Intensive psychotherapy of a borderline patient.

A detailed case report of the long-term intensive psychotherapy of a borderline patient illustrates my approach to such patients. It also raises questions about the value of interpretations in the early phases of therapy of such patients, regardless of which conflicting theories are chosen as the basis of these interpretations. Stress is placed on the value of empathic attunement to the patient, staying with the patient through the many vicissitudes of long-term treatment, and the developmental use the patient made of a long treatment, reliving certain phases of development in the transference. Acquisition of internalized controls may need to occur in this way before the patient is ready to utilize interpretations. Also illustrated are the difficulties in convincing insurance companies and other third parties to support long-term psychotherapy and the effects of such intensive interaction over the years on the psychotherapist.

The outpatient psychotherapy of the borderline patient.

This paper discussed common problems in the outpatient psychotherapy of borderline patients, especially their rage, seductiveness, and abrupt negative shifts. The definition of "borderline" is not settled. Even DSM-III-R mixes it up with other personality disorders. There are no pathognomonic symptoms, no specific personality constellations, and no compelling evidence for a definitive stage in infant development when this disorder is fixed; all stages are involved, from faulty foundational to oedipal periods. It is a descriptive diagnosis and typical presentations of such patients are reviewed. In the psychotherapeutic approach, limits must be set first, but these must be flexible and reasonable. Medications are used rarely and with care. We attempt to form an alliance by (a) getting the patient to join us in a study of himself or herself, especially a study of when rage and maladaptive behavior emerges, and (b) providing a consistent and reasonable ambience. The ultimate aim is uncovering and interpreting when the patient is ready for it, more and more approximating psychoanalytic treatment as the patient's pathology permits. The special phenomena of the self-object (Kohut), transitional object (Modell), and disruptive extreme erotic or raging (Kernberg) transferences were reviewed, as well as the pitfalls of therapist anxiety and impatience in dealing with them. While archaic transferences predominate, we serve as an auxiliary microscopic ego and appeal to the rational adult part of the patient's ego in a phenomenological investigation. We interpret early only if we cannot get the patient to examine what has led to the explosions and when distortions or projection without insight continues to predominate. The dangers of early transference interpretations are discussed. Therapy is long, tedious, and requires the willingness to patiently catalyze the patient's resumed development and endure the periodic disruptions. Countertransference problems and what to do about them are reviewed.

Psychosis after open heart surgery: a phenomenological study.

This brief self-reflective phenomenological study attempts to throw light on the inner mental processes that go on immediately following open heart surgery. The combination of organic assault, medication, post-traumatic stress, and psychological injury involved produces an abnormal mental state that can better be treated if it is understood from the point of view of the patient.

The unbearable obscurity of being.

This cross-disciplinary study attempts to investigate the Being-question: what is the ultimate ground of everything there is? Psychotic solutions to this problem are compared with Kundera's literary approach (On the Unbearable Lightness of Being), and with famous metaphysical solutions. Special attention is given to Heidegger's attempt to grapple with this question, as exemplified in his four- (in the English translation) volume study of Nietzsche--who regarded Being as "a vapor and a fallacy." Psychoanalytic conceptions of the origin of the sense of Being in the mother-infant interaction, and in the ego's ongoing awareness of itself are examined, especially since in psychoses, borderline disorders, and other narcissistic disorders the sense of Being and the ego's experience of itself often are defective. Genetic and dynamic psychoanalytic considerations also clarify the historical preoccupation with the Being-question. It is concluded that only through consensual validation can psychotic solutions be distinguished form solutions having a general sense of validity. The methodology for exploring the validity of answers to the Being-question is contrasted with scientific method, and the necessity for clear exposition--limited by the inevitable boundaries of one's culture and language--is emphasized; for only through a historical process of dialectic can there be hope of eventual consensual validation on solutions to the problem.

On the unique impact of Richard Strauss's Elektra.

