Elective: Character: A Revisiting

Fourth Year Adult Psychoanalytic Training (APT)
2023-24, 1st Trimester — Fridays, 3:30-5:00pm
Michael Pauly, MD


Introduction

Psychoanalysis is a hell of an endeavor… requiring conscious and unconscious bravery on behalf of both individuals committing themselves to the yet-to-be-known experience to come. The power of the past, the unconscious, and the repetition compulsion are enormous. Faith that an intimate engagement with the historical and inner worlds of the patient in interaction with the analyst will offer something new and therapeutic is a necessary and reassuring factor. In addition to faith there is in my opinion a role for non-defensively used knowledge (explicit and implicit).

As Winnicott said, the mother (analyst) holds the situation over time so that something can be done about something. The something(s) that Winnicott refers to are numerous. Much has been said about the psychological demands of the solitary, dyadic, and triadic situations that must be navigated as one moves towards psychological maturity.

Absent of significant character pathology, the caregiver naturally feels pulled to surrender and offer themselves to their newborn. They are made use of as an auxiliary ego - alpha function providing-container as well as a real whole object waiting to be discovered as the infant gradually lets go of their bundle of projections (omnipotent control). There really is no choice here. Caregiving must be done and it is done on the grounds that it is natural and necessary. There is a background of faith that growth will happen and that the early setup is not a forever state of things.

When it comes to engaging in an analysis both participants make a choice, and given the impact of the already lived-life and resultant presenting character, it is not a given that growth will occur. How do you choose with whom you are willing to conduct an analysis? How do you make sense of what leads you to eagerly say yes to one person and be reluctant with another? Does knowledge of character structure and type play a role in understanding your feeling-based intuitive process and make it more explicit? Does it inform your treatment recommendation and assessment of the treatment trajectory and prognosis?  Does it help you anticipate the transference-countertransference situations that are likely to come? Does it help with choosing a technique or school of thought within which to ground yourself?

What are we to do with the material that is collected in the clinical encounter? We are all subjected to the experience of being the recipient of the multilayered communications that are present in every clinical moment. Without a way of organizing oneself in the face of the entropic situation one is at risk of getting lost and drifting into the primary process world with the patient.

While there is a mother-infant unit, there is also a separate mother collecting herself and reflecting on the matter at hand. Additionally, there is also in the internal or external field a partner with whom both the child and she engage. While it is true that the move from primary to secondary process is reductive and leaves out elements of absolute truth (Bion’s O), without it we would be in an unsymbolized undifferentiated space. The analyst has a responsibility to offer more than a holding mirroring containing environment. What constitutes the more than an analyst needs?

Our patients expect that we will allow the majority of ourselves to be immersed while maintaining one foot in the secondary process world to allow something to be said about the somethings that are being presented. Aside from those persons with merger-based demands (intolerance of separateness), our patients prefer we not get lost within them. They want us to be durable and help them achieve a greater degree of self-cohesion, narcissistic stability, understanding of themselves, and the capacity to navigate closeness and distance within relationships.

Explicit knowledge (paternal function) serves grounding, containing, organizing functions that complement the self-object empathy-based elements (maternal functions) of the relationship and further facilitates a way of being present and available to the intimacy of the moment. One may choose to move beyond mirroring and say something to the patient about what the experience with them has generated in their own separate mind (explanation, interpretation, reconstruction, countertransference disclosure, reverie story etc) without it being an interruption in the closeness of the relationship. Thorough understanding of character structure and type is helpful in organizing these therapeutic actions.

In thinking about this course, I have been trying to understand how for some the idea of character diagnosis is a threat; trying to understand how it evokes the idea that the knowing or thinking analyst is actually not with their patient, or the idea that a knowing analyst generates not only the potential misuse of power but is in fact equated regardless of what the analyst does with their knowledge as a damaging fact in and of itself. This I think is what leads to an overvaluing of mirroring and the no memory or desire concept...which in my mind is best taken as a capacity to have alongside many others.

My thoughts also go to Britton's paper on triangular space and the hyper-subjective stance in which a dyadic merger is overvalued and the idea of objectivity and being seen or thought about is devalued and dreaded. The opposition to explicit knowledge in some circumstances is related to overvaluing maternal functions at the expense of paternal functions. There is a fear of the action that is equated with the paternal functions (boundaries, descriptions, interpretations, confrontations, asymmetrical power) and an unhelpful collapsing of assertion with hostility (a defense against aggression) thereby risking a disruption in the relationship. A second idea is that it is a defense about one's difficulty finding something to say, i.e. a defense against the experience of a knowledge deficit, or self-doubt, and related shame.

The above contribute to the contemporary pull to castrate the analyst and flatten all asymmetries. It is an overcorrection away from the hyper-objective classical analytic authoritative stance which itself is a defense against emotional closeness with one's patients (subjective joining) and the importance of accepting one’s ignorance, uncertainties and limits, and allowing oneself to doubt and to not know.

The neurotic course was designed to convey that if the dyadic relationship has unfolded well enough (good enough facilitating environment / mother / breast) the individual will have begun to internalize a mental space (internalized environmental mother), establish self-other boundaries, and experience and integrate love and hate (affect tolerance, self and object constancy). The capacity for separation and individuation and the capacity for concern for the other even during times of frustration (depressive position, whole rather than need satisfying object relations) will develop, allowing them to navigate the increased complexity of triangular spaces (exclusion, excluding, witnessing, being witnessed, competition) and have a flexible ability to move between the subjective and objective positions (consolidated depressive position, repression based rather than splitting based defenses). The idea that knowing and being organized interferes rather than facilitates closeness is a sign that one does not believe either in the importance of or the ability of the analyst moving constantly between the two states of being with and thinking about their patient.

