Psychopathology I: Neurotic-Level Personality and Symptom Disorders

Second Year Adult Psychoanalytic Training (APT)
2020-21, 3rd Trimester — Fridays, 1:45-3:15pm
Charlotte Malkmus, MA LMHC
Michael Pauly, MD


Introduction

Welcome to Psychopathology I: Neurotic-Level Personality and Symptom Disorders.

We have chosen to organize this course to first convey an understanding of the developmental underpinnings of neurotic character organization and to then explore the related intrapsychic and interpersonal (including transferential-countertransferential) manifestations of neurotic-level psychopathology.

The following are the types of questions we hope to explore throughout the course:

  • What is implied by the term neurotic character?
  • What is it that one looks for in the consultation period that differentiates between neurotic and the less organized structures that underlie borderline / psychotic characters or states?
  • What are the developmental / relational experiences that may have facilitated or hindered the psychic achievements that characterize a neurotic level organization?
  • What are the predominant conflicts and / or defenses that characterize the various diagnostic categories within neurotic-level symptom or character presentations?

Discussion of clinical material is essential in bringing to life and making personally relevant the concepts we will be exploring. Hence, we strongly encourage you to bring vignettes and short process-notes to class.

March 19, 2021 — What constitutes Neurosis?

32 pages

Sugarman emphasizes that neurosis is defined not in terms of the manifest content of the patient’s verbal material but rather in terms of a mental organization based on the achievement of certain capacities (self-reflective capacity, capacity for affect regulation, capacity for narcissistic regulation, and internal conflict).

Ogden & Gabbard explore the pull towards symptom-focused treatments and encourage the analyst to resist this in exchange for a truth-focused treatment aimed at helping the patient dream themselves more fully into existence.

Auchincloss E.; Samberg, E. (2012), “Neurosis”, in Psychoanalytic Terms and Concepts, pp167-169.

Sugarman, A. (2007). Whatever Happened to Neurosis? Who are we Analyzing? And How? Psychoanal. Psychol., 24:409-428.

Ogden; Gabbard (2010) The Lure of the Symptom In Psychoanalytic Treatment, JAPA, 58:533-544.

March 26, 2021 — Neurotic Level Transference – Countertransference and the Pain of Change

32 pages

Extending the discussion from thinking about the role of content versus underlying personality organization (mental capacities) we now shift our attention to the transference-countertransference experience and the pain (narcissistic depression) involved in change.

Sugarman aims in this paper to redefine insight as a process he calls insightfulness. He suggests that patients present with mentalizing difficulties and that the focus of psychoanalysis is to regain inhibited or repudiated mentalization, not to regain access to specific repressed content. In this way the analyst helps the patient become aware of the experience and causes for regressions to action modes, with an emphasis on helping them subordinate this tendency to the verbal, symbolic mode. He extends his thinking to more broadly to conceptualize transference as the interpersonalization of mental structure. What do you think?

Lax’s paper offers a close look at the adaptive developmental processes involved in symptom and character formation (ego syntonic) and puts forward a way of working through the analytic processes of change by encouraging the curiosity essential to making that which is ego-syntonic ego-dystonic, struggled with, and given up / mourned.

Sugarman, A. (2006) Mentalization, Insightfulness, and Therapeutic Action: The Importance of Mental Organization; IJP, 87:965-987.

Lax, R.F. (1989). “The Narcissistic Investment in Pathological Character Traits and the Narcissistic Depression: Some Implications for Treatment.” IJP, 70:81-90.

April 2, 2021 — Triangularity and Relationship to Neurotic Character

32 pages

The Oedipal situation has long been regarded as the developmental triangular space allowing the child to work out conflict with two parents.

Winnicott, in this chapter, stresses that the depressive position in emotional development is an achievement, reached as early as the second half of the first year. He describes the mother’s holding of the situation over time as enabling the baby to work through coexisting love and hate (think affect tolerance, tolerance of ambivalence). He states that he wishes he could rename this position as the “stage of concern” rather than the “depressive position” given the need to delineate it from clinical depression. Attainment of the depressive position (repression-based defenses, concern for the other) helps to distinguish patients from more primitive mental organizations (paranoid-schizoid position / splitting-based defenses, concern for the self).

Britton presents his idea that the observed link between the child’s parents forms the “closure of the Oedipal triangle” and generates a relational triangular space, which if handled well makes possible a “third position” in the mind of the child. It provides a developmental hypothesis for the conditions allowing for the development of an observing ego, reflective capacity, and tolerance of separateness / exclusion that are consistent with neurotic mental organization and healthy relationships. The model can similarly be used to understand the conditions leading to narcissistic and borderline characters (and hysterical/histrionic) and the transference-countertransferential experience one has working with these patients.

