Levels of Severity of Personality Organization: Implications for Treatment Southwest Psychoanalytic Society December 1, 2018 Nancy McWilliams, PhD, Rutgers University

Early Freudian Ideas of “Fixation” Oral phase: birth to 18 months. Child is organized around eating/survival; exploration by mouth; development of talking. Anal phase: 18 months to 3 years. Child faces original socialization into demands of community. Toilet training and attendant issues of cooperation vs. resistance, submission vs. rebellion, cleanliness vs. dirt, promptness vs. lateness. Oedipal phase: 3 to 6 years. Child perceives others as in relationship, with attendant issues of envy and competition; awareness of dangers of death and body injury, and associated fantasies.

Melanie Klein’s “positions” Paranoid-schizoid position: Self-centric. Splits between all-good and all-bad percepts. Effort to preserve the sense of good inside and project the bad outside. Depressive position: Appreciation of separateness of others leads to realization that caregivers and the self are combinations of good and bad, gratification and frustration.

Erikson’s Developmental Levels Basic Trust vs. Distrust: birth to 18 months Autonomy vs. Shame and Doubt: 18 months to 3 years Initiative vs. Guilt: 3 to 6 years Further stages through the lifespan

Mahler’s Separation-Individuation Stages (Autistic phase: First month) Symbiotic phase: 2 months to 5 months Separation-Individuation phase: 5 months to 3 years: Hatching (differentiation): 5-10 months Practicing: 10-16 months Rapprochement: 16-24 months “on the way to object constancy”: 24-36 months Object Constancy: From 3 years on.

Fonagy’s Phases of Development Psychic equivalence phase: birth to 18 months: The external world is isomorphic with the internal world. Pretend phase: 18 months to 3 years: Internal state is decoupled from external reality but thought to have no implications for the outside world. Mentalization phase: 3 years and upward: Capacity for plausible interpretation of one’s own and others’ behavior in terms of underlying mental states: Reflective function.

Factors influencing level of functioning Fixation: Temperament and early life experience did not allow full maturation into the subsequent stages. Repressed versus unformulated affect Regression: Traumatic experience has knocked the person back to previous modes of functioning. Traumatic loss as activating paranoid-schizoid dynamics even in very psychologically healthy people

Origins of the concept of a borderline range of organization: Stern, A. (1938). Psychoanalytic investigation and therapy in the borderline group of neuroses. Psychoanalytic Quarterly, 7, 467-489. Knight, R. (1953). Borderline states. Bulletin of the Menninger Clinic, 17, 1-12. Grinker, R. R., Werble, B., & Drye, R.C. (1968). The borderline syndrome: A behavioral study of ego functions. New York: Basic Books. Hartocollis, P. (Ed.) (1977). Borderline personality disorders: The concept, the syndrome, the patient. New York: International Universities Press. Stone, M. (1980). The borderline syndromes: Constitution, personality, and adaptation. New York: McGraw-Hill.

Dimensional conceptualizations emerging from clinical experience Jacobson, E. (1971). Depression: Comparative studies of normal, neurotic, and psychotic conditions. New York: International Universities Press. Kernberg, O. F. (1988). Clinical dimensions of masochism. Journal of the American Psychoanalytic Association, 36, 1005-1029. Kernberg, O. F. (1984). Aggressivity, narcissism and self- destructiveness in the psychotherapeutic relationship: New developments in the psychology and psychotherapy of the severe personality disorders. New Haven, CT: Yale University Press. Steiner, J. ( 1993). Psychic retreats: Pathological organizations in psychotic, neurotic, and borderline patients. London: Routledge. Meloy, J. R. (Ed). (2001). The mark of Cain: Psychoanalytic insight and the psychopath. Hillsdale, NJ: Analytic Press.

Kernberg’s Borderline personality organization drawing on Klein, Object Relations theory, Ego Psychology Kernberg, O. F. (1975). Borderline states and pathological narcissism. New York: Jason Aronson. Kernberg, O. F. (1976). Object relations theory and clinical psychoanalysis. New York: Jason Aronson. Kernberg, O. F. (1984). Severe personality disorders: Psychotherapeutic strategies. New Haven, CT: Yale University Press. Steiner, J. (1993). Psychic retreats: Pathological organizations in psychotic, neurotic and borderline patients. London: Brunner-Routledge. Yeomans, R. E., Clarkin, J. F., & Kernberg, O. F. (2015). Transference-Focused Psychotherapy for Borderline Personality Disorder: A clinical guide. Washington, DC: American Psychiatric Publishing.

