Paul Ian Steinberg

Interpersonal problems associated with narcissism among psychiatric outpatients.

Narcissistic personality disorder is the subject of extensive discussion in the literature. Yet, the validity of this diagnostic category remains questionable. This is owed, in large part, to the relative absence of empirical work that has examined narcissism in clinical samples. Descriptions and findings from studies involving non-clinical samples suggest that narcissism is associated with considerable interpersonal impairment. The objective of the present study was to examine this possibility in a sample of psychiatric outpatients. Consecutively admitted patients (N=240) to a day treatment program completed measures of narcissism, interpersonal problems, and general psychiatric distress. Patients were categorized into high, moderate, and low narcissism groups. The groups were compared on overall interpersonal impairment, as well as on particular domains of interpersonal behavior. Treatment duration and discharge status were also compared among the three groups. Analysis of covariance and chi-square analyses were used. At baseline, higher levels of narcissism were significantly associated with greater interpersonal impairment. The interpersonal style of the more narcissistic patients was particularly characterized by domineering, vindictive, and intrusive behavior. At post-treatment, only the association between narcissism and intrusive behavior remained significant. Change in interpersonal difficulties following treatment did not differ significantly among the groups. However, failure to complete treatment was associated with narcissism. The results underscore the interpersonal impairment associated with narcissism and support the notion of narcissistic personality disorder as a valid diagnostic category.

Predictors of premature termination of day treatment for personality disorder

Background: Premature termination is a common problem in the treatment of personality disorder. Efforts to improve compliance should begin by recognising risk factors for premature termination. This prospective study identified predictors of premature termination from a day treatment program for personality disorder. Methods: Consecutively admitted patients with a personality disorder (n = 197) were assessed with self-report and interview measures. Patient personality characteristics were the primary predictors. Others were demographic, initial disturbance, and personality disorder variables. Cox proportional hazards regression was used. Results: Risk of terminating prematurely significantly increased if the patient had been previously hospitalised for psychiatric difficulties, was younger, had fewer prior contacts with health and social services, and had more severe borderline personality disorder traits. Conclusions: Information about which patients are at high risk for premature termination can help clinicians take measures to modify the risk. This might involve selection decisions, pre-treatment preparation, close monitoring during treatment, or addition of adjunctive interventions.

Narcissism and Relational Representations Among Psychiatric Outpatients

Pathological narcissism is associated with maladaptive interpersonal behavior, although less is known regarding the internal relational representations of narcissistic patients. The authors examined the relationship between pathological narcissism and two constructs that reflect internal representations of relational patterns: quality of object relations and attachment style. Patients attending a psychiatric day treatment program (N = 218) completed measures of narcissism, general psychiatric distress, and attachment style in terms of attachment avoidance and anxiety. A semistructured interview was used to assess quality of object relations. Multiple regression analysis was conducted, controlling for general psychiatric distress. Pathological narcissism was associated with anxious attachment, but not with avoidant attachment. Narcissism was also associated with lower levels of quality of object relations. The implications of these results are discussed in terms of internal representations of self-other relations.

A Renewed Interest in Day Treatment

Dear Editor: Day treatment, a form of partial hospitalization, can be helpful for patients who do not require inpatient care but who may benefit from more intensive care than is possible for outpatients. It differs from other forms of partial hospitalization (that is, day hospital and day care) in that it emphasizes both treatment and rehabilitation. Treatment is concerned with alleviating symptoms and recovery from illness. Rehabilitation focuses on the patients adapting to a disability and facilitates adaptive functioning in the community. Historically, day treatment programs were offered to patients who were in some degree of remission from acute psychotic illness or to patients who suffered from long-term disorders (for example, personality disorders). Day treatment was viewed as superior to outpatient care because it provides more intensive treatment and rehabilitation. It experienced considerable use from the 1950s to the late 1980s. However, day treatment declined in the 1990s owing to inadequate funding arrangements and a move toward assertive community treatments. Recently, this trend has reversed. Contributing to the renewed growth of day treatment is the recognition that, while many currently available treatments effectively reduce symptomatology, they often have minimal impact on functional impairments. This has contributed to high rates of relapse and recurrence. Multimodal treatments that focus on reducing illness and enhancing functional capacity are believed to offer an optimal intervention approach. Day treatment is seen as satisfying this need. It offers intensive and structured clinical services within a stable therapeutic milieu that typically incorporates group psychotherapy, biological psychiatry, milieu principles, and a systems orientation. Many of the day treatment programs that have recently evolved differ from those used in the past. The newer day treatment programs are short-term (ranging from 3 to 12 weeks), whereas historically, day treatment lasted for several months. In addition, rather than being psychodynamically based, many of the new programs are guided by the principals of cognitive-behavioural therapy; nearly all new programs incorporate some insight-oriented interventions. Finally, the application of day treatment has expanded beyond the patient populations it served in the past. It is now being used for mood disorders (1), obsessive-compulsive disorder (2), postnatal depression (3), eating disorders (4), and substance abuse disorders (5). …

Learning Within Psychotherapy Supervision

Supervision of psychotherapy cases is the central mode of learning psychotherapy for beginning therapists. In this paper, the authors discuss the process of learning within supervision in terms of the psychological work of the supervisee. This work includes addressing anxiety about psychotherapy and supervision; identification with the supervisor; maturation, introspection, and reflection; recognition of parallel process and intersubjectivity; appreciation of the nature of the therapeutic and supervisory relationships; and development of a therapeutic identity. In fostering these processes, supervision has an important role in the development of the beginning therapist.

