Psychopathology II

Second Year Adult Psychoanalytic Training (APT)
2023-24, 2nd Trimester — Fridays, 3:30-5:00pm
Michael Pauly, MD
Babak Roshanaei-Moghaddam, MD

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Introduction

Early analysts emphasized the fixed character structure of patients. It is our opinion that while this fixed view is defensible it is less clinically useful than a flexible model whereby structures and defenses and emergent clinical phenomena are thought to be greatly influenced by the framing, containing, and holding capacities of the analytic situation and person of the analyst.

We will approach the affect-laden enveloping quality of the work with a focus on the developmental conditions and clinical manifestations of this psychopathology spectrum. This is rich, intricate, challenging, and at times uncomfortable work. Unbearable discomfort can lead to empathic failure and a collapse of the space for thought on both sides of the relationship. We will emphasize how the analyst is affected by such patients, the various means by which disturbing experience is transmitted, and how these processes are a ubiquitous, inevitable, and potentially useful reparative part of the analytic process.

Immersing oneself in the literature relevant to this psychopathology spectrum can lead to similar disorganizing affective states in the reader, accompanied by a reactive wish for a clear durable ways of conceptualizing and organizing the material; a wish for more clarity where entropic disorganization often reigns.

Theory can be used defensively to retreat from the immediacy of the emotional intimate moment, or it can be used adaptively to hold one’s mind together and allow for greater closeness and explanatory and therapeutic abilities. It is our hope that as a group we can cultivate the space to together metabolize the fragments and integrate the experience into a good-enough clarifying whole.

As you read through the articles for this class recall Sugarman’s model for a neurotically organized mind consisting not of particular mental content but rather of certain mental capacities (i.e. self-reflective capacity, capacity for affect regulation, capacity for narcissistic regulation, and internal conflict). We will make use of this to understand the struggles that characterize the phenomena that present in borderline states and states of narcissistic fragmentation / breakdown.

Learning Objectives

1. The candidate, as a result of gaining greater knowledge of the hypothesized etiologies of borderline-level character disorders, will have a greater capacity to understand, empathize, and connect interpersonally with this clinical population, and thereby improve the odds of treatment retention and a positive clinical outcome.
2. The candidate, as a result of gaining a greater understanding of and capacity to work with the intense transference-countertransference phenomena and enactments that are present when working with this clinical population, will have an increased ability to assist their patient in identifying and reflecting on these phenomena, and thereby improve the odds of a positive clinical outcome.
3. The candidate, as a result of gaining a greater capacity to work with collapses in reflective functioning under the weight of unbearable affect, will become more capable of assisting this population in such a way that they are better able to tolerate, regulate, and reflect on their affect states and associated triggers, thereby improving their defensive structures, self-understanding, interpersonal relationships, and overall life functioning.

December 1, 2023 — Etiology – Conceptualization

[48 pages]

We will begin with Fonagy, Robbins, and Winnicott to highlight the relational – etiological factors contributing to the emergence of these character / self- disorders.

In Attachment and Borderline Personality, Peter Fonagy outlines how the caregivers’ reflective capacity impacts their child’s capacity for mentalization and the development of a secure attachment. He links these concepts with the idea that early trauma may result in a child’s inhibition of mentalization in an effort to avoid the pain of reflecting on their lived experience, thereby resulting in impaired reflective abilities and an impaired sense of self. Per Fonagy, these impairments may explain the link between childhood maltreatment and borderline character pathology.

In The Mental Organization of Primitive Personalities and its Treatment Implications, Michael Robbins encourages us to think of more primitive personalities as differing in qualitative rather than quantitative ways and that assumptive errors along these lines lead to technical approaches that may be regressive or promote what Winnicott described as an analysis with the false self.

Fonagy, P. (2000) Attachment and Borderline Personality Disorder, Journal of the American Psychoanalytic Association. 48:1129-1146.

Robbins, M. (1996) “The Mental Organization of Primitive Personalities and its Treatment Implications”, JAPA, 44(3):755-784