine, I focus on three areas about which I have questions: the concept and clinical use of mutual enactment, BCPSG's use of nonlinear dynamic systems theory, and certain problems revolving around science and social construction.     

The Fusion of Horizons: Dissociation,Enactment, and Understanding

All understanding is context dependent, and one of the most significant contexts for clinical purposes is the self-state. How we understand the other, and ourselves, depends on the state(s) we occupy. Dissociations between an analyst's self-states can, therefore, limit or impede understanding of the analysand by depriving the analyst of a fitting context within which to grasp what the analysand says and does. Clinical understanding may require the breach of such dissociations. I lay out some of the implications of thinking about transference and countertransference along these lines, with detailed examples illustrating the consequences of the analyst's dissociations and their eventual resolutions. Among the advantages of this way of thinking is that it amounts to a psychoanalytic account of the hermeneutic circle.     

The Interpersonal Field: Its Place in American Psychoanalysis

Today the concept of the interpersonal field, while seldom credited to those who created it, is widely used in psychoanalysis. After reviewing how the concept of the field defines interpersonal and relational psychoanalysis, I take up the rejection of the idea in American mainstream psychoanalysis in the decades just after it was proposed by Sullivan and Fromm, why that rejection took place, and how the entire discipline of psychoanalysis in North America might have fared if the idea had been widely recognized earlier than it was.     

Field Theory in Psychoanalysis,Part I: Harry Stack Sullivan and Madeleine and Willy Baranger

This is the first of two articles comparing conceptions of the field in interpersonal/relational psychoanalysis (IRP) and Bionian field theory (BFT). This article compares the thinking of the originators of IRP and BFT, Harry Stack Sullivan and Madeleine and Willy Baranger.     

Breathing Together: Reply to Harris and Shaw

These two very different but complementary discussions address two different “registers” of my thinking in my paper on patients who “live in airless intrapsychic worlds.” Harris is most interested in the meta-theoretical and historical contexts and frames of my theory and clinical approach, viewing my contribution as an example of various broad trends in contemporary relational psychoanalytic thought. Shaw, by contrast, engages with my particular insights and clinical/theoretical framework for understanding and working with patients whose struggles very much resemble and overlap with the struggles of the adult children of “traumatically narcissistic” parents, which his seminal work has focused on. In my Replies I voice my appreciation of each of their unique perspectives on my ideas, and engage with each of them regarding certain differences in our theoretical and clinical sensibilities.     

The Hard-to-Engage Patient: A Treatment Failure

I discuss the relatedness with certain hard-to-engage patients as a kind of dissociative enactment, and I present a case illustration of a man whom I liked but could not help.     

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.     

Editorial

Abstract

This paper will examine the current crisis in psychoanalysis in terms of the profession's decline, the apparent lack of patients, the ongoing debate over what constitutes psychoanalysis versus other therapies, and the lack of clinical focus in those debates. The concept of analytic contact will be introduced, and clinical material is used to showcase this concept as a bridge from the circular political debates to a more meaningful examination of what is psychoanalytic. In addition, case material will explore how patients tend to fight off the establishment of analytic contact in favor of safer, less threatening modes of relating. The author suggests that most patients fight off analytic contact and try to shift the treatment into something less analytic. It is up to the analyst to detect this, interpret it, and notice any countertransference collusion that may occur. Although the state of psychoanalysis as a profession is less than stellar in the eyes of the public, and the profession is apt to sabotage itself with endless debates about what constitutes true analytic work, the end is not necessary near. This paper proposes analytic contact to be the more useful focus of research and productive area of clinical exploration. If the decline of our field is to turn around, it will be on the clinical battlefront, not in terms of the theorizing among disagreeing groups of territorial analysts afraid of losing their political high-ground. The concept of analytic contact assumes that a deep exploration of intrapsychic phenomena, conflicts, and defenses, all within the realm of the transference, is the best clinical method of helping the mentally troubled individual. This genuine chance of change is best administered by a trained psychoanalyst. This simple idea is something the profession has contaminated with its often pointless arguments over frequency, analyzability, couch, and so forth. The clinical material will show that what happens in the room between analyst and patient is what best defines the true psychoanalytic treatment.