دانلود کتاب Hatred, Emptiness, and Hope: Transference-Focused Psychotherapy in Personality Disorders - Original PDF - Libsan

دانلود کتاب Hatred, Emptiness, and Hope: Transference-Focused Psychotherapy in Personality Disorders - Original PDF

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Introduction The present volume continues my investigation of the psychopathology and treatment of severe personality disorders. It focuses on the analysis of particular clinical features of personality pathologies and describes contemporary psychoanalytic object relations theory as a general theoret- ical frame of treatment that allows us to conceptualize both normal per- sonality functioning and the very nature of personality disorders. This volume also includes my recent contributions to understanding the rela- tionship between neurobiological dispositions and their interaction with psychodynamic developments, again, both in normality and psychopa- thology. Finally, this volume explores the application of object relations theory to group processes, love relations, and therapists’ training. Part I of the book includes major theoretical statements. Chapter 1, “Object Relations Theory and Transference Analysis,” presents a brief, updated summary of contemporary object relations theory and its direct relevance to transference analysis, the fundamental therapeutic approach of transference-focused psychotherapy (TFP). This chapter summarizes the theoretical approach that informs the new psychotherapeutic devel- opments in the treatment of severe personality disorders that are de- scribed throughout the entire volume. Chapter 2, “Some Implications of New Developments in Neurobiology for Psychoanalytic Object Relations Theory” summarizes developments in neurobiology regarding the con- ceptualization of affect systems and their role as the motivational basis ix x HATRED, EMPTINESS, AND HOPE for establishing internalized dyadic self- and object-relations structures. This chapter shows how the underlying limbic and cortical brain struc- tures and functions contribute to embedding the fundamental concepts of self and of significant others. It proposes that the formation of such dy- adic structures is an essential task of higher levels of psychic functioning. Part II, on technique, updates empirical studies of the Personality Disorders Institute at Weill Cornell Medical College, expanding the ap- plications of TFP, exploring its relationship to standard psychoanalytic technique, and outlining a general comprehensive theory of technique that applies to both psychoanalysis and its derived psychotherapies. Chapter 3, “Extensions of Psychoanalytic Technique: The Mutual Influ- ences of Standard Psychoanalysis and Transference-Focused Psycho- therapy” presents an updated view of TFP in comparison with standard psychoanalytic technique that differentiates more sharply these two technical approaches and discusses the problems in training therapists efficiently in both modalities. Chapter 4, “Therapeutic Implications of Transference Structures in Various Personality Pathologies,” presents an overview of transference developments in different modalities of severe personality disorders and the modifications in technical approaches to transference analysis related to these structural differences. It is a highly specialized description of TFP in action. Chapter 5, “Affective Domi- nance, Dyadic Relationship, and Mentalization,” focuses on two basic premises from which the therapist enters every therapeutic session—that is, the alertness to affective dominance and the diagnosis of the predom- inant dyadic object relationship linked to it. By illustrating this approach with clinical cases, the chapter also points to similarities and differences between TFP and mentalization-based therapy (MBT), an alternative psychodynamic approach to severe personality disorders. Chapter 6, “Reflections on Supervision,” describes my personal experience as well as general controversial issues regarding the supervision of psychoan- alytic and derivative treatments. In the process, the chapter details our collective experience of training and supervising clinicians in TFP over many years at the Personality Disorders Institute. Part III, on specific psychopathologies, deals with particular disor- ders within the broad field of