Psychopathology II: Borderline States

Hello, and welcome to Psychopathology II: Borderline States.

Early analysts emphasized the fixed character structure of such “primitive” patients. It is my opinion that this fixed view is reductionistic and less clinically useful than a more 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 collapses 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 clearer more durable way of conceptualizing and organizing the material; a wish for more clarity where entropic disorganization often reigns. It is my hope that as a group we can cultivate the space to together metabolize the fragments and integrate the experience into a good-enough whole.

As you read through the articles for this class recall from psychopathology I Sugarman’s model for a neurotically organized mind consisting not of particular mental content but rather 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.

Process: Middle Phase

The Middle Phase is that period in psychoanalysis between the Opening Phase and Termination.

Theory: Modern Structural Theory (Post-Freudian Ego Psychology) and American Object Relations

In the first part of this course, you will become conversant with key concepts and terminology derived from post-Freudian ego psychology as it was originally elaborated by Heinz Hartmann, Anna Freud and others.  For example, you will gain an understanding of what Hartmann referred to as the average expectable environment, autonomous ego functions, secondary autonomy, intersystemic and intrasystemic conflict, and the conflict-free sphere.  You will also become versed in the multitude of defense mechanisms (as enumerated by Anna Freud) that the ego utilizes to defend itself from forbidden id-wishes and impulses.  Moreover, you will become acquainted with ego psychology’s influence on psychoanalytic technique.  For instance, you will learn what Kurt Eissler meant by parameter and what should be done when the analyst deviates from classical technique.  Additionally, you will learn Leo Stone’s perspective on why the analyst deviates from classical technique as a developmental necessity for some patients.  Moreover, you will learn about Charles Brenner’s perspective on how the ego is in continuous inter and intrasystemic conflict, and how the ego’s conflict can lead to compromise formation.

In the second part of this course, you will become conversant with key concepts taken from American Object Relations Theory. We begin with chapters from Jay Greenberg and Stephen Mitchell’s seminal book, “Object Relations in Psychoanalytic Theory.”  In these chapters, you will acquire a working knowledge of two deeply divergent models of object relations theory: Freud’s drive model, in which object relations with others are determined by the individual’s need to satisfy primary instinctual drives, vs. a relational model in which interpersonal needs with real people, including the analyst, are considered as important if not more important than endogenously derived drives.  For example, to set the stage, you will read and discuss authors whose theories have drawn heavily from interpersonal psychoanalysis and studies involving infant observation.  Also, you will learn how Harry Stack Sullivan significantly influenced the shape and direction of American Object Relations Theory.  Specific key concepts that you will learn and become conversant with are self-system,dynamisms, personifications, Prototaxic, Parataxic and Syntactic experience, as well as Sullivan’s theory of anxiety.  Additionally, you will become knowledgeable about and conversant with W. Ronald D. Fairbairn’s object relations theory.  Fairbairn’s theory is considered to be a radical departure from Freud and ego psychology and is foundational to understanding contemporary relational theory.

In the third part of the course you will acquire an understanding of Joseph Sandler’s contributions to American Object Relations Theory. For example, you will learn to distinguish between such evocative concepts as introjection and identification; representation and image; self-representation and object-representations. You will also become knowledgeable about Sandler’s theory of how the ego constructs a representational worldfrom the original undifferentiated sensorium of the infant.  You will learn about Sandler’s theory of the importance of affect, e.g., safety as the central motivational force in the internal world of the infant, hence supplanting instinctual drives as primary indicator of behavior.  You will also be introduced to Sandler’s theory of role-responsiveness and how this concept is a precursor to today’s concept of countertransference-enactment.

In the final part of this course, you will become conversant with Hans Loewald’s theory of motivation and therapeutic action.  For example, you will learn what Loewald meant when he wrote that the analyst was a newobject for the patient.  In addition, you will acquire knowledge of how Otto Kernberg has developed a contemporary psychoanalytic theory of drives, integrating this theory with contemporary affect theory and with psychoanalytic object relations theory. Finally, you will become familiar with the views of Nancy Chodorow, who provides an example of current theorizing founded on some of the historical developments we will have studied this term.  For instance, you will learn what she means by intersubjective ego psychology.  These final two weeks of the term are intended to bring us to current applications of ego psychological thought and to set the stage for subsequent theory classes in Self and Relational and Intersubjective theories.

Please begin your reading for each week by reading through the corresponding week’s summaries below. This will help orient you to key points in the reading and the flow of the course overall.

