Eve Caligor

Transference-focused psychotherapy.

Transference-Focused Psychotherapy (TFP) is a manualized evidence-based treatment for borderline and other severe personality disorders that is based on psychoanalytic object relations theory. The treatment contracting/setting the frame, managing countertransference, and the interpretative process are three critical components of TFP. We provide vignettes to illustrate these techniques and data that support their role in facilitating treatment outcome.

The Independent Mind in British Psychoanalysis.

not address the profound theoretical differences among the Independents. Further, to use Rayner’s own words, his choice of topics to cover and authors to emphasize is “idiosyncratic,” clearly colored by the author’s own interests and intellectual development. Finally, Rayner is writing about a tradition he values and sees himself as part of, and this comes through very clearly in the tone with which he describes the Independents. These limitations do not significantly detract from the value or the interest of this book. The Independent Mind in British Ps~chonnaZ~sis exemplifies the strengths of the Independent tradition as Rayner has described it. Rayner brings a comfortable acceptance of his own subjectivity as he summarizes a vast amount of material in a way that is nevertheless balanced and free of polemics. As he does so, he organizes and pulls together the disparate and often contradictory contributions of the Independents into a coherent system, providing a complex integration of their work. The reader emerges with a multilevel understanding of the various and at times subtle factors that bind the Independents together as a school. Rayner suggests that it is a hallmark of the Independent mind to move between and show the coherence of different systems of thought and different levels of thought within a given system. One could argue that these qualities are necessary for any psychoanalytic thinking. But to the extent that it has been especially characteristic of the Independents to think in this fashion, this book is a fine example of the rich and complex contributions that have emerged from this tradition.

Structured Interview of Personality Organization (STIPO): preliminary psychometrics in a clinical sample.

In this article, we describe the development and preliminary psychometric properties of the Structured Interview of Personality Organization (STIPO), a semistructured interview designed for the dimensional assessment of identity, primitive defenses, and reality testing, the three primary content domains in the model of personality health and disorder elaborated by Kernberg (1984; Kernberg & Caligor, 2005). Results of this investigation, conducted in a clinical sample representing a broad range of personality pathology, indicate that identity and primitive defenses as operationalized in the STIPO are internally consistent and that interrater reliability for all 3 content domains is adequate. Validity findings suggest that the assessment of ones sense of self and significant others (Identity) is predictive of measures of positive and negative affect, whereas the maladaptive ways in which the subject uses his or her objects for purposes of regulating ones self experience (Primitive Defenses) is predictive of measures of aggression and personality disorder traits associated with cluster B personality disorders. We discuss implications of these findings in terms of the theory-driven and trait-based assessment of personality pathology.

Psychiatric Diagnosis and Chronic Pain: DSM-III-R and Beyond

Abstract An overview of the psychiatric disorders that seem to be of most importance in evaluating and treating chronic pain patients is presented. Data are reviewed on the prevalence of DSM-III psychiatric diagnoses in patients with chronic pain. Special attention is paid to psychiatric disorders and clinical issues that have been relatively neglected in discussions of chronic pain, and unresolved questions that could be addressed in future research are identified.

The Interpretive Process in the Psychoanalytic Psychotherapy of Borderline Personality Pathology

While all patients become more concrete in their psychological functioning in areas of conflict, especially in the setting of transference regression, in the treatment of patients with severe personality pathology this process poses a particular clinical challenge. In the psychoanalytic psychotherapy of patients with severe personality pathology in general, and borderline personality disorder in particular, the interpretive process serves multiple functions. This process comprises a series of steps or phases that can be viewed as moving the patient further away from a single, poorly elaborated, and concrete experience in the transference, which dominates and floods subjectivity, and toward more fully elaborated, complex, stable, and integrated representations of the analyst and of what he or she evokes in the patients internal world.

Narcissistic personality disorder: diagnostic and clinical challenges.

“Mr. A” is a 42-year-old married man presenting to a private-practice psychotherapist complaining of problemswithhiswife.He is a successful entrepreneur, highly competitive, who describes enjoying social gatherings, where he tends to be the center of attention, as well as challengesatwork,wherehebelieves thathehasa superior ability to solveproblems.Hecomesto treatmentbecausehe is wondering whether or not to stay in his marriage. Mr. A described having lost all sexual interest in his wife during their early years together. Throughout themarriage, he has maintained a series of lovers whom he has housed, supported, and then cut off and replaced. He feels that this arrangementhashadno impact onhis relationshipwithhis wife but wonders if he would do better with someone else. “Mr. B” is a 34-year-old single man with a history of cocaine and alcohol abuse, currently unemployed. He presented to the emergency department complaining of pain following a dental procedure and requesting Percocet (acetaminophen and oxycodone). Although he was initially ingratiating with the attending physician who took his history, when she explained that she would have to speak with his oral surgeon before writing a prescription for anarcotic,Mr.Bbegan to insult andbullyher. The attending spoke with Mr. B’s “girlfriend,” whose contact information he had provided. The girlfriend explained that she had recently broken things off withMr. B because he had been exploiting herfinancially; since being fired 1 year earlier from a high-paying financial job, he had been unable to find employment that met his lofty expectations for himself, preferring instead to live off money from his father and his girlfriend. “Mr. C” is a 29-year-old single man with a history of insulin-dependentdiabeteswhopresents toanoutpatient clinic for treatment of dysthymia and social phobia. He has held a series of low-level jobs that “have not worked out,” and he currently works part-time doing data entry. Mr. C described his mood as chronically “miserable.” Socially isolated and easily slighted, he has no interests, takespleasure innothing, androutinelywonders “whether life isworth living.”When feeling down, he often “forgets” to administer his insulin, resulting in multiple hospitalizations for hyperglycemia. He constantly compares himself with others, feeling envious and resentful, and describes himself as deficient and defective. At the same time, he resents that others fail to recognize all he has to offer. At times he engages in fantasies of his employer publicly acknowledging his special talents and promoting him; at other times, he has fantasies of humiliating his boss with a display of superior knowledge. “Ms. D” is a 44-year-old single woman referred to a group specializing in severe personality disorders. She complained of “refractory depression” for which shewas on medical disability. She had been treated for 10 years with every modality her local hospital could offer, including ECT. She portrayed her previous therapists in scathingly derogatory terms, seeming tofind gratification in their failed attempts to help her. Her group therapist diagnosed her with narcissistic personality disorder based on the gap between her self-image as an extremely gifted but unrecognized author and the reality that she had written almost nothing. Antisocial features consisted of chronic lying, a history of prostitution in her 20s, and “working the system” to obtain disability payments rather than taking onwork that shewas able to do. Therewere no neurovegetative symptoms of depression. When her new therapist raised the possibility of working toward employment,Ms. D coolly declared that shewould kill herself, orhim, ifhe interferedwithherabilitytoobtainherbenefits.

