Borderline and Narcissistic Conditions

Integrated Child & Adult Psychoanalytic Psychotherapy (ICAPP)
2021-22, 3rd Block — Mondays, 6:30-7:45pm
Scot Gibson, MD
Kelly Lippman, LMHC


In this eight-week course, we will focus on the dynamics and treatment of Narcissistic and Borderline character organization. Through readings and case material, we aim to strike a balance between clinical theory and practice experience. In our sessions we will review key concepts in the readings for each week while applying these to our own clinical experiences.

In preparation for our sessions, while reading the material for the week, you may find it useful to attend to your emotional reactions in addition to your critical thinking. In what ways do you like/not like, agree/disagree with the writer? Why? What relevance, if any, does the material have for your clinical work? How does it help inform your understanding of a particular case or cases?

Learning Objectives

In this class, participants will learn to:

  1. elaborate a psychodynamic conception of personality, levels of personality organization (neurotic-borderline-psychotic), and types of character organization;
  2. diagnose and treat patients with narcissistic and borderline character organizations;
  3. develop their own nuanced view of psychoactive prescribed medications in a psychoanalytic or psychodynamic treatment setting.

January 24, 2022 — Personality and Personality Disorders

[61 pages]

Caligor, E.; Kernberg, O.F.; Clarkin, J.F.; & Yeomans, F.E. (2018) Ch2, Personality and Personality Disorders Within the Framework of Object Relations in Psychodynamic Therapy for Personality Pathology, pp21-76.

A general introduction to a commonly-used contemporary psychoanalytic formulation of personality.

Erwin, E., Ed. (2001). The Freud Encyclopedia: Theory, Therapy, and Culture. New York: Routledge. pp355-359.

A Freudian conceptualization.

Optional Reading

Lingiardi, V.; McWilliams, N. (Eds.) (2017). Ch1, “Personality Syndromes” in Psychodynamic Diagnostic Manual (2nd Edition, PDM-2). New York: Guilford Press. pp15-29

This reading provides a brief background on conceptualizing personality structure and developmental levels.

January 31, 2022 — Narcissism

[45 pages]

Morrison, A. (1986) Introduction in Essential Papers on Narcissicm, pp1-16

A brief historical introduction to the psychoanalytic lineage of thought on narcissism.

Kohut, H. & Wolf, E.S. (1978). The Disorders of the Self and their Treatment: An Outline. Int. J. Psycho-Anal., 59:413-425.

Kohut created a new way to think about narcissism that diverged from Freudian ideas of internal conflict.  Kohut, instead, conceptualized problems with narcissism as problems of incomplete development.  His ideas contained new conceptualization of treatment: the therapist, rather than interpret internal conflicts, would instead work toward the further development of the self (then a new concept in psychoanalysis) through empathic mirroring, tolerance for idealization, and attention to the process of rupture and repair in the therapeutic dyad.

Miller, A. (1979). Depression and Grandiosity as Related Forms of Narcissistic Disturbances. Int. Rev. Psycho-Anal., 6:61-76.

Alice Miller’s 1981 book, The Drama of the Gifted Child, became an international bestseller on the basis of her ideas of how childhood trauma (often perpetrated by a narcissistic parent) manifests in adult personalities.  This paper outlines some of the ideas eventually elaborated in her famous book, specifically what can happen to a child when they are “narcissistically cathected” by a narcissistic parent.  Miller eventually broke with psychoanalysis and became a critic of the profession, feeling it was too authoritarian, engaged in victim-blaming, and was not focused enough on childhood trauma.

Optional Reading

Lingiardi, V.; McWilliams, N. (Eds.) (2017). "Narcissistic Personalities" in Psychodynamic Diagnostic Manual (2nd Edition, PDM-2). New York: Guilford Press. pp46-48.

McWilliams, N. (2011). Ch 8, "Narcissistic Personalities" in Psychoanalytic Diagnosis: Understanding Personality Structure in Clinical Process (2nd Edition), pp176-195.

These two readings are good, general summaries of contemporary psychoanalytic conceptions of narcissistic personalities.  The excerpt from Psychoanalytic Diagnosis is a bit more in-depth and gives more direction toward treatment.

February 7, 2022 — Narcissism, cont.

[60 pages]

Shaw, D. (2014) Chapter 2, “The Adult Child of the Traumatizing Narcissist: Enter Ghosts!” in Traumatic Narcissism: Relational Systems of Subjugation. New York: Routledge. pp22-42.

Shaw, D. (2014) “But What Do I Do?” Finding the Path to Freedom in Traumatic Narcissism: Relational Systems of Subjugation. New York: Routledge. pp89-115.

Daniel Shaw is a relational thinker who views prominent conceptions of narcissism (such as those of Kohut and Kernberg) as failing to take into account the fact that narcissistic disturbances are problems with relationships, rather than problems with internal psychic structures.  Like Miller to some degree, he views narcissism as a result of childhood relational trauma.  He focuses on the character of the traumatizing narcissist, who traumatizes others by forcing them into a rigid relational system that serves only his own needs.