Human Development: Infant Observation (3 Trimesters)

Observing an infant weekly from birth to one year gives a unique opportunity to learn about early child development as it is happening “under a microscope.”  The evolution of the earliest relationships with parents and siblings and others can be seen in all their complexity.  The baby’s own experiences; its efforts to hold itself together, to develop trust, to have and internalize a good object and to develop symbols can all be seen and the growth of the infant’s internal world can be inferred in the process.

For most observers, there is valuable “carry over” from this experience into clinical work. Infant observation supports the growth of an analyst’s ability to recognize the infantile part of patients in the treatment situation, whatever their age. Nuanced observation is an essential skill for psychoanalysts and this class will stimulate the development of an observing mind.

Infant observation is a time consuming and at times profoundly disturbing experience. Observers are immersed in the affective experience of the baby and caregiver within a frame that favors reflection rather than action. Therefore, our group discussion is an essential class component, a vehicle for support and additional learning.

Each of you will be expected to find a family to observe with a baby whose birth will occur near the beginning our class meetings in September. Ideally, you will meet with the parent(s) at least once prior to the delivery/adoption of the infant. In that first meeting you will get to know the family, explain the process and listen carefully to what the parents share about their experience as they prepare to welcome a baby into the family. You will write a summary of this initial contact with the family to share in class. Following your initial visit, once the baby is born/adopted, you will observe the baby for one hour each week and write a process summary to share with the class. Your written reflection will enable you to remember your experience and illuminate that experience for the group. Record what you saw, heard and felt. Attend also to what you find remains out of your memory. When you come to class, please bring a copy of that week’s writing for your colleagues. You may find it helpful to create a notebook within which each observation is kept. These notes are confidential and are not to be shared outside of the group or with the family.  At the top of each note write:

Your Name

Date

Observation Number

Baby’s birth date and age in weeks/months

You will each prepare a final paper to be presented in class, approximately three pages in length, which summarizes what you learned from the observation and class experience. 

September 13, 2019 — Introductory Class

Video: Observation Observed, Tavistock Clinic. 

At the end of this introductory class, associates will be able to:

  • Discuss infant observation guidelines and methodology.
  • Formulate a plan for finding a family and baby to observe and consider ways to present themselves when doing so.  
  • Consider the importance of maintaining frame, boundaries and neutrality in their observation experience.
  • Know how to record their experiences in writing.  
  • Begin to have an appreciation for the experiential group process

September 2019 – June 2020

Learning objectives

Through the experience of observing, writing about and discussing a baby and caregiver as well as noticing their own responses to what is observed, associates will develop the following knowledge, skills and attitudes:

Knowledge:

Associates will recognize moment by moment examples of how an infant’s mind and somatic self develop from his/her early caregiving experience. 

Associates will learn to observe attachment patterns in infants and caregivers. 

Associates will acquire a rich experiential foundation for deeper exploration of theoretical and developmental material in subsequent didactic courses.

Associates will be able to use their infant observation experience to improve treatment interventions and efficacy by recognizing early developmental deficits in the clinical setting.

Skills:

Associates will develop the capacity to distinguish between what they observe and what they think. 

Associates will deepen their capacity to reflect on and remain in contact with feeling states observed in the baby, caregiver and those they experience while observing, rather than discharging their feelings through action.  

Associates will hone their ability to make use of countertransference as a clinical tool to understand and empathize with both the infant and caregiver’s experiences.

Associates will further refine their ability to write about clinical process in a nuanced way that distinguishes between observed process moments and the inferences and hypotheses made regarding the infant’s or the parent’s experience or state of mind.

Attitudes

Associates will further develop a reverie based analytic stance of openness to clinical observation of patient and self. 

FINDING A BABY AND FAMILY FOR INFANT OBSERVATION:

While looking for a family and baby, you might include some of the following in your communication:

As a part of an extensive study program in child development, I am required to do an infant observation and I am looking for a volunteer.

This observation involves seeing the same infant for one year.  I will be viewing the ongoing development of the baby during weekly one-hour visits.  The observations are not intended to disrupt your family routine in any way.

Previous baby observation volunteers have found this to be a rich and rewarding experience that deepens their own appreciation of the many early developmental milestones. If, however, during the year you become uncomfortable with my presence/observation you may stop participation at any time.

My background is in Clinical Psychology and Psychoanalysis [ADD YOUR OWN HERE] and I bring to this observation ten years of clinical experience in the field of child development [ADD YOUR OWN HERE].  I also bring great excitement to watch your infant grow and develop his/her first year of life.

If you are interested in volunteering or have any questions at all, please call me at 206-328-XXXX [YOUR NUMBER].  I will be happy to tell you more about the study or give you whatever information you and your family may need to make a decision about participating.

Thank you for your consideration.