Aging, Dying, and the Analytic Process.

The panel discussion presented at the New York Psychoanalytic Society and Institute's 1066th Scientific Meeting held on June 8, 2023, takes up aging and dying of an analyst and their impact on patients and on the nature of analytic process. Participants reflect on conflicts and challenges arising with more analysts and patients living to an advanced age, on the unregulated nature of analysts' retirement, and on multilayered meanings of analysts' ethical commitment to their work.

Borderline personality disorder: a comprehensive review of diagnosis and clinical presentation, etiology, treatment, and current controversies.

Borderline personality disorder (BPD) was introduced in the DSM-III in 1980. From the DSM-III to the DSM-5, no major changes have occurred in its defining criteria. The disorder is characterized by instability of self-image, interpersonal relationships and affects. Further symptoms include impulsivity, intense anger, feelings of emptiness, strong abandonment fears, suicidal or self-mutilation behavior, and transient stress-related paranoid ideation or severe dissociative symptoms. There is evidence that BPD can be reliably diagnosed and differentiated from other mental disorders by semi-structured interviews. The disorder is associated with considerable functional impairment, intensive treatment utilization, and high societal costs. The risk of self-mutilation and suicide is high. In the general adult population, the lifetime prevalence of BPD has been reported to be from 0.7 to 2.7%, while its prevalence is about 12% in outpatient and 22% in inpatient psychiatric services. BPD is significantly associated with other mental disorders, including depressive disorders, substance use disorders, post-traumatic stress disorder, attention-deficit/hyperactivity disorder, bipolar disorder, bulimia nervosa, and other personality disorders. There is convincing evidence to suggest that the interaction between genetic factors and adverse childhood experiences plays a central role in the etiology of BPD. In spite of considerable research, the neurobiological underpinnings of the disorder remain to be clarified. Psychotherapy is the treatment of choice for BPD. Various approaches have been empirically supported in randomized controlled trials, including dialectical behavior therapy, mentalization-based therapy, transference-focused therapy, and schema therapy. No approach has proved to be superior to others. Compared to treatment as usual, psychotherapy has proved to be more efficacious, with effect sizes between 0.50 and 0.65 with regard to core BPD symptom severity. However, almost half of the patients do not respond sufficiently to psychotherapy, and further research in this area is warranted. It is not clear whether some patients may benefit more from one psychotherapeutic approach than from others. No evidence is available consistently showing that any psychoactive medication is efficacious for the core features of BPD. For discrete and severe comorbid anxiety or depressive symptoms or psychotic-like features, pharmacotherapy may be useful. Early diagnosis and treatment of BPD can reduce individual suffering and societal costs. However, more high-quality studies are required, in both adolescents and adults. This review provides a comprehensive update of the BPD diagnosis and clinical characterization, risk factors, neurobiology, cognition, and management. It also discusses the current controversies concerning the disorder, and highlights the areas in which further research is needed.

Borderline Personality Disorder: A Review.

Importance: Borderline personality disorder (BPD) affects approximately 0.7% to 2.7% of adults in the US. The disorder is associated with considerable social and vocational impairments and greater use of medical services. Observations: Borderline personality disorder is characterized by sudden shifts in identity, interpersonal relationships, and affect, as well as by impulsive behavior, periodic intense anger, feelings of emptiness, suicidal behavior, self-mutilation, transient, stress-related paranoid ideation, and severe dissociative symptoms (eg, experience of unreality of one's self or surroundings). Borderline personality disorder is typically diagnosed by a mental health specialist using semistructured interviews. Most people with BPD have coexisting mental disorders such as mood disorders (ie, major depression or bipolar disorder) (83%), anxiety disorders (85%), or substance use disorders (78%). The etiology of BPD is related to both genetic factors and adverse childhood experiences, such as sexual and physical abuse. Psychotherapy is the treatment of choice for BPD. Psychotherapy such as dialectical behavior therapy and psychodynamic therapy reduce symptom severity more than usual care, with medium effect sizes (standardized mean difference) between -0.60 and -0.65. There is no evidence that any psychoactive medication consistently improves core symptoms of BPD. For discrete and severe comorbid mental disorders, eg, major depression, pharmacotherapy such as the selective serotonin reuptake inhibitors escitalopram, sertraline, or fluoxetine may be prescribed. For short-term treatment of acute crisis in BPD, consisting of suicidal behavior or ideation, extreme anxiety, psychotic episodes, or other extreme behavior likely to endanger a patient or others, crisis management is required, which may include prescription of low-potency antipsychotics (eg, quetiapine) or off-label use of sedative antihistamines (eg, promethazine). These drugs are preferred over benzodiazepines such as diazepam or lorazepam. Conclusions and Relevance: Borderline personality disorder affects approximately 0.7% to 2.7% of adults and is associated with functional impairment and greater use of medical services. Psychotherapy with dialectical behavior therapy and psychodynamic therapy are first-line therapies for BPD, while psychoactive medications do not improve the primary symptoms of BPD.

