Personality Disorders and Treatment Sam Olivier & Loray Daws

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The Personality Disorders
and
Treatment
Presenters:
Sam Olivier
Clinical Psychologist
Loray Daws
Clinical Psychologist
Loray Daws & Sam Olivier (2007)
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Structure of Presentation
1. The Therapeutic Frame
2. Developmental Psychoanalysis
3. Character structure
4. Therapeutic Implications
5. Difficulties in the therapeutic
setting
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The Frame
Possibly a set of guiding rules; preferably a source of thought
Boundaries differ amongst disciplines - basic ground rules apply
Adherence required as deviation becomes clear call to action -
interpretation, supervision etc.
Actual part of therapy
Associated with the function and person of therapist
Internalised as such - becomes part of inner structure over time
Defines appropriate gratification
Is holding and containing
Because there are rules, it provides opportunity for expression of
pathology, relational trauma, developmental deficits etc.
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Without Saying
Training
Professionalism
Registration and Peer recognition
- Acting within bounds
Indemnity
Ethics
Records
Appearance
Physical Health
Psychological Health
Own therapy
Supervision
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No unilateral change in the frame, whether from patient or practitioner is without repercussions and should be dealt
with as a form of acting out, resistance or other forms of unconscious communication
Acting-out and acting-in will be dealt with later, but important to understand that deviations from the frame poses
the following possible difficulties:
Loss of rules of relatedness that foster the necessary therapeutic symbiosis/alliance
Immediately different forms of adaptation and gratification with concomitant loss of understanding
Loss of modelling and of a model of thinking, feeling and relatedness
Deviations
Consistency
Open-standing-ness in terms of method
Relative anonymity of practitioner
Interventions restricted to method
Method
Total privacy
Confidentiality
Disciplines and contexts may differ, but preferable the absence of prior, concomitant or post-treatment relationship
including relatives, friends of patients
Absence of physical contact, including relatives, friends of patients
Analytic attitude central - a willingness to observe, engage with and enhance experience with a neutral stance by
the practitioner
Relationship
Clear-cut fee
Reliable billing system
Charging for the role as professed
Gifts
For and from the practitioner
Money
Set time for sessions
Set duration of sessions
Responsible attendance
Vacation policy
Time
Neutral setting
Regular, private location
Might include such detail such as seating arrangements etc.
Location
Setting up clear understanding of role, purpose, expectation
Might include information regarding diagnostic practices etc.
After initial explication further explanation, possibly with interpretation
Practitioner already exemplary in terms of role
First
Interview
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Developmental psychoanalysis:
The Menninger approach
Developmental Psychoanalysis
Mahler and birth of the human infant
Stages- autism, symbiosis,
separation-individuation (hatching,
practicing, rapproachment)
Object Constancy
Oedipus
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Preneurotic character Continued depen-
dence on object to
provide sense of well-
being
Ambivalence toward
caretaker
Anxiety and depres-
sion - fear of loss of
love of object
Ninor aspects of the
above
Whole self (and
object)
representations
Continuation of above Consolidation of
previous stages
Achievement of object
constancy
On-the-way-to-
object-constancy
(25 months to 3
years)
Borderline personality
(original point of
difficulty according to
Kernberg and
Nasterson)
Narcissistic personality
(Kernberg and Rinsley
place between rappro-
chement and object
constancy
!nhibition of self-
assertion (abandon-
ment fears)
Heightened anxiety
Excessive splitting
Excessive aggression
Proclivity to
depression
Belief in magic
solutions
Withdrawal of libidinal
supplies for autonomy
Reward for aggressive
behaviour
Excessive overhauling
of child, with disregard
for child's authentic
needs
Reward for premature
independence
Continuation of above Respond without
anxiety to infant's
conflicting needs for
both dependence and
autonomy
Consolidation of
autonomy; acceptance
of separateness from
mother (height of
dependence and
reliance on idealised
caretaker
Rapprochement
(16 to 25
months)
Narcissistic personality
(original point of diffi-
culty according to some)
Some primary affective
disorders
Formation of patho-
logic grandiose self
(to protect self)
Excessive aggression
Failure to explore
!nhibiting exploration or
abandoning child
Failing to mirror
pleasure at new skills or
deflating at will
Split self-object
representations
Positive self-image
differentiates from
object image first
Tolerate, enjoy, and set
appropriate limits on
