Employing multiple theories and evoking new ideas: the use of clinical material

In this paper, I wish to illustrate how working with a patient who had a certain kind of narcissistic difficulty led me to develop particular clinical strategies to facilitate the development of a sturdier sense of self, greater affect tolerance and modulation, the diminution of harshness of her superego, and the ownership of projected parts of herself, and to decrease paranoid ideation. I call upon concepts from various theoretical schools of psychoanalysis to make sense of the dynamic intricacies of the patient's psychological organization as they revealed themselves in the analytic process. These conceptualizations of the patient's difficulties and of clinical interventions to address them result in a hybrid theory of both theory and technique. What transpired in the clinical work also led me to propose an additional way to understand this kind of patient's difficulties with accepting interpretations or any view that differed from the patient's subjectivity. I am proposing that 'otherness' itself, rather than only specific conflictual aspects of the self, is disowned. It is the analyst's empathic stance toward all that is repudiated--the specific disowned aspects of the self and 'otherness' itself--along with empathy for the patient's conscious state that will enable reinternalization and ultimately healing.     

An application of bi‐logical theory to the study of psychic change and mourning4

The authors propose that the process of psychic change involves the ‘working through’ of mourning for the loss of ‘theories of life’ that are based on narcissistic omnipotent beliefs. These theories need to be changed by other more realistic ones regarding how to resolve the inherent and natural problems of existence. Questioning the ‘truth’ of these theories of life, as well as the acquisition of the perception of the existence of time, makes up part of the process referred to, and this applies to the analyst in a certain way as much as to the patient. Such problems are lived, re‐edited and revised in the transference/countertransference relationship. The authors present a clinical illustration. They explore the concepts of symmetry, asymmetry, homogenization and differentiation in MatteBlanco's bi‐logical theory and propose that these are important to the comprehension of the dynamic of the psychic changes which occur in a non‐static analytic process.     

The analyst's theory: A third source of countertransference

The author asserts that the analyst's theory, personal and/or academic, is an important source of countertransference which complicates our traditional understanding of the analyst's emotional responses as being constructed from a mix of his transferences and the patient's effects on him. From this perspective, theory - because it has no intrinsic relevance to the essential phenomena of individual analytic processes - may be a confounding, as well as a necessary, factor in clinical work. Although the analyst's theory might be conceptualized as a component of his personality that shapes his emotional reactions to a patient, the author believes that there is a valuable increment of conceptual clarity and additional clinical utility to thinking about a more direct role of theory in the process of countertransference formation. He uses aspects of the clinical analysis of narcissistic resistances to illustrate how some theories might predispose an analyst to confounding unconscious enactments by generating either positive or negative countertransferences which can be used defensively by the patient and/or analyst. He also illustrates how, in some contexts, an analyst's theory might attenuate potentially informative countertransference reactions and interfere in this way with the analyst's apprehension of the patient's psychic functioning. Finally the author addresses the importance of 'fit' between an analyst's working theory and a patient's psychopathology, and considers implications of his ideas for psychoanalytic training and practice.     

Links between grievance, complaint and different forms of entitlement

The author argues that different kinds of object relationships underlie the phenomena of grievance and complaint. Grievance is addressed to an object held responsible for a failure of idealisation, and the object is scolded or punished for this failure. Nursing grievance can restore the ideal object in phantasy and block mourning the ideal. With pathological grievance the self is seen as ideal and awareness of dependence on the libidinal other is denied, as are the passage of time and the transience of experience. An attitude of narcissistic entitlement to be special and exempt from ordinary reality is seen as intrinsic to the more persistent and pathological forms of grievance, and this narcissistic entitlement fuels grievance. Turning to complaint, the author argues that complaint is addressed to an object that is less idealised; there is more open acknowledgement of the need for and dependence on the other to realise liveliness. Complaint is the voice of the authentic lively self and intrinsic to complaint is a sense of lively entitlement. The author presents clinical material to illustrate these themes, and to show movement between complaint and grievance. Some technical difficulties in working with grievance are discussed.     

An entire life in one glance: a psychoanalytic reading of Revolutionary Road

This article, starting from an analysis of the film Revolutionary Road (2009; director, Sam Mendes), addresses the topic of conflictuality in relationships between couples, especially in those characterized by intense violence and a relational configuration of the sadomasochistic type. In particular, the film – in highlighting sequential moments in the couple’s life, from its formation through to its tragic conclusion – seems to strengthen the hypothesis that the specific quality of falling in love is a contributing factor in determining the dramatic unfolding of a couple’s relationship. The relationship is characterized by an experience of intense, erotic sensoriality, and by the nature of the unconscious fantasy underlying the bond between the couple that began with the moment of falling in love, a bond in which deep needs for fusion predominate. The presence of this neediness impedes a more adequate working through of the conflicts and the transition to more satisfying ways of relating.     