Differential neural response to psychoanalytic intervention techniques during structural interviewing: A single-case analysis using EEG.

Background: Previous studies detected changes in the electroencephalographic (EEG) signal as an effect of psychoanalytic interventions. However, no study has investigated neural correlates of specific psychoanalytic interventions in the EEG power spectrum yet. In the present case study, we contrasted three types of interventions (clarification, confrontation, and interpretation) and a neutral control condition during a structural psychoanalytic interview conducted while EEG was recorded. Methods: A 27-year-old male patient diagnosed with major depressive disorder and borderline personality disorder with recurrent suicidal and self-injurious behavior underwent a structural interview while recording EEG. Two independent experts selected by consensus the characteristic episodes of the four conditions (clarification, confrontation, interpretation, and neutral control) within the interview, which were included in the EEG analyses. Fast Fourier transformation (FFT) was applied to subsegments of the intervention type to analyze the EEG power spectra. Alpha and beta power from central, frontal, and parietal sites were considered in linear mixed-effects models with segments as a random factor with maximum-likelihood estimates due to the lack of balance in the length of the interview segments. Results: The interventions "interpretation" and "confrontation" showed a significantly lower alpha power compared with the control condition in the central electrodes. In the frontal and parietal sites of the alpha power and all beta power sites, the omnibus tests (full model/model without intervention) and comparisons relative to control conditions showed no significant overall result or failed significance after alpha error correction. Conclusion: Incisive interventions, such as confrontation with discrepancies and interpretation of unconscious intrapsychic conflicts, may have provoked temporary emotional lability, leading to a change in psychic processing akin to interference from external stimuli. This conclusion is consistent with the finding that interpretations, which are potentially the most concise interventions, had the strongest effects on alpha power. Using EEG during therapeutic psychoanalytic intervention techniques might be a helpful tool to evaluate differential responses to the psychotherapeutic process on a neural level. However, this single-case result has to be replicated in a larger sample and does not allow generalizations.

Extensions of Psychoanalytic Technique: The Mutual Influences of Standard Psychoanalysis and Transference-Focused Psychotherapy.

The author describes the differences between standard psychoanalysis and transference-focused psychotherapy (TFP) and reviews particular difficulties that psychodynamically trained clinicians have in learning TFP. In delineating differences between standard psychoanalysis and TFP, the author discusses mutual influences between standard psychoanalytic techniques and techniques of TFP. TFP is an extension and modification of standard psychoanalysis, but with quantitative modifications geared to the treatment of the most severe segment of personality disorders that tend not to be treatable by standard analysis. TFP includes some features that are directly facilitated by psychoanalytic education, such as the importance of free association and the organization of interpretations in terms of the analysis of defense, motivation, and impulse. On the other hand, TFP provides new strategies, enhancing standard psychoanalytic treatment, when it modifies technical neutrality under certain circumstances, allows for the analysis of "incompatible realities," and accelerates interventions under conditions of severe acting out when technical neutrality is not possible to maintain. The author demonstrates the advantages of systematic training in TFP within psychoanalytic institutes as a true enrichment of technical training. He proposes that psychoanalysis as a profession consists of a broad spectrum of treatment approaches based upon the combined utilization of psychoanalytic techniques, with specific modifications to be organized in specific forms of psychoanalytic psychotherapy. TFP may be the closest modification to standard psychoanalysis proper and is clearly defined and manualized. This has permitted empirical research that has already demonstrated the effectiveness of TFP.

Challenges for the Future of Psychoanalysis.

