A Primer for Beginning Psychotherapy

William N. Goldstein

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135057619
• Edition: 2
• Topic: Psychologie
• Subtopic: Psychothérapie

Designed especially for students and mental health professionals in the early stages of their careers, this primer is a practical guide to psychotherapy --

1
CHAPTER

The Patients

1.Who Are the Patients?

Patients include anybody and everybody. They come from all walks of life, all socioeconomic states, and all ethnic groups. They present with unending variation in regard to character traits, personalities, and behavior. What they have in common is that they suffer from problems that interfere with their attaining their life goals, maximizing their potentials, and leading basically contented lives. Their problems stem from conflicts that are at least partially outside of their awarenesses. These problems vary in intensity and present either as symptoms or as personality traits and patterns. Often the problems are overtly bothersome to the patients. At other times, although they do not cause discomfort, they interfere with the patients’ lives in ways that have become apparent to them.

2.Can Patients Be Conveniently Placed into Diagnostic Groups?

Patients can be classified in endless ways. One diagnostic system, particularly useful for psychotherapy, places all patients into one of four large groupings: normal-neurotic, narcissistic, borderline, and psychotic. Each of these groupings can be differentiated by a focus on ego functioning. Although not currently in vogue, a focus on ego functioning is a most effective way of both describing and understanding patients. Although based on psychoanalytic theory, this approach can be thought of as a bridge between descriptive and dynamic thinking in that ego functions can be examined totally descriptively or can be viewed as an aid to dynamic understanding.

Anna Freud (1936) and Hartmann (1939) were among the first to list and describe various functions of the ego. More recently, Beres (1956) and Bellak (1958) enumerated a number of ego functions, including reality testing, sense of reality, adaptation to reality, impulse control and frustration tolerance, object relations, thought processes, defensive functioning, autonomous functions, and the synthetic integrative function. Bellak (1970) and Bellak and Meyers (1975) added several other ego functions: judgment, adaptive regressive in the service of the ego, stimulus barrier, and mastery competence. Of these, I (1985) emphasize the first seven when making the differential diagnosis between the four large groupings. In addition, I focus on interpersonal relations, identity, and stability of affect.

Through an assessment of ego functioning, all individuals can be classified into one of the four large groupings. A diagnosis made in this way can serve as a supraordinate or first-level diagnosis. Later, more specific and secondary diagnoses can be added, providing further descriptive information. If one desires, Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) diagnoses can be used as the secondary diagnosis. One caveat is in order. There will be individuals on the borders between the different groupings, and this can lead to certain ambiguities and uncertainties. Nevertheless, diagnoses made in accordance with the four large groupings are seen as basic with regard to psychotherapeutic approach.

The remainder of the questions in this chapter relate to ego functioning (Goldstein, 1985). If one is not accustomed to a focus on ego functions, reading this chapter might be difficult. To aid with this task, an appendix on ego functions is provided. Some might want to read the more clinical parts of the primer first, then, with the help of the appendix, return to this chapter.

3.What Are the Characteristics of the Normal-Neurotic Grouping?

The hallmark of the normal-neurotic grouping is basically good ego functioning. All ego functions in this grouping are basically intact, with minimal episodic regressions varying from person to person. Thus, the normal-neurotic individual is characterized by intact reality testing, secondary process thinking, good interpersonal relations, good adaptation to reality, good impulse control and frustration tolerance, a stable identity, and affective stability. Defenses are typically mature and neurotic in day-to-day functioning, with neurotic defenses becoming accentuated under stress. There is occasional slippage to immature and borderline defenses, mostly under stress. The preponderance of certain specific neurotic defenses in day-to-day functioning, especially under stress, differentiates one neurotic classification from another. Thus, a “typical” obsessive-compulsive individual tends to use intellectualization, isolation of affect, undoing, reaction formation, and rationalization, whereas a “typical” hysterical person tends to use repression, dramatization, and heightened affect. It should be noted that the hysterical individual referred to here is that of the psychoanalytic literature rather than the DSM-IV histrionic personality.

Regarding object relations, the normal-neurotic presents a clearly integrated, cohesive, and stable sense of self and a similarly integrated, cohesive, and stable sense of objects. Others are viewed as complex individuals, clearly having needs and desires of their own. The normal-neurotic typically respects these needs while displaying a certain amount of concern, empathy, and sensitivity. The normal-neurotic thus does not view others as need-fulfilling objects, nor does he or she display identity diffusion. Elaborating on some of the ego functions, interpersonal relations and adaptation to reality may vary somewhat, often in accordance with the pattern of neurotic defenses employed. There can be some slippage in frustration tolerance and impulse control, as well as in affective stability. Rarely are there any problems with reality testing or thought processes.