infant's exploration
Exploration with
temporary ability to
ignore mother (height of
omnipotence)
Practicing
(10 to 16
months)
Schizoid personality
Some primary affective
disorders
Premature differentia-
tion and chronic anger
Anxiety over
differentiation
Proclivity to
depression
!ncreased resistance to
child's move toward
autonomy
Start of differentiation
of body image from
that of mother
Consistent frame of
reference for infant
Physical differentiation
from mother
Differentiation
(5-10 months)
SEPARATION-INDIVIDUATION
Symbiotic psychosis
Schizophrenia
Schizoaffective
syndromes
Psychopath
Borderline personality
Failure of optimal
attachment (e.g. false
self)
Defensive detachment
Persistent unresponsi-
veness to needs
Start of parasitic
symbiosis
Fused self-object
representation
good-enough mother"
- Satisfy needs
- Buffer and modify
incoming stimuli
- Act as auxiliary ego
Attachment to the
caretaker
Symbiosis
(+ weeks to 5
months)
!nfantile autism No anticipatory
position at nursing
No reaching out
No smiling response
Serious failure of
care-taking (perhaps
inadequacy of
organism)
Undifferentiated
matrix
Total management of
infant's needs
Homostatic equilibrium Normal autism
(birth to + weeks)
DIAGNOSIS RELA-
TED TO ARREST
INFANT'S PATHO-
LOGIC RESPONSE
FORMS OF CARE-
TAKER PATHOLOGY
STATUS OF SELF-
OBJECT
CARETAKER'S ROLE INFANT'S ROLE PHASE
Chathman19S5
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Self-Object and Affect
THE SELF REPRESENTATION
In both normal and abnormal functioning, the self is a complex
psychological structure that is constituted and experientially divided
by reflexive self-awareness-by the tension that arises from
coordinating subjective and objective perspectives on the self.
Disturbances in reflexive self-awareness are central to the
development of severe psychopathology.
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Reflexive Self-Awareness in
Normal Development
The construction of a self-representation requires reflexive self-
awareness-the ability as a subject to reflect on oneself as an object.
Thus, unlike object representations, which involve only what can one
observe and infer about others, the self-representation has (at least) two
sources: (a) subjective self-awareness, or the experience of oneself as "a
center of initiative and a recipient of impressions ; and (b) objective
self-awareness, or observations of oneself as an object among other
objects-a self among other selves. Objective self-awareness includes an
understanding that one is an object not only for oneself but also in the
eyes of others. This division within the self, this capacity for reflexive
self-awareness, first emerges during the second year of life as, for
example, an ability to recognize oneself in the mirror
But even at the advanced level of self-understanding, the two sources of
self-knowledge, subjective and objective self-awareness, can result in
highly discrepant self-images-in disjunctions between, on the one hand,
one's experiential or prereflective self-feelings and, on the other, the
person one appears to be, both in one's own eyes and in those of others.
Thus, the capacity for reflexive self-awareness necessarily produces
psychological tension and conflict
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Patient Description
Patient A.: Self-Descriptions
Admission Depends on how I'm feeling. Sometimes I'm
outgoing, but other times I'm withdrawn. (What else?) I don't
know. I don't want to describe myself. (?) Cause I get upset
when I do.
Inquiry: (Can you tell me what upsets you?) I'm either too
conceited or too modest to answer something like this.
1 years
Lonely, Insecure. Hiding behind a facade. Has common sense.
Abnormal opinions. One of my abnormal opinions is that people
who want to kill themselves should be allowed to kill
themselves-and I wasn't referring to myself either. Mature-
can be mature-haven't really acted it during the psych. testing,
I sort of fooled around. Should have more confidence.
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James Masterson (1985) on
Capacities of the Self
(a) spontaneity and aliveness of affect,
(b) self-entitlement,
(c) self activation, assertion and support,
(d) acknowledgement of self-activation and
maintenance of self esteem,
(e) soothing of painful affects,
(f) continuity of self,
(g) commitment,
(h) creativity, and
(i) intimacy,
DEFENSIVE FUSED PART-UNIT AGGRESSIVE FUSED PART-UNIT
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Linking Affect
Being unique, special, great, admired, adored,
Perfect, entitled
Linking Affect
Abandonment, depression
OBJECT
(omnipotent)
OBJECT
(harsh, attacking,
devaluing)
SELF
(grandiose)
SELF
(inadequate,
fragemented,
unworthy),
unentitled)
Splitting, avoidance, denial, acting-out, clinging, projection, projective
identificaton
Ego Defense
Mechanisms
Poor reality perception, impulse control, frustration tolerance, ego boundaries Ego Functions
Split Object Relations Unit of
Narcissistic Personality Disorder
Masterson Approach
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Narcissistic Character
Johnson, S.M.
