Personality Pathology: Developmental Perspectives

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Personality pathology is rooted in early development and affects a wide range of affects, behaviours and cognitive processes. Every year thousands of articles about the etiology pf personality pathology are published in various professional or scientific reviews. There is a growing distance between the generalist's practice and our increasingly precise scientific knowledge.However, no one can read everything and therefore, it behoves us to ask ourselves the following questions: is the most recent better than what came before? Is the measurable and demonstrable necessarily clinically interesting? Must what interests the clinician be measured and proved?Whilst theory and clinical research are becoming increasingly precise, innumerable socio-economic forces are pressing for a simplification in clinical practice. "Shrinks" are fashionable! They are everywhere: in the workplace, on television, on the radio. Their services are paid for by private or company insurance, provided that it is a "quick fix", not too expensive, and that we do not indulge in vague meanderings round "mal de vivre"! Dissatisfaction with life!In short, the generalist today finds himself torn between two opposing forces. He seeks to practise from a secure base and to keep his knowledge up to date, while being aware that this in turn will give rise to an increasingly varied clinical practice, in which he deals with serious pathologies as well as working with patients requesting help in more ordinary situations. Whatever the profile of his practice the generalist has to be able to work with personality disorders and understand how they arise. This essential competence enables him to make informed clinical decisions.So, the modest aim of this book is to be of use to the generalist in his daily practice. Of course it does not exempt anyone from thinking and doing his own reading according to his interests and particular queries.The integrative structure which is the basis of this work is known both as Relational Psychotherapy and as Object Relational Gestalt-therapy. It is written for all psychotherapists interested in finding out about developmental issues. The reader who is not familiar with the clinical theory of relational psychotherapy will find in the first chapters, a synthesis of its main features. This should allow him to read and make wise clinical use of the chapters on the main developmental issues.

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CHAPTER ONE: Developmental issues in the etiology of personality disorders

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The definitions of personality disorders in the DSM help us to form a clinical picture of how enduring and ego-syntonic psy-chopathology arises. This multi-axial system is the basis of and framework for classification in American empirical psychiatry. This methodology has some disadvantages. In order to separate personality disorders from clinical syndromes, the American Psychiatric Association (APA) has had to opt for an empirical epistemol-ogy designed to allow communication between clinicians of varying disciplines. However, this has meant giving up a whole heritage of knowledge that has been constructed over the last century, that of traditional psychodynamic and developmental epistemology. The DSM may well allow us to diagnose from verifiable observation, but it is of no use when it comes to understanding the etiology and the psychic function of a personality disorder.

These pathologies seem to be sufficiently specific in character for us to be able to distinguish them from Axis I disorders, and place them on Axis II. Let us examine their characteristics: they are generally present from early adulthood, tend to be ego-syntonic, and appear in a variety of contexts. They are woven into the very identity of the person: hence their name of personality disorders. Since these are intimately connected with the identity of the individual, we must understand that the person is immersed in what both defines him and is also the source of his suffering. Nowadays we cannot approach these complex structures of identity in a one-dimensional manner. Personality disorders are the result of several etiological factors, of nature and of nurture, genetic and psychological, as well as risk and resilience factors, present in the person and in his developmental environment.

 

CHAPTER TWO: Relational psychotherapy

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Object Relations Gestalt Therapy (ORGT) evolved from the integration of concepts from British Object Relations into Gestalt-therapy. Those clinicians that have adopted this system wish to use the well-documented capacity of Gestalt-therapy to increase their patients’ experiential understanding while maintaining the search for meaning so necessary to the human spirit. This system formalizes dialogic Gestalt practice applicable to personality disorders as defined by DSM.

ORGT believes that psychological health comes not only from creative adjustment in the immediacy of the felt sense (GT) but from a tendency for the Self to embrace its own continuity and to establish in itself an irreversible felt sense of otherness (OR). In order for the individual who suffers from a personality disorder to achieve this state, he/she must disentangle a series of experiential impasses of which that individual understands only the consequences, rarely the process, never the causative issues.

In this chapter the reader is invited to explore the theoretical foundations of this approach, of how its conception of normal development and pathogenesis were arrived at and how they fit the therapeutic model. This is dealt with in detail in La relation d’objet en Gestalt-thérapie (Delisle, 1998).