Although I know many people who function quite well, adapting flexibly and reasonably to the vicissitudes of life, I do not think that I know anyone whom I would call “normal.” All people use numerous neurotic defenses and have at least some minimal episodic difficulties with a number of the ego functions. If one had to differentiate between the “so-called” normal and the neurotic, one might emphasize the exaggerated use of certain neurotic defenses with a corresponding decrease in adaptation in the latter group. Because distinctions between the normal and neurotic are both arbitrary and subjective, the normal and neurotic are here classified together to provide the “healthy” grouping in this diagnostic classification.

4.What Are the Characteristics of the Borderline Grouping?

The hallmark of the borderline grouping is a characteristic ego profile consisting of a specific pattern of four relative ego strengths and four underlying ego weaknesses (Goldstein, 1985, 1996). The relative ego strengths are as follows:

1.The relative intactness of reality testing.

2.The relative intactness of thought processes.

3.The relative intactness of interpersonal relations.

4.The relative intactness of the adaptation to reality.

It must be stressed that these four strengths are only relative; they easily break down to various degrees in various situations. Because these four relative strengths stand out superficially, they enable the borderline patient to present a fairly “normal” appearance. These relative strengths, particularly the first two, most clearly differentiate the borderline from the more psychotic individual.

The underlying ego weaknesses are as follows:

1.The combination of poor impulse control and poor frustration tolerance.

2.The proclivity to use primitive ego defenses.

3.The syndrome of identity diffusion.

4.Affective instability.

In contrast to the strengths, which stand out on a superficial level, these weaknesses become clearly apparent only with in-depth understanding. Except during regressed states, a detailed history or a relationship over time is needed for these weaknesses to clearly emerge. Because the weaknesses are beneath the surface and are not detected superficially, they do not detract from the borderline's appearance of normality. These underlying weaknesses, however, most clearly differentiate the borderline from the more neurotic individual. The relative ego strengths and underlying ego weaknesses are now examined briefly.

The Relative Ego Strengths

Reality testing. The strength here is that, on a surface level, and in day-to-day functioning, reality testing is basically intact. The weakness can emerge under stress and in very close interpersonal situations in which there is a tendency for this ego function to regress, sometimes leading to brief psychotic episodes. Regarding symptomatology, it is sometimes difficult to differentiate these regressions from other psychotic episodes. What does distinguish these episodes is their brevity (from minutes up to a day or two), their spontaneous reversibility, and their relationship to clear-cut precipitating events. These transient psychotic episodes under stress are allowable but certainly not mandatory to making the diagnosis of borderline.

Thought processes. The strength is that, in day-to-day functioning and in structured situations, thought processes are predominantly secondary processes. The weakness can come about under stress and in unstructured situations (such as projective psychological testing) when primary process sometimes emerges. Although there is the tendency to find a psychological test pattern of secondary process on the Wechsler Adult Intelligence Scale (WAIS) and primary process on the Rorschach, there is much disagreement as to how frequently this test pattern will actually be found in the borderline patient.

Interpersonal relations. The strength here is that the borderline patient often seems to do adequately in terms of interpersonal relations. On the surface, he or she seems to “relate” to others, can have many acquaintances, and sometimes can maintain long-term relationships. Weaknesses emerge when, under closer scrutiny, it becomes apparent that the relationships are often characterized by a lack of depth and a lack of concern for the other individual as a person. The other person is seen as someone who can be used to meet the borderline patient's needs rather than as a person in his or her own right. Empathy is lacking, and the borderline individual often vacillates between superficial relationships and intense, dependent relationships that are marred by primitive defenses. In their relationships, borderline patients are often very sensitive to real or imagined abandonments and to real or perceived slights, rejections, rebuffs, disappointments, and failures.

Adaptation to reality. The strength here is that adaptation is often superficially intact. The borderline patient may seem of normal appearance and may seem to display adequate achievement in work or school. Weaknesses in this area emerge when, under closer scrutiny, it is noted that the adaptation is far from optimal. There are certain “exceptional” borderlines who can maximize certain strengths and adapt adequately over time, particularly in structured settings. These individuals often do quite well professionally while displaying much more chaos in their social lives. Typically, these people display certain marked ego strengths together with their weaknesses. Strengths often include high intelligence and the ability to use obsessive-compulsive defenses. This exceptional group, more than others, seeks out intensive psychotherapy.