This paper summarizes the current crisis of psychoanalysis in its relations to the scientific and cultural environment. It proposes tasks to assure the survival and contributions of psychoanalysis as science, profession, and humanistic discipline. It proposes emphasis on empirical research in the boundaries with the neurosciences and social psychology, and the development of an infrastructure for research linked to its educational program. It proposes renovation in training, abolishment of the training analysis system, and systematic teaching and research on the psychoanalytic psychotherapies focused on specific pathologies. This overall proposal stresses the need to collaborate and potentially integrate psychoanalytic institutions within university settings, and the development of active interdisciplinary engagements with other sciences and the community at large. Finally, it stresses the role of contemporary object relations theory to reunify the presently diverging schools of psychoanalytic theory and technique.

Thoughts on Transference Analysis in Transference-Focused Psychotherapy.

Transference-focused psychotherapy (TFP) represents a specific extension of psychoanalytic therapy for treatment of individuals with personality disorders, who may be helped without the more significant time investment required of a standard psychoanalysis. The treatment represents a contemporary formulation of psychoanalytic psychotherapy, updated in 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. In TFP, the transference signifies the enactment in the here and now of a specific affective relationship between patient and therapist that reflects one aspect, defensive or impulsive, of a pathogenic dynamic unconscious conflict. This conflict needs to be analyzed, interpreted, and resolved. Various elements of transference analysis in TFP are discussed in this article.

Development and Validation of the Interview of Personality Organization Processes in Adolescence (IPOP-A).

The assessment of personality and personality pathology in adolescence represents a critical topic to understand adolescent's difficulties, predict long-term outcome in adulthood, and indicate adequate treatment. Personality Organization, and its underlying dimensions, plays an essential role in shaping how adolescents face their developmental tasks as they are connected with psychosocial functioning and psychopathological severity. However, few measures are available to assess personality organization during adolescence. The aim of the present research is to investigate the psychometric properties of the Interview of Personality Organization Processes in Adolescence (IPOP-A), a semi-structured interview designed for the assessment of the main personality organization dimensions in adolescence. Three studies were performed to explore the psychometric properties of the IPOP-A, in terms of factor structure, reliability, convergent, and discriminant validity. Exploratory and confirmatory factor analysis supported the IPOP-A construct validity. Furthermore, IPOP-A showed good reliability and evidenced a convergent and discriminant validity with DSM-oriented personality patterns, emotion dysregulation, identity disturbance, and psychopathology. Our results provide evidence of IPOP-A validity to assess emerging personality organization in adolescence. Furthermore, the IPOP-A is a promising tool to use in the clinical consultation and treatment planning for the adolescent.

Malignant Narcissism and Large Group Regression.

This paper explores the mutual relationship between large group regression and leadership with the characteristic of the syndrome of malignant narcissism. Regressed large groups intuitively search for such leadership and personalities with these characteristics are prone to aspire to the correspondent role. The underlying dynamics of groups and leaders are complementary and determine a mutually reinforcing psychopathology. This paper will explore these dynamics, their social consequences, and discuss potential preventive and therapeutic interventions that protect society from this psychosocial psychopathology.

Reflections on Supervision.

This paper explores basic tasks involved in the supervisory process, and frequent problems in carrying out these tasks. Basic tasks include clarification of mutual expectations of supervisor and supervisee; the establishment of mutual trust as fundamental for countertransference analysis; "parallel process" exploration and clarification of explicit and implicit theoretical assumptions by both supervisor and supervisee. Frequent problems include the extent of initial evaluation of patients; problems of intervening "without memory or desire"; transference and countertransference diagnoses and interpretive consequences; clarification of affective dominance; interventive shifts with severe psychopathology, and realistic goals of patient, supervisee and supervisor. Limitations to supervision include specific psychopathologies, cognitive limitations, and a generally restricted capacity for empathy by the supervisee.

Therapeutic Implications of Transference Structures in Various Personality Pathologies.

Definitions of specific organizations of transference developments are proposed for neurotic, borderline, narcissistic, schizoid, symbiotic, and psychotic character structures. These distinct organizations of transference developments correspond to the underlying characteristics of internalized object relations stemming from the conflictual implications of split-off, idealized, and persecutory self- and object representations. The transference structures described have implications for the corresponding application of psychoanalytic technique. Clinical cases illustrate the relationship between personality structure, transference organization, and psychoanalytic techniques.

