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 신현근 박사 강의안: 성격 조직의 발달 단계  
 

과목:  진단과 평가      

주제:  성격 조직의 발달 단계

강사신현근 박사

내용강의안

주교재: McWilliams, N. (2011). Psychoanalytic diagnosis (2nded.). New York: Guilford Press.

 

 Developmental Levels of Personality Organization

1.       OVERVIEW

1.1.    This chapter focuses on what many analysts have seen as the maturational issues embedded in a person’s character— the unfinished or impeded business of early psychological development: what Freud called fixation and what later analysts called developmental arrest.

1.2.    Historically, analysts have conceived of a continuum of overall mental functioning, from more disturbed to healthier.

1.2.1.They have explicitly or implicitly construed individual personality as organized at a particular developmental level and structured by the individual’s characteristic defensive style.

1.2.2.The first dimension conceptualizes a person’s degree of healthy psychological growth or pathology (psychotic, borderline, neurotic, “normal”); the second identifies his or her type of character (paranoid, depressive, schizoid, etc.).

 

2.       HISTORICAL CONTEXT: DIAGNOSING LEVEL OF CHARACTER PATHOLOGY

2.1.    Introduction

2.1.1.Men and women with hysterical conditions (which included what today would be diagnosed as posttraumatic problems), phobias, obsessions, compulsions, and nonpsychotic manic and depressive symptoms were understood to have psychological difficulties that fall short of complete insanity.

2.1.2.People with hallucinations, delusions, and thought disorders were regarded as insane. People we would today call antisocial were diagnosed with “moral insanity” (Prichard, 1835) but were considered mentally in touch with reality.

2.2.    Kraepelinian Diagnosis: Neurosis versus Psychosis

2.2.1.Emil Kraepelin (1856– 1926) is usually cited as the father of contemporary diagnostic classification.

2.2.2.Kraepelin observed mental patients carefully, with the aim of identifying general syndromes that share common characteristics.

2.2.3.In addition, he developed theories about the etiologies of those conditions, at least to the extent of regarding their origins as either exogenous and treatable or endogenous and incurable (Kraepelin, 1913).

2.2.4.Freud went beyond description and simple levels of deduction into more inferential formulations; his developing theory posited complex epigenetic explanations as preferable to Kraepelin’s basic internal– external versions of causality. Still, Freud tended to view psychopathology by the Kraepelinian categories then available.

2.2.5.Before the category of “borderline” emerged in the middle of the 20th century, analytically influenced therapists followed Freud in differentiating only between neurotic and psychotic levels of pathology, the former being distinguished by a general appreciation of reality and the latter by a loss of contact with it.

2.2.5.1.              A neurotic woman knew at some level that her problem was in her own head; the psychotic one believed it was the world that was out of kilter.

2.2.5.2.              When Freud developed the structural model of the mind, this distinction took on the quality of a comment on a person’s psychological infrastructure: Neurotic people were viewed as suffering because their ego defenses were too automatic and inflexible, cutting them off from id energies that could be put to creative use; psychotic ones suffered because their ego defenses were too weak, leaving them helplessly overwhelmed by primitive material from the id.

2.2.5.3.              The neurotic-versus-psychotic distinction had important clinical implications. The gist of these, considered in light of Freud’s structural model, was that therapy with a neurotic person should involve weakening the defenses and getting access to the id so that its energies may be released for more constructive activity. In contrast, therapy with a psychotic person should aim at strengthening defenses, covering over primitive preoccupations, influencing realistically stressful circumstances so that they are less upsetting, encouraging reality testing, and pushing the bubbling id back into unconsciousness.

2.3.    Ego Psychology Diagnosis: Symptom Neurosis, Neurotic Character, Psychosis

2.3.1.In the psychoanalytic community, in addition to a distinction between neurosis and psychosis, differentiations of extent of maladaptation, not simply type of psychopathology, gradually began to appear within the neurotic category.