Masterson, Rinsley, and other developmental perspectives Masterson, Rinsley, and other developmental perspectives influenced by Margaret Mahler’s work Masterson, J. F. (1972). Treatment of the borderline adolescent: A developmental approach. New York: Wiley- Interscience. Masterson, J. F. (1976). Psychotherapy of the borderline adult: A developmental approach. New York: Brunner/Mazel. Rinsley, D. B. (1982). Borderline and other self disorders: A developmental and object-relations perspective. New York: Jason Aronson. Adler, G. (1985). Borderline psychopathology and its treatment. New York: Jason Aronson. Cohen, C.P., & Sherwood, V. R. (1996). Becoming a constant object in psychotherapy with a borderline patient. Northvale, NJ: Jason Aronson.

John Gunderson and other psychiatric researchers John Gunderson and other psychiatric researchers focus on hospital management Gunderson, J. G., & Singer, M. T. (1975). Defining borderline patients: An overview. American Journal of Psychiatry, 132, 1-10. Skodol, A. E., Gunderson, J. G, Pfohl, B., et al. (2002). The borderline diagnosis I: Psychopathology, comorbidity, and personality structure. Biological Psychiatry, 51: 936-950. Skodol, A. E., Siever, L. J., Livesley, W. J., et al., The borderline diagnosis II: Biology, genetics, and clinical course. Biological Psychiatry, 51: 936-950. Gunderson, J. G., & Hoffman, P. D. (2005). Understanding and treating borderline personality disorder: A guide for professionals and families. Washington, DC: American Psychiatric Association.

Giovanni Liotti’s multiple integration model Giovanni Liotti’s multiple integration model influenced by cognitive psychology and attachment theory Karpman, S. B. (1968). Fairy tales and script drama analysis. Transactional analysis bulletin, 7, 39-43. Guidano, V. F., & Liotti, G. (1983). Cognitive processes and emotional disorders. New York: Guilford Press. Liotti, G., Cortina, M., & Farina, B. (2008). Attachment theory and multiple integrated treatments of borderline patients. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 36, 295-315.

Contributions of research on affect and its communication Tomkins, S. S. (1995). Script theory. In E. V. Demos (Ed.), Exploring affect: The selected writings of Silvan Tomkins (pp. 312-388). New York: Cambridge University Press. Panksepp, J. (2004). Affective neuroscience: The foundations of human and animal emotions. New York: Oxford University Press. Panksepp, J., & Biven. L. (2012). The archeology of mind: Neuroevolutionary origins of human emotions. New York: Norton. Anstadt, Th., Merten, J., Ullrich, B., & Krause, R. (1997). Affective dyadic behavior, core conflictual relationship themes and success of treatment. Psychotherapy Research, 7, 397-417.

Peter Fonagy and Mentalization- Based Therapy Peter Fonagy and Mentalization- Based Therapy based on attachment research Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2002). Affect regulation, mentalization, and the development of the self. New York: Other Press. Bateman, A., & Fonagy, P. (2004). Psychotherapy for borderline personality disorder: Mentalization-based treatment. London: Oxford University Press.

Russell Meares’s Conversational Model Russell Meares’s Conversational Model based on self psychology, research in trauma and dissociation Stevenson, J., & Meares, R. (1992). An outcome study of psychotherapy for patients with borderline personality disorder. American Journal of Psychiatry, 149, 358-362. Meares, R. (2012). A dissociation model of borderline personality disorder. New York: Norton. Meares, R. (2012). Borderline personality disorder and the conversational model. New York: Norton.

Gregory and Remen’s Dynamic Deconstructive Psychotherapy Gregory, R. J., & Remen, A. L. (2008). A manual-based psychodynamic therapy for treatment-resistant borderline personality disorder. Psychotherapy: Theory, Research, Practice, Training, 45, 15-27.

Marsha Linehan’s Dialectical Behavior Therapy Marsha Linehan’s Dialectical Behavior Therapy based on behaviorism, cognitive therapy, zen buddhism, personal experience Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.

Jeffrey Young’s Schema Therapy based on cognitive psychology Young, J. E. (1999). Cognitive therapy for personality disorders: A schema-focused approach. Sarasota, FL: Professional Resource Press.