severe personality disorders. Chapter 7, “Psychodynamics and Treatment of Schizoid Personality Disorders,” presents our experience with these complex disorders. Schizoid struc- ture has received less attention in recent times than other types of severe personality disorders, particularly borderline and narcissistic personal- ity disorders. This chapter presents a diagnostic update and summa- rizes the specific contributions of the TFP approach to the treatment of schizoid personality. Chapter 8, “Psychotic Personality Structure,” ex- plores the differences between borderline personality organization and psychotic personality organization. It describes the development of psy- chotic features as a potential transitory regression in patients with bor- xiIntroduction derline personality organization, as well as a reflection of a psychotic structure that only emerges during treatment. It proposes correspond- ing differences in technique for transitory psychotic developments aris- ing in sessions, for transference psychosis, and for the emergence of major psychotic illness during the course of TFP. The chapter also ana- lyzes the nature and shifts in reality testing in the context of transference analysis. Chapter 9, “Narcissistic Pathology of Love Relations,” deals with the specific pathology of narcissistic personalities, the great diffi- culties of these patients in establishing and maintaining a love relation in depth, and the general study of sexuality and the capacity to love as part of the diagnostic evaluation of all patients with severe personality disorders. It also considers the influences of the therapist’s own emo- tional maturity in the assessment of this aspect of psychopathology. Part IV deals with the application of object relations theory to inpa- tient hospital treatment, to group regression and political leadership, and to psychoanalytic education. Chapter 10, “Psychoanalytic Ap- proaches to Inpatient Treatment of Personality Disorders: A Neglected Dimension,” examines the inpatient treatment of patients with person- ality disorders, a neglected therapeutic approach in the United States. Although pioneered predominantly in the United States, inpatient treat- ment has been developed in new ways in recent European experiences, with relatively extended hospital treatment of severe personality disor- ders. This chapter summarizes both the North American and recent Eu- ropean experiences with an important therapeutic instrument that, mostly for financial reasons, has been underutilized in the United States. It offers important technical tools that are relevant for the repetitive brief hospitalizations of regressed borderline patients that have replaced se- lective long-term inpatient treatment. This approach may be the basis for the development of optimal treatment of very regressed stages of illness in the future. Chapter 11, “Malignant Narcissism and Large Group Re- gression,” applies psychoanalytic object relations theory and the devel- oping knowledge of the social functioning of some personality disorders to the study of the mutual influences of severe leadership pathology in organizational and political structures and the psychological conditions that underpin large group regression. Political circumstances that foster such large group regression in social subgroups and leadership with ma- lignant narcissistic features tend to reinforce each other, with potentially damaging and dangerous consequences to the social community. This chapter is a contribution to the clarification of these potentially threaten- ing and damaging social developments. Chapter 12, “Challenges for the Future of Psychoanalysis,” applies the psychoanalytical approach that underlies this volume to the analysis of particular conditions of psycho- analysis today as a profession, an educational enterprise, and a social or- ganization within the mental health sciences. This chapter and the book end with recommendations for innovations that may strengthen the role xii HATRED, EMPTINESS,AND HOPE of psychoanalysis as a profession, a treatment approach, and a social or- ganization. It proposes solutions to organizational problems, particu- larly stressing the urgent need for development of empirical research, psychoanalytic psychotherapies, and radical renovation in its educa- tional structure.