Etiological constellation:
Parents narcissistically cathect the child and disallow the child's
legitimate narcissistic cathexis of the parents. The child is used to
mirror, aggrandize, or fulfill the ambitions and ideals of the parent.
The child's real magnificence and vulnerability are not
simultaneously supported. Rather, the parents need the child to be
more than he is for self-fulfillment and idealize him or need him to
be less than he is and humiliate him, or both. This results in a deep
injury to the experience of the real self and a consequent deficit in
self-esteem regulation. The natural system of feedback and
correction affecting the balance of ambitions, ideals, and abilities
fails to mature such that ambitions and ideals remain grandiose,
while corrective negative feedback about abilities must remain
rigidly disavowed.
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Symptom constellation:
The individual harbours a grandiose false self characterized by
omnipotence, pride, self-involvement, entitlement, perfectionism,
and excessive reliance on achievement for the maintenance of self-
esteem with manipulation, objectification, and devaluation of
others. When this compensatory false self breaks down, the
individual shows great vulnerability to shame or humiliation,
feelings of worthlessness, difficulty in self-activation, and work
inhibition. This low self-esteem dominated depression may be
accompanied by hypo-chondriacal preoccupations, psychosomatic
illness, anxiety, and loneliness. An even deeper real-self crisis
includes the deeply felt enfeeblement and fragmentation of the self;
emptiness, void, and panic at the realities of an arrested
development; and long-suppressed real affects relating to the
original narcissistic injuries.
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Cognitive style and defences:
In the grandiose, false-self state, the narcissistic demonstrates
cognitive errors that will maintain the grandiosity, e.g.,
externalization of responsibility (i.e., blaming others), denial of
negative input, disavowal of his own negative attributes,
devaluation of positive contributions from others, unrealistic
identification with idealized others, etc.
In the symptomatic or collapsed state, there is a preoccupation
with symptoms, defensive rumination on self-worth, physical
symptoms, procrastination, or other preoccupations that keep
the demands and affects of the underlying real self at bay.
Splitting keeps these two states separate and unintegrated.
Feeling his real self, the narcissist always experiences at least
some disorganization, vulnerability, and unfamiliar but vital
affects. Here the individual may feel he is losing his mind, but, if
managed correctly, it is here that he begins to find himself.
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Script decisions and pathogenic beliefs:
"I must be omnipotent, perfect, special. I must know without learning, achieve without
working, be all powerful and universally admired. I must not make a mistake or I am
worthless, nothing, and disgusting. I must be a god or I am nothing. If I am
vulnerable, I will be used, humiliated, or shamed. I can't let anyone really matter to
me. All that I own, including my friends and family, must reflect and confirm my
perfection and superiority. I will never be humiliated again. Others are superior to me.
Others ate inferior to me."
Self-representation:
Split-grandiose or worthless as outlined above.
Object representations and relations:
Object representations are best understood using the four basic narcissistic
transferences suggested by Ko-hut: (1) Merger - where the individual achieves a
sense of security and worth through fusion. Here the individual will freely use the
other with-out recognizing the actual self-other boundary; (2) twinship-where the
individual achieves a sense of enhanced identity and self-worth by assuming
exaggerated similarity between the self and other; (3) mirroring-where the individual
relates to the other solely as one who enhances self-esteem by serving as a prizing,
understanding, acknowledging "part-object;" and (4) idealization-where the other
enhances self-cohesion and esteem by being perfect in one or more respects and
serving as a source for emulation. Idealization may also serve to create the perception
of the perfect merger, twinship, or mirroring object. Others typically feel used by the
narcissistic, but if he is effective in his false self, others are attracted to him for his
charisma and talent. The use of others to discover the real self, rather than
aggrandize the false self, is pivotal in the desired maturation of the narcissist's
relationships.
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Affective characteristics:
Narcissists are frequently noted for the "as if' or artificial quality of
feelings, the inability to feel for others, and their extremely easily
wounded pride. At lower levels of ego development, acting-out and
impulse control disorders are common. At higher levels, there is
great intolerance for most feelings, although a high level of affective
responsiveness is held in check. Silently born shame and humiliation
are common.
