Psychopathology II: Borderline States

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


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

December 8, 2023 — Etiology (Cont'd)

[24 pages]

“Fear of Breakdown” is a classic. In it, Winnicott tells us that there is a storing in the implicit memory system lived events of past emotional overwhelm (primitive agonies) that have not been fully psychologically experienced. Having not been thought about these haunt the person and at times present in treatment as a fear of breakdown. This paper and its concepts offer a foundational link to many papers that follow in this course. Thomas Ogden walks us through Winnicott’s paper. Please bring in clinical material of your own.

Winnicott, D.W. (1974) “Fear of Breakdown”, International Review of PSA, 1:103-107

Ogden, T.H. (2014) “Fear of Breakdown and the Unlived Life”, IJP, 95:205-223

December 15, 2023 — Part vs Whole Object-Relating

[26 pages]

Donald Winnicott’s paper “The Use of an Object” deserves to be read many times over. In it, he introduces his distinction between object relating and object usage. He walks the reader through the transition from object relating to object usage (the capacity of which is determined by an adequate facilitating environment). The transition requires the placing of the object outside of the subject’s omnipotent control. Failure to make this transition can explain many areas of difficulty in this population (separation-individuation, narcissistic rage, capacities to empathize / love, stability of interpersonal relationships, acceptance of external reality).

Ogden, in his paper “Destruction Reconceived: On Winnicott’s ‘The Use of an Object and Relating through Identifications’” generously helps us make sense of Winnicott’s foundational paper.

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

Ogden, T.H. (2016). Destruction Reconceived: On Winnicott’s “The Use of an Object and Relating through Identifications”. International Journal of Psychoanalysis, 97(5):1243-1262

January 5, 2024 — Neurotic vs Perverse Syntax and the Relationship to Reality

[28 pages]

In these chapters, Lee Grossman differentiates the syntax of neurotic individuals and those he categorizes as perverse (within which he would include borderline and narcissistic individuals). He distinguishes between the two groups based on their relationship to reality and the use of repression in the case of neurotics and disavowal in the case of those categorized as perverse.

One can connect Grossman’s thinking with Winnicott’s Object Usage paper in terms of the impact of a not-good enough object (inadequate facilitating environment) resulting in an inability to mourn one’s omnipotence, disavow reality rather than mourn fantasy wishes (repression), and control rather one’s object rather than related in a mutual – reciprocal way that recognizes the other’s subjectivity.

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

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

January 12, 2024 — Trauma

[37 pages]

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


Joyce McDougall provides us with ample clinical material to show the impact of traumatic experiences that occur in the preverbal period of development. She highlights how these early experiences present via route of the non-verbal expressions affecting that analyst’s countertransference. She calls these primitive communications. Her paper speaks of the analytic process as helping to transform action-communications / action-symptoms into that which can be verbally represented in language, allowing containment of the experience.

McDougall, J. (1978) “Primitive Communication and the Use of Countertransference-Reflections on Early Psychic Trauma and its Transference Effects”, Contemp. Psychoanal., 14:173-209

January 19, 2024 — Trauma

[49 pages]

In this article, Davies and Frawley update the definition of dissociation in accordance with contemporary research on traumatic states and demonstrate the manifestations and impact of dissociative phenomena in the psychoanalytic treatment of adult survivors of childhood sexual abuse. Please bring any clinical material that the reading of this article brings to mind.

Lawrence Brown, in Julies Museum links trauma’s destruction of one’s internal thinking-containing capacity with the concretization of thought. His clinical example highlights the importance in these cases of the analyst’s imaginative capacity being crucial for helping their patients begin to think and dream, and to free themselves from the mental captivity of concrete thought. How do you share your imaginative capacity with your patients?

Davies, J.M. Frawley, M.G. (1992). Dissociative Processes and Transference-Countertransference Paradigms in the Psychoanalytically Oriented Treatment of Adult Survivors of Childhood Sexual Abuse. Psychoanal. Dial., 2(1):5-36.

Brown, L. (2006) “Julie’s Museum: The evolution of thinking, dreaming and historicization in the treatment of traumatized patients” IJP, 87:1569-1585

January 26, 2024 — Reflective Collapse, Disintegration, Emptiness and Suicide

[27 pages]

John Maltsberger, in The Decent Into Suicide, discusses the factors leading to suicidal collapse (affective flooding, desperate maneuvers to counter the emerging mental emergency, loss of control as the self begins to disintegrate, and grandiose mental scheming for mental survival) and connects these with the difficulties in the realm of affect regulation, ego helplessness, narcissistic surrender, breakdown of the representational world, and loss of reality testing.

In The Subjective Experience of Emptiness, Otto Kernberg writes about the chronic emptiness analysts often encounter when working with patients suffering from character pathology. He provides readers with important distinctions between depressive, narcissistic, and schizoid emptiness as experienced in the patients’ emotional worlds and in the countertransference.

Maltsberger, J.T. (2004) The descent into suicide. International Journal of Psychoanalysis 85:653-667

Kernberg, O. (1985) “The Subjective Experience of Emptiness” Borderline Conditions and Pathological Narcissism. Jason Aronson (213-224).