Threats of violence to third parties in group psychotherapy

This article considers threats of violence toward third parties during group therapy. An approach to preserve the group work, protect the threatened individuals, maintain the threatening patients treatment, and protect the group leader medicolegally is described. Obtaining expert legal advice is very important. Reluctance to seek legal advice and inform third parties needs to be resolved. Knowledge of jurisdictional laws pertaining to disclosure is essential.

Hatred and fear: projective identification in group psychotherapy

Severely disturbed patients suffering from personality disorders employ a variety of primitive defenses in interpersonal situations that, when unmodified, will invariably perpetuate the chronic relational difficulties experienced by these patients. Among such primitive defenses used by personality disorder patients is projective identification. Ogden (1979) defines projective identification as a group of fantasies and accompanying object relations having to do with the ridding of the self of unwanted aspects of the self; the depositing of those unwanted ‘‘parts’’ into another person; and finally, the ‘‘recovery’’ of a modified version of what was extruded (p. 357). In the context of group therapy, projective identification can have a significant negative impact of the emotional and interpersonal interactions among members of the group, including the therapist. Knowledge of the concept of projective identification is useful for understanding regressive phenomena driven by intense affects such as rage. A therapist’s awareness of how to identify, understand, and manage projective identification is crucial for overcoming what could otherwise become an impasse in group therapy. This article describes a group therapy session that is used to illustrate an experience involving projective identification. Projective identification is specifically focused on as both an intrapsychic experience and an interpersonal process (Grotstein, 1985). The session occurred in an unstructured psychodynamic psychotherapy group that was provided in the context of a day treatment programme for patients with severe personality disorders (Piper, Rosie, Joyce, & Azim, 1996). Pete, the primary subject of the session, is a middle aged, unemployed individual diagnosed with self-defeating personality disorder and dysthymic disorder.

Book Review: Psychotherapy: Unfree Associations: Inside Psychoanalytic InstitutesPsychotherapy: Unfree Associations: Inside Psychoanalytic Institutes. KirsnerDouglas. London (UK): Process Press; 2000. 324 p. US

cult to understand journal articles and scientific trials that employ the sophisticated language of biostatistics, there is a comprehensive review of clinical trials that includes such hard-to-digest methododology as metaanalysis, analysis of group trials, the effects of placebo and nonspecific factors on the outcome of trials, and the significance of their inclusion. There is a good discussion of the general principles of drug therapy—a subject that it is most important for practising psychiatrists to consider before deciding on what medication to prescribe for their clients.

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then took over their parents’ parenting capacity. Segal stated that having a vulnerable parent may even feel like living in a collapsed world. I loved the creative way she uses references to C.S. Lewis and J.R. Tolkien to evoke a picture of the powerlessness of children and a yearning to rescue a magical mother world, perhaps representing the vulnerable mother in the head. The final chapter, Chapter 11 explores the relationships with professionals created as a result of illness. Segal considers both the point of view of the professional, as well as the person with illness. She considers the internal conflicts which may arise and thinks about how they may be played out in external ways. She explores the complexity of these relationships and argues that illness also makes professionals feel bad. The Trouble with Illness presents a detailed exploration of the world of illness. There is little in the way of prescription with ideas presented to be thought about, reflecting Segal’s many years of experience. She communicates a sense that anything is possible with illness and assumptions should not be made. The thread throughout the book is that illness makes people feel bad; it undermines and wrong-foots people. I would have liked to know more about the impact of the digital age. There are many unanswered questions about this, such as does cyberspace reduce feelings of isolation or increase them? Segal acknowledges that this is an area which needs further investigation but this does not detract from the importance of this book. I believe that this comprehensive book is essential to have by one’s side when entering the world of illness. Psychodynamic Practice 197

Lectures on technique

The editors note that regret, which they suggest differs from remorse in being less object-related and more narcissistically oriented, has been ignored in the psychoanalytic literature. The first section of the book is devoted to the developmental substrate of regret and of its vicissitudes over the lifespan. The second section deals with fiction, poetry and movies pertaining to regret. The final section addresses the clinical issues pertinent to regret. It elucidates the psychopathological dimension of ego restriction associated with regret. The contributors discuss masochism, wishful fantasies and reversing the flow of time, nostalgia, and the temporal fracture of life, using clinical vignettes. Part I, Developmental Realms, begins with The capacity for regret in children and adolescents, in which Susan Donner makes creative use of the four sons metaphor in the Haggadah to organise not only an understanding of developmental and clinical manifestations of regret in children and adolescents, but also the technical approaches needed to work effectively with children, given differences in ages, capacities and states of mind. Four extended case examples show that regret can be observed in a variety of presentations in children and adolescents. Donner shows that experiencing regret is a potential and, in some cases, an actual developmental achievement that can be viewed as evidence of movement towards the depressive position. She notes that whether or not regret can be experienced during childhood and adolescence depends in part on the ability for containment, metabolism, and later reintroduction of the affect by a caregiver at a time and in a manner the child can absorb. Therefore, the analyst can play a critical role in the development of the child’s ability to experience regret in a positive manner, and also an expansion of affect tolerance and reflective functioning within the larger family in educational environments.