MASTER SLAVE PART-UNIT SADISTIC OBJECT-SELF IN EXILE PART UNIT
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Part-Object Representation:
a maternal part-object
which is manipulative,
coercive, is the master and
wants only to use, not relate
to
Reality ego plus pathologic (or pleasure) ego Split Ego
Splitting, avoidance, denial, acting-out, clinging, projection, projective identification, use of
fantasy to substitute for real relationships and self reliance
Primitive Ego Defense
Mechanisms
Poor reality perception, frustration tolerance, impulse control, ego boundaries Ego Defects
Split Object Relations Unit of
Schizoid Disorder of the Self
Masterson Approach
which is sadistic, dangerous,
devaluing, depriving,
abandoning
Part Self - Representation:
a part-self representation of
a dependent, a slave who
provided a function for the
object and is a victim
being alienated, in exile,
isolated but self-contained
to self-reliant
AFFECT
In jail, but connected, existence acknowledged,
relief in not being alienated
AFFECT - ABANDONMENT DEPRESSION
Depression, rage, loneliness, fear of cosmic
aloneness, despair
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Parenting is abusive to harsh to un-attuned, cold, distant, and
unconnected. The child experiences itself as hated, unwanted, or
insignificant. With the limited resources of an infant the
individual can only withdraw, dissociate, or internally migrate.
The blocking of the most basic expressions of existence and the
withdrawal of energy from external reality, others, and life itself
produce deadness and disconnectedness.
Chronic anxiety, avoidant behaviours, conflict over social contact,
trust, and commitment are definitional. There is usually evidence
of self-destructive or self-damaging behaviour, self\-hatred or
disapproval of self, poor self-care and self-soothing. The
individual often shows an inability to know her own feelings and
to make sustained social or intimate contact. To a great extent,
this individual can be defined as one who is out of contact with
self and others.
Schizoid Character
Johnson, S.M.
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Cognitive style:
Isolation of thinking from feelings with abstract thinking often
well developed. Concrete operations in relation to the physical
world often poorly developed. "Social" intelligence is often
impaired.
Defences:
Projection, denial, intellectualization, "spiritualization,"
withdrawal, isolation of affect, dissociation, and fugue states. The
individual may have poor memory, especially for interpersonal
events, conflict, and childhood.
Script decisions or pathogenic beliefs:
I have no right to exist. The world is dangerous. There is
something wrong with me. If I really let go, I could kill someone.
I will figure it all out. The true answers in life are spiritual and
other-worldly."
Schizoid Character
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The self is experienced as damaged, perhaps defective or evil.
The individual questions his own right to exist and invests in
intellectual or spiritual pursuits identifying with his intellect and
spirit.
Others are seen as non-accepting, threatening, and more
powerful than the self. The individual is particularly sensitive to
harshness in the social environment. She often projects hostility
onto others and elicits hostility through projective identification.
The person experiences chronic fearfulness and often terror.
Affect is isolated and / or suppressed. The individual doesn't
know how he feels and can appear cold, dead, and out of touch
with himself. Primitive, suppressed rage underlies the fear and
terror.
Schizoid Character
REWARDING OR LIBIDINAL PART-UNIT
(RORU)
WITHDRAWING OR AGGRESSIVE PART-UNIT
(WORU)
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which offers approval of
regressive and clinging
behaviour
Reality ego plus pathologic (or pleasure) ego Split Ego
Splitting, avoidance, denial, acting-out, clinging, projection, projective
identification
Primitive Ego Defense Mechanisms
Poor reality perception, frustration tolerance, impulse control, ego boundaries Ego Defects
Split Object Relations Unit
of the Borderline
Masterson Approach
which withdraws, is angry
and critical of efforts toward
separation-individuation
being the good, passive
child - unique and special /
grandiose
being inadequate, bad, ugly,
and insect, etc.
AFFECT
- feeling good
- being taken care of
- being loved
- being fed
- gratifying the wish
for reunion
AFFECT - ABANDONMENT DEPRESSION
- homicidal rage
- suicidal depression
- panic
- hopelessness and
helplessness
- emptiness and void
- guilt
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Parents block self-agency, adventure, and self-control by anxious,
withdrawn, threatened, or punitive responses to those behaviours,
which serve to produce distance, establish difference, demonstrate
aggression, or establish a self-determined identity. Concomitantly,
merger, empathy, and identification with and dependency on
parents are overvalued. This yields an adopted, accommodated,
other-determined self based on the overuse of incorporative
introjection and uncritical identification. Identity formation relying
on the more mature transmutative processes of assimilation and
accommodation, are underutilized.
