Front Matter

Introduction

Acknowledgments

PART I
Major Theoretical Statements

1 Object Relations Theory and Transference Analysis

2 Some Implications of New Developments in Neurobiology for Psychoanalytic Object Relations Theory

PART II
Technique

3 Extensions of Psychoanalytic Technique The Mutual Influences of Standard Psychoanalysis and Transference-Focused Psychotherapy

4 Therapeutic Implications of Transference Structures in Various Personality Pathologies

5 Affective Dominance, Dyadic Relationship, and Mentalization

6 Reflections on Supervision

PART III
Specific Psychopathologies

7 Psychodynamics and Treatment of Schizoid Personality Disorders

8 Psychotic Personality Structure

9 Narcissistic Pathology of Love Relations

PART IV
Application of Object Relations Theory

10 Psychoanalytic Approaches to Inpatient Treatment of Personality Disorders A Neglected Dimension

11 Malignant Narcissism and Large Group Regression

12 Challenges for the Future of Psychoanalysis

Index

The present volume continues my investigation of the psychopathology and treatment of severe personality disorders. It focuses on the analysis of particular clinical features of personality pathologies and describes contemporary psychoanalytic object relations theory as a general theoretical frame of treatment that allows us to conceptualize both normal personality functioning and the very nature of personality disorders. This volume also includes my recent contributions to understanding the relationship between neurobiological dispositions and their interaction with psychodynamic developments, again, both in normality and psychopathology. Finally, this volume explores the application of object relations theory to group processes, love relations, and therapists’ training.

Part I of the book includes major theoretical statements. Chapter 1, “Object Relations Theory and Transference Analysis,” presents a brief, updated summary of contemporary object relations theory and its direct relevance to transference analysis, the fundamental therapeutic approach of transference-focused psychotherapy (TFP). This chapter summarizes the theoretical approach that informs the new psychotherapeutic developments in the treatment of severe personality disorders that are described throughout the entire volume. Chapter 2, “Some Implications of New Developments in Neurobiology for Psychoanalytic Object Relations Theory” summarizes developments in neurobiology regarding the conceptualization of affect systems and their role as the motivational basis for establishing internalized dyadic self- and object-relations structures. This chapter shows how the underlying limbic and cortical brain structures and functions contribute to embedding the fundamental concepts of self and of significant others. It proposes that the formation of such dyadic structures is an essential task of higher levels of psychic functioning.

Part II, on technique, updates empirical studies of the Personality Disorders Institute at Weill Cornell Medical College, expanding the applications of TFP, exploring its relationship to standard psychoanalytic technique, and outlining a general comprehensive theory of technique that applies to both psychoanalysis and its derived psychotherapies. Chapter 3, “Extensions of Psychoanalytic Technique: The Mutual Influences of Standard Psychoanalysis and Transference-Focused Psychotherapy” presents an updated view of TFP in comparison with standard psychoanalytic technique that differentiates more sharply these two technical approaches and discusses the problems in training therapists efficiently in both modalities. Chapter 4, “Therapeutic Implications of Transference Structures in Various Personality Pathologies,” presents an overview of transference developments in different modalities of severe personality disorders and the modifications in technical approaches to transference analysis related to these structural differences. It is a highly specialized description of TFP in action. Chapter 5, “Affective Dominance, Dyadic Relationship, and Mentalization,” focuses on two basic premises from which the therapist enters every therapeutic session—that is, the alertness to affective dominance and the diagnosis of the predominant dyadic object relationship linked to it. By illustrating this approach with clinical cases, the chapter also points to similarities and differences between TFP and mentalization-based therapy (MBT), an alternative psychodynamic approach to severe personality disorders. Chapter 6, “Reflections on Supervision,” describes my personal experience as well as general controversial issues regarding the supervision of psychoanalytic and derivative treatments. In the process, the chapter details our collective experience of training and supervising clinicians in TFP over many years at the Personality Disorders Institute.