2.3.2.The first clinically important one was Wilhelm Reich’s (1933) discrimination between “symptom neuroses” and “character neuroses.” Therapists were learning that it was useful to distinguish between a person with a discrete neurosis and one with a character permeated by neurotic patterns. This distinction lives on in the DSM, in which conditions labeled “disorder” tend to be those that analysts have called neuroses, and conditions labeled “personality disorder” resemble the old analytic concept of neurotic character.

2.3.3.If it was a symptom neurosis that the client suffered (equivalent to “Axis I disorder without comorbid personality disorder”), then one suspected that something in the person’s current life had activated an unconscious conflict and that the patient was now using maladaptive mechanisms to cope with it— methods that may have been the best available solution in childhood but that were now creating more problems than they were solving.

2.3.3.1.               The therapist’s task would be to determine the conflict, help the patient understand and process the emotions connected to it, and develop new resolutions of it.

2.3.3.2.              The prognosis was favorable, and treatment might be relatively short (cf. Menninger, 1963).

2.3.3.3.              One could expect a climate of mutuality during therapy, in which strong transference (and countertransference) reactions might appear, but usually in the context of an even stronger degree of cooperation.

2.3.4.If the patient’s difficulties amounted to a character neurosis or personality problem, then the therapeutic task would be more complicated, demanding, and time consuming, and the prognosis more guarded.

2.3.4.1.              This is only common sense, of course, in that trying to foster personality change obviously poses more challenges than helping someone get rid of a maladaptive response to a specific stress.

2.3.4.2.              But analytic theory went beyond common sense in specifying ways in which work on a person’s basic character would differ from work with a symptom not embedded in personality.

2.3.5.For a long time, the categories of symptom neurosis, character neurosis, and psychosis constituted the main constructs by which we understood personality differences on the dimension of severity of disorder.

2.3.5.1.               A neurosis was the least serious condition, a personality disorder more serious, and a psychotic disturbance quite grave.

2.3.5.2.              These formulations maintained the old distinction between sane and insane, with the sane category including two possibilities: neurotic reactions and neurotically structured personalities.

2.3.5.3.              Over time, however, it became apparent that such an overall scheme of classification was both incomplete and misleading.

2.3.6.One drawback of this taxonomy is its implication that all character problems are more pathological than all neuroses.

2.3.6.1.              One can still discern such an assumption in the DSM, in which the criteria for diagnosing most personality disorders include significant impairments in functioning.

2.3.6.2.              And yet some stress-related neurotic reactions are more crippling to a person’s capacity to cope than, say, some hysterical and obsessional personality disorders.

2.4.    Object Relations Diagnosis: The Delineation of Borderline Conditions

2.4.1.Even in the late 19th century, some psychiatrists were identifying patients who seemed to inhabit a psychological “borderland” (Rosse, 1890) between sanity and insanity. By the middle of the 20th century, other ideas about personality organization suggesting a middle ground between neurosis and psychosis began to appear. Adolph Stein (1938) noted that people with qualities he called “borderline” got worse rather than better in standard psychoanalytic treatment. Helene Deutsch (1942) proposed the concept of the “as-if personality” for a subgroup of people we would now see as narcissistic or borderline, and Hoch and Polatin (1949) made a case for the category of “pseudoneurotic schizophrenia.”

2.4.2.By the middle 1950s, the mental health community had followed these innovators in noting the limitations of the neurosis-versus-psychosis model. Numerous analysts began complaining about clients who seemed character disordered, but in a peculiarly chaotic way. Because they rarely or never reported hallucinations or delusions, they could not be considered psychotic, but they also lacked the consistency of neurotic-level patients, and they seemed to be miserable on a much grander and less comprehensible scale than neurotics. In treatment, they could become temporarily psychotic— convinced, for example, that their therapist was exactly like their mother, yet outside the consulting room there was an odd stability to their instability. In other words, they were too sane to be considered crazy, and too crazy to be considered sane. Therapists began suggesting new diagnostic labels that captured the quality of these people who lived on the border between neurosis and psychosis. In 1953, Knight published a thoughtful essay about “borderline states.”

2.4.3.By 1980, the term had been sufficiently researched to appear in the DSM (DSM-III; American Psychiatric Association, 1980) as a personality disorder.