Psychotic Personality Structure.

This article discusses the concept of psychotic personality organization. I relate psychotic personality organization to observations and speculations about psychotic transferences and to behavioral developments during the treatment of chronically psychotic patients (particularly those with schizophrenia). The overwhelming theoretical perspectives used are twofold: (1) object relations theory and (2) a model integrating neurobiological advances in the study of psychosis with contemporary psychodynamic perspectives.

Treinta métodos para destruir la creatividad de los candidatos a psicoanalistas / Thirty ways to destroy the creativity of psychoanalytic candidates / Trente méthodes pour détruire la créativité des candidats a psychanalystes

El autor examina aspectos formales de la formación psicoanalítica que provienen de fomentar o inhibir la creatividad en el trabajo de los candidatos. Cita treinta características de los institutos psicoanalíticos que inhiben la creatividad de los candidatos en su trabajo y que, indirectamente, arrojan luz sobre problemas de la formación psicoanalítica que requieren nuestra atención. Tales características incluyen el hacer, sistemáticamente, más lento el progreso institucional de los candidatos; la enseñanza repetitiva e incuestionable de los artículos clave de Freud; tendencias monolíticas en cuanto a los enfoques teóricos; aislamiento de los candidatos respecto de las actividades profesionales y científicas de la sociedad psicoanalítica; incremento de las relaciones jerárquicas entre los docentes del psicoanálisis; rituales de graduación; desánimo de contribuciones originales por parte de los candidatos; aislamiento intelectual de los institutos; falta de presentación de trabajos clínicos por los miembros docentes de más experiencia; descuido del estudio de las controversias relativas a la técnica psicoanalítica; características «paranoiagénicas » de la relación entre docentes respecto de los requisitos exigidos a los candidatos; el sistema «convoy» (de superprotección); descuido del estudio de los límites científicos y culturales y de las aplicaciones del psicoanálisis y efectos de los conflictos institucionales sobre la admisión de analistas en formación

The author examines formal aspects of psychoanalytic training relevant to the fostering or inhibiting of creativity in the work of candidates. He refers to thirty features of psychoanalytic institutes that inhibit candidates' creativity and, by implication, illustrate problems in psychoanalytic education that require our attention. These features include systematic slowing clown of institutional progression of candidates, repetitive and unquestioning teaching of key papers by Freud, monolithic tendencies regarding theoretical approaches, isolation of candidates from the professional and scientific activities of the psychoanalytic society, accentuation of the hieratical relations among the psychoanalytic faculty, graduation rituals, discouragement of original contributions by candidates, intellectual isolation of institutes, lack of full presentation of clinical work by senior members of the faculty, neglect of studies of controversies regarding psychoanalytic technique, "paranoiagenic" features of the relationship among faculty and rega.rding requirements far candidates, the "convoy" system, neglect of explorat1on of the sc1ent1fic and cultural boundaries and applications of psychoanalysis and the eff ects of institutional conflicts around the appointment of training analysts

L' auteur examine des aspects formels de la formation psychanalytique venant a promouvoir ou inhiber la créativité dans le travail des candidats. Il cite trente caractéristiques des instituts psychanalytiques qui inhibent la créativité des candidats dans leur travail et qui, indirectement, mettent l' accent sur les problemes de la formation psychanalytique qui exigent notre attention. Ce sont des caractéristiques telles que rendre, systématiquement, plus lent le processus institutionnel des candidats; l' enseigne~e?t répétitif et indiscutable des articles dé de Freud; des tendances monohth1ques en ce qui concerne les approches théoriques; l'isolement des candidats concernant les activités professionnelles et scientifiques de la Société Psychanalytique; l' augmentation des relations hiérarchiques entre les enseignant.s de la psychanalyse; rites de remise de diplomes; découragement de contnbutions originales de la part des candidats; isolement intellectuel des instituts; manque de présentations de travaux cliniques par les Membres enseignants plus expérimentés; négligence de l' étude des différends relatifs a la technique psychanalytique; caractéristiques «parano'iagéniques» de la relation entre les enseignants concernant les requis exigés aux candidats; le systeme «conboy» (de surprotection); négligence de l' étude des limites scientifiques et culturelles et des applications de la psychanalyse; et effets des conflits institutionnels sur l' admission des analystes en formation

What's Next? A Clinical Overview.

