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Interpretation itself has several phases, corresponding to the beginning phase of therapy. During interpretation, patient and therapist work to understand the nature of the patient's disturbed object relationships by the "unconscious meanings of their behavior in their transferential relationship with the therapist" (McGinn, 1998, p. 192) the first phase of interpretation is a time for exploration and free association; at this point, the patient is expressing and the therapist is formulating the meanings of those expressions in terms of object relations. This is followed by an "empathic confrontation," in which the therapist gently guides the patient's maladaptive unconscious object relations into consciousness. Once the patient is conscious of his behaviors, the final phase of interpretation can take place, which is sometimes called a "genetic interpretation" (McGinn, 1998, p. 192). This is when the therapist "uses his interpretations of the current relationship between himself and the patient and links it to unconscious meanings from the patient's past" (McGinn, 1998, p. 192). The purpose of interpretation is to provide the background information and understanding necessary for successful transference work.
The present relationship between therapist and patient is the basis for a second technique common to or therapy -- transference analysis -- corresponding roughly to the middle stage of therapy. It is assumed that all patients will begin to "transfer" pathological relationship patterns (object relations) from their past onto the therapist, allowing the therapist to analyze what is going wrong outside of therapy based on what occurs in-session (McGinn, 1998). This is somewhat overlapping with interpretation, but at this point the therapist needs to gradually take on a stable role as a "good-object" for the patient. Then, using his prior interpretation, the therapist can tie the patient's symptoms and treatment goals to one or more overriding themes of abnormal relating (McGinn, 1998). The trustworthy, good-object stance of the therapist will then allow patient and therapist to bring these abnormal behavior patterns into consciousness, where they can hopefully be redefined and reworked into healthier object relations during the final phases of therapy.
The role of the therapist
The role of the or therapist is different from traditional psychoanalysts in that he is expected to show a degree of empathy for the patient's traumatic past and dysfunctional patterns of relating. The patient is likely very frightened, on a primitive level, of bringing his "split-off" object relations into consciousness where they can be confronted and transformed; the therapist needs to be gentle and understanding in order to facilitate successful transference and conscious integration of the self. In addition, the or therapist must work to keep his own countertransference emotions (the reactions and emotions he experiences as a result of being the target of the patient's transference), conscious and in check (McGinn, 1998). If the therapist doesn't successfully maintain his stance as an objective, neutral transference object, he may become just another "all-bad" object relation to the patient, and therapeutic efforts will be thwarted.
Finally, as mentioned earlier, the therapist must be schooled in recognizing the responding appropriately to the various primitive defense mechanisms a patient will exhibit, such as projection, introjection, splitting, dissociation, etc. The therapist must act as a guide, steering carefully around complex and counterproductive defense mechanisms, in order to bring the patient to a point where he can see the truth behind his disorder as a result of personal insight (Murdock, 2009).
I believe this model of therapeutic treatment, based on or theory, will be an excellent fit for my plans to work with adults with axis-two personality disorders. I personally find the object relations paradigm of the development of the self to be highly understandable and applicable to any form of personality disorder. In particular, I agree with Otto Kernberg's take on the very difficult to treat borderline patient, in terms of those patients' severe splitting between good people and bad people, and in terms of the borderline patient being "stuck" in an immature, black and white, paranoid-schizoid point-of-view.
The challenges I face will apply to all patients with personality disorders. In very general terms, I will be dealing with patients who not only initially see me and treat me as "all-bad" or "all-good," but who are very skilled at manipulating others to behave and react in ways they find familiar. I will have to be very aware at all times of these defense mechanisms, to ensure that I react appropriately and helpfully. For example, a patient who has internalized abusive tendencies from a parent may in turn "attribute those abusing tendencies to the therapist and unconsciously provoke in the therapist such abusive feelings toward them (McGinn, 1998, p. 192). This can happen in very subtle and sneaky ways, particularly with certain personality disordered individuals, so I will have to remain vigilant. Neutrality and empathy will not always be easy, but they are critical to my success as a therapist.
Buckley, P. (1996). An Object Relations Perspective on the Nature of Resistance and Therapeutic Change. American Journal of Psychotherapy, 50 (1), 45+.
Buckley, P. (1994). Self-Psychology, Object Relations Theory and Supportive Psychotherapy. American Journal of Psychotherapy, 48 (4), 519+.
Knight, Z. (2006). Some Thoughts on the Psychological Roots of the Behavior of Serial Killers as Narcissists: an Object Relations Perspective. Social Behavior and Personality, 34 (10), 1189+.
McGinn, L. (1998). Interview: Otto F. Kernberg, M.D., F.A.P.A., Developer of Object Relations Psychoanalytic Therapy for Borderline Personality…[continue]
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