2.4.3.1.               This development has had mixed effects: It has legitimated a valuable psychoanalytic concept but at the price of losing its original meaning as a level of functioning.

2.4.3.2.              The concept of borderline psychology represented in the DSM drew heavily on the work of Gunderson (e.g., 1984), who had studied a group that most analysts would have diagnosed as having a hysterical or histrionic psychology at the borderline level.

2.4.3.3.              Kernberg (1984), one of the originators of the concept, began having to differentiate between “borderline personality organization” (BPO) and the DSM’s “borderline personality disorder” (BPD).

2.4.4.The concept of “borderline” as a level of psychological functioning had evolved over decades of clinical experience, coming to be generally viewed as a stable instability on the border between the neurotic and psychotic ranges, characterized by lack of identity integration and reliance on primitive defenses without overall loss of reality testing (Kernberg, 1975).

2.4.4.1.               I worry that with the DSM definition having become accepted, we are losing a way of talking about, say, obsessional or schizoid people at the borderline level (e.g., the “quiet borderline” patient of Sherwood & Cohen, 1994).

2.4.4.2.              If all our empirical research on borderline phenomena applies narrowly to the more self-dramatizing, histrionic version of borderline-level personality organization, we are left in the dark about the etiology and treatment of other personality disorders at the borderline level.

2.4.5.By the second half of the 20th century, many therapists struggling to help clients that we now see as borderline found themselves drawing inspiration and validation from writings of analysts in the British object relations movement and the American interpersonal group, who looked at patients’ experiences with key figures in childhood.

2.4.5.1.              These theorists emphasized the patient’s experience of relationship: Was the person preoccupied with symbiotic issues, separation– individuation themes, or highly individuated competitive and identificatory motifs?

2.4.6.Erikson’s (1950) reworking of Freud’s three infantile stages in terms of the child’s interpersonal task made a significant clinical impact, in that patients could be conceptualized as fixated at either primary dependency issues (trust vs. mistrust), secondary separation– individuation issues (autonomy vs. shame and doubt), or more advanced levels of identification (initiative vs. guilt).

2.4.7.These developmental-stage concepts made sense of the differences therapists were noticing among psychotic-, borderline-, and neurotic-level patients: People in a psychotic state seemed fixated at an unindividuated level in which they could not differentiate between what was inside and what was outside themselves; people in a borderline condition were construed as fixated in dyadic struggles between total enmeshment, which they feared would obliterate their identity, and total isolation, which they equated with traumatic abandonment; and people with neurotic difficulties were understood as having accomplished separation and individuation but as having run into conflicts between, for example, things they wished for and things they feared, the prototype for which was the oedipal drama.

2.4.8.By the late 20th century there was, both within the psychoanalytic tradition and outside it, a vast literature on borderline psychopathology, showing a bewildering divergence of conclusions about its etiology.

2.4.9.Recent empirical studies of borderline personality, most of them using the DSM definition, have looked at all these aspects.

2.4.9.1.              There is some evidence for constitutional predispositions (Gunderson & Lyons-Ruth, 2008; Siever & Weinstein, 2009); some for misattuned parenting around attachment and separation issues (Fonagy, Target, Gergeley, Allen, & Bateman, 2003; Nickell, Waudby, & Trull, 2002); and some for the role of trauma, especially relational trauma in early attachment (Schore, 2002) but also later experiences of sexual abuse (Herman, 1992).

2.4.9.2.              It is probable that all these factors play a role, that borderline psychology is not a single entity and is multidetermined, like most other complex psychological phenomena. Current psychoanalytic writing, especially about borderline dynamics, has drawn heavily on empirical findings in the areas of infant development, attachment, and trauma. One consequence has been a significant paradigm shift, as unquestioned notions of fixation at a normative developmental phase have been challenged by evidence for different experiences of attachment and for the destructive effects of recurrent trauma even long after the preschool years.