The unique and remarkable impact of the opera Elektra is explored. This opera rests not only on its dramatic portrayal of the oedipal theme, but also on an inspired expression of archaic emotions, prelogical thought, and preoedipal concerns. This accounts for its unique impact, and serves as a warning to clinicians confronted with manifest oedipal material to be sensitive to the diagnostic implications when oedipal material is permeated with more primitive expressions, producing a curious and eerie ambience and much disquiet in the therapist.

Thirty unresolved psychodynamic questions pertaining to feminine psychology.

The psychoanalytic view of feminine psychology is rapidly changing. This paper organizes and presents thirty areas of currently unresolved questions on this controversial topic, as they have appeared in the literature of psychoanalysis and psychotherapy beginning with Freud's original publications, for consideration for future research, study, and discussion.

Heidegger for psychotherapists.

"Philosophical anthropology," and a powerful continental movement in philosophy and psychology have greatly influenced the practice of psychiatry in Europe. Martin Heidegger brought this approach to a position of prominence and wide attention and I describe his views pertinent to modern psychotherapy on (a) human living and (b) the epistemological foundation of psychiatry and psychotherapy.

Lacan's practice of psychoanalytic psychotherapy.

Lacan's efforts in the psychoanalytic psychotherapy of patients with structural deficits aim at separating truth, desire, and ideals from each other so that the analysand is freed up to find or create the desire that gives him or her "joy." This paper presents Lacan's use of the "bridge metaphor" towards that purpose, and illustrates the application of Lacan's early concepts in actual clinical work.

Heidegger's "authenticity" in the psychotherapy of adolescents.

Those aspects of Heidegger's thought culminating in his notion of "authenticity" are described, and the use of his concepts in the psychotherapy of certain adolescents is suggested. This paper offers some details of Heidegger's position and its applicability to psychotherapy. Heidegger attempted to get around the scientistic attitude of our time by use of a phenomenological description of how we actually live our lives. He described what he called our inauthentic immersion in the "they" or the everyday of life, which he argued generates self-forgetfulness, self-centeredness, an anxious sense of life having no meaning or value, and the convinction that nothing really matters. In that situation only peak experiences or "thrills" such as sexual ecstasy, dangerous exploits, fights, or drugs are used to "make it all worthwhile." These are typical complaints and descriptions from adolescent (as well as borderline) patients, of course, and represent self pathology or a possibly temporary state of identity diffusion. Heidegger's solution, one which can be used with certain intellectually inclined adolescents who are not judged suitable for uncovering psychotherapy at the time, is a kind of self-focussing. In this procedure one stands back and reviews options and possibilities in the attempt to shape one's life in accordance with ideals and values that are determined by actual focus on them rather than by a mindless immersion in everyday practices. I suggest that this kind of intellectual exchange with certain adolescents, especially if it is accompanied by a proper idealizing relationship, has as its value the development of an increased sense of cohesiveness of the self, and a sense of meaningful and authentic living in which life begins to attain a unified flow characterized by cumulativeness and direction that can be articulated in a temporal narrative. The encouragement of such a narrative is a worthwhile tactic to consider in the psychotherapy of certain adolescents.

Psychoanalysis at the millennium.

This article explains and discusses the immense complexity of the psychoanalytic process as it is becoming increasingly understood at the millennium, and offers the possibility that it can be viewed from at least five channels of psychoanalytic listening. The careful ongoing examination of the transference-countertransference interactions or enactments, and their "analytic third" (32) location in the transitional space is extremely important in psychoanalytic practice. We must be careful in our interpretations of the clinical data not to stray any farther from the fundamental concepts of Freud than is necessary, lest we end up with a set of conflicting speculative metaphysical systems and become a marginalized esoteric cult. Freud's work remains our basic paradigm, the core of psychoanalysis, even though his papers on technique and his emphasis on the curative power of interpretation are from a one-person psychology standpoint and his view of psychoanalysis as just another empirical 19th-century science requires proper understanding and emendation in the light of accumulated clinical experience since his time.