Part III, on specific psychopathologies, deals with particular disorders within the broad field of severe personality disorders. Chapter 7, “Psychodynamics and Treatment of Schizoid Personality Disorders,” presents our experience with these complex disorders. Schizoid structure has received less attention in recent times than other types of severe personality disorders, particularly borderline and narcissistic personality disorders. This chapter presents a diagnostic update and summarizes the specific contributions of the TFP approach to the treatment of schizoid personality. Chapter 8, “Psychotic Personality Structure,” explores the differences between borderline personality organization and psychotic personality organization. It describes the development of psychotic features as a potential transitory regression in patients with borderline personality organization, as well as a reflection of a psychotic structure that only emerges during treatment. It proposes corresponding differences in technique for transitory psychotic developments arising in sessions, for transference psychosis, and for the emergence of major psychotic illness during the course of TFP. The chapter also analyzes the nature and shifts in reality testing in the context of transference analysis. Chapter 9, “Narcissistic Pathology of Love Relations,” deals with the specific pathology of narcissistic personalities, the great difficulties of these patients in establishing and maintaining a love relation in depth, and the general study of sexuality and the capacity to love as part of the diagnostic evaluation of all patients with severe personality disorders. It also considers the influences of the therapist’s own emotional maturity in the assessment of this aspect of psychopathology.

Part IV deals with the application of object relations theory to inpatient hospital treatment, to group regression and political leadership, and to psychoanalytic education. Chapter 10, “Psychoanalytic Approaches to Inpatient Treatment of Personality Disorders: A Neglected Dimension,” examines the inpatient treatment of patients with personality disorders, a neglected therapeutic approach in the United States. Although pioneered predominantly in the United States, inpatient treatment has been developed in new ways in recent European experiences, with relatively extended hospital treatment of severe personality disorders. This chapter summarizes both the North American and recent European experiences with an important therapeutic instrument that, mostly for financial reasons, has been underutilized in the United States. It offers important technical tools that are relevant for the repetitive brief hospitalizations of regressed borderline patients that have replaced selective long-term inpatient treatment. This approach may be the basis for the development of optimal treatment of very regressed stages of illness in the future. Chapter 11, “Malignant Narcissism and Large Group Regression,” applies psychoanalytic object relations theory and the developing knowledge of the social functioning of some personality disorders to the study of the mutual influences of severe leadership pathology in organizational and political structures and the psychological conditions that underpin large group regression. Political circumstances that foster such large group regression in social subgroups and leadership with malignant narcissistic features tend to reinforce each other, with potentially damaging and dangerous consequences to the social community. This chapter is a contribution to the clarification of these potentially threatening and damaging social developments. Chapter 12, “Challenges for the Future of Psychoanalysis,” applies the psychoanalytical approach that underlies this volume to the analysis of particular conditions of psychoanalysis today as a profession, an educational enterprise, and a social organization within the mental health sciences. This chapter and the book end with recommendations for innovations that may strengthen the role of psychoanalysis as a profession, a treatment approach, and a social organization. It proposes solutions to organizational problems, particularly stressing the urgent need for development of empirical research, psychoanalytic psychotherapies, and radical renovation in its educational structure.

I have been privileged by my personal relationships with distinguished psychoanalysts and psychiatrists in the past whose influence continues to inspire my work at present, although they all have left this world—Drs. Betty Joseph, Andre Green, Joseph Sandler, Anne-Marie Sandler, Ignacio Matte-Blanco, Edith Jacobson, and Martin Bergmann. I am profoundly grateful to them, and they continue to be active in my mind.

Colleagues and friends in the United States who continue to inspire and encourage me include Dr. Harold Blum, Dr. Robert Michels, and Dr. Robert Tyson. Dr. Michels’ critical review of my work, always available when needed, has been essential. In Germany, I have had creative and stimulating interactions over many years with Dr. Peter Buchheim, who has been a crucial support and influential leader in communicating my work and the work of our Institute within the German language countries, and with Drs. Susanne Hörz, Mathias Lohmer, Philipp Martius, Rainer Krause, Almuth Sellschopp, Agnes Scheider-Heine, and Gerhard Roth. Dr. Roth, in particular, is a distinguished neuroscientist who has stimulated my thinking about the neurobiological determinants of the self-structure. Dr. Peter Zagermann has focused on institutional complications in teaching psychoanalysis and psychoanalytic psychotherapy, and Dr. Martin Engelberg on the administrative and political dynamics of social organizations. Dr. Manfred Lütz inspired me to explore the spiritual aspects of dyadic relations and their connection to religious convictions. Dr. Rainer Krause alerted me to the subtle and complex communicative aspects of affect expression. The European community of transference-focused psychotherapists includes distinguished psychoanalysts and professors of psychiatry, including Dr. Stephan Doering, leader of this community in Europe; Drs. Melitta Fischer-Kern, Peter Schuster, Anna Buchheim, and George Brownstone in Austria; and the late Dr. Gerhard Dammann in Switzerland. The recent loss of Dr. Dammann, a pioneer in the contemporary approach to the inpatient treatment of personality disorders and an expert on schizoid pathology, has been a painful personal experience. Other members of the psychoanalytic community who have stimulated my interest and influenced my work include Drs. Anna Maria Nicoló and Paolo Migone in Italy, Drs. Claudio Eizrik and Elias da Rocha Barros in Brazil, Dr. Sara Zac de Filc in Argentina, and Drs. Ivan Arango and César Guerrero in Mexico.