This rich and comprehensive set of studies on the borderline personality disorder presents the reader with an up-to-date review of new findings and developments in our understanding of this serious and highly prevalent condition. It also outlines areas of controversies and open questions regarding conceptual models, psychopathology, genetic and environmental etiologic features, neurobiology, and treatment.

Malignant Narcissism in Relation to Clinical Change in Borderline Personality Disorder: An Exploratory Study.

BACKGROUND: Normal and pathological narcissism have been the focus of considerable theoretical discussion and empirical research in recent years in personality psychology and psychopathology. Kernberg [1-4] has argued that there is a particularly dysfunctional and impairing variant of narcissistic disturbance known as malignant narcissism. This exploratory study sought to develop, using established assessment methods, a dimensional measure of malignant narcissism that incorporates the key features of grandiose narcissism, paranoid propensities, psychopathic features, and proclivity for a sadistic and aggressive interpersonal style. Method and Sampling: This study examined 57 subjects, diagnosed with borderline personality disorder that were treated using 3 different empirically supported treatments in a previous study [5], for possible deviance on the proposed malignant narcissism index. It also evaluated 2 important clinical domains of change in relation to malignant narcissism. To wit, it was predicted, based on Kernberg's [3, 4] clinical model, that elevated levels of malignant narcissism would be significantly associated with slower rates of improvement in both general psychosocial/psychological functioning and anxiety among treated individuals. RESULTS: Higher levels of malignant narcissism were associated, as predicted, with slower rates of improvement in both global functioning and anxiety. The proposed malignant narcissism index was a more powerful predictor of slowed improvement in global functioning than simple narcissistic personality disorder features. CONCLUSIONS: The heuristic potential of the malignant narcissism construct is discussed and the utility of a dimensional approach to this construct is explored, especially in reference employing personality traits/processes to better understand pathological configurations and personality disturbance.

La negación [denial] de la realidad / The denial of reality / La négation de la réalité

El autor reflexiona sobre cómo la realidad externa puede jugar un papel singular en tratamientos con pacientes con graves trastornos de la personalidad. Así, durante el curso de la asociación libre, aspectos muy relevantes de la realidad externa pueden no aparecer en el discurso o hacerlo muy marginalmente, cuando, sin embargo, puede estar resultando el escenario de actuaciones con importantes consecuencias potenciales. Así, la realidad externa puede estar resultando negada. Aun suponiendo alejarse de una supuesta neutralidad técnica ideal, el autor aboga por que el analista pueda formular preguntas directas sobre partes poco claras de la realidad externa presente del paciente y, en su caso, interpretar la negación. Del mismo modo, para detectar inhibiciones o perspectivas autolimitadas sobre su futuro, el autor reflexiona sobre la conveniencia de dejarse fantasear/imaginar sobre las mejores expectativas potenciales de vida del paciente. Se discute cómo la neutralidad puede o no verse afectada con todo ello. Ilustra todo ello con material clínico de pacientes en psicoanálisis o en psicoterapia focalizada en la transferencia

The author discusses how external reality may play a fundamental role in treatment with patients with severe personality disorders. During the course of free association, very relevant aspects of external reality may not figure in the discourse, or may do so very marginally, when the scenario may nevertheless be arising from acting out with significant potential consequences. In this way, external reality maybe being denied. While presumably moving away from a hypothetical ideal of technical neutrality, the author argues for the analyst formulating direct questions regarding parts of the patient's present external reality that are unclear, and where appropriate interpreting the denial. In the same way, in arder to detect inhibitions or self-limiting views of the future, the author discusses the advantages of the patient fantasizing his best potential life outcomes. He discusses how neutrality may or may not however be affected. All of this is illustrated by clinical material from patients in psychoanalysis or in transference-focused psychotherapy