The phenomenology of Erwin Straus and the epistemology of psychoanalysis.

The contributions of Erwin Straus, a phenomenologist psychiatrist of reknown in Europe but little known in the United States are summarized. His emphasis on the wholeness of the world as it unfolds in its sensory splendor, as opposed to the traditional psychiatric efforts toward the reduction of psychic experience into quasi-mathematical and medical categories is explained.

Effects of the therapist's philosophical premises on psychotherapeutic process.

This article focuses on differences in assumptions forming the philosophical foundations of psychotherapy leading to profound differences in the interpretation of the clinical data of psychotherapy and corresponding variations of basic technique. These differences are not reconcilable because they are directly opposed; only the principle of complementarity, as described in the paper, permits a constructive approach to the antinomies.

A practical approach to the psychotherapy of the borderline patient.

Guidelines for the ordinary psychotherapist in the day-to-day office treatment of so-called borderline patients are presented. Practical pointers for handling problems of diagnosis, working alliance, transferences, middle phase, and termination are given, followed by a brief discussion of the future of the concept of borderline patient.

Current issues in intensive psychotherapy.

Seven current critical areas in intensive psychotherapy are discussed. (1) Social polemics, centering around the conflict between the humanistic and individualizing thrust of intensive psychotherapy, and the dehumanization of our current dark age; (2) training, where the resident is caught in a dilemma between techniques stressing fast relief and the possibilities of longer intensive therapy that stand in stark contrast to these techniques; (3) fundamental philosophical choices on the part of every practitioner that various types of therapy require; (4) delineation of intensive psychotherapy primarily defined as a modified form of psychoanalysis; (5) establishing the methodology of psychoanalysis and its derivative discipline, intensive psychotherapy; (6) use of intensive psychotherapy as the treatment of choice for pre-Oedipal disorders, severe character disorders, borderline patients, and certain others, such as some schizophrenic patients; (7) the collision between certain irreconcilable views such as those of Kohut and Kernberg that forces further choices on the therapist. This latter unresolved area could be placed in perspective by appeal to ego psychology which, as in the work of Blanck and Blanck, and others, is still a viable alternative and forms a critical area of investigation.

Some philosophical assumptions of intensive psychotherapy.

This paper moves from general considerations about the task of philosophy and epistemology to specific considerations of the postulates and principles that lie behind certain selected psychotherapeutic systems. In a field in which there is so much disagreement it is mandatory to review the fundamental premises behind various forms of psychotherapeutic endeavors for, whether we like it or not, we are forced in the practice of psychotherapy to make certain philosophical assumptions and conceptions. These differ and conflict, and our choices will affect our clinical work.

What is intensive psychotherapy?

The fundamental practical premises underlying the practice of intensive psychotherapy are investigated in this article. Based on ego-psychology orientation, mental illness is classified in terms of premature ego development, ego distortions, ego deviations, ego regression, and ego defects. General healing factors are reviewed, first as presented, for example, in Frank's "demoralization hypothesis." The forms of psychotherapy may be classified in terms of how they approach the problem of demoralization and failure of ego adaptation, into counseling, supportive, reeducative, and psychoanalytic. Intensive psychotherapy is conceived of as a derivative discipline of psychoanalysis. It is different in that the goals are more limited, and active interventions ("parameters" or "departures") are often unavoidably called for, making it less "neat and orderly," more taxing on the therapist, and more of an art. It is similar in that an emphasis on the patients' spontaneous associations and an attempt to retain analytic neutrality as much as possible leads to the formation of transferences and resistances which may be dealt with by interpretation. However, full-blown transference neuroses usually do not form as in classical psychoanalysis, limiting the depth and extensiveness of the procedure. Intensive psychotherapy is the treatment of choice for selected cases of schizophrenia, severe personality disorders, and psychosomatic conditions.

