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Handbook of Dynamic Psychotherapy for Higher Level Personality Pathology
This book provides an approach to understanding and treating higher level personality pathology. It describes a specific form of treatment called "dynamic psychotherapy for higher level personality pathology" (DPHP), which was designed specifically to treat the rigidity that characterizes that condition. Handbook of Dynamic Psychotherapy for Higher Level Personality Pathology provides a hands-on approach to a treatment method that offers a broad range of patients the opportunity to modify maladaptive personality functioning in ways that can permanently enhance their quality of life.
The authors provide a clear, specific, and comprehensive description of how to practice DPHP from beginning to end, presented in jargon-free exposition using extensive clinical illustrations. Throughout, the book emphasizes fundamental clinical principles that enable the clinician to think through clinical decisions moment-to-moment and also to develop an overall sense of the trajectory and goals of treatment. Taking a diagnosis-driven approach, the book describes goals, strategies, tactics, and techniques, demonstrating the flexibility of the approach across a relatively long course of treatment. Finally, the authors provide a sophisticated discussion of integrating dynamic psychotherapy with medication management and other forms of treatment.
The authors provide a clear, specific, and comprehensive description of how to practice DPHP from beginning to end, presented in jargon-free exposition using extensive clinical illustrations. Throughout, the book emphasizes fundamental clinical principles that enable the clinician to think through clinical decisions moment-to-moment and also to develop an overall sense of the trajectory and goals of treatment. Taking a diagnosis-driven approach, the book describes goals, strategies, tactics, and techniques, demonstrating the flexibility of the approach across a relatively long course of treatment. Finally, the authors provide a sophisticated discussion of integrating dynamic psychotherapy with medication management and other forms of treatment.
284 pages, Hardcover
First published February 5, 2007
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August 22, 2023
This is a practical handbook in a specific form of psychodynamics; that is the psychodynamic of higher personality pathology (DHPP). DHPP is the practical application of object relation theory which mainly expanded and systematized by Otto Kernberg.
Object relations theory stipulates that a pathological personality structures tends to split off their internal self experiences and conflicts to the external objects. Instead of being able to internalized and thus allowing for ruminations, these patients dissociates, projects and splits their pathos to the external objects which give rise to free-floating frustrations and anxieties. There’s a corrosion to the concept of identity and wholesale crumbling of integration of inner experiences. Some would call this as possessing an external locus of control. As Epictetus rightly observed, try to control the things you will never control, you will be forever in despair.
But this is exactly the pathos of these personality disorder patients. Their organizations has become rigid and inflexible; most of the patients already possessed these maladaptive traits during their adolescents; the most formative and plastic years of psychological and neurological development. And this is what make managing these cases as extremely difficult. A patient with personality disorder has poor prognosis; imagine managing a personality disorder patients with a comorbid other psychiatric conditions.
I have encountered 2 extremely difficult cases in the terms of personality disorder comorbid with other psychiatric disorders. The first case is a 65 years old (!!) female who is a wife of an extremely well-to-do and influential businessman who was admitted for a third allegedly suicidal attempt this year. She was previously managed as major depressive disorder, but as I flipped through her clinic notes for the past 10 years, there’s a prevalent trend of soft bipolarity through out the course of her illness; with further close history-taking, we were able to pinpoint a hypomanic episode and revised the diagnosis to bipolar type II mood disorder. Previous medications on escitalopram, duloxetine and augmentation with cariprazine was ineffective. Changed the medications upon revision of diagnosis to quetiapine showed immediate improvements in term of her mood and sleep.
The suicidal attempts was then seen in a new light; they were impulsive actions from undiagnosed hypomanic/cyclothymic personality. The trigger was the house; it was the house who in a way has turned into a haunted house that haunted her. Explorations of her childhood history revealed her as an ambivalent child who oscillates between dependant and avoidant organizations. She married her childhood sweetheart (which was the husband), and after the business took off, the husband built a house. Of course, the husband asked for her opinion in the planning of the constructions, but she was too afraid to give any opinions lest her opinion would make the house ugly etc. But when the house is erected, she was perplexed from her extreme repulsion while living in the house. The house became an edifice of her ambivalence; to everyone bewilderment, she insisted for the washing machine to be put in the porch.
My encounter with her initially was greeted with heavy resistance from her. I have arrived to a general idea of the house becoming the perpetual bogeyman, and also her underlying obsessive trait, on top of her avoidant-dependent traits. The position of the washing machine is significant, as putting it in the porch, would mean quite literally, “airing your dirty laundery” to everyone’s eyes. And so, I pointed to her what is the difference between a house and a home. She was astounded from my question and immediately clamped off.
To me, it is sufficient that I have identified the theme, the story the patient wants to present, the next step would be a downstream intervention; talking with the family members, mending her relationship with her estranged husband etc. Medications also helped in terms of allowing the stabilization of her mood and thus allowing for better judgment and introspections. By the final family session, she pointed to her husband and said to me, “That is my home”.