Psychiatric Assessment of Aggressive Patients: A Violent Attack on a Resident

Aggressive patients often target psychiatrists and psychiatric residents, yet most clinicians are insufficiently trained in violence risk assessment and management. Consequently, many clinicians are reluctant to diagnose and treat aggressive and assaultive features in psychiatric patients and instead focus attention on other axis I mental disorders with proven pharmacological treatment in the hope that this approach will reduce the aggressive behavior. Unclear or nonexistent reporting policies or feelings of self-blame may impede clinicians from reporting assaults, thus limiting our knowledge of the impact of, and best response to, aggression in psychiatric patients. The authors pre-sent the case of a young adult inpatient with a long history of antisocial and assaultive behavior who struck and injured a psychiatric resident. With this case in mind, the authors discuss the diagnostic complexities related to violent patients, the importance of assessing violence risk when initially evaluating a patient, and the relevance of risk assessment for treatment considerations and future management. This report illustrates common deficiencies in the prevention of violence on inpatient psychiatric units and in the reporting and response to an assault, and has implications for residency and clinician training.

Why We Recommend Analytic Treatment for Some Patients and Not for Others

One hundred consecutive patients applying for analysis completed a comprehensive battery of structured interviews and self-report questionnaires assessing dimensions of psychopathology and psychological functions that analysts consider important when evaluating patients for analysis. Patients were evaluated for analysis by a candidate supervised by a training analyst. Fifty patients were accepted for analysis and fifty rejected. In both groups, psychiatric morbidity and psychosocial impairment were high, with a 50% current and 74% lifetime diagnosis of mood disorder, 56% current and 61% lifetime history of anxiety disorder. The mean Beck Depression Inventory score fell in the moderate range, 19.1 (SD = 11.0), mean Hamilton Depression score in the mild range, 14.1 (SD = 7.8), and the mean Hamilton Anxiety score in the moderate range, 14.6 ( SD = 8.1), with 57% meeting criteria for an Axis II diagnosis, and mean social adjustment in the moderate to high pathology range. Patients accepted and rejected for analysis did not differ with regard to any of these dimensions. Accepted patients scored lower on measures of impulsivity, aggression, and sociopathy, and on scores of personality rigidity, primitive defenses, and outward aggression. The major finding was the striking similarity between patients accepted and rejected for psychoanalytic treatment.

The Efficacy of Psychotherapy: Focus on Psychodynamic Psychotherapy as an Example

The growing number of individuals seeking treatment for mental disorders calls for intelligent and responsible decisions in health care politics. However, the current relative decrease in reimbursement of effective psychotherapy approaches occurring in the context of an increase in prescription of psychotropic medication lacks a scientific base. Using psychodynamic psychotherapy as an example, we review the literature on meta-analyses and recent outcome studies of effective treatment approaches. Psychodynamic psychotherapy is an effective treatment for a wide variety of mental disorders. Adding to the known effectiveness of other shorter treatments, the results indicate lasting change in many cases, especially for complex and difficult to treat patients, ultimately reducing health-care utilization. Research-informed health care decisions that take into account the solid evidence for the effectiveness of psychotherapy, including psychodynamic psychotherapy, have the potential to promote choice, increase mental health, and reduce societys burden of disease in the long run.

Will Patients Accept Randomization to Psychoanalysis? A Feasibility Study

The feasibility of using a randomized design in a psychoanalytic outcome study was evaluated. Our hypothesis was that it would be feasible to randomize patients to psychoanalysis three or four times weekly on the couch for five years, supportive expressive therapy once or twice weekly for up to forty sessions, and cognitive behavior therapy once or twice weekly for up to forty sessions. Successful randomization was defined as a 30% recruitment rate among eligible patients. Recruitment began in September 2009 and closed in April 2010. A total of 132 subjects responded to study advertisements, 107 of whom (81%) were triaged out. The remaining 25 were scheduled for the first of two clinical interviews, and 21 of 25 (88%) completed the interview. Eleven of the 25 (44%) were determined to be eligible based on inclusion and exclusion criteria. Eight of the 11 accepted the idea of randomization and completed the diagnostic assessment phase. Calculated on the basis of 8 of 11 eligible patients accepting randomization, the 95% confidence interval was that 39% to 92% of eligible subjects would participate in a larger study of this design. Our findings support the feasibility of implementing an RCT comparing psychoanalysis as defined by the American Psychoanalytic Association (three or four times weekly on the couch for approximately five years) with shorter-term dynamic or cognitive behavioral therapy once or twice a week. Pre-treatment characteristics of these eight patients are presented, as are initial reliability data for the treatment adherence scales used in this trial.