February 2, 2024 — Projection, Splitting and Countertransference Enactment

[35 pages]

Kathleen White in Surviving Hatred and Being Hated: Some Personal Thoughts About Racism from a Psychoanalytic Perspective, brings a discussion of the experience of being the object (as a result of one’s race) of toxic attributions and projections. She highlights the subsequent response(s): the self-hatred stemming from the internalization and identification with such projections; and the emergence of the hatred of the other. She stresses that hatred is learned and that the analytic endeavor must include helping patients recover the learning process in hateful experiences so that unlearning and relearning is possible. Please bring in accounts of any experiences (personal or professional) this paper stimulates in you.

Alex Bateman, in Thick-Skinned Organizations and Enactment in Borderline and Narcissistic Disorders, proposes that narcissistic and borderline individuals move between thick and thin- skinned positions, lending an instability to the clinical picture which is both a danger and an opportunity for the treatment. He helpfully uses clinical material to outline his impression of the three countertransference experiences contributing to enactment (complementary, concordant, and defensive) and to highlight three levels of enactment (collusive, defensive, and the un-named role of father, corrective). The last he feels serves as a new helpful developmental experience that moves the treatment forward.

White, K.P. (2002). Surviving hating and being hated: Some personal thoughts about racism from a psychoanalytic perspective.. In Contemporary Psychoanalysis, 38, pp. 401-422

Bateman, A. (1998) Thick-Skinned Organizations and Enactment in Borderline and Narcissistic Disorders. IJP, 79:13-25.

February 16, 2024 — Hysteria / Psychosomatic States

Presenter: Babak Roshanaei-Moghaddam, MD

[32 pages]

This course would be incomplete without making connections between early life trauma, deficits in the capacity to mentalize, symbolically represent, and reflect on internal psychic experience, and the expression of psychic phenomena through bodily experience and illness.

Anita Weinreb in, Healing the Split Between Body and Mind: Structural and Developmental Aspects of Psychosomatic Illness, follows the analytic journey of two women with multiple somatic problems. They discover and examine how their bodies became the vehicle into which unprocessed feelings had been emptied and how with treatment helped them to develop the ability to verbally represent their experience, contain it, and reflect upon it, thereby revealing the underlying conflicts and functions embedded in their previous somatic expression.

Trevor Lubbe’s Diagnosing a Male Hysteric gives readers a detailed clinical account of a patient who uses sex as a defense against fears of separation and exclusion to compensate for early developmental deficits.

Weinreb, A. (2010) Healing the Split Between Body and Mind: Structural and Developmental Aspects of Psychosomatic Illness. Psychoanal. Inquiry. 30(5):430-444

Lubbe, T. (2003). “Diagnosing a Male Hysteric” Int. J. Psychoanal., (84)(4):1043-1059

February 23, 2024 — Perversion - Sadism and Masochism

Presenter: Babak Roshanaei-Moghaddam, MD

[52 pages]

The last two weeks of this course are dedicated to the exploration of perverse mechanisms, within which sadomasochism resides. While somewhat heavy on the reading, given the difficulty engaging, surviving, and proving helpful to this character type, we hope the time spent is worthwhile.

Sheldon Bach’s chapter, Sadomasochistic Object Relations, is invaluable in terms of working with sado-masochistically organized individuals. The chapter draws on many of the themes described in articles earlier in the course (difficulties in the realms of separation- individuation, developmental trauma, role of aggression, inability to mourn, narcissistic omnipotence, failures of seeing the other as separate, concrete mental processes) to explain the developmental line of perverse relating and guide the treatment approach.

Emmanuel Ghent’s Masochism, Submission, Surrender, provides us with a link between Winnicott’s groundbreaking work from the 60’s and 70’s and the relational theory of Jessica Benjamin in the 2000’s. Ghent posits masochism as a distorted attempt at surrender, which he defines as a universal desire to be wholly known by the other.

Bach, S. (1994) Ch1, “Sadomasochistic Object Relations” in The Language of Perversion and The Language of Love. London: Aronson, pp3-25.

Ghent, E. (1990). Masochism, Submission, Surrender—Masochism as a Perversion of Surrender. Contemp. Psychoanal., 26:108-136.

March 1, 2024 — Perverse Relatedness

[42 pages]

Richard Tuch, in Murder on the Mind: Tyrannical Power and other Points Along the Perverse Spectrum, gives a comprehensive overview of the history of thinking about perversion and perverse relatedness.

In Perverse Female Relating, Andrea Celenza updates old notions of perversion that were based on male development as normative and gives readers a new self-structure to consider: the Objectified Self. She suggests that in contrast to male perverse relatedness, a hallmark of female perverse relating is self-objectification, the aim of which is to control a dangerous subjectivity within.

Tuch, R. (2010) Murder on the Mind: Tyrannical Power and other Points Along the Perverse Spectrum. Int. J. Psycho-Anal., 91:141-162.

Celenza, A. (2013) “Perverse Female Relating: The Objectified Self.”  Contemporary Psychoanalysis, 49:586-605