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CHAPTER 1 Object Relations Theory and Transference Analysis Psychoanalytic Object Relations Theory What follows is an overview of the essential theory and technique of transference-focused psychotherapy (TFP), a modified psychoanalytic treatment geared to the treatment of individuals with personality disor- ders, particularly severe disorders. TFP is a psychodynamic psycho- therapy derived from psychoanalytic principles and techniques and represents an extension of the psychoanalytic model to cover the entire range of severity of personality disorders. It is based on a contemporary formulation of psychoanalytic psychotherapy, updated in the light of both empirical research and scientific developments in boundary fields close to the psychodynamic endeavor, particularly affective neuroscience and the psychology of couples and small groups (Yeomans et al. 2015). Classical psychoanalytic theory proposed that the etiology of personal- ity disorder symptoms and a broad spectrum of symptomatic neuroses— including depressive reactions, anxiety syndromes, sexual difficulties, particular inhibitions, and severe disturbances in interpersonal rela- 3 4 HATRED, EMPTINESS, AND HOPE tions—were all related to unconscious intrapsychic conflicts derived from pathogenic developments during infancy and childhood. These uncon- scious intrapsychic conflicts essentially develop between libido and ag- gression—that is, the fundamental drives described by Freud as the basic human motivational systems—on the one hand and the infantile reality- imposed defenses against them, the mechanisms of defense centering on repression and related defensive operations, on the other. The dis- covery of primitive defensive operations centering on splitting and re- lated defense mechanisms predating the dominance of repression and the division of mind into a defensive “ego” as opposed to a repressed “id,” permitted the clarification of the earliest structure of the mind. These structures centered on dissociated idealized and persecutory in- ternalized object relations, reflecting respectively libido and aggression. Thus, the notion of libido and aggression (or the death instinct) as basic sources of intrapsychic conflict, and the enormous influence of uncon- scious intrapsychic factors in maintaining and expressing them as neu- rotic symptoms and pathological character traits, mark the essence of classical psychoanalytic theory. In light of today’s knowledge and understanding, this basic formu- lation must be modified. Neurobiological research has demonstrated the key functions of primary, inborn, genetically determined, and con- stitutionally given affect systems as primary motivational forces, per- haps best classified in models of positive and negative affect systems. Positive affect systems include attachment, eroticism, and play bond- ing, or a general affiliative urge directed toward other members of the same species. These are positive, pleasurable affect systems that moti- vate the organism to develop relations with significant others to gratify the basic psychological need for positive emotional connections. They combine longings for dependency, erotic intimacy, and affiliative enjoy- ment and jointly constitute what Freud described as libido. The negative affective systems of fight-flight and separation-panic jointly constitute what Freud described as the aggressive drive or death drive and represent the entire spectrum of negative emotional dispositions. In addition, an exploratory or searching affective system reflects a general interest in actively exploring the environment that may reinforce the correspond- ing systems upon gratification of any positive or threatening activation of any negative affective systems. From a broad biological perspective, affect systems permit the survival of the individual and the species be- cause they motivate the individual to seek nourishment, protection, so- cial cooperation, and security and ensure the reproduction of the species while equipping individuals to fight or escape from harmful stimuli or en- vironmental dangers. Affect systems thus constitute homeostatic mecha- nisms that operate beyond the need for intra-organismic control, such as maintenance of temperature, blood pressure, and elimination func- tions, by expanding homeostatic control over psychological functions 5Object Relations Theory and Transference Analysis that equip and require human beings to be in intimate touch and to ne- gotiate their needs with other human beings.

