The Psychoanalytic Therapy of Severe Disturbance

Paul Williams

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780367106195
• eBook ISBN: 9780429921889
• Topic: Psychologie
• Subtopic: Histoire et théorie en psychologie

This book presents the proceedings of the of the conference on the Psychoanalytic Therapy of Severe Disturbance held in Belfast in June 2008. The aim of the conference was to offer a state of the art communication of the key psychoanalytic thinking and approaches to the conceptualisation and treatment of severe disturbance. The result of a unique gathering of the most eminent psychoanalysts in the field with insights into their work on personality disorder, psychotic states and the nature and function of suicidal ideation.This book will be of interest to mental health professionals - psychiatrists, psychoanalysts, psychotherapists, psychologists, social workers and nurses who have an interest in psychoanalysis and psychotherapy.

CHAPTER ONE
The therapeutic action in psychoanalytic psychotherapy of borderline personality disorder

Glen O. Gabbard

How does psychoanalytic psychotherapy work? Let me state at the outset that the answer is clear—we don’t know. Therapeutic action has been much discussed in the psychoanalytic literature, but many of the discussions are inextricably bound to particular psychoanalytic theories. Times have changed; we no longer practice in an era in which interpretation is regarded as the exclusive therapeutic arrow in the analyst’s quiver (Gabbard and Westen, 2003). Abend (2001) observed that “no analyst today would suggest that the acquisition of insight is all that transpires in a successful analysis, or even that it identifies the sole therapeutic influence of the analytic experience” (p. 5). As Abend implies in his distinction between psychoanalysis and “therapeutic influence,” there has been an unfortunate divide between what is analytically pure and what helps the patient. In recent contributions (Gabbard, 2007; Gabbard and Westen, 2003), I have argued that we need to identify what strategies help patients change, rather than worrying about adherence to a particular analytic ideal. In any case, Wallerstein (2000) stressed that after reviewing the data from the monumental 30-year follow-up of the Menninger Foundation Psychotherapy Research Project patients, differentiating therapeutic change from analytic change is virtually impossible anyway.

There is no single path to therapeutic change. Single mechanism theories of therapeutic action, no matter how complex, are unlikely to prove therapeutically useful simply because there are a variety of targets of change and a variety of strategies for effecting change in those targets.

While there once was a debate regarding whether insight or the therapeutic relationship was the key vehicle for change, that either/ or polarization of interpretation vs. the relationship with the therapist has given way to a broad consensus that both aspects of treatment contribute to change in the patient (Cooper, 1989; Jacobs, 1990; Pulver, 1992; Pine, 1998; Gabbard, 2000; Gabbard and Westen, 2003).

Another shift over time has been away from an archaeological approach to psychoanalytic treatment. Rather than focusing on the excavation of buried relics in the patient’s past, most contemporary analytic therapists, especially those who work with borderline personality disorder, focus more on the here-and-now interaction between the therapist and the patient. The therapist’s participation in enactments and projective identification allow her to identify a characteristic “dance” that the patient recreates in a variety of settings based on that patient’s internal object relations. Hence by studying what transpires between therapist and patient, one has a sense of what has come before and what is going on every day outside the treatment relationship.

Attempting to study the therapeutic action of psychotherapy is complex. If one asks patients what was helpful some time after their treatment, what one hears is often disappointing to the psychoanalytic therapist. One of my patients came back to see me several years after she had terminated a multi-year analytic process. I asked her what she had found most helpful, and she replied, “Each day when I came to your office, you were there.” She evidently failed to recall any of my carefully formulated interpretations or any of the insights she’d gathered in the course of her treatment with me. I realized, however, that my “being present” meant a lot to her because she had a father who was perennially absent. Hence what was important to her and what was important to me may have been entirely different. Patients may not really know what helped them.

If one investigates the issue of how therapy works by interviewing therapists, one immediately has to deal with the stark reality that they are a biased group. They are narcissistically invested in the outcomes of their patients, and they may view the patient’s improvement in terms that shed favourable light on how they conceptualized and formulated the treatment. Moreover, those who are adherents to a particular theoretical school will emphasize strategies deriving from that school regardless of whether or not they were helpful to the patient.

Researchers, on the other hand, have the advantage of objectivity when studying therapeutic action. However, they also are viewing the process from a disadvantaged point of view in some respects. Psychoanalytic psychotherapy is largely about the interior spaces of the patient and the subtle interactions that occur unconsciously between two people. The therapist who is immersed in the transference-countertransference vicissitudes has an immediate sense of who the patient is and what the patient needs in the way of specific therapeutic strategies. Moreover, there are moments of meeting (Stern et al, 1998) that may be extraordinarily meaningful to both patient and therapist but are not part of a therapeutic plan. They occur spontaneously when the two parties share a joke or a deeply moving experience where tears come to the eyes of both. A psychotherapy researcher studying a transcript may entirely miss such moments.

