Leonard Horwitz

Transference interpretation in the psychotherapy of borderline patients : a high-risk, high-gain phenomenon

&NA; The effectiveness of transference interpretation in the psychodynamic psychotherapy of patients with borderline personality disorder has been highly controversial. Both highly expressive approaches that stress the value of transference interpretation and supportive strategies that eschew transference work have been advocated in the literature. We review this literature and identify three emerging trends in thought: (1) Primarily interpretive approaches should be reserved for patients with greater levels of ego strength. (2) Whichever technique is used, a strong therapeutic alliance is the foundation of treatment. (3) Expressive and supportive techniques should not be juxtaposed as polarized opposites; supportive interventions often pave the way for transference interpretation. Our psychotherapy process study revealed that transference interpretations tended to have greater impact‐both positive and negative‐than other interventions made with patients with borderline personality disorder. We conclude that such factors as neuropsychologically based cognitive dysfunction, a history of early trauma, patterns of object relations involving interpersonal distance, masochistic tendencies, and anaclltic rather than Introjective psychopathology are among the patient characteristics that influence the impact of transference interpretation on the therapeutic alliance. Bias toward expressive technique and countertransference issues appear to be relevant to the therapists difficulty in shifting to a more supportive approach when indicated.

The Capacity To Forgive: Intrapsychic and Developmental Perspectives

The topic of forgiveness, despite its importance for the continuity of relationships and for the mental health of the aggrieved party, is relatively neglected in the psychoanalytic literature, perhaps because it is often seen as the province of religion and carries the connotation of reaction formation and inauthenticity. However, genuine forgiveness involves significant intrapsychic work, conscious and unconscious working through of ones anger, and putting the offense into the context of an integrated view of the whole person of the offender. Early developmental structures are the ground on which the relative ability to let go of a grievance depends. While later motives and defenses (e.g., fear of retraumatization, avoidance of shame) may also play a role, these early structures are primary. They are described here in terms of attainment of the depressive position and the development of a sense of secure attachment, the capacity to mentalize, and the ability to mourn.

The effect of therapist interventions on the therapeutic alliance with borderline patients.

The authors draw attention to the problems of establishing and maintaining a therapeutic alliance in the psychotherapy of the borderline patient. They elaborate an extensive methodology designed to study the manner in which shifts in collaboration occur in response to therapist interventions. This report demonstrates how one particular borderline patient increased his ability to collaborate with the therapist in response to a transference focus in the psychotherapy. Methodological problems are noted as are directions for future research. Only a series of patients studied with this or with similar methodology will allow for a sophisticated and empirical rationale for choosing a particular form of psychotherapy for a particular kind of borderline patient.

Narcissistic Leadership in Psychotherapy Groups

ABSTRACT Narcissistic leaders in groups are capable of impeding progress of their patients and, at worst, can produce iatrogenic effects. Significant interferences may occur when the therapist is unable to tolerate the expression of negative transferences and when they need to be idealized by their patients. The rare therapist who is a malignant narcissist is capable of inflicting severe damage by sadistically exploiting the group to satisfy his or her own pathological needs. Less severe interferences consist of inhibition in making transference interpretations, reluctance to seek out training or supervision, and a difficulty in protecting patients against being scapegoated as a result of the displacement of negative feelings toward the therapist onto a member. The universality of these issues among therapists is discussed and possible remediation is proposed.

Depth of transference in groups.

An ongoing controversy in the field of group psychotherapy is whether transference regression is greater in groups than in individual treatment. There appears to be a general consensus that group behavior may be understood as operating on at least three levels--the conscious--rational, the oedipally determined transference, and the preoedipal maternal transference level. The more rational levels are associated with transference dilution, whereas the more primitive levels accompany transference intensification. Dilution occurs as a result of reality demands and inputs of the group situation and because of multiple targets of displacement. Transference intensification is a product of mutual stimulation, contagion effect, frustrating inputs, and support of the group theme. Certain patients benefit most from the dilution features of a group, and others profit most from intensification. The therapists technique and the patients pathology are the main determinants of which aspect gets emphasized and utilized.