The Underlying Ego Weaknesses

Poor impulse control and poor frustration tolerance. Invariably, the borderline patient displays the combination of poor frustration tolerance and poor impulse control. There is an inability to delay, a demand for immediate gratification, and a proclivity to act out under stress. To make matters more difficult, these characteristics are sometimes combined with a sense of entitlement. These difficulties frequently present themselves clinically by a tendency for states of disruptive anger, by use of drugs and alcohol to avoid frustration and obtain temporary gratification, and by an inclination to flee the work or interpersonal situation under stress. There is a tendency in some for impulsive suicidal threats and attempts, in addition to other self-destructive behavior.

The proclivity to use primitive ego defenses. In day-to-day functioning, the borderline patient, with marked individual variation, uses a combination of mature, neurotic, immature, and borderline defenses. Under stress, he or she displays a marked tendency to rely on borderline defenses. In marked regressions, he or she may also use psychotic defenses. Borderline defenses include splitting, primitive idealization, projection, projective identification, primitive denial, omnipotence, and devaluation. Primitive defenses are thought to include, in addition to these borderline defenses, acting out and the psychotic defenses.

Splitting refers to the tendency to view individuals and things (external objects) as either all good or all bad. Primitive idealization, devaluation, and omnipotence are viewed as derivatives of splitting. Primitive idealization is the positive component of the split directed toward an external object (or individual). The external object is viewed as all good not for any realistic reason but because the patient has the need or wish to see it as all good. Devaluation is the negative component of the split, directed toward an external object or toward the self. Omnipotence is the positive component of the split directed toward the self. Although many patients make rapid reversals from one side of the split to the other, particularly under stress, others tend to maintain their primitive idealizations and devaluations over long periods of time.

The denial characteristic of most borderline patients is of a primitive, global, and blatantly unrealistic nature, somewhat akin to splitting. Two events or facts are clearly remembered in consciousness, yet one is totally denied or ignored. Alternatively, an event or fact is clearly remembered, but there is total disregard of its implications, consequences, and relevance.

Projective identification is the most confusing of all borderline defenses. One does not need to use the term projective identification; one can use other language to describe the same phenomenon. However, this term has become commonplace, and it behooves one to understand it. The most common usage of projective identification is as follows (Goldstein, 1991). A projection is followed by an interpersonal interaction in which the projector actively pressures the recipient to think, feel, and act in accordance with the projection. It is this coercive interpersonal interaction that is the essential feature of projective identification. What is confusing about the term is the varying definitions of projection, whether the process must include a blurring of self and object representations, and whether a reinternalization process (occurring after the interpersonal interaction) should be part of the concept.

Identity diffusion. This term refers to an identity that is not integrated or cohesive but diffuse. It is an identity based on multiple contradictory, unintegrated self-images. Correspondingly, there are multiple contradictory unintegrated object images. At one time, one self-image is evoked, and, at another time, a different one is invoked. The same applies to object images. Neither a comprehensive view of the self nor such a view of objects has ever been attained. As a result, borderline individuals are unable to describe themselves or others in a meaningful way. There is a lack of temporal continuity regarding the self and others, along with an overall distortion of the perceptions of self and others. Sometimes the borderline patient experiences an inner lack or void, a sense of emptiness or depletion. Various types of stimulating activities, including self-mutilating behaviors, are sometimes used to rid oneself of these painful feelings. Other terms frequently used to describe this problem include lack of an integrated self-concept, lack of a sense of self, lack of a real self, lack of a stable identity, and lack of a coherent sense of self.

Affective instability. The presence of irritability; intense affect, usually depressive or hostile; anger as the main affect experienced; and depressed, lonely, and empty feelings are frequently emphasized. Aggression is not used in constructive, ego-syntonic, adaptive ways, such as sublimations, work, recreation, and enjoyment. Thus, the aggression often breaks through directly in disruptive ways, such as outbursts of anger and rage, or the aggression is defended against in maladaptive ways and results in other ego-dystonic affect states such as depression, boredom, and empti...

Table of contents

• Front Cover
• Half Title
• Title Page
• Copyright
• Contents
• Preface
• Preface to the First Edition
• 1 The Patients
• 2 The Therapists
• 3 The Psychotherapy
• 4 Larger Issues Regarding Psychotherapy
• 5 The Office Setting
• 6 The Initial Interview
• 7 Arrangements
• 8 Transference and the Therapeutic Alliance
• 9 Basic Strategy
• 10 Therapeutic Interventions
• 11 Interventions Regarding Anxiety and Defense
• 12 Special Issues and Problems
• 13 Phases, Trends, and Termination
• 14 Contemporary Schools of Thought
• Appendix
• References
• Index