Donner, M. (2006) “Tearing the child apart: The contribution of narcissism, envy, and perverse modes of thought to child custody wars.” Psychoanalytic Psychology 23(3): 542-553.

An extremely practical and useful view of the problems of narcissism in high-conflict parenting and divorce.  This is an issue that we as therapists will all likely encounter multiple times in our practices.

Optional Reading

Association of Family and Conciliation Courts (2010) “Guidelines for Court-Involved Therapy”

Very helpful resource when you find yourself working with someone who is involved in a family court proceeding. The unconscious pressures in these cases can pull a therapist quickly off track. These guidelines can keep you oriented and boundaried in a way that protects you and your client. We won’t discuss these in class, but they are good to have in your resource pile.

February 14, 2022 — Narcissism into Borderline

[58 pages]

Kernberg, O. (1967). Borderline Personality Organization. Journal of the American Psychoanalytic Association, 15:641-685.

Kernberg was one of the most prominent early theorizers of borderline personality, and has led a group that has created Transference-Focused Psychotherapy, an empirically-validated manualized, psychoanalytic psychotherapy for borderline (and other) personality disorders. This is one of his early review articles on the topic.

Kernberg, O. (1974). Contrasting Viewpoints Regarding the Nature and Psychoanalytic Treatment of Narcissistic Personalities: A Preliminary Communication. J. Amer. Psychoanal. Assn., (22):255-267.

This article provides a summary of how Kernberg’s position on narcissism differs from Kohut’s, and also provides a bridge between our focus on narcissistic and borderline personalities.

February 28, 2022 — Borderline Personality

[41 pages]

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

Sir Peter Fonagy is another research-oriented psychoanalyst who has, like Kernberg and his group, developed psychoanalytically-based manualized therapies for personality pathology. He and his group (including Mary Target and Anthony Bateman) developed the concept of mentalization, which is based on Bowlby, Ainsworth, and Main’s attachment research.  The concept and his modes of treatment based on it have been extremely popular and influential in the last 20 years.

Winnicott, D.W. (1969) The Use of an Object. IJP, 50:711-716.

This short paper by Winnicott outlines his concept of object usage, which is the process by which a child discovers, through attempts to destroy an object, that the object is separate from her and thus cannot be destroyed through hostile feelings.  Prior to this, the child feels that all objects live within her sphere of omnipotence, and thus are not safe from her aggressive impulses.  Only after this separateness has been established, can the object truly be available to be “used” in her ongoing development.  This simple idea is an expression of the genius of Winnicott, and has enormous implications for treatment, including the use of aggression by the patient to establish a sense of safety within the therapeutic dyad.

Geist, R.A. (2011). The Forward Edge, Connectedness, and the Therapeutic Process. Int. J. Psychoanal. Self Psychol., 6(2):235-251.

This is a lovely case example, by a supremely sensitive therapist, of a woman who would very likely be diagnosed with “borderline personality disorder.”  It shows (among many ideas) how the focus on the connectedness within the dyad, despite expressions of aggression by the patient, creates the environment for growth and a movement toward health.

March 7, 2022 — Psychoanalytic Conceptions of Suicide

[36 pages]

Maltsberger, J.T. (2004). The descent into suicide. Int. J. Psycho-Anal., 85(3):653-667.

John Maltsberger was a psychoanalyst and suicidologist who drew attention to the aspects of affect flooding and related self-disintegration within suicidal crises. His four-part model of suicidal collapse brings nuance and specificity to the multiple interlocking internal aspects of a suicidal moment.

Sharma, S. & Fowler, J.C. (2018) Restoring Hope for the Future: Mentalization-Based Therapy in the Treatment of a Suicidal Adolescent, The Psychoanalytic Study of the Child, 71:1, 55-75.

Sharma and Fowler apply Maltsberger’s framework to the treatment of a suicidal adolescent, while also noting the particular developmental amplification of affect storms within adolescence.

March 14, 2022

[41 pages]

Kalsched, D. (2013) Dissociation and the Dark Side of the Defensive System: Dante’s Encounter with “Dis” in the Inferno in Trauma and the Soul: A Psycho-spiritual Approach to Human Development and Its Interruption. New York: Routledge. pp86-126.

Donald Kalsched is a Jungian psychoanalyst. In this chapter he uses Dante’s Inferno to explore how defenses, which we ordinarily think of as self-protective can also trap us in a landscape of our own private “hell.” His use of literature and clinical examples illuminate the tangled connection between unbearable affect and dissociative defenses as well as how unalterable this can seem, clinically.

March 21, 2022 — Psychopharmacology

[24 pages]
In the article, Adele Tutter examines the possible meanings of psychopharmaceutical medications within a treatment, particularly ways in which “medication can be personified, acting and functioning as object in the psychoanalytic setting.”  I hope the article can be a jumping off point for a discussion about what roles medications have played in treatments in which you have played a part.

Tutter, A. (2006). Medication as Object, JAPA, 54:781-804.