Group-Centered Interventions in Therapy Groups

Currently the great controversy in the group field is that between the therapist who uses existentialist methods, encounter techniques, marathons, and nonverbal methods versus the traditional, psychoanalytically oriented group approach. A less visible, but nonetheless significant split among the &dquo;traditionalists&dquo; is that between those group therapists who focus upon the group as a whole as opposed to those who decry the idea of the therapy group functioning

Forty years of group psychotherapy at the Menninger Clinic.

Abstract Despite the skepticism and indifference to group psychotherapy that existed in the 1950s and 1960s within the psychoanalytic community in general and among the staff and administration of the Menninger Clinic in Topeka, Kansas in particular, a few clinicians there forged ahead in pursuit of incorporating this modality as an accepted treatment. After gaining some acceptance first in the hospital, we experienced a slow rate of growth, except with our trainees who were generally enthusiastic about group work. Many of them were intrigued first by their exposure to the group dynamics seminars and later by the didactic courses and supervised group work that eventually came to be required by the accrediting body for residency programs of the American Psychiatric Association. Visiting senior consultants and teachers, mainly associated with the American Group Psychotherapy Association, as well as an esteemed clinician from the Tavistock Clinic, also lent credibility and legitimacy to our effort. When group treatment began to be adopted by units of the Menninger Hospital in the early 1970s, there was a significant sea change in the attitude of the organization and group psychotherapy became a well established modality.

Exciting opportunities ahead.

First, you will have the opportunity to understand in depth through direct experience the kind of inner struggles patients undergo as they attempt to form relationships and use a group for personal growth. I still remember vividly my fears of diving into the uncertain waters of these groups, and I knew that I either screwed my courage to the sticking post and entered into the fray or left the group feeling like I did not have the guts to risk exposing an aspect of my personal life that perhaps portrayed me in a less than favorable light.

Book Review: BEING OF TWO MINDS: THE VERTICAL SPLIT IN PSYCHOANALYSIS. By Arnold Goldberg. Hillsdale, NJ: The Analytic Press, 1999, 185 pp.,

The title of this book suggests a state of ambivalence or indecisiveness in which a person is unable to decide between alternative courses of action equally attractive or distasteful. However, this everyday sense of the phrase is hardly Arnold Goldberg’s topic in this brief but provocative book. Rather, he is describing a form of pathology in which two divergent states of mind, two self-organizations each with its own values and goals, exist side by side, one predominating over the other at any given time. The work is an elaboration and extension of Kohut’s concept of the vertical split. Kohut originally introduced the concept to deal with the oscillation between feelings of grandiosity and inferiority that is often observed in narcissistic personality disorders. What he formulated was a split between a better structured, more adaptive self and a fragmented, more pathological one. The two facets of the vertical split have more or less equal access to consciousness, and one is kept at bay by the other by the mechanism of disavowal. By contrast, the horizontal split uses the classical topographic model, in which unacceptable impulses and defenses are kept out of consciousness by the mechanism of repression. Goldberg amplifies these ideas along a continuum from normal to pathological, amply illustrated by richly described case material. He uses Kohut’s distinction between narcissistic behavior disorder and narcissistic personality disorder, but most of the cases he presents involve lapses and eruptions into behavioral realms. The prototypical vertical split, he argues, is seen in marital infidelity. While the several marital problems he presents differ in certain details, they all involve men who are unable to tolerate or find sufficient gratification in a monogamous relationship. One of the cases is reminiscent of the film Captain’s Paradise, in which a man feels equally devoted to his wife and his mistress and wants to give up neither: “Dirk was of two minds, but this was not a case of one hidden and one overt. Rather, they made alternating claims for control and dominance” (p. 106). Goldberg’s general formulation regarding this constellation is that it involves a disorder of narcissism in which a potential or actual narcissistic injury occurs and the person turns to the disavowed sector for restorative B o o k R e v i e w s