Transforming

Hyman Spotnitz's Modern Psychoanalytic approach, through which psychoanalysis is conducted as a “talking cure,” has profoundly influenced my understanding of how to function therapeutically with patients. Ultimately patients are helped to address and verbalize whatever is on their minds, including the full range of what they experience vis-à-vis the analyst and the analysis, especially experiences of negative impact. To this end, inquiry is favored over interpretation. Patients with implosive defenses are especially resistant to experiencing the therapist as the agent of fault—as the caregiving object who fails and disappoints. Instead, anger and hate are turned against the self. When such a patient feels safe enough to place the analyst in the position of “the object not protected,” the angry and hateful feelings that are unleashed may severely test the analyst's emotional resilience. Management of such “bad-analyst-feelings,” with clinical examples, is discussed. Also discussed are how a patient's transference predispositions are dealt with in the Modern Psychoanalytic approach; the use of the couch and how it favors an analysis that is conducted as a talking cure; and the problematic consequences that might ensue from the analyst's self-disclosure.     

Narcissistic Personality Disorder and suicidal behavior in mood disorders

The relationship of Narcissistic Personality Disorder (NPD) to suicidal behavior is understudied. The modest body of existing research suggests that NPD is protective against low-lethality suicide attempts, but is associated with high lethality attempts. Mood-disordered patients (N = 657) received structured interviews including Axis I and II diagnosis and standardized clinical measures. Following chi-square and t-tests, a logistical regression model was constructed to identify predictors of suicide attempt. While there was no bivariate relationship of NPD on suicide attempt, in the logistic regression patients with NPD were 2.4 times less likely to make a suicide attempt (OR = 0.41; 95% CI = 0.19 - 0.88; p < 0.05), compared with non-NPD patients and controlling for possible confounding variables. NPD was not associated with attempt lethality. NPD patients were more likely to be male, to have a substance use disorder, and to have high aggression and hostility scores. Limitations include that the sample consists of only mood-disordered patients, a modest sample size of NPD, and the data are cross-sectional. The multivariate protective effect of NPD on suicide attempt is consistent with most previous research. The lower impulsivity of NPD patients and less severe personality pathology relative to other personality disorders may contribute to this effect. No relationship of NPD to attempt lethality was found, contradicting other research, but perhaps reflecting differences between study samples. Future studies should oversample NPD patients and include suicide death as an outcome. Clinical implications include discussion of individualized suicide risk assessment with NPD patients.     

How To Eliminate Narcissism Overnight: DSM-V and the Death of Narcissistic Personality Disorder

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition appears likely to eliminate the diagnosis of narcissistic personality disorder. There are significant problems with the discriminant validity of the current narcissistic personality disorder critiera set; furthermore, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition's narrow focus on "grandiosity" probably contributes to the wide disparity between low narcissistic personality disorder prevalence rates in epidemiological studies and high rates of narcissistic personality disorder in clinical practice. Nevertheless, the best course of action may be to refine the narcissistic personality disorder criteria, followed by careful field testing and a search for biomarkers, rather than wholesale elimination of the narcissistic personality disorder category. The construct of "malignant narcissism" is also worthy of more intense empirical investigation.     

A character in search of character: Narcissistic Personality Disorder and Ego State Therapy

The individual diagnosed with Narcissistic Personality Disorder presents with grandiosity, extreme self-involvement, and lack of interest in and empathy for others. This paper reviews current theories concerning the development and treatment of Narcissistic Personality Disorder, and introduces the use of Ego State Therapy for its treatment. The ego state model of treatment will be described and demonstrated with case material. Initially ego states that reveal the grandiosity will be accessed. As therapy progresses, ego states that hold the underlying feelings of emptiness, rage, and depression are able to emerge. With further treatment, transformation and maturation of the ego states occur, reflecting the changes in internal structure and dynamics as well as improvement in external interpersonal relationships. Issues concerning Ego State Therapy as utilized with personality disorders will be discussed and contrasted with more traditional methods of treatment.     