Auchincloss E.; Samberg, E. (2012), “Oedipus Complex”, in Psychoanalytic Terms and Concepts, pp180-183

Winnicott, D.W. (1954). Ch 21, “The Depressive Position in Normal Development” in Collected Papers, pp262-277.

Britton, R. (2004). Subjectivity, Objectivity, and Triangular Space. Psychoanal Q., 73(1):47-61.

April 9, 2021 — Oedipus Revisited: Triangularity, Gender and Culture

48 pages

Balsam challenges the myth of Oedipus as universal and offers alternate ways of conceptualizing female development and triangulated object relations.

Tang and Smith provide us with a rich and thought-provoking paper exploring the cross-cultural relevance of the Oedipus complex, stressing different aspects of the mother-father-son triad, and in so doing introduce the importance of accounting for the parental attitudes within the triad significantly affecting the developmental experience.

Balsam, R.H. (2015). “Oedipus Rex: Where are We Going, Especially with Females?” Psychoanalytic Quarterly, 84(3):555-588.

Tang; Smith (1996). “The Eternal Triangle Across Cultures: Oedipus, Hsueh, and Ganesa”. Psychoan. Study of the Child, 51: 562-57.

April 16, 2021 — Panic

Mid-term evaluations should be conducted in the closing minutes of your classes today. This is a discussion that should be allowed at least 10 minutes, but no more than 30 minutes. No written records are necessary.

Midterm Class Evaluation Discussion Questions


37 pages

Busch, in the first of two articles, proposes that dyadic conflicts intensify the danger of navigating triadic situations which threaten to disrupt one’s insecurely held dyadic attachment, thereby triggering panic.

In the second of these articles Busch & Sandberg attend to the unmentalized / unrepresented somatic and emotional experiences associated with panic. They review multiple models (energetic, object relational, intersubjective and relational) for conceptualizing the etiological factors (misattunement, trauma) leading to representational deficits and propose a way of working whereby somatic and emotional experiences are first symbolized, thereby allowing the conflictual electments and compromise formation functions of panic to be interpreted.

Busch, F.; et al (1999). “Oedipal Dynamics in Panic Disorder.” JAPA, 47:773-790.

Busch; Sandberg (2014). “Unmentalized Aspects of Panic and Anxiety Disorders.” Psychodynamic Psychiatry, 42(2):175-195.

April 23, 2021 — Trauma and Its Implicit Level Re-enactment

36 pages

Khan first walks the reader through a history of the conceptualization of anxiety, ending with the emphasis of the subjective experience of helplessness being at the center of all trauma. Heavily influenced by Winnicott, he then turns his attention to the “mother as protective shield”, which he says constitutes the “average expectable environment” for the anaclitic needs of the infant. He proposes that breaches in the protective shield (failures in the environment) achieve traumatic status cumulatively and in retrospect and that the failures, occurring at the pre-verbal stages of the mother-infant relationship, are not seen directly but rather are observed in the derivatives of the child / adult patient’s implicit mental processes and relational styles.

Fosshage is paired with Khan to offer a contemporary way of working with the implicit memory system and relational style (derivatives of the pre-verbal experiences) of the patient. He stresses that patients need help with both the autobiographical scenarios of the explicit memory system and the mental modes of the implicit memory system, as each contributes to the sense of self, other, and self-with-other.

Khan, M.M.R. (1963). “The Concept of Cumulative Trauma.” Psychoanalytic Study Of the Child, 18:286-306.

Fosshage, J.L. (2004). “The Explicit and Implicit Dance In Psychoanalytic Change.” Journal of Analytic Psychology, 49:49-65.

April 30, 2021 — The Cumulative Trauma of Racism

38 pages

Holmes invites the reader to think about internalized racism and classism as toxic introjects that impede or otherwise compromise success in individuals, leading to success neurosis and impaired self-esteem.

Hamer challenges the old notion of race as a mere symbol of deeper intrapsychic material and asks the reader to think fluidly about the myriad possible meanings of race in the treatment relationship. This requires a much more thorough consideration of the realities of race than is custom of most white clinicians.

Holmes, D.E. (2006). The Wrecking Effects of Race and Social Class on Self and Success. Psychoanal. Quarterly., 75(1):215-235

Hamer, F. M. (2002). Guards at the gate: Race, resistance, and psychic reality. In Journal of the American Psychoanalytic Association, 50, pp. 1219-1237

May 7, 2021 — Depression

46 pages 

In Mourning and Melancholia, Freud introduces many concepts. Most pertinent to this class is his distinguishing mourning (grief) from melancholia (depression) by the over identification with the lost object and hence a diminishment in the regard for the self during times of loss. Please bring clinical material of your own.