2.4.10.    Despite the complexity of the etiologies of borderline conditions, I think it can still be useful to view people with a vulnerability to psychosis as unconsciously preoccupied with the issues of the early symbiotic phase (especially trust), people with borderline personality organization as focused on separation– individuation themes, and those with neurotic structure as more “oedipal” or capable of experiencing conflicts that feel more internal to them.

2.4.11.    The most prevalent kind of anxiety for people in the psychotic range is fear of annihilation (Hurvich, 2003), evidently an activation of the brain’s FEAR system (Panksepp, 1998) that evolved to protect against predation; the central anxiety for people in the borderline range is separation anxiety or the activation of Panksepp’s PANIC system that deals with early attachment needs; anxiety in neurotic people tends to involve more unconscious conflict, especially fear of enacting guilty wishes.

 

3.       OVERVIEW OF THE NEUROTIC– BORDERLINE– PSYCHOTIC SPECTRUM

3.1.    Characteristics of Neurotic-Level Personality Structure

3.1.1.It is an irony that the term “neurotic” is now reserved by most analysts for people so emotionally healthy that they are considered rare and unusually gratifying clients.

3.1.1.1.              In Freud’s time, the word was applied to most nonorganic, nonschizophrenic, nonpsychopathic, and non-manic– depressive patients— that is, to a large class of individuals with emotional distress short of psychosis.

3.1.1.2.              We now see many of the people Freud called neurotic as having borderline or even psychotic features (“ hysteria” was understood to include hallucinatory experiences that clearly cross the border into unreality).

3.1.1.3.              The more we have learned about the depth of certain problems, and their stubborn enmeshment within the matrix of a person’s character, the more we currently reserve the term “neurotic” to denote a high level of capacity to function despite emotional suffering.

3.1.2.People whose personalities would be described by many contemporary analysts as organized at an essentially neurotic level rely primarily on the more mature or second-order defenses.

3.1.3.Myerson (1991) has described how empathic parenting allows a young child to experience intense affects without having to hang on to infantile ways of dealing with them.

3.1.4.People with healthier character structure strike the interviewer as having a somewhat integrated sense of identity (Erikson, 1968). Their behavior shows some consistency, and their inner experience is of continuity of self through time.

3.1.5.Neurotic-level people are ordinarily in solid touch with what most of the world calls “reality.”

3.1.5.1.              Some portion of what has brought a neurotic patient for help is seen by him or her as odd; in other words, much of the psychopathology of neurotically organized people is ego alien or capable of being addressed so that it becomes so.

3.1.6.People in the neurotic range show early in therapy a capacity for what Sterba (1934) called the “therapeutic split” between the observing and the experiencing parts of the self.

3.1.6.1.              Even when their difficulties are somewhat ego syntonic, neurotic-level people do not seem to demand the interviewer’s implicit validation of their ways of perceiving.

3.1.7.Their histories and their behavior in the interview situation give evidence that neurotic-level people have more or less successfully traversed Erikson’s first two stages, basic trust and basic autonomy, and that they have made at least some progress toward identity integration and a sense of initiative.

3.1.7.1.              They tend to seek therapy not because of problems in essential security or agency, but because they keep running into conflicts between what they want and obstacles to attaining it that they suspect are of their own making.

3.1.7.2.              Freud’s contention that the proper goal of therapy is the removal of inhibitions against love and work applies to this group; some neurotic-level people are also looking to expand their capacity for solitude and play.

3.1.7.3.              Being in the presence of someone at the healthier end of the continuum of character pathology feels generally benign.

3.1.7.3.1.                    The counterpart of the patient’s possession of a sound observing ego is the therapist’s experience of a sound working alliance.

3.1.7.3.2.                    Often from the very first session, the therapist of a neurotic client feels that he or she and the patient are on the same side and that their mutual antagonist is a problematic part of the patient.

3.1.7.3.3.                    In addition, whatever the valence of the therapist’s countertransference, positive or negative, it tends not to feel overwhelming. The neurotic-level client engenders in the listener neither the wish to kill nor the compulsion to save.