Borderline Character
Johnson, S.M.
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Deficient in a solid sense of identity, selfconcept, and behaviors that
define a unique self. Identity found in relationship to intimate others
with whom the individual merges. This lack of firm boundaries can l
ead to confusion about responsibility, susceptibility to invasion by the
affects or thoughts of significant others, and, in borderline
functioning, to actual fusion states. This propensity to be taken over
by others can lead to fears of loss of autonomy and to fears of total
engulfment, which prompt rigid distancing. These maneuvers, in turn,
lead to fears of abandonment and identityless isolation. Many other
symptoms serve to preserve the original merged relationship, rebel
against it, or, more commonly, both. The actual preservation of family
pain going back generations is not uncommon. Separation guilt,
survivor guilt, and weakened aggression are common.
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Cognitive style:
Boundary confusion results in poor reality testing with regard to
who is responsible for what. In lower functioning individuals (i.e.,
borderlines), this leads to over-externalization of responsibility and
blame. In higher functioning individuals, this results in excessive
responsibility for others leading to the cognitive errors of
separation and survivor guilt. These individuals often have
difficulty discriminating their own likes and dislikes, beliefs,
opinions, etc. Except at the lowest levels of structural
development, aggression is denied and projected and is thereby
unavailable for use.
Defences:
Merger, denial, projection, identification, coercion, manipulation,
externalization, omnipotent responsibility (an expression of
grandiosity), turning against the self, projective identification,
splitting.
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Script decisions and pathogenic beliefs:
"I am nothing without you. You are taking me over or swallowing
me up. I owe you myself. I am responsible for you, and / or you
are responsible for me. I can't be happy if you aren't happy. I can't
tolerate difference between us. I can't tolerate being too close. My
happiness, success, survival will hurt you or is at your expense.
Your separateness, success, or happiness that does not include
me, hurts me and is gained at my expense. I can't survive without
you."
Depends on connection with the other but is otherwise unclear with
varying degrees of boundaryless features. Based excessively on
incorporative introjection and identification. An independent,
assertive self is denied or split off.
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Others experienced as exceedingly important with blurring of self-
other differentiation. Others often experienced as engulfing or
abandoning (i.e., split). Particularly at lower levels of structural
development, these individuals are experienced by others as
manipulative and coercive.
At lower structural levels, the affective instability is characterized
by panic and rage at abandonment and / or engulfment. At higher
levels, guilt is common and associated with excessive responsibility
for others. Anxiety may be stimulated by anything that leads to
separation (e.g., differences of opinion, success, freedom from
symptoms, etc.)
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Using the structure to understand
(a) The role of Frame
(b) The role of interpretation, clarification, confrontation,
and other methods.
(c) Once a week to more than- supportive, psychoanalytic
psychotherapy and psychoanalysis
(d) Special difficulties- benign vs malignant regression,
acting in and out, suicide gestures (type of importance),
substance abuse, and so forth.
(e) Empathic responsiveness and the role of counter-
transference.
Therapy
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The following works may serve as basis for both reflection on
clinical technique and deepening understanding on how
people with disorders of the self function and manage
internal pain and trauma. The list does not exhaust the
field as you may well know. It also at times helps to also
review the bibliography of each book to trace the
development of thought of each of these master clinicians.
Finally, please consult both quantitative and qualitative
psychodynamic methodologies as they add to our capacity
to understand very complex phenomena.
Regards
Loray Daws and Sam Olivier
Colleagues
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Adler, G. (1985). Borderline psychopathology and its treatment. New York: Aronson.
American Psychiatric Association. (1980). Diagnostic and statistical manual of mental
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Amsterdam, B. K. and Levitt, M. (1980). Consciousness of Self and Painful Self-
Consciousness. Psychoanal. Study Child 35:67-83
Arnow, D., & Cooper, S. H. (1984). The borderline patient's regression on the
Rorschach: An object-relations interpretation. Bulletin of the Menninger Clinic, 48, 25-
36.
Auerbach, J. S. (1993). The origins of narcissism and narcissistic personality disorder:
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Balint, M. (1979). The basic fault: Therapeutic aspects of regression. New York:
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Beebe, B. and Lachmann, F. M. (1988). The Contribution of Mother-Infant Mutual
Influence to the Origins of Self- and Object Representations Psychoanal. Psychol.
5:305-337
References
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