Hermeneutics for psychotherapists.

Hermeneutics as a method of approach has been used differently by many different authors, and in this paper I have reviewed the history and evolving employment of the hermeneutic approach. For the purposes of psychotherapists, the point of hermeneutics is that, in contrast to the natural sciences, it focusses away from the classical notion of the neutral independent observer (or subject or psychotherapist) as detached from the object of his or her study, the patient. All understanding in the human sciences is viewed by hermeneutics as arising out of a fusion of horizons between the investigator and the humans being investigated. The "knowledge" which arises from such an investigation is not some sort of immutable truth or essence, but is context dependent and a function of the "prejudices" which the investigator brings to the investigation. Diagnoses and formulations in the practice of psychotherapy, if the hermeneutic approach is employed, cannot be viewed as disease entities and natural science "facts," but rather as temporary formations that change with changing times, historical eras, cultures, and prevailing prejudices and practices. The problem of a hermeneutic psychiatry would be to steer between the Scylla of naive realism ignoring the major participation of the psychotherapist on the one hand, and the Charybdis of relativism, nihilism, and hopeless skepticism on the other. Much work remains to be done in order to clarify the role and limitations of hermeneutics, and to incorporate it into the clinical practice of psychotherapy, and this work must be done against the prevailing ideology of scientific materialism that characterizes our historical era. A hermeneutic psychiatry offers us the best hope of not losing sight of the methodological horizons that delimit our clinical work, and of widening these horizons so as to provide further understanding of our patients.

Intensive psychotherapy for the psychiatrist's family.

A series of intensive psychotherapy cases of wives and children of psychiatrists reveals that the special problems they present may be divided into those at the onset of treatment, those in the process of the treatment, and special countertransference problems. Paradoxically, early recognition and acceptance of psychotherapy are a foremost problem involving the psychiatrist as father or spouse. During therapy, narcissistic injuries to the psychiatrist father or spouse and loyalty problems in the patient emerge as special problems. Countertransference revolves around peer relationships and "psychopolitics," as well as referrals of other patients.

The death instinct and the future of humans.

Freud's notion of the "death instinct" has been conceived of by many subsequent authors in many ways. One of the misuses of it is as an excuse for passivity in the face of the current crisis in human affairs. This paper reviews the "death instinct" concept and attempts to understand the disavowal of the dangers to our species and our planet on the basis of our current narcissistic cultural orientation. It examines the use of praxis by a variety of continental thinkers to counter this disavowal and emphasizes the obligation of all mental health professionals to participate, through direct action and through educational contributions, in the elimination of these evils.

Psychoanalytic listening II.

This paper employs a rhetorical form designed to clarify and sharpen the focus of the very special stance required--which must be painstakingly learned under careful supervision--in order to effectively tune in to communications coming from the unconscious of the patient. This is the hardest task that must be mastered to become truly empathic and sensitive in dyadic relationships, a unique expertise that marks the psychiatrist as a genuine specialist in medical practice. Regardless of theoretical orientation, neither the form or content of any therapeutic intervention can be appropriate unless it is empathically based. Clinical vignettes illustrate the lack of such empathy, and readings are suggested that enhance our approach to learning this skill, borrowing especially from Kohut and Bion. The great importance of the often ignored "background" of the patient's communication is emphasized, and is illustrated from the field of music in the work of John Cage and Anton Webern. The congruence between this clinical psychiatric problem and the main thrust of Continental philosophy, which attempts to put man back in touch with himself, is described. Suggestions are offered to supervisors how to develop these skills in the novice. Finally, a discussion is presented of the effect on the professional and personal life of the therapist who has not developed these skills, emphasizing the dangers of "burn-out" in therapists and the implicit philosophy of life in a money-oriented practice of psychotherapy. The dangers of not attending to such matters even during residency training are pointed out, in an attempt to raise the consciousness level of the therapist to the extreme importance of background practices both in the patient and the therapist.