Contemporary relational psychoanalysis based on interpersonal and relational theories, dissociation studies Davies, M. G., & Frawley, M. G. (1994). Treating the adult survivor of childhood sexual abuse: A psychoanalytic perspective. New York: Basic Books. Stern, D. B. (1997). Unformulated experience: From dissociation to imagination in psychoanalysis. Hillsdale, NJ: The Analytic Press. Bromberg, P. (1998). Standing in the spaces: Essays on clinical process, trauma, and dissociation. Hillsdale, NJ: The Analytic Press. Maroda, K. J. (2010). Psychodynamic techniques: Working with emotion in the therapeutic relationship. New York: Guilford Press.

Areas of Agreement about work with Borderline Patients 1. Centrality of therapeutic relationship 2. Importance of limits, boundaries, contracts 3. Discouragement of regression 4. Expectation of intensity, strong counter- transferences, permeability, enactment 5. Inevitability of either-or dilemmas 6. Requirement that the therapist be more emotionally expressive 7. Necessity of supervision and consultation

Eigen, M. (1986). The psychotic core. New York: Jason Aronson

A psychotic level of personality organization Gordon, R. M. (2009). Reactions to the Psychodynamic Diagnostic Manual (PDM) by psychodynamic, CBT, and other non-psychodynamic psychologists. Issues in Psychoanalytic Psychiatry, 31, 55-62. Gordon, R. M., & Bornstein, R. F. (2017). Construct validity of the Psychodiagnostic Chart: A transdiagnostic measure of personality organization, personality syndromes, mental functioning, and symptomatology. Psychoanalytic Psychology, 34(1), 1-9.

Empirical support for a severity dimension Sharp, C., Wright, A. G. C., Fowler, J. C., Frueh, B. C., Allen, J. G., Oldham, J., & Clark, L. A. (2015). The structure of personality pathology: Both general (‘g’) and specific (‘s’) factors? Journal of Abnormal Psychology, 124(2), 387-398.

Clinical and ethical implications of a dimensional view of psychosis It allows therapists and patients to relate empathically as one vulnerable human being to another. It permits therapists to think about and address issues of safety as central to patients in the psychotic range. Psychotic-level dynamics of terror and humiliation require clinicians to be both realistically authoritative and profoundly egalitarian. Normalizing is usually important for patients with psychotic tendencies. Education is usually necessary for patients dealing with psychotic confusions. Therapists of patients with psychotic tendencies need to be especially appreciative of health-seeking aspects of their symptoms. Therapy should be conversational and active.

Therapy with Patients in the Psychotic Range: Classic Resources Fromm-Reichmann, F. (1950). Principles of intensive psychotherapy. Chicago: University of Chicago Press. Sullivan, H. S. (1962). Schizophrenia as a human process. New York: Norton. Searles, H. F. (1965). Collected papers on schizophrenia and related subjects. New York: International Universities Press. Arieti, S. (1974). Interpretation of schizophrenia (2nd ed.). New York: Basic Books. Karon, B. P., & VandenBos, G. R. (1981). Psychotherapy of schizophrenia: The treatment of choice. New York: Jason Aronson. Eigen, M. (1986). The psychotic core. New York: Jason Aronson. Sass, L. A. (1992). Madness and modernism: Insanity in the light of modem art, literature, and thought. New York: Basic Books. Steiner, J. (1993). Psychic retreats: Pathological organizations in psychotic, neurotic and borderline patients. London: Routledge.

Therapy with patients in the psychotic range: Newer resources Atwood, G. E. (2011). The abyss of madness. New York: Routledge. McWilliams, N. (2015). More simply human: On the universality of madness. Psychosis, 7, 63-71. Garrett, M., & Turkington, D. (2011). CBT for psychosis in a psychoanalytic frame. Psychosis, 3, 2-13. Garrett, M. (in press). Psychotherapy for schizophrenia. In Sadock, B. J. & Sadock, V. A. (Eds.). Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 10th ed. Marcus, E. R. (2003). Psychosis and near psychosis: Ego functions, symbol structure, treatment. Madison, CT: International Universities Press. Saks, E. R. (2008). The center cannot hold: My journey through madness. New York: Hyperion Press. Lauveng, A. (2012). A road back from schizophrenia: A memoir. New York: Skyhorse. Werman, D. S. (2015). The practice of supportive psychotherapy. New York: Routledge.

Thank you! nancymcw@aol.com