 

CHAPTER THREE: Object relations development theories: an overview

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Psychoanalysis has sometimes been accused of having become a hermetically sealed system, unwilling to be open to the influence of other approaches. However, even though its history is one of violent theoretical and clinical disputes, such as the huge disagreements between Melanie Klein and Anna Freud, contemporary psychoanalysis is nevertheless pluralistic. Its practice has evolved so much that today one might be justified in asking whether classical analysis in its present form may be threatened with extinction. However, regardless of how it is practised, psychoanalytic theory is today part of our universal heritage. We can reasonably selectively employ certain of its more illuminating points without actually having to adopt the whole of its theoretical basis, framework, and techniques.

In this chapter the reader will be given a quick summary of key psychoanalytic theories of development that will be used to inform the analysis of the essential issues of development in the following chapters. In a notable piece of work in 1983, Greenberg and Michell proposed that these diverse theories could be seen through the lens of their respective strengths and weaknesses, and additionally from the angle of their similarities. These authors approach the plurality of psychoanalytic theory using a preliminary epistemological differentiating tool to answer the question: what came first and what has grown out of it? Greenberg and Mitchell classify psychoanalytical theories of development under three major ideological lines: instinct or drive theories, relational theories, and mixed theories. While this system of classification is not unanimously accepted by the psychoanalytic community, for our purpose it will serve to underline one of the seminal points of object relations developmental theory.

 

CHAPTER FOUR: Attachment issues

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The most important developmental issue involved in attachment is the establishment of the basis of our affective security, which forms the basis of the quality and the solidity of our engagement with others. When the attachment process is correctly negotiated, the capacity and the desire for contact and intimacy are installed in the infant. Interdependence then seems natural and it is accepted calmly. Those who have successfully mastered this developmental phase are better able to experience the reality of separations, without developing excessive abandonment anxiety. They are capable of being alone, without their solitude seeming to deprive them of creativity and productivity. The Other is not essentially a menace nor does he seem like the ultimate, perfectly secure refuge. The integrated representation that organizes the personality function could be expressed as follows:

“I am safe. The Other can care for me and protect me. My needs are natural, acceptable and tolerable.” The Other remains there and is able to respond. This basic security, the consequence of a good metabolization of the attachment process, can be observed in adults in love. In 1987, Hazan and Shaver demonstrated how one can find, in the romantic experience, the same types of attachment organization as in children.

 

CHAPTER FIVE: Treating attachment issues

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Relational psychotherapy, with its roots in both Gestalt-therapy and object relations theory, essentially sees treatment of attachment issues as a reactivation and resolution of developmental processes. This reactivation has been shown to be fundamental in the treatment of attachment disorders. This is why it is necessary to identify the client’s relational issues outside the therapy room because they carry the imprints of the developmental issues that were not resolved at the attachment stage. In addition, it is necessary to reactivate these issues within the framework of the therapeutic work. This means that the therapeutic relationship, before it can be a reparative space, must be a space for reconstruction and attempting to make sense of what is unresolved. Levy, Orlans, and Winger (1999) describe this process as: revisit, revise, revitalize. In order for the therapist to be able to do this he must develop and maintain three fundamental competencies: reflexive competency, affective competency, and interactive competency.

 

CHAPTER SIX: Self-esteem issues

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The concept of self-esteem has captured the attention of a good number of contemporary theoreticians. More often associated with narcissism in the psychoanalytic tradition, self-esteem has also been studied and commented on from a humanistic-existential angle, notably by Nathaniel Branden (1984). Among contemporary psychodynamic authors, the work of McWilliams (1994), Johnson (1987, 1994), Gabbard (1994), as well as Gunderson and Phillips (1998), offers a useful developmental point of view based on Kohut’s or Kernberg’s ideas. Before addressing the theme of the development of self-esteem, let us explain the parameters of our field of interest. When writing about self-esteem, I shall refer to the developmental issue as it has been studied since the 1970s, by humanistic psychologists, as well as those of the psy-chodynamic school, such as Kohut. When I use the term narcissism and its derivatives, I shall rather be referring to the pathological indicators of the phenomenon.

The concepts of narcissism and of self-esteem are so often linked in contemporary theory that it is easy to jump to conclusions, one of which is to link wounded self-esteem and narcissistic vulnerability with the pathology of the same name. But all personality structures have a narcissistic function: to protect self-esteem through certain specific defences.