Because all the methodologies to study therapeutic action have a set of problems associated with them, we must acknowledge that we may continue to be in the dark for some time in solving this puzzle. Greenberg (2005) has suggested that the therapeutic action of psychoanalytic treatment may ultimately be unknowable for any specific patient.

Empirical research on transference interpretation

Despite the fact that the therapeutic action of psychoanalytic psychotherapy may be unknowable, we nevertheless will embark on an overview of what is known about effective treatment for borderline personality disorder, with the assumption that the research seeking to find an efficacious treatment will shed some light on therapeutic action. We know that at least five different types of therapy have now been empirically validated in randomized controlled trials: mentalization-based therapy (Bateman and Fonagy, 1999), dialectical behaviour therapy (Linehan et al, 2006), transference-focused therapy (Clarkin et al, 2007), schema-focused therapy (Giesen-Bloo et al, 2006), and supportive psychotherapy (Clarkin et al, 2007).

Two of these empirically validated treatments are psychodynamic forms of therapy: mentalization-based therapy (MBT) and transference-focused therapy (TFP). One of the central controversies in the discussion of these two treatments is the role played by transference interpretation. While there is no head-to-head comparison in the literature between MBT and TFP, there is a small body of literature that has investigated the relative role of psychoanalytic treatments that focus on transference interpretation vs. those that do not.

In a landmark Norwegian study, Høglend (2006) conducted a randomized controlled trial of dynamic psychotherapy designed to determine the impact of a moderate level of transference interpretations (1–3 per session) in a once-weekly psychotherapy for the duration of one year. One hundred patients were randomly assigned to a group using either interpretation of the transference or a group that did not use such interventions. The authors included brief vignettes from the therapy so the reader could gain some understanding of the types of interventions considered to be transference interpretations. They attempted to avoid the “allegiance effect” so common in psychotherapy research, where researchers pit their favoured treatment against one that they don’t really think will work. The investigators cross-trained therapists in each of the therapies used and arranged for the same therapists to conduct both treatments. The results came as something of a surprise: there were no overall differences in outcome between the two treatment cells, but the subgroup of patients with impaired object relations benefited more from the therapy using transference interpretation than from the alternative treatment.

The conventional wisdom in predicting psychotherapy outcome has long been that “the rich get richer” (Gabbard, 2006). In other words, patients who have greater psychological resources and more mutually gratifying relationships tend to form a solid therapeutic alliance with the therapist and gain greater benefit from the therapy. Such patients would, according to conventional thinking, be more capable of tolerating transference interpretation than those who are more disturbed with a shakier therapeutic alliance with the therapist. Moreover, studies of transference interpretation in brief dynamic therapy indicate that there is not a positive correlation between that particular intervention and outcome (Piper et al, 1991).

When the patients who had lower scores on the quality of object relations in the Høglend study were examined, it was discovered that 61% of those subjects were diagnosable with personality disorders on the SCID-II (Spitzer et al, 1990). By contrast, only 20% of those measured as having had high quality object relations had personality disorders. Hence there appeared to be a correlation between personality disorders and improvement with transference interpretation.

The study design had shortcomings that must be taken into account. Axis I disorders were not rigorously diagnosed using standard research interviews. For example, the effects of depression on outcome could not be evaluated with precision. It is also possible that some experienced therapists secretly felt that the patients deprived of transference work were getting less than optimal treatment. Similarly, while investigators attempted to “blind” the raters who were listening to the audiotapes, the content of these tapes might well indicate to which group the patient belonged (Gabbard, 2006). Nevertheless, a subsequent report from Høglend et al (2008) showed that the beneficial effect of transference interpretation for this subgroup of patients was sustained at three years’ follow-up.

Therapeutic action and borderline personality disorder

While the findings of the Norwegian study are of heuristic value, they are not specific for any particular personality disorder. When we focus on borderline personality disorder in particular, we have at least one randomized controlled trial that emphasizes transference interpretation. In a head-to-head comparison of transference-focused therapy (TFP), dialectical behaviour therapy (DBT), and supportive therapy (SP) at Cornell-Westchester, 90 patients were randomly assigned to one of these three treatment groups. Over a 12-month period, six domains of outcome measures were assessed at 4-month intervals by raters blind to the treatment group. When results were analyzed using individual growth-curve analysis, all three treatments appeared to have brought about positive change in multiple domains to a roughly equivalent extent. However in some areas, TFP seemed to do better than the alternative treatments. In fact, TFP was associated with significant improvements in 10 out of the 12 variables across the six symptom domains, compared with improvement of six variables with SP, and five with DBT. Only transference-focused psychotherapy brought about significant changes in impulsivity, irritability, verbal assault, and direct assault. Both TFP and DBT—therapies that specifically target suicidal behaviours—did better than supportive therapy in reducing suicidality.

