Three papers were presented that were indicative of two major trends in psychoanalysis at the present time: the need to demonstrate the validity and reliability of research into psychotherapy and the need to mesh psychoanalytic thinking with new knowledge of the neurobiological substrate of the mental apparatus. In addition, the recent tendency to “re-Kraeplinize” psychiatry was manifested in some of the work presented at the panel.
The first paper was “Towards a Total Inventory of Personality” by Michael Stone. Using borderline personality disorder as an example, Stone notes that personality types in DSM-III, in earlier studies, can be viewed as dimensions along which any person can vary. He feels that by refining this characterological approach he can make a contribution to determinations of outcome. He does this, listing a larger array of traits, positive, and negative.
He has devised a category of 76 traits in all, of which 36 are “troublesome to other people” and 14 are traits “troublesome primarily to the self.” He uses a Personality Profile Scale based on these traits to evaluate his borderline patient population and believes this is useful generally in the personality disorders to capture all aspects of personality, negative and positive, that could have some bearing on outcome of psychiatric disorder, including those category-defined personality disorders of DSM-III.
To quote him:
[U]se of the more complete trait-list, from which part of the scale (the negative trait section) was derived offers clinicians a way of looking in greater depth at the particularities of the maladaptive side of patients whom they are evaluating. It may also enhance the clinicians' alertness to the existence of traits that might have been overlooked. In particular chronic anger-hostility, dishonesty and contempt are major impediments in all types of psychotherapy.”
Harold Koenigsberg presented a paper entitled “A Method of Analyzing Therapist Interventions in the Psychotherapy of Borderline Patients.” Stating that outcome studies have shifted from broadly defined treatments to the study of process-outcome relationships in psychotherapies that are carefully delineated, he and his colleagues are attempting to find a reliable and clinically relevant way to analyze therapist interventions. He feels that it is thereby possible to study the relationship between outcome and specific psychotherapeutic techniques, the effect of the therapist's actions on the emerging therapeutic process, the extent to which the therapist is actually carrying out the prescribed treatment, and the
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assessment of the therapists skills. He states that manuals for psychodynamic psychotherapy and even for psychoanalysis can be devised and will “operation-alize therapist interventions.”
The group doing this study employs a systematic approach to the treatment of borderline patients developed by them earlier. The current paper is an attempt to find a method to evaluate whether therapists are following the precepts of this treatment approach and how successful the interventions have been.
A manual incorporating their psychodynamic psychotherapy for the treatment of severe outpatient or hospitalized borderline patients has been developed, and described in an earlier paper, using the ego-psychology-object-relationship approach of Kernberg. They admit, however, that “skilled conduct of psychotherapy is a function of many therapist variables in addition to the use of an array of appropriately selected and timed interventions, e.g., tact, empathy, warmth, ability to recognize thematic patterns, toleration of affects, and clear use of language.” These they intend to study in another paper.
They employed core techniques of expressive psychotherapy—clarification, confrontation, and interpretation—in a setting that protected their patients from destructive acting-out, employing a verbal treatment contract and using limit setting in instances of poor impulse control.
A computer-generated profile has been developed to score transcripts of psychotherapy sessions for major session themes, form of therapist intervention, and thematic direction. Objective ratings of their data that are reliable and valid can be obtained by more than one individual, they believe. In addition they feel that they have established a method for rating the appropriateness of the therapist's diagnosis and interventions with respect to those themes, and the extent to which the interventions are supportive or interpretive. This measures the therapist's adherence to the technical method prescribed in their treatment manual for borderline patients, and aspects of the skill in carrying out this technique.
Michael Robbins in a paper entitled “Psychoanalytic and Biological Approaches to Mental Illness: Schizophrenia” deals with “the powerful contemporary thrust not merely to elucidate the biology of normal and pathological thinking and behavior, but to reduce phenomenology of mind and meaning to an organic essence and pronounce the role of disciplines such as psychoanalysis which respect the functional autonomy of mental processes obsolete.” He proposes a model in which biological and psychoanalytic theories of mental theories not only exist but complement one another. He disputes that mental phenomena can be reduced to their material elements and that the whole is a sum of its biological parts. Schizophrenia, like other mental phenomena, “represents unique organizations at a different level of complexity which require new concepts and principles.”
Additive thinking, he feels, is no more satisfactory than reductionist thinking, for example, as in trying to speculate on the interaction of genetic and environmental factors, since it “overlooks crucial distinctions between scientific systems.” He prefers the “pluralistic notion of a model hierarchy, from which perspective mental illness can be considered from either frame of reference, organic or psychological, depending on one's purpose at the time.”
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Robbins is distressed by the current Kraepelinian climate in which case discussions ignore and confuse the two frames of reference. In schizophrenia, he states, genetic relationships do not explain why individuals genetically at risk do not develop schizophrenia, and points out those authors who concede the etiological importance of developmental factors. He notes, as have others, the factor of premorbid vulnerability, as described by Zubir and others. “The pre-schizophrenic must negotiate the same developmental task and social/interpersonal stresses as others, but their meaning to him and his mode of resolution may differ because of constitutional differences in his psychic makeup … in the context of … early object relations.”
He postulates a reparative mother who preventsschizophrenia by instituting psychological changes. In addition, clinical data often obscure the early presence of psychotic pseudomutuality skew, in which psychotic functioning is required for psychological survival because it protects other family members from having to deal with realistic feedback. This system only becomes manifest when the now-patient has to leave the compensatory symbiotic cushion of the family, and undergoes an adaptive disequillibration. This is compounded by regression, which is viewed as secondary to social pressures that define continuation of the lifestyle as abnormal.
Robbins postulates four characteristic preschizophrenic personality traits that he believes show the interaction of psychogenic and constitutional factors: (1) aversion to object relations, (2) hypersensitivity to stimuli, (3) difficulties with voluntary attention and concentration and poor integration, and (4) mental nihilism—“an urge towards mindless and emotionless states of mental oblivion and a powerful reluctance or version to mental work, encompassing fear, anger, sadness and despair, and also loving and erotic arousal.” Here he notes instances of family interactions that affected an underlying organic tendency in the same direction.
He explores the ways in which the organic substrate of schizophrenia will modulate the therapeutic intervention, since cognitive and affective differences and symbiotic relations will mold the transference. Effective compensatory structures, in both a psychoanalytic and organic neurological sense, he feels, must develop for cure. There is a question as to whether there is a critical period of development beyond which this cannot occur. There are many unanswered questions.
The discussant, Gerald Sarwer-Foner, noted that the definition of “borderline” was broader than is customary in the two papers that dealt with borderlinepersonalitystructure. Discussing Stone's paper, he says “It was no surprise, therefore, that in such a broad categorization one would find some individuals who can relate and test reality in a relative sense even when psychotic.… In this context … categorizations of the patients' personality traits, their capacity to relate or not relate, their capacity to withstand aggression, their capacity to need isolation at certain times, and the recurrent cycles of this is a worthwhile exercise.” He found similar merit in the Koenigsberg paper. In discussing Robbins's paper he praised his mastery of the difficulties involved in combining the psychoanalytic
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and biological frames of reference in the treatment of schizophrenic patients. He pointed out, however, that a sicker and unselected group, the Chestnut Lodge McLaughlin surveys, showed 25% remission, and that Robbins's results might reflect his selection process of patients with whom he had made a conscious decision to intervene.
Seymour Post agreed that studies of the validity and reliability of research in psychotherapy were essential, since they will be reflected in the attitude of the public and third-party payers to our efforts. He agreed also with Sarwer-Foner in praising Robbins's attempt to meld psychoanalytic and biological frames of reference. He found his model of the interaction between the two worthy of further study. The findings of neurobiology that mental (interpersonal) changes are associated with changes in the brain empowers psychoanalysis to attempt to comprehend and treat mental conditions. Robbins's observations about the constellation of qualities that define schizophrenic youngsters in a family setting are deserving of our interest and further study to confirm his findings.
Post also noted that Robbins appeared to have refined the Fromm-Reichmann concept of the “schizophrenogenic mother” under the influence of systems theory toward a concept of a “schizophrenogenic” family structure. Robbins's theoretical conceptualization depends ultimately on clinical evidence for its proof, and it is here that the paper shows a flaw. Post noted that the clinical results that Robbins believed to validate his theoretical conceptions required corroboration by his peers, noting that declaration of cure in extremely sick patient populations had proven treacherously unpredictable in the past.
Post also deplored the tendency to “re-Kraeplinize” psychiatry, stating that the conflict-resolution model as described by Arlow and Brenner was, for him, a more satisfactory way to deal with the vast array of possible characterological variations that can develop in the human than the descriptive variations, no matter how numerous the categories, that are currently in vogue. Studies using this method, while more complex and almost impossibly difficult, may prove more rewarding in the long run.
Audience response to the excellent papers was most appreciative.
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Post, S.C. (1991). 34th Winter Meeting. J. Am. Acad. Psychoanal. Dyn. Psychiatr., 19(3):484-487