 

CHAPTER SEVEN: Treating self-esteem issues

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We shall address the treatment of self-esteem issues from the multiple viewpoints of relational psychotherapy. The difficulties in making contact that lie at the heart of these pathologies will be understood and worked through from two points of view. These perspectives, adopted and practised in the pluralist vein of contemporary psychoanalysis, are those of Kohut and Kernberg. Historically, they have been involved in rather a conflict-ual relationship, of which it may be said, if one is not constrained by institutional loyalty, that it says as much if not more about politico-institutional as about clinical disagreement. From Kohut’s point of view, narcissistic pathology is the result of arrested development. We imagine that the person who manifests this pathology has been hindered in his normal need to idealize and de-idealize. This point of view is very near to our thinking about the evolution of personality disorders. In reality, personality disorder results from the mixture of risk and resilience factors, in both the biological and the social spheres. When risk factors are greater than resilience factors, the process of development is interrupted or perverted. We begin, in fact, with the two perspectives already described earlier: Kohut’s which considers failure as arrested development and Kernberg’s who sees it as a perversion of this process.

 

CHAPTER EIGHT: Issues of eroticism

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The processes of attachment are more or less the same for boys and girls. The issues around narcissism, even if they do present gender-specific content, are relatively similar. What is more, those who have written about these developmental issues have, for the most part, spoken of the infant, or of the child or of the baby. The young “girl” or young “boy” are rarely differentiated. In general the first two developmental issues that we have looked at up to now have been “unisex” or at least pre-differentiated in the area of sexuality.

However, we are now going to enter a very different and well-differentiated universe. This universe of the differentiation of the sexes has become full of social, cultural, and political significance over the last 30 years, which makes research less than straightforward. It can often be seen that these different perspectives can lead to some confusion between the sender and the receiver when approaching this developmental issue. This confusion tends to cloud the distinction between the field of differences and the field of inequalities. So much so, that the former may be mistaken for the latter. Each one of us has grown up, developed, and discovered ourselves irremediably incarnated in a sexualized body. Our identity, our way of seeing ourselves and the world, depends on the odds of our biological destiny. Even at the extreme limits of empathy of one human being for another, lies this total difference between one sex and the other, this opposite sex that attracts us, that worries us sometimes and that remains quite foreign and strange to us. Our age has not completed its exploration of the relationship between the sexes. It is tempting to disqualify the words of the Other, as soon as they belong to the other camp, but if we do this, we divide ourselves into entities that are unable to engage in dialogue. This would result in a particular epistemology claiming that women do not know how to talk about the sexual development of men and that men, following Freud, must confess to their ignorance of the mystery of feminine sexuality and keep their thoughts to themselves.

 

CHAPTER NINE: Treating eroticism issues

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In order to treat issues around love and sexuality we must first allow a theme to emerge through specific types of impasse that will appear in various experiential fields. Then, meaning must be clinically constructed in order to finally resolve the issue or fully achieve the task at hand. These themes are likely to emerge just as much in fields 1 and 2 as in field 3. As with developmental issues, these impasses are treated and meaning is constructed through cycles of reproduction, recognition, and reparation.

It would, though, be wrong to believe that all impasses in the areas of love and sexuality result from the developmental issues that we have been looking at here. Many people come into therapy because something is not quite right in their romantic relationships but it does not necessarily follow that every romantic impasse is the result of a developmental problem in the area of eroticism. Unresolved issues of attachment and self-esteem are just as likely to undermine the romantic sphere. In other words, pre-Oedipal issues often appear in the romantic sphere and it is important to recognize them for what they are. What particularly characterizes a romantic impasse linked to an unresolved developmental erotic issue is above all a relationship between desire and the forbidden, and other similar bipolar dynamics such as:

 

CHAPTER TEN: Developmental crises in adult life

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The psychotherapist’s job is to find the roots of his client’s suffering by employing active presence, resonance, and empathic listening in order to tune in to a network of signals that lead him to identify the roots of unfinished business. Affective and interactive presence needs to be supported by knowledge and understanding of the developmental past.

But not all suffering can be put down to unfinished developmental business. Development is a life-long process. Sometimes, predictable developmental phases turn into crises without being exact reproductions of unfinished business. What follows is a consideration of development in adulthood and the crises that may occur.

Crises in adulthood are often life’s turning points, altering the direction and modulating the experiences of the rest of one’s life.

Developmental crises in adulthood are characteristically different from those of early development. Issues of attachment, self-esteem, and eroticism are common to everyone. Of course, not all of us have yet been through every typical adult crisis, but then, we have not finished living yet! Sometimes the client is older than the therapist and is going through crises that the therapist has not yet experienced. When we are working through early developmental issues, even if the therapist is younger than the client and there is a fundamental empathic understanding, there is less possibility of experiential and emotional mutuality. The therapist must, therefore, possess the right combination of relational qualities and information if he is to help the client.

 

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