3.2.    Characteristics of Psychotic-Level Personality Structure

3.2.1.At the psychotic end of the spectrum, people are much more internally desperate and disorganized. Interviewing a deeply disturbed patient can range from being a participant in a pleasant, low-key discussion to being the recipient of a homicidal attack.

3.2.1.1.              Especially before the advent of anti-psychotic drugs in the 1950s, few therapists had the natural intuitive talent and emotional stamina to be significantly therapeutic to those in psychotic states.

3.2.1.2.              One of the finest achievements of the psychoanalytic tradition has been its inference of some order in the apparent chaos of people who are easy to dismiss as hopelessly and incomprehensibly crazy, and its consequent offer of ways to understand and mitigate severe mental suffering.

3.2.2.It is not difficult to diagnose patients who are in an overt state of psychosis: they express hallucinations, delusions, and ideas of reference, and their thinking strikes the listener as illogical.

3.2.2.1.              There are many people walking around, however, whose basic psychotic-level internal confusion does not surface conspicuously unless they are under considerable stress.

3.2.3.I share with many analysts the view that it is also useful to conceive of some people who may never become diagnosably psychotic as nevertheless living in a symbiotic– psychotic internal world or, in Klein’s (e.g., 1946) terms, in a consistently “paranoid– schizoid” state.

3.2.3.1.               They function, sometimes quite effectively, but they strike one as confused and deeply terrified, and their thinking feels disorganized or paranoid.

3.2.4.To understand the subjective world of psychotic-level clients, one must first appreciate the defenses they tend to use.

3.2.4.1.              These processes are preverbal and prerational; they protect one against a level of “nameless dread” (Bion, 1967) so overwhelming that even the frightening distortions that the defenses themselves may create are a lesser evil than that state of terror.

3.2.5.Second, people whose personalities are organized at an essentially psychotic level have grave difficulties with identity— so much so that they may not be fully sure that they exist, much less whether their existence is satisfying.

3.2.5.1.              They are deeply confused about who they are, and they usually struggle with such basic issues of self-definition as body concept, age, gender, and sexual orientation.

3.2.6.People with psychotic tendencies have trouble getting perspective on their psychological problems.

3.2.6.1.              They lack the “reflective functioning” that Fonagy and Target (1996) have identified as critical to cognitive maturation.

3.2.6.2.              This deficit may be related to the well-documented difficulties that schizophrenic people have with abstraction (Kasanin, 1944).

3.2.7.Early psychoanalytic formulations about the difficulties that psychotic people have in getting perspective on their realistic troubles stressed energic aspects of their dilemma; that is, they were expending so much energy fighting off existential terror that none was left to use in the service of coping with reality.

3.2.7.1.              Ego psychology models emphasized the psychotic person’s lack of internal differentiation between id, ego, and superego, and between observing and experiencing aspects of the ego.

3.2.7.2.              Students of psychosis influenced by interpersonal, object relations, and self psychology theories (e.g., Atwood, Orange, & Stolorow, 2002) have referred to boundary confusion between inside and outside experience, and to deficits in attachment that make it subjectively too dangerous for the psychotic person to enter the same assumptive world as the interviewer.

3.2.8.The critical thing for therapists to appreciate is that close to the surface in people with psychotic-level psychologies, one finds both mortal fear and dire confusion.

3.2.9.The nature of the primary conflict in people with a potential for psychosis is literally existential: life versus death, existence versus obliteration, safety versus terror.

3.2.10.    Despite their unusual and even frightening aspects, patients in the psychotic range may induce a positive countertransference. This reaction differs a bit from warm countertransference reactions to neurotic-level clients: One may feel more subjective omnipotence, parental protectiveness, and deep soul-level empathy toward psychotic people than toward neurotic ones.

3.2.11.    People with psychotic tendencies are particularly appreciative of sincerity.

3.2.11.1.          In fact, the countertransference with psychotic-level people is remarkably like normal maternal feelings toward infants under a year and a half: They are wonderful in their attachment and terrifying in their needs.

3.2.11.2.          They are not yet oppositional and irritating, but they also tax one’s resources to the limit. I should not work with a schizophrenic, a supervisor once told me, unless I was prepared to be eaten alive.