Acting,feeling and thinking: psychoanalytic psychotherapy with Tracey

This paper consists of a case study and commentary which formed a part of the inaugural lecture in a series entitled ‘Working with Psychosomatic Issues’*. The audience consisted of psychoanalytic, body psychotherapy and integrative practitioners. The presentation was divided into three parts, (1) an outline of philosophical themes that inform perspectives on health, illness and psychosomatic phenomena, (2) the case study reproduced below and (3) a summary of Winnicott's work (1960, 1966, 1988) on ‘the indwelling of the psyche in the soma’. The case study describes work with a young woman who harms herself through self-hitting and, in addition, expresses other physical manifestations of psychological distress. The core approach of the practitioner is psychoanalytic. The work is informed also by postmodern sensibilities and phenomenological themes.     

Internal state of emergency – working with an international student suffering from trauma in a student counselling service

In this paper I look at the suicidal state of mind of an international student who comes from a country at war and has been traumatized by a violent event. The student is tortured by an internal dilemma surrounding unbearable feelings of guilt and shame that arise when she leaves her home country to study abroad. Her dilemma or survivor guilt triggers an internal contract with herself, whereby she is internally persecuted when she makes an attachment to the university and her course. I suggest that an individual in this state of mind, suffering from post-traumatic stress, has regressed to a primary state of unintegration where the self is at the mercy of psychotic anxieties and the student is at risk of suicide. It is suggested that a safety net made up of the student services and the wider health service can provide a symbolic or mental space and containment for the student's state of mind until she can function as a student.     

Challenges in treating patients with psychosomatic disorders: some patterns of resistance

The treatment of people suffering from psychosomatic disorders poses important clinical challenges to psychoanalytic practice, including early abandonment, difficulties in engagement and superficial involvement in the treatment. The lack of systematic research on the subject suggests that a better understanding of the resistances and dynamics involved in such episodes is needed. Using supervision group to study treatments and inspired by action-research paradigm, this paper presents the results of an 18-month mixed-method qualitative clinical research on treating 22 cases. Thematic analysis revealed a frequent pattern of resistance to experience emotions that presented in two states: failure of repression (thin-skin) and massive repression (thick-skin). Narcissistic dynamics in the therapeutic relationship taking the form of ‘resistance to transference’ and a tendency to action were evident in both presentations. Symmetric and complementary counter-transference reactions, which compromised treatment, were also identified. Some technical implications are highlighted, such as the need to focus in the recovery of the patient's actual emotional experience and to understand such experience in the context of the ‘here and now’ of the therapeutic encounter. These findings suggest the need for a flexible approach to therapeutic work that moves between an ‘intrapsychic’ and a ‘relational’ focus.     

The Treatment of Histrionic and Narcissistic Personality Disorder Behaviors: A Single-Subject Demonstration of Clinical Improvement Using Functional Analytic Psychotherapy

This article presents single-subject data for the treatment of histrionic and narcissistic personality disorder behaviors using a relatively brief course of an interpersonal therapy, Functional Analytic Psychotherapy (Kohlenberg & Tsai, 1991). The treatment produced significant changes in these behaviors both statistically and qualitatively. Empirical methods for analyzing the changes across sessions and for determining that the therapist engaged in the proposed mechanism of clinical change are discussed. While these data are for one subject, the results of treatment provide both a method of treating difficult and long-standing client behaviors such as these, and for assessing the progress of therapy.     

自恋型人格的理论模型与神经生理机制

自恋作为一种人格特质, 核心特征是具有夸张和膨胀的自我观点。当前研究将自恋型人格与不同的自我特征相联系, 这些特征包括了夸张性、崇拜的需要、自我中心和高自尊、情感共情缺乏和述情障碍, 研究表明自恋的夸张性和崇拜需要源自扭曲的自我观点和自我提升。当前研究发现额中回、内侧前额叶皮层、眶额叶皮层、揳前叶和前脑岛与自我提升和自我评估有关。前脑岛、右背外侧前额叶皮层和右侧后扣带回皮层与共情缺失有关。未来研究应注重将遗传学、电生理学、生物化学、脑成像等技术的结合, 构建自恋型人格形成的神经生理模型。