Fragile Selves: Working with Narcissistic and Borderline States of Mind

In this talk Professor Jeremy Holmes surveys the great analytic and literary thinkers on narcissism, providing a sense of the condition’s unconscious origins, it’s pathological development in childhood and giving examples of its appearance in life, the therapy room and in stories from Eastern and Western Culture. Following Kohut’s notion of the parental task being to offer ‘optimal frustration’ to the child, Professor Holmes concludes that the therapeutic challenge in repairing narcissistic wounding is to ‘walk the line’ offering a deep empathy that is nevertheless tempered by challenging the patient’s isolating self-centredness and illusion of self-sufficiency.

Audio lecture – 50 mins

Pathological narcissism can be interpreted as a defence against the terror of fragmentation, a fear Kohut referred to as, ‘the deepest anxiety a man can experience.’ Drawing on ideas from Lacan, Bollas, Kohut and Buddhist philosophy, Dr Phil Mollon suggests that we all bound to make identities from the culture we are all born into, the images others have of us in their minds.

However, pathological narcissism develops because there is no negotiation at all between the infant’s own nascent grandiosity and his mother’s idea of her perfect baby. This causes the infant to split off his own grandiosity and a personality develops that swings between self-regard and self-denigration in an ongoing effort to avoid the psychotic outbreak of a still fragmented underlying psychic structure.

Audio lecture – 45 mins

Neville Symington’s hopeful view of narcissism is linked to his spirituality. Narcissism is rooted in a turning away from that which should be nurturing. Paranoia, projection and self-destructiveness all stem from a quite reasonable rejection by the infant of the demands of the ‘guilty adult’. His clinical examples show how the therapeutic encounter can convert isolating perceptions and affects into genuinely creative and transformative experiences.

Audio lecture – 50 mins

In this joint talk, couples’ therapists Susanna Abse and Jenny Riddell focus in on the mutual dependence inherent in the myth of Narcissus and Echo. Sharing examples from their clinical work, they detail how working with couples has led them to think more about the role of Echo, or the ‘thin-skinned’ narcissist in the problematic dynamics that couples encounter and seek to resolve.

Audio lecture – 45 mins

Dr. Mizen presents her theory of a neurobiological and developmental pathway for symbolisation and its failures in those with borderline presentations.

Her ‘Relational Affective Hypothesis’ describes how neurobiological mechanisms promote mother infant interaction launching a developmental process through which the ability to symbolise emerges. Triangulation, which is key to developing the capacity to symbolise, may fail through relational or the psychodynamic defence mechanism of projective identification leading to a concrete emotional world and a disordered sense of physical and psychological identity.

The result is the emergence of two conflicted states of mind and patterns of interpersonal relating which give rise to the affective instability and impulsiveness of people with a diagnosis of borderline personality disorder and a disordered sense of what belongs to whom.

Video lecture with slides – 45 mins

Borderline Personality Disorder (BPD) is a severe disturbance of personality-functioning. It is characterised by affect and impulse-control disturbances associated with deficits in emotion regulation, as well as a pervasive pattern in self-image and persistent difficulties in interpersonal relationships. Current models of the aetiology and adaptive dysfunction of BPD are now converging as an attachment disorder that formed in the first years of life. These patients commonly experienced abusive and neglectful developmental backgrounds, a growth-inhibiting relational environment not only for social-emotional development but for early brain maturation.

Models of developmental psychopathology suggest that borderline attachment histories alter the development of regulatory cortical-sub-cortical limbic-autonomic circuits of the early developing right brain. In line with these models, a number of recent neurobiological studies now show right brain and orbitofrontal deficits in BPD patients. The clinical relevance of this documented maturational failure for diagnosis and treatment is discussed in the light of research.

Audio lecture with slides – 1 hr 40 mins

With reference to various theorists, Dr Clara Mucci argues that the most severe personality disorders develop when an infant is traumatised early in life. Trauma inhibits normal infant brain development, causing borderline symptoms of impulsivity and unstable mood. It also warps the infant’s sense of self, leading to narcissistic symptoms of aggression, grandiosity and shame.

Video lecture with slides – 40 mins

In this talk, Dr Diana Diamond describes the attachment style underlying borderline and narcissistic disorders. These have been identified over a randomised control trial of patients who exhibit either or both personality characteristics. BPD is linked primarily to preoccupied and/or unresolved attachment and NPD with dismissing/or cannot classify attachment representations in which the individual oscillates between dismissing and preoccupied attachment strategies.

Audio lecture – 55 mins

In these talks Dr David Celani outlines Fairbairn’s pioneering model which describes how object relations influence personality development. He has found this particularly useful in the treatment of borderline patients who are generally considered difficult and unrewarding to work with.

Fairbairn’s Ideas
Video lecture with slides – 35 mins

Fairbairn’s Structural Model and Examples
Video lecture with slides – 45 mins

Treating the Hysteric, Obsessive and Narcissist
Video lecture with slides – 45 mins

Case Study: Clumsy Guy
Video lecture – 10 mins

Referencing a detailed case study Jay Greenberg explains Freud and Winnicott’s differing attitudes to the viability of working with and overcoming narcissistic defences. Greenberg outlines his encounters with a particular patient whose responses showed her need to remain unaffected by his interpretations. He suggests that whilst narcissistic patients are severely provoked by a therapist who can withstand their aggression, only therapists who are unafraid to differentiate from these patients really have anything to give them.