I am hoping that this course, designed to ground ourselves in what we know about character structure and diagnosis, will complement the incredible amount of psychoanalytic knowledge (implicit and explicit) you have cultivated in your first three years of psychoanalytic training.

Initially I felt that each class would be paired with a clinical presentation by a member of the group. In an effort to enrich the experience I have decided against this and instead ask that everyone write weekly about a clinical experience that came to mind while reading the assignments. Ideally this will be seen as an opportunity to learn more about all of our clinical work and discuss our experiences from the framework of understanding character structure and type while remaining open and interested in what lies beyond the edge of our knowledge.

Learning Objectives

  1. At the end of this course the candidate will feel more confident using clinical data to generate character and structural diagnoses.
  2. Based on their understanding of character and structural diagnosis the candidate at the course’s end will be able to better anticipate important elements of the therapeutic process.
  3. The candidate will be able to better recognize the impact of inaccurate/incomplete structural formulations on therapeutic progress and make use of this understanding to better navigate the therapeutic relationship and increase the likelihood of successful therapeutic outcomes.

September 8, 2023 — A discussion: Benefits and Limitations of Character Diagnosis

[37 pages]

What are we listening for within the initial consultation period? What are the available organizing models for making sense of that which we learn? McWilliams and Ogden differ tremendously in their approach to data collection. What approach do you take? How do you make sense of what you learn during the initial consultation hour(s)?

McWilliams, N. (2011), Ch1, “Why Diagnose?” in Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (2nd Edition), pp7-20.

Ogden, T. (1992) Comments on Transference and Countertransference in the Initial Analytic Meeting, Psychoanalytic Inquiry 12:2, pp225-247.

September 15, 2023 — Developmental Levels & Their Implication

[57 pages]

McWilliams, N. (2011), Ch3, “Developmental Levels of Personality Organization”, in Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (2nd Edition), pp43-69. 

McWilliams, N. (2011), Ch4, “Implications of Developmental Levels of Organization”, in Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (2nd Edition), pp70-99.

September 22, 2023 — Perversion & Preview of Sadomasochism

[21 pages]

Grossman, L. (2023) Ch1, “Neurosis as a Way of Thinking” in The Psychoanalytic Encounter and the Misuse of Theory, pp11-18.

Grossman, L. (2023) Ch4: “Perverse Syntax and the Perverse Attitude Toward Reality” in The Psychoanalytic Encounter and the Misuse of Theory, pp32-42

Lingiardi, V.; McWilliams, N. (Eds.) (2017). “Sadistic Personalities” in Psychodynamic Diagnostic Manual (2nd Edition, PDM-2). New York: Guilford Press. pp51-52

September 29, 2023 — Perversion (Continued)

[11 pages]

Grossman, L. (2023) Ch 5: “Reality Testing in Perverse Organization” in The Psychoanalytic Encounter and the Misuse of Theory, pp43-51

Lingiardi, V.; McWilliams, N. (Eds.) (2017). “Psychopathic Personalities” in Psychodynamic Diagnostic Manual (2nd Edition, PDM-2). New York: Guilford Press. pp50-51

October 6, 2023 — Narcissistic Character

[23 pages]

*The mid-term class evaluation will be conducted during this session. Please use these questions to facilitate your discussion: Midterm Evaluation Questions

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

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

October 13, 2023 — Narcissistic Character (Continued)

[21 pages]

Bach, S. (1994) Ch2, “Problems of Narcissistic Love” in The Language of Perversion and The Language of Love. London: Aronson, pp29-49.

Auchincloss E.; Samberg, E. (2012), “Disorders of the Self”, in Psychoanalytic Terms and Concepts, pp235.

Auchincloss E.; Samberg, E. (2012), “Vertical Split”, in Psychoanalytic Terms and Concepts, pp281.

October 20, 2023 — Masochistic Personalities

[39 pages]

McWilliams, N. (2011) Ch 12, “Masochistic (Self-Defeating) Personalities” in Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (2nd Edition), pp267-288.

Grossman, L. (2023) Ch 6, “The Object Preserving Function of Sadomasochism” in The Psychoanalytic Encounter and the Misuse of Theory, pp52-68

October 27, 2023 — Depressive and Manic Personalities

[37 pages]

McWilliams, N. (2011) Ch 11, “Depressive and Manic Personalities” in Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (2nd Edition), pp235-266.

Lingiardi, V.; McWilliams, N. (Eds.) (2017). “Depressive Personalities (Including Hypomanic Defenses and Masochism)” in Psychodynamic Diagnostic Manual (2nd Edition, PDM-2). New York: Guilford Press. pp29-33

November 3, 2023 — Obsessive and Compulsive Personalities

[24 pages]

McWilliams, N. (2011) Ch13, “Obsessive and Compulsive Personalities” in Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process, pp279-300.

Lingiardi, V.; McWilliams, N. (Eds.) (2017). “Obsessive-Compulsive Personalities” in Psychodynamic Diagnostic Manual (2nd Edition, PDM-2). New York: Guilford Press. pp39-40

November 10, 2023 — Schizoid Personality & Closure

[24 pages]

McWilliams, N. (2011), Ch9, “Schizoid Personalities” in Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process (2nd Edition), pp196-213.

Lingiardi, V.; McWilliams, N. (Eds.) (2017). “Schizoid” in Psychodynamic Diagnostic Manual (2nd Edition, PDM-2). New York: Guilford Press. pp40-42

Grossman, L. (2023) Ch 8, “Neurotic, Perverse, and Psychotic Action” in The Psychoanalytic Encounter and the Misuse of Theory, pp78-80