McWilliams’ clear writing style serves as a great introduction to the experience of depression and to understand its differentiation from mourning /grief as well as differentiation from masochism and depleted-type narcissism.

Freud, S. (1917). “Mourning and Melancholia” in The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume XIV, pp237-258.

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

Recommended

Given the complexity and importance of understanding the concepts in Mourning and Melancholia I have included Ogden’s paper in which he gives his analysis and extends his thinking to show how Freud’s paper served as the beginning of an object relations theory.  Ogden, he shares dream and clinical material from a patient of his to reveal the “frozen quality of the melancholic’s unconscious internal object world”.

May 14, 2021 — Masochism / Self-Defeating Personalities

38 pages

Meyers breaks the functioning of masochism down into four categories (regulation of guilt; maintenance of object relations, regulation of self-esteem, importance in self-definition).

McWilliams offers in this chapter a comprehensible way of understanding neurotic-level manifestations of masochistic character and helpfully distinguishes masochistic self-defeating characters from that of the depressive character. She offers clinical examples, notably drawing our attention to the need for tactful confrontation in the place of expressed empathy and to watch for the provoked countertransference that oscillates between a wish to rescue and a wish to retaliate (felt irritability / sadistic pole).

Auchincloss E.; Samberg, E. (2012), “Masochism”, in Psychoanalytic Terms and Concepts, pp145-147.

Meyers, H. (1988). “A consideration of treatment techniques in relation to the functions of masochism” in Masochism: Current Psychoanalytic Perspectives (Glick, R. and Meyers, D. eds.) pp175-188.

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

May 21, 2021 — Obsessionality and a return to Sexuality

36 pages

Obsessional character and obsessional symptoms have been a central focus throughout the history of psychoanalysis. Freud’s work with obsession contributed to the core concepts of compromise, unconscious guilt, aggression, and ambivalence and lead to new descriptions of defenses beyond repression, including reaction formation, displacement, regression, undoing, and isolation. Obsessional psychopathology illustrates how cognitive processes can be recruited for the management of psychological conflict and the uniting fear of loss of control.

Bergstein aims to invite the analyst to reconceptualize the verbose obsessional patient (typically thought of as neurotic) and to work at a more primitive unmentalized level with them. She proposes that the obsessional patient is aiming to shield themselves from the pain of intense emotional experience and inherent fear of surrendering to the feeling-based rather than thought-based self. Does this fit with your experience working with obsessional people?

Atlas discusses sexuality in the framework of relational psychoanalysis in an effort to counter the fact that contemporary psychoanalytic approaches as they turned away from drive theory often abandoned sexuality altogether. This paper calls for a return to the centrality of sexuality in understanding the mind, development, and interpersonal / object relations.

Auchincloss E.; Samberg, E. (2012), “Obsession”, in Psychoanalytic Terms and Concepts, pp178-180.

Bergstein, A. (2016). Obsessionality: Modulating the Encounter with Emotional Truth and the Aesthetic Object. J. Amer. Psychoanal. Assn., 64(5):959-982.

Atlas, G. (2018) Has Sexuality Anything to Do with Relationality?, Psychoanalytic Dialogues, 28:330-339.

May 28, 2021 — Narcissism

53 pages

This week is likely the heaviest in terms of reading. Please invest the time deserved to these relational / interpersonal theory-oriented papers, which I believe are extremely helpful in capturing the dynamics of narcissism and their treatment implications.

Mitchell, in addition to giving the reader a grounding in the history of thought surrounding narcissism, proposes that “narcissistic illusions are usefully understood neither solely as a defensive solution for an internal psychic economy, nor solely as a pure efflorescence of infantile mental life, but most fundamentally as a form of participation with others.” He sees narcissistic phenomena as an invitation to a particular form of interaction with the analyst.

Bromberg says that the heart of the pathology for predominantly narcissistic individuals is connected with their struggle to be both “in the world” and “separate from it” (remember Britton and the third position) without endangering the grandiose self (i.e. the internal structure they depend upon for a sense of identity). He thus proposes that treatment requires the integration of mirroring and the dissolution of the mask.

Mitchell, S.A. (1986). The Wings of Icarus: Illusion and the Problem of Narcissism. Contemporary Psychoanalysis, 22:107-132.

Bromberg, P.M. (1983). The Mirror and the Mask – On Narcissism and Psychoanalytic Growth. Contemporary Psychoanalysis, 19:359-387.