3.2.12.    This “consuming” feature of their psychology is one reason that many therapists prefer not to work with individuals with schizophrenia and other psychoses.

3.2.12.1.          In addition, as Karon (1992) has noted, the access of psychotic patients to deeply upsetting realities that the rest of us would prefer to ignore is often too much for us.

3.2.12.2.          In particular, they see our flaws and limitations with stunning clarity.

3.2.12.3.          It can be effective and rewarding to work with clients in the psychotic range if one is realistic about the nature of their psychological difficulties.

3.3.    Characteristics of Borderline Personality Organization

3.3.1.One of the most striking features of people with borderline personality organization is their use of primitive defenses.

3.3.1.1.              Because they rely on such archaic and global operations as denial, projective identification, and splitting, when they are regressed they can be hard to distinguish from psychotic patients.

3.3.1.2.              An important difference between borderline and psychotic people, though, is that when a therapist confronts a borderline patient on using a primitive mode of experiencing, the patient will show at least a temporary responsiveness. When the therapist makes a similar comment to a psychotically organized person, he or she will likely become further agitated.

3.3.2.Borderline patients are in some ways similar to and in others different from psychotic people on the dimension of identity integration. Their experience of self is likely to be full of inconsistency and discontinuity.

3.3.2.1.              Unlike patients with psychosis, they rarely sound concrete or tangential to the point of being bizarre, but they do tend to dismiss the therapist’s interest in the complexities of themselves and others.

3.3.2.2.              Fonagy (2000) writes that borderline clients are insecurely attached and lack the “reflective function” that finds meaning in their own behavior and that of others. They cannot “mentalize”; that is, they cannot appreciate the separate subjectivities of other people. In philosophical terms, they lack a theory of mind.

3.3.3.Clients in the borderline range may become hostile when confronted with the limited continuity of their identity.

3.3.3.1.              In general, borderline patients have trouble with affect tolerance and regulation, and quickly go to anger in situations where others might feel shame or envy or sadness or some other more nuanced affect.

3.3.4.In two ways, the relation of borderline patients to their own identity is different from that of psychotic people.

3.3.4.1.              First, the sense of inconsistency and discontinuity that people with borderline organization suffer lacks the degree of existential terror of the schizophrenic. Borderline patients may have identity confusion, but they know they exist.

3.3.4.2.              Second, people with psychotic tendencies are much less likely than borderline patients to react with hostility to questions about identity of self and others. They are too worried about losing their sense of ongoing being, consistent or not, to resent the interviewer’s focus on that problem.

3.3.5.Despite these distinctions, both borderline and psychotic people, unlike neurotics, rely heavily on primitive defenses and suffer a basic defect in the sense of self. The dimension of experience on which the two groups differ substantially is reality testing.

3.3.5.1.              Borderline clients, when interviewed thoughtfully, demonstrate an appreciation of reality no matter how crazy or florid their symptoms look.

3.3.5.2.              It used to be standard psychiatric practice to assess the degree of the patient’s “insight into illness” in order to discriminate between psychotic and nonpsychotic states.

3.3.6.The capacity of someone at the borderline level to observe his or her own pathology— at least the aspects of it that impress an external observer— is quite limited.

3.3.6.1.              They just want to stop hurting or to get some critic off their back.

3.3.7.In nonregressed states, because their reality testing is fine and because they may present themselves in ways that compel our empathy, they do not look particularly “sick.”

3.3.7.1.              Sometimes it is only after therapy has proceeded for a while that one realizes that a given patient has a borderline structure.

3.3.7.2.              Usually the first clue is that interventions that the therapist intends to be helpful are received as attacks.

3.3.7.3.               In other words, the therapist keeps assuming a capacity for reflective functioning that the patient mostly lacks. (In older language, the therapist is trying to talk with an observing ego, something the client cannot access, especially when upset.)

3.3.7.4.              The patient knows only that some aspect of the self is being criticized. The therapist keeps trying to forge the kind of alliance that is possible with neurotic-level patients and keeps coming to grief in the effort.

