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TitlePersonality-Disordered Patients: Treatable and Untreatable
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LanguageEnglish
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Table of Contents
                            FRONT MATTER
	TERMS OF USE
	COVER
	COPYRIGHT INFORMATION
	CONTENTS
	PREFACE
1 AMENABILITY TO TREATMENT IN THE REALM OF PERSONALITY DISORDER
2 PERSONALITY DISORDERS MOST AMENABLE TO PSYCHOTHERAPY: BORDERLINE PERSONALITY DISORDER
3 PERSONALITY DISORDERS MOST AMENABLE TO PSYCHOTHERAPY: THE ANXIOUS CLUSTER AND RELATED DISORDERS
4 PERSONALITY DISORDERS OF INTERMEDIATE AMENABILITY TO PSYCHOTHERAPY