Video lecture with slides – 45 mins

Phil Mollon uncovers the core feelings which are the source of problematic narcissistic behaviour. He uses illustrations from the work of Heinz Kohut, whose case studies show how patients’ dreams, sexual fantasies and perversions can all provide clues to the childhood events that caused their narcissistic wounding.

Video lecture with slides – 50 mins

Frank Lachmann believes that infant research shows that how we perceive, remember, feel and behave are relationally co-created between child and caregiver. He argues that when we combine this understanding of early development with knowledge of the organisation of the mind and transference, new therapeutic possibilities emerge. Deep, enduring change occurs when therapist and client are affectively related. This is especially true for narcissistic patients who have difficulty connecting to and bonding with others. Working with such patients can also evoke negative feeling in the therapist which can sabotage the process.

Despite the challenges of working with affect and showing empathy, Lachmann argues that integrating these aspects into treatment is deeply transformative, especially so for these patients who have deep early developmental deficits and who have been traditionally seen as ‘treatment resistant.’

Video lecture – 55 mins

In this talk Ruthie Smith explains how a person with a disorganised attachment (Type D) has suffered from wounding and complex attachment trauma in early infant development, which adversely affected their subsequent personality development. Such clients attract less empathy than those with other emotional difficulties or behaviours, not least because as a result of their fragmentation and weak ego boundaries, they unconsciously project painful and uncomfortable feelings into others. Clients who exhibit disorganised attachment patterns have traditionally diagnosed as suffering from ‘borderline personality disorder’.

Ruthie proposes that it is helpful to view and work with this client group through the lens of trauma, working with the body as well as the mind. Good results in facilitating affect-regulation and gradually transforming relational patterns have been found using Energy Psychotherapy techniques in combination with talking therapy, which can also be used as self-help tools by the client. Since these methods work at the level of cellular memory in the body they have the capacity to help break down otherwise seemingly intransigent patterns, although this is long term and complex work. Ruthie’s talk is informed by neurobiology.

Video lecture – 1 hr 30 mins

In this talk, Jack Nathan describes how BPD symptoms present and how therapists can best support those with these behaviours. He makes the case for the use of benign authority – an approach where the practitioner attunes to the ‘logic’ of the borderline’s internal experience, whilst also attending to challenging persistent acting out behaviours, through limit setting. There is always a dialectical tension between these two functions.

In the face of the challenges the borderline patient can pose, benign authority can support the therapist in not succumbing to the twin dangers of, on the one hand a ‘maternal’ masochism, and on the other, ‘paternal’ sadism.

Audio lecture with slides – 30 mins

Working with Borderline Personality Disorder (Lola)

In this video, Dr Hepple demonstrates the main features of Cognitive Analytic Therapy when working with a Borderline Client. CAT has been taken up widely within the NHS as although it is time-limited it has shown itself to be very effective in alleviating these patient’s distress and promoting improved self-management and self-care.

Video Role Play – 30 mins

Working with Narcissism (Kenneth)

In this video, Dr Hepple demonstrates the main features of Cognitive Analytic Therapy when working with a Narcissistic Client. CAT has been taken up widely within the NHS as although it is time-limited it has shown itself to be very effective in alleviating these patient’s distress and promoting improved self-management and self-care.

Video Role Play – 30 mins

In this interview, Elizabeth Wilde McCormick explains the characteristics of the borderline personality within the framework of Cognitive Analytic Therapy (CAT). Grounded in the cognitive revision of object relations theory, a central tenet of CAT is that from birth we all internalise a complex web of relationships which CAT names as reciprocal roles. Until revised these roles may dominate our adult relationships and are likely to be acted out in therapy, which is where the valuable work of noticing and choosing to change may be invited. Patients who are described as borderline tend to have reciprocal roles related to neglectful early care such as abusing/attacking in relation to abused and attacked. The resulting deep emotional states may shift suddenly in response to perceived threat and this is likely to be enacted during a therapy and is an essential form of communication. It is the therapeutic work to contain and name the different states and create safety and this is challenging for therapists who often feel deskilled, confused, afraid or angry.

Elizabeth elaborates her understanding of how these states operate within the psyche as ways of managing difficult feelings that cannot be otherwise described. In the early stages, the therapeutic work is simply that of recognition of what is being felt or enacted. By developing an observer-self, who learns to recognise these emotions, it becomes possible to find language for them – the key to containment. Ultimately, clients become more able to tolerate relationships, to be less reactive and more responsive.

Video lecture – 35 mins

Marcus West and Dr Anne Alvarez discuss contemporary questions around the diagnosis and treatment of so-called Narcissistic and Borderline Personality Disorders. They also share some of the therapeutic tips and pitfalls they have learnt from their extensive but different experiences of working with adults and adolescents.

Video discussion – 1 hr 5 mins