3.3.8.Eventually, one learns that one must first just weather the affective storms that seem to keep raging, while trying to behave in ways that the patient will experience as different from whatever influences have shaped such a troubled and help-resistant person.

3.3.9.Masterson (1976) has vividly depicted, and others with different viewpoints report similar observations, how borderline clients seem caught in a dilemma: When they feel close to another person, they panic because they fear engulfment and total control; when they are alone, they feel traumatically abandoned.

3.3.9.1.              This central conflict of their emotional experience results in their going back and forth in relationships, including the therapy relationship, in which neither closeness nor distance is comfortable.

3.3.9.2.              Living with such a basic conflict, one that does not respond immediately to interpretive efforts, is exhausting for borderline patients, their friends, their families, and their therapists.

3.3.9.3.              They are famous among emergency psychiatric service workers, at whose door they frequently appear talking suicide, for manifesting “help seeking– help rejecting behavior.”

3.3.10.    Masterson saw borderline patients as fixated at the rapprochement subphase of the separation– individuation process (Mahler, 1972b), when the child has attained some autonomy yet still needs reassurance that a caregiver remains available and powerful.

3.3.10.1.          This drama unfolds around age 2, when children typically alternate between rejecting mother’s help (“I can do it myself!”) and dissolving in tears at her knees.

3.3.10.2.          Masterson (1976) believed that borderline patients have had mothers who discouraged them from separating in the first place or neglected them when they needed to regress after attaining some independence.

3.3.11.    Transferences in borderline clients tend to be strong, unambivalent, and resistant to ordinary kinds of intervention.

3.3.11.1.          The therapist may be perceived as all good or all bad.

3.3.11.2.          If a well-intentioned but clinically naïve therapist tries to interpret transference as one would with a neurotic person (e.g., “Perhaps what you’re feeling toward me is something you felt toward your father”), he or she will find that no relief or helpful sense of insight follows; in fact, often the client will simply agree that the therapist is actually behaving like the earlier object.

3.3.11.3.          Also, it is not uncommon for a borderline person in one state of mind to perceive the therapist as godlike in power and virtue, and in another (which may appear a day later) as weak and contemptible.

3.3.12.    Not surprisingly, countertransference reactions with borderline clients tend to be strong and upsetting.

3.3.12.1.          Even when positive (e.g., dominated by fantasies of rescuing the devastated patient), they may have a disturbing, consuming quality.

3.3.12.2.           Analysts in hospital settings (Gabbard, 1986; Kernberg, 1981) have noted that with some borderline patients, staff tend to be either oversolicitous (seeing them as deprived, weak, and in need of extra love to grow) or punitive (seeing them as demanding, manipulative, and in need of limits).

3.3.12.3.          Inpatient personnel frequently find themselves divided into opposing camps when treatment plans for borderline clients are discussed (Gunderson, 1984; Main, 1957).

3.3.12.4.          Outpatient practitioners may move internally between one position and the other, mirroring each side of the client’s conflict at different times.

3.3.12.5.          It is not unusual for the therapist to feel like the exasperated mother of a 2-year-old who will not accept help yet collapses in frustration without it.

4.       SUMMARY

4.1.    This chapter has given a cursory overview of evolving efforts to describe different realms of character organization.

4.2.    From Kraepelinian distinctions between the sane and the insane, through early psychoanalytic conceptions of symptom versus character neuroses, to taxonomies that emphasize either neurotic-level, borderline, or psychotic-level structure, to characterizing clients in terms of attachment pattern and traumatic influences, therapists have sought to account for the varying reactions of their individual clients to their efforts to be of help.

4.3.    I have argued that the assessment of a person’s central preoccupation (security, autonomy, or identity), characteristic experience of anxiety (annihilation anxiety; separation anxiety; or more specific fears of punishment, injury, and loss of control), primary developmental conflict (symbiotic, separation– individuation, or oedipal), object relational capacities (monadic, dyadic, or triadic), and sense of self (overwhelmed, embattled, or responsible) constitutes one useful dimension of psychoanalytic diagnosis.

 
 
 
 
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