The members of our European community of TFP experts who have influenced particularly my empirical research work include Drs. Massimo Ammaniti and Chiara De Panfilis in Italy and Drs. Miguel Angel González-Torres, Alfons Icart, and Luis Valenciano in Spain. My work has been significantly shaped by the work of researchers and professors in the mental health field such as Drs. Nancy McWilliams, Vamik Volkan, Salman Akhtar, Michael Garrett, and Peter Fonagy. Dr. Mark Solms has deeply influenced me with his incorporation of Jaak Panksepp’s work on the neurobiology of affects as directly related to the psychoanalytic theory of drives. Panksepp’s detailed description of affect systems and their basic motivational role in human psychology, together with Dr. Gerhard Roth’s influence, have deeply inspired me to explore the boundaries between intrapsychic structure and neurobiological determinants.

By far, the greatest influencers on my work, providing ongoing challenges and stimulation as well as profound encouragement, have been the members of the Personality Disorders Institute at Cornell, and my deepest gratitude goes to them. First of all, Dr. John Clarkin, co-director of the Institute, has fundamentally directed our empirical research, has constantly challenged me to explore the behavioral aspects of intrapsychic functioning, and has stimulated related research throughout our international TFP community. Dr. Eve Caligor carried out important enrichments of our technical approach to the entire spectrum of personality disorders; Dr. Frank Yeomans has effectively directed our national and international educational activities; and Dr. Diana Diamond specialized in the study of attachment and narcissism and their importance in the field of psychoanalytic object relations theory. Our research collaboration with Drs. Mark Lenzenweger, Michael Posner, David Silbersweig, and Kenneth Levy in the United States has been essential. Our specialized adolescent personality disorders group, which includes Dr. Alan Weiner in New York, Drs. Lina Normandin and Karin Ensink in Canada, and Drs. Marion Braun, Werner Köpp, Maya Krischer, and Irmgard Kreft in Germany, are vigorously developing our approach to personality disorders in adolescence and expanding it to the study of personality disorders in children. Drs. Monica Carsky, Richard Hersch, Eric Fertuck, Catherine Haran, Michael Stone, Barry Stern, Nicole Cain, and Jill Delaney, the senior members of the clinical and research team at the Personality Disorders Institute, are carrying out important clinical and research contributions and jointly have been an ongoing source of new ideas and efforts that have helped me develop my own work. I am particularly grateful to Ms. Jill Delaney for her personal help in the careful and detailed editing of this book, for her teaching of psychodynamic psychotherapy, and for her inspired organizational capacity with directing all our major conference work.

The technical support of my work has been carried out efficiently by Mrs. Janie Blumenthal, who diligently typed and organized the chapters of this book. I also wish to express my heartfelt gratitude to my personal secretary and longstanding former administrative secretary at the Personality Disorders Institute, Ms. Louise Taitt, who over the years has provided me with caring protection of my time, shielding me from many administrative and bureaucratic temptations and guarding my time for creative work.

All of this would not have been possible without the strong, trusting, stimulating, and protective support of the chairpersons of the Department of Psychiatry of Weill Cornell Medical College, particularly, throughout the years, Drs. Robert Michels, Jack Barchas, and Francis Lee. Dr. Lee, who is presently a professor and the chairman of the Department of Psychiatry, has strongly encouraged our work and is watching over our future, and I feel very grateful to him.

I also wish to express my profound gratitude to the late Mr. Alvin Dworman and to the Dworman Family Fund, who have generously contributed to the finances of our research enterprise, and to Dr. and Mrs. Michael Tusiani for their confidence and generous support of the Borderline Personality Disorder Resource Center, our educational support center for patients with severe personality disorders, their families, and the therapists who treat them.

Last, but not least, I want to thank my wife, Dr. Catherine Haran, who, in her double function as a senior clinician and researcher at the Personality Disorders Institute and as a loving provider of unfailing emotional support under all conditions of professional institutional weather, has helped me to produce this book. This work is dedicated to her as an expression of my profound love and gratitude. The experience of our life together has profoundly influenced the section on love included herein.