Therapists’ projection: The effects of therapists’ relationship themes on their formulation of clients’ relationship episodes

Abstract

In this analogue study, therapists identified the core conflictual relationship themes (CCRT; wishes, responses of others, and responses of self) in relationship episodes taken from multiple clients in Luborsky and Crits-Christoph (1998). Judges identified the therapists’ own CCRT using the Relationship Anecdotes Paradigm (Luborsky, 1990 Luborsky, L., Barber, J. P., Schaffler, P. and Cacciola, J. 1990. “The narratives told during psychotherapy and the types of CCRTs within them”. In Understanding transference: The CCRT method, Edited by: Luborsky, L. and Crits-Christoph, P. 117–132. New York: Basic Books.  [Google Scholar]). Profile similarity analysis was used to examine the relationship between therapists’ CCRT and the CCRT that they identified. Projection was identified by a significant relationship between the therapists’ own CCRT pattern and the CCRT pattern that they rated in relationship episodes from Luborsky and Crits-Christoph, especially for wishes. The therapists’ tendency to project was moderated by therapeutic experience and receipt of personal therapy.     

Change in Attachment and Reflective Function in Borderline Patients with and without Comorbid Narcissistic Personality Disorder in Transference Focused Psychotherapy

Research has consistently found high rates of comorbidity between narcissistic personality disorder (NPD) and borderline personality disorder (BPD). Patients with this complex clinical presentation often present formidable challenges for clinicians, such as intense devaluation, entitlement, and exploitation. However, there is a significant gap in the literature in identifying the clinical characteristics of these NPD/BPD patients. In this article, we present recent research describing patients with comorbid NPD/BPD, as compared with patients with BPD without NPD (BPD), from two randomized clinical trials for the treatment of borderline personality disorder, with a particular emphasis on attachment status and mentalization. We anchor our discussion of these patients in object relations and attachment theory, and we describe our treatment approach, transference focused psychotherapy (TFP). We conclude by using case material to illustrate our research findings, highlighting the significant differences between patients with NPD/BPD and BPD/non-NPD in terms of their attachment classification.     

A latent structure analysis of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Narcissistic Personality Disorder criteria

The aim of this study was to examine the latent structure of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), Narcissistic Personality Disorder (NPD) criteria in a group of 641 outpatients. The consecutively admitted outpatients were administered the Structured Clinical Interview for DSM-IV Axis II Personality Disorders, Version 2.0, and the Personality Questionnaire. Both confirmatory and exploratory factor analyses (CFA and EFA, respectively) were used to evaluate whether the NPD criteria measure a single latent trait. Latent class analysis was used to assess the diagnostic accuracy of the individual DSM-IV NPD criteria. Mean above minus below a cut (MAMBAC) and maximum covariance (MAXCOV) taxometric analyses were used to evaluate whether the latent distribution of the DSM-IV NPD features is actually discrete. Both CFA and EFA results showed that the 9 DSM-IV NPD criteria loaded on 2 correlated factors. The latent class analysis results suggested a 3-class solution for NPD criteria; relevant differences in diagnostic efficiency were observed among the NPD criteria. MAMBAC and MAXCOV analyses provided consistent evidence of taxonic (ie, discrete) latent structure for NPD. This study gave only partial support to the validity of the DSM-IV NPD construct. Taxometric analyses indicated that a typological model is appropriate for describing NPD, but CFA and EFA suggested the existence of 2 distinct-albeit correlated-clusters of narcissistic features. As a whole, the DSM-IV criteria discriminated NPD from other personality disorders, but diagnostic accuracy statistics did not replicate the rank order of diagnostic efficiency of NPD criteria proposed by the DSM-IV.     

From Familiar and Familial Repetition to the Anxiety of Living Differently

This article attempts to summarize the author's view of what is generative in the psychoanalytic process. Included in this discussion are reflections on the ideal aims of psychoanalysis and a perspective on mutative action. One clinical example is used to illustrate the author's theses.     

Comparison of Attachment Styles in Borderline Personality Disorder and Obsessive-Compulsive Personality Disorder

The intense, unstable interpersonal relationships characteristic of patients with borderline personality disorder (BPD) are thought to represent insecure attachment. The Reciprocal Attachment Questionnaire was used to compare the attachment styles of patients with BPD to the styles of patients with a contrasting personality disorder, obsessive-compulsive personality disorder (OCPD). The results showed that patients with BPD were more likely to exhibit angry withdrawal and compulsive care-seeking attachment patterns. Patients with BPD also scored higher on the dimensions of lack of availability of the attachment figure, feared loss of the attachment figure, lack of use of the attachment figure, and separation protest. The findings may be relevant for understanding the core interpersonal psychopathology of BPD and for managing therapeutic relationships with these patients.     