In a report from the same study on a different dimension of these findings, Levy et al (2006) demonstrated that TFP produced additional improvements that were not found with either DBT or SP. The study subjects who received TFP were more likely to move from an insecure attachment classification to a secure one. In addition, they showed significantly greater changes in mentalizing capacity (measured by reflective functioning) and in narrative coherence, compared with those in other groups. Problems in mentalization (a capacity to attribute independent mental states to the self and others in order to explain and predict behaviour) have been identified as a specific area of psychopathology in borderline personality disorder, and another empirically validated treatment, MBT, has been designed to address it. This randomized controlled trial of the three studies at Cornell-Westchester provided suggestive evidence that other therapeutic approaches may also have beneficial effects on the capacity to mentalize.

While this particular study suggests that TFP is superior to either treatment, it is also important to note that supportive psychotherapy did almost as well as TFP but was provided once weekly instead of twice weekly like the TFP. To be sure, SP in this study was a psychoanalytically sophisticated treatment that shared much in common with TFP, but proscribed transference interpretations. It was not simply a control condition involving giving praise and advice. The study also raises a provocative question that goes unanswered with the data—would reflective functioning and the other symptom domains have improved to the same degree as TFP if the supportive therapy had been offered twice weekly?

Giesen-Bloo et al (2006) did a direct comparison between TFP and schema-focused therapy (SFT) that lasted three years. In this randomized controlled trial, SFT seemed to produce better outcomes than transference-focused therapy. However, Yeomans (2007), a consultant to the project, clarified that the therapists doing TFP in the study were actually not well trained in that approach so that the comparison was not valid. In his view, they were using a more generic form of dynamic therapy rather than the specific transference-focused psychotherapy developed by Kernberg, Clarkin, and the other members of the research team.

MBT vs. TFP

As noted earlier, two different psychodynamic psychotherapies, mentalization-based therapy (MBT) and transference-based therapy (TFP), have both been shown to be efficacious for BPD patients in randomized controlled trials. Moreover, TFP, a treatment not specifically designed to improve mentalizing, nevertheless showed greater gains in that area than either of the control treatments.

When one takes into account the differences between MBT and TFP, one has difficulty attributing the therapeutic action to the transference interpretation component. The two modalities approach transference interpretation quite differently. MBT explicitly de-emphasizes the provision of insight through transference interpretation. The rationale is that transference interpretation, especially of anger, is likely to destabilize borderline patients (Gunderson et al, 2007).

Instead, MBT focuses on the current mental state and mental functioning of the patient. This strategy is designed to help patients become introspective and develop more of a sense of self-agency. In other words, the patient begins to find a sense of interiority and subjectivity through interaction with a therapist who is curious about the mental functioning of both patient and therapist and through their alternative perspectives on shared experiences. An MBT therapist would not be likely to interpret that a particular feeling the patient is having has its origins in childhood experiences with a parent.

By contrast, TFP sees unintegrated anger as a core problem. Therapists trained in this modality address the splitting off of anger and its associated self and object representations. Through the use of interpreting transference developments, they attempt to integrate anger and the object and self-representations associated with it into whole object rather than split off part-object relations (Gunderson et al, 2007). Given these differences, how do we understand that both MBT and TFP are effective in promoting mentalizing and improving the symptoms of BPD?

There are several possible answers: 1) all therapeutic approaches provide a systematic conceptual framework that organizes the internal chaos of the borderline patient. Patients with BPD characteristically are in a healthcare system that is chaotic. Because of the splitting mechanism typical of borderline patients, they often receive highly disparate advice from different treaters and diverse treatment agencies. They may feel pulled from all angles by their healthcare system or even thrown out of the system because they are thought to be “manipulators” or “splitters.” Any therapeutic strategy based on an ...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• FOREWORD
• ACKNOWLEDGEMENTS
• WELCOME
• CHAPTER ONE The therapeutic action in psychoanalytic psychotherapy of borderline personality disorder
• CHAPTER TWO Transference Focused Psychotherapy (TFP)
• CHAPTER THREE The mentalization based approach to psychotherapy for borderline personality disorder
• CHAPTER FOUR Psychoanalytic group therapy with severely disturbed patients: Benefits and challenges
• CHAPTER FIVE The fiend that sleeps but does not die: Toward a psychoanalytic treatment of the addictions
• CHAPTER SIX Some considerations about the psychoanalytic conceptualisation and treatment of psychotic disorders
• CHAPTER SEVEN "First you were an eyebrow" and "How do I know that my thoughts are my thoughts?"
• CHAPTER EIGHT Pre-suicide states of mind
• CHAPTER NINE Individual and large-group identities: Does working with borderline patients teach us anything about international negotiations?
• PLENARY DISCUSSION
• INDEX