L'auteur réfléchit sur le fait que la réalité externe peut jouer un role singulier dans les traitements avec des patients atteints de troubles de la personnalité séveres. Ainsi, au cours de l'association libre, des aspects tres pertinents de la réalité externe peuvent ne pas apparaítre dans le discours ou le faire de façon tres marginale alors qu'ils peuvent étre le scenario d'agirs aux importantes conséquences potentielles. Ainsi, la réalité externe pourrait étre déniée. Méme si cela suppose s' éloigner d'une neutralité technique idéale hypothétique, l' auteur préconise que l' analyste puisse formuler des questions directes sur des parties peu claires de la réalité externe présente dans le patient, et, si nécessaire, interpréter le déni. De la méme façon, pour détecter des inhibitions ou des perspectives autolimitées sur le futur, l'auteur réfléchit sur la convenance de se laisser fantasmer sur les meilleures attentes possibles de la vie du patient. Il discute comment la neutralité peut ou non se voir affectée par tout cela. Il illustre tout cela avec du matériel clinique de patients en psychanalyse ou en Psychothérapie Focalisée dans le Transfert

Aplicación de la psicoterapia focalizada en la transferencia a los conflictos de pareja / Appflyfing psychotherapy focused on the transference on coupfle conflicts / Aplicació de la psicoteràpia focalitzada en la fransferència als conflictes de parella

En el presente artículo, se abordan la evaluación y el tratamiento de parejas que se encuentran en conflicto. Existen tres niveles de experiencia, la sexual, la emocional y la de valores, que nos permiten valorar el funcionamiento de la pareja. Si los tres niveles funcionan mal, lo más probable es que la pareja se acabe rompiendo. Si, como mínimo, uno de ellos funciona, los conflictos de pareja pueden ser tratados psicoterapéuticamente. Partimos de la base de que estas disfunciones son generadas por conflictos del pasado de cada participante de la pareja que no han sido resueltos y que están presentes en los conflictos actuales. A través de una viñeta clínica, describimos cómo la psicoterapia puede contribuir a elaborarlos y resolver así los conflictos de pareja

In this article, we are speaking about the evaluation and the treatment of couples that are having conflicts. There are three levels of experience: sexual, emotional and the values, allowing us to assess the functioning of the couple. If the three levels don't work properly, it's most likely that the couple breaks up. If at least one of them works, the couple conflicts can be treated psychotherapeutically. We start from the base that these disorders are generated by past conflicts of each participant of the couple and that haven't been resolved and are still present in the current conflicts. Through a clinical sketch, we describe how the psychotherapy could contribute to their elaboration and thus resolving the couple's conflic

En el present article, s'aborden l'avaluació i el tractament de parelles que es troben en conflicte. Existeixen tres nivells d'experiència, la sexual, l'emocional i la de valors, que ens permeten valorar el funcionament de la parella. Si els tres nivells funcionen malament, el més probable és que la parella acabi trencant-se. Si, com a mínim, un d'ells funciona, els conflictes de parella poden ser tractats psicoterapèuticament. Partim de la base que aquestes disfuncions són generades per conflictes del passat de cada participant de la parella que no han estat resolts i que estan presents en els conflictes actuals. Amb una vinyeta clínica, descrivim com la psicoteràpia pot contribuir a elaborar-los i resoldre així els conflictes de parella

Thoughts on the Present and Future of Psychoanalytic Education.

This paper originated in a series of dialogues between the authors over a period of approximately one year, focused on present problems (and possible solutions) in psychoanalytic education, internationally but particularly in the U.S. Both authors have been involved in psychoanalytic education and governance over many years and share a concern with where psychoanalysis presently stands and where it is going. They share the experience of being part of what today is a significant minority of psychoanalysts involved in academic pursuits, thus being situated at the boundary between psychoanalysis and university-based psychiatry as professions. Having been involved in the leadership of both psychoanalytic and psychiatric organizations, they share an interest in organizational theory, an additional joint interest influencing their approach to institutional aspects of psychoanalysis. Despite these commonalities, however, they have been identified as having differently shaded positions and views within psychoanalytic politics: Robert Michels, as relatively conservative regarding controversial issues in psychoanalytic institutional functioning and governance, and Otto Kernberg as inclined toward rapid change regarding these issues (Auchincloss and Michels 2003; Kernberg 2014). This difference determined a dynamic of particular interest in their dialogue: the extent to which mutual respect yet differing viewpoints might issue in an analysis and joint recommendations that might be of interest to the field. In what follows, their achievement in that direction is spelled out in some detail.