Piaget and Psychoanalysis,II

The author, a young Chinese-born psychoanalyst and physician, presents her analytic work with a 91-year-old Jewish-American man who had been living with a “fear of death” for almost five decades. The author addresses her own struggle with countertransference related to both age- and cultural-differences as well as the “physician versus analyst” dilemma.     

The Problem of Will and Intentionality in Psychoanalysis

The author contrasts the classical psychoanalytic perspective on the relationship between culture, especially race, and transference with interpersonal and relational models. Recent developments in contemporary psychoanalytic theory provide a more comprehensive theoretical formulation of the relationship between culture, the unconscious, and the interpersonal field. The author takes the position that culture is an essential aspect of the transference-countertransference field, rather than something to peel away or move past in order to reach more deeply laden conflicts. Cultural transference-countertransference is constructed by patient and analyst together, and reflects interpersonal relations as well as internalized self-object representations. Transference-countertransference enactments between patient and analyst are conceived as embodying aspects of the historical relations between their respective cultures. While transference may have intrapsychic origins in the form of internalized self-object relations, it may also be a manifestation of a patient's sociocultural roots and family-of-origin's cultural heritage, including relationships to the dominant group. The author examines these ideas from a treatment between a white therapist and a black patient.     

Obsessive-Compulsive Personality Disorder and Eating Disorders

Obsessions, compulsions, and personality traits such as perfectionism and inflexibility are commonly described in eating disorder patients. A lack of precise clarification has existed in defining the presence of obsessive-compulsive disorder and obsessive-compulsive personality disorder in the various eating disorder subtypes. Research clarifying these definitions and the components of perfectionism as it pertains to eating disorders is reviewed in this article.     

Etiological Relationships Between Eating Disorder Symptoms and Dimensions of Personality Disorder

A preliminary exploration of the etiological factors that may contribute to the relationship between eating disorder symptoms and personality disorder traits is reported based on a general-population twin sample of 221 pairs. Symptoms of eating disorder, assessed using the Health Information Questionnaire (HIQ), formed 3 factors: Concern for Overeating, Purging, and Body Mass Index (BMI). Modest genetic influences were observed on Concern for Overeating, possible non-additive genetic effects on Purging, and substantial additive genetic effects for BMI. Substantial nonshared environmental effects occurred with the Concern with Overeating and Purging scales, and common environmental effects were noted for the Concern with Overeating scale. Personality disorder traits were assessed using the Dimensional Assessment of Personality Pathology-Basic Questionnaire (DAPP-BQ). Phenotypic, genetic, and environmental correlations between the HIQ scales and higher-order personality disorder factors were modest. The strongest relationship was between Concern with Overeating and Emotional Dysregulation. Relationships among DAPP-BQ basic trait scales and eating disorder symptoms were modest and relatively non-specific. The strongest relationships were with the Concern with Overeating scale. Purging also showed a modest relationship with affective lability and self-harm.     

A tripartite model of the therapeutic relationship: Theory,research, and practice

Abstract

The development and empirical examination of a tripartite model of the therapeutic relationship over nearly three decades are described. The model asserts that all therapeutic relationships, to varying degrees, consist of a real relationship, a working alliance, and a transference-countertransference configuration. Research testing propositions about how each of these components is related to treatment process and outcome, and to each other, is presented. Many propositions have been supported, but some have been disconfirmed. Although the tripartite, or perhaps a quadripartite, model appears to be empirically and theoretically viable, continued research and theoretical development will serve to refine the model further. The development and testing of additional models that unpack the global concept of the therapeutic relationship would also be useful.     

Ferenczi's “Madness”

Seven contributions from a combination of psychoanalysts, writers, and one academic are discussed. All contributors try to arrive at some understanding of how psychoanalysis has been depicted in the media and why so many of these portrayals tend to be outlandish. The authors' speculations range from efforts to deal with the threat of someone who can see unconscious process to a satirization and exaggeration of what may be actual qualities in many analysts. Each author's implicit or explicit psychoanalytic theory has much to do with his or her respective hypotheses.