چکیده فارسی

فصل 1 تئوری روابط شیء و تحلیل انتقال نظریه روانکاوی روابط شیء آنچه در زیر می آید مروری بر نظریه و تکنیک اساسی روان درمانی متمرکز بر انتقال (TFP)، یک درمان روانکاوی اصلاح شده است که برای درمان افراد مبتلا به اختلال شخصیت طراحی شده است. ، به خصوص اختلالات شدید. TFP یک روان درمانی روان پویشی است که از اصول و تکنیک های روانکاوی مشتق شده و بسط مدل روانکاوی را برای پوشش کل دامنه شدت اختلالات شخصیت نشان می دهد. این مبتنی بر فرمول‌بندی معاصر روان‌درمانی روان‌کاوانه است که در پرتو تحقیقات تجربی و پیشرفت‌های علمی در زمینه‌های مرزی نزدیک به تلاش‌های روان‌پویشی، به‌ویژه علوم اعصاب عاطفی و روان‌شناسی زوج‌ها و گروه‌های کوچک به‌روز شده است (Yeomans et al. 2015). نظریه روانکاوی کلاسیک پیشنهاد می کند که علت علائم اختلال شخصیت و طیف گسترده ای از روان رنجورهای علامتی - از جمله واکنش های افسردگی، سندرم های اضطرابی، مشکلات جنسی، مهارهای خاص، و اختلالات شدید در روابط بین فردی- 3 4 - همه مربوط به تعارضات درون روانی ناخودآگاه ناشی از تحولات بیماری زا در دوران نوزادی و کودکی بودند. این تعارضات درون روانی ناآگاهانه اساساً بین میل جنسی و پرخاشگری ایجاد می شود - یعنی انگیزه های اساسی که فروید به عنوان سیستم های انگیزشی اساسی انسان توصیف می کند - از یک سو و واقعیت کودکی - دفاع تحمیلی در برابر آنها، مکانیسم های تمرکز دفاعی. از سوی دیگر در مورد سرکوب و عملیات دفاعی مربوطه. کشف عملیات دفاعی بدوی با تمرکز بر شکافتن و مکانیسم‌های دفاعی مرتبط که پیش از تسلط سرکوب و تقسیم ذهن به یک «خود» دفاعی در مقابل یک «id» سرکوب‌شده، روشن‌سازی اولیه‌ترین ساختار را ممکن می‌سازد. ذهن این ساختارها بر روابط ابژه درونی شده آرمانی و آزاردهنده تفکیک شده متمرکز بودند که به ترتیب منعکس کننده میل جنسی و پرخاشگری بودند. بنابراین، مفهوم میل جنسی و پرخاشگری (یا غریزه مرگ) به عنوان منابع اساسی تعارض درون روانی و تأثیر عظیم عوامل درون روانی ناآگاهانه در حفظ و بیان آنها به عنوان علائم عصبی و ویژگی های شخصیتی بیمارگونه، ماهیت نظریه کلاسیک روانکاوی در پرتو دانش و درک امروزی، این فرمول اساسی باید اصلاح شود. تحقیقات نوروبیولوژیکی کارکردهای کلیدی سیستم‌های عاطفی اولیه، ذاتی، تعیین‌شده ژنتیکی و بر اساس قانون اساسی را به عنوان نیروهای انگیزشی اولیه نشان داده‌اند که شاید به بهترین وجه در مدل‌های سیستم‌های عاطفه مثبت و منفی طبقه‌بندی می‌شوند. سیستم های عاطفه مثبت شامل دلبستگی، اروتیسم، و پیوند بازی، یا یک میل عمومی وابسته به سایر اعضای همان گونه است. این‌ها سیستم‌های تأثیر مثبت و لذت‌بخشی هستند که ارگانیسم را برای ایجاد روابط با افراد مهم برای ارضای نیاز روان‌شناختی اولیه برای ارتباطات عاطفی مثبت برمی‌انگیزد. آنها اشتیاق به وابستگی، صمیمیت شهوانی، و لذت وابستگی را با هم ترکیب می کنند و به طور مشترک آنچه را فروید به عنوان میل جنسی توصیف می کند، تشکیل می دهند. سیستم‌های عاطفی منفی جنگ-گریز و جدایی-وحشت به طور مشترک آن چیزی را تشکیل می‌دهند که فروید به عنوان انگیزه پرخاشگرانه یا انگیزه مرگ توصیف می‌کند و نشان‌دهنده کل طیف تمایلات عاطفی منفی است. علاوه بر این، یک سیستم عاطفی اکتشافی یا جستجوگر منعکس کننده علاقه عمومی به کاوش فعال محیط است که ممکن است سیستم های متناظر را در صورت رضایت از هرگونه فعال سازی مثبت یا تهدیدآمیز هر سیستم عاطفی منفی تقویت کند. از منظر بیولوژیکی گسترده، سیستم‌های تأثیرگذار بقای فرد و گونه‌ها را امکان‌پذیر می‌سازد، زیرا فرد را به جستجوی تغذیه، حفاظت، همکاری اجتماعی و امنیت برمی‌انگیزد و از تکثیر گونه‌ها اطمینان حاصل می‌کند و در عین حال افراد را برای مبارزه یا جنگیدن تجهیز می‌کند. فرار از محرک های مضر یا خطرات محیطی. بنابراین، سیستم‌های تأثیرگذار، مکانیسم‌های هموستاتیک را تشکیل می‌دهند که فراتر از نیاز به کنترل درون ارگانیسمی، مانند حفظ دما، فشار خون، و عملکردهای حذف، با گسترش کنترل هموستاتیک بر عملکردهای روان‌شناختی عمل می‌کنند. از انسان ها می خواهد که در تماس صمیمی باشند و نیازهای خود را با انسان های دیگر مذاکره کنند.

ادامه ...

This modification of classical motivational psychoanalytic theory from the original dual drive theory into one based on the neurobiology of affect systems culminates, however, in the eventual integration within individuals of the positive and negative affect systems in the context of their interactions with other human beings. Clinically, the unconscious struggles involving love and aggression as supraordinate integration of positive and negative affects reflect the basic nature of unconscious in- trapsychic conflict that must be discovered, understood, and resolved in the course of psychotherapeutic treatment (Kernberg 2018). Another significant change in the classical theory of unconscious in- trapsychic conflict is the discovery of multiple functions of unconscious mental processes that constitute a dominant etiological factor for much psychopathology. These processes include the cognitive integration of sensory perception, of procedural memory to maintain homeostatic functions such as learning skills, and of the specific unconscious declar- ative memory processes that reflect the unconscious conflicts mentioned earlier—in other words, the dynamic unconscious motivating the de- velopment of psychological symptoms and personality disorders. We now assume the origin of the dynamic unconscious resides in primary conscious affective experiences in the interaction between infant and mother—that is, in the impact of conscious affect activation. Because the infant hippocampus is immature prior to the second year of life, this cen- tral neurobiological structure involved in affective, long-range declara- tive memory storage is not yet available. Therefore, these early affective experiences leave learned skills and behavior patterns but no subjective experiential evidence. This is the cause of infantile amnesia. Only after the second year of life can the split between positive and negative affec- tive experiences remain consciously available. This occurs under struc- tural intrapsychic conditions that may express intrapsychic conflicts at a conscious but dissociated level via defensive operations based upon splitting. Idealized and persecutory internalized object relations are rep- resented in subjective split experiences. Only in the third year of life and with the achievement of identity integration will repressive mechanisms dominate. Intrapsychic conflicts will then become the dynamic uncon- scious (“the id”) in a concrete sense. Thus, the dynamic unconscious, in its advanced form of truly unconscious, repressed pathogenic conflicts, only covers the advanced intrapsychic structures of psychopathology re- lated to these conflictual dynamics. In short, the concept of the dynamic unconscious has evolved into complex stages of psychological develop- ment that each have different ways of organizing intrapsychic conflicts and defenses in general (Kernberg 2021). Psychoanalytic object relations theory proposes that the activation of conflictual affect systems related to unresolved dynamics from the past 6 HATRED, EMPTINESS,AND HOPE is always expressed as a particular experience of the individual’s “self” in relation with a significant “other” under the impact of a dominant af- fect. In other words, the activation of affects always involves the activa- tion of a subjective interpersonal experience, positive or negative, and the expression of this experience in the relation with a significant other or object. A specific experience of the self is always connected with a spe- cific experience of the object and thus constitutes a fundamental psycho- logical entity that, through declarative affective memory, remains a core feature of the subjective nature of psychological functioning. Units of positive and negative affects and their corresponding self and object representations are the “building blocks” of the mind. Their integration leads to the gradual achievement of an integrated self, interacting with significant others and, in turn, reflecting integrated positive and negative views of those others. Psychoanalytic object relations theory, in short, proposes that the internalization of significant relationships between the self and others under the impact of peak affect states is the fundamental dyadic infrastructure of the mind

ادامه ...

CONTENTS Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii PART I Major Theoretical Statements 1 Object Relations Theory and Transference Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2 Some Implications of New Developments in Neurobiology for Psychoanalytic Object Relations Theory . . . . . . . . . . . . . . . . . . . . . . 15 PART II Technique 3 Extensions of Psychoanalytic Technique The Mutual Influences of Standard Psychoanalysis and Transference-Focused Psychotherapy . . . . . . . . . . . . 35 4 Therapeutic Implications of Transference Structures in Various Personality Pathologies . . . . . . 61 5 Affective Dominance, Dyadic Relationship, and Mentalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 6 Reflections on Supervision . . . . . . . . . . . . . . . . . . . . 113 PART III Specific Psychopathologies 7 Psychodynamics and Treatment of Schizoid Personality Disorders . . . . . . . . . . . . . . . . . . . . . . . . 133 8 Psychotic Personality Structure . . . . . . . . . . . . . . . . 147 9 Narcissistic Pathology of Love Relations . . . . . . . . . 165 PART IV Application of Object Relations Theory 10 Psychoanalytic Approaches to Inpatient Treatment of Personality Disorders A Neglected Dimension . . . . . . . . . . . . . . . . . . . . . . . . 191 11 Malignant Narcissism and Large Group Regression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213 12 Challenges for the Future of Psychoanalysis . . . . . . 233 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251

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