She was discharged subsequently. A recent follow-up showed that she is taking charge in her life more, notedly endorsing a large-scale renovation to bring in the washing machine into the home now (her husband has no problem at all with the money).
Thus, while not exactly applying the principles of DHPP, the aim for the therapy is to make the personality organization as less rigid and more flexible. The projection of the patient’s pathos must be made conscious to the patient, and to allow patient to make connection to it, thus transforming it from a previously mystical and visceral connections to a much less overwhelming and material experience.
The principles behind all psychodynamics is cure by transference; that is by inducing catharsis by bringing to light and under rational scrutiny of the unresolved conflicts.
Definitely, I don’t see making a career out from analyzing personality disorder patients, for it would be much of a hassle. But as it is a component that made management much more challenging, it is reasonable for all psychiatrist to get a hold on how to tackle personality disorders.
Object relations theory stipulates that a pathological personality structures tends to split off their internal self experiences and conflicts to the external objects. Instead of being able to internalized and thus allowing for ruminations, these patients dissociates, projects and splits their pathos to the external objects which give rise to free-floating frustrations and anxieties. There’s a corrosion to the concept of identity and wholesale crumbling of integration of inner experiences. Some would call this as possessing an external locus of control. As Epictetus rightly observed, try to control the things you will never control, you will be forever in despair.
But this is exactly the pathos of these personality disorder patients. Their organizations has become rigid and inflexible; most of the patients already possessed these maladaptive traits during their adolescents; the most formative and plastic years of psychological and neurological development. And this is what make managing these cases as extremely difficult. A patient with personality disorder has poor prognosis; imagine managing a personality disorder patients with a comorbid other psychiatric conditions.
I have encountered 2 extremely difficult cases in the terms of personality disorder comorbid with other psychiatric disorders. The first case is a 65 years old (!!) female who is a wife of an extremely well-to-do and influential businessman who was admitted for a third allegedly suicidal attempt this year. She was previously managed as major depressive disorder, but as I flipped through her clinic notes for the past 10 years, there’s a prevalent trend of soft bipolarity through out the course of her illness; with further close history-taking, we were able to pinpoint a hypomanic episode and revised the diagnosis to bipolar type II mood disorder. Previous medications on escitalopram, duloxetine and augmentation with cariprazine was ineffective. Changed the medications upon revision of diagnosis to quetiapine showed immediate improvements in term of her mood and sleep.
The suicidal attempts was then seen in a new light; they were impulsive actions from undiagnosed hypomanic/cyclothymic personality. The trigger was the house; it was the house who in a way has turned into a haunted house that haunted her. Explorations of her childhood history revealed her as an ambivalent child who oscillates between dependant and avoidant organizations. She married her childhood sweetheart (which was the husband), and after the business took off, the husband built a house. Of course, the husband asked for her opinion in the planning of the constructions, but she was too afraid to give any opinions lest her opinion would make the house ugly etc. But when the house is erected, she was perplexed from her extreme repulsion while living in the house. The house became an edifice of her ambivalence; to everyone bewilderment, she insisted for the washing machine to be put in the porch.
My encounter with her initially was greeted with heavy resistance from her. I have arrived to a general idea of the house becoming the perpetual bogeyman, and also her underlying obsessive trait, on top of her avoidant-dependent traits. The position of the washing machine is significant, as putting it in the porch, would mean quite literally, “airing your dirty laundery” to everyone’s eyes. And so, I pointed to her what is the difference between a house and a home. She was astounded from my question and immediately clamped off.
To me, it is sufficient that I have identified the theme, the story the patient wants to present, the next step would be a downstream intervention; talking with the family members, mending her relationship with her estranged husband etc. Medications also helped in terms of allowing the stabilization of her mood and thus allowing for better judgment and introspections. By the final family session, she pointed to her husband and said to me, “That is my home”.
She was discharged subsequently. A recent follow-up showed that she is taking charge in her life more, notedly endorsing a large-scale renovation to bring in the washing machine into the home now (her husband has no problem at all with the money).
Thus, while not exactly applying the principles of DHPP, the aim for the therapy is to make the personality organization as less rigid and more flexible. The projection of the patient’s pathos must be made conscious to the patient, and to allow patient to make connection to it, thus transforming it from a previously mystical and visceral connections to a much less overwhelming and material experience.
The principles behind all psychodynamics is cure by transference; that is by inducing catharsis by bringing to light and under rational scrutiny of the unresolved conflicts.
Definitely, I don’t see making a career out from analyzing personality disorder patients, for it would be much of a hassle. But as it is a component that made management much more challenging, it is reasonable for all psychiatrist to get a hold on how to tackle personality disorders.
May 30, 2021
Sehr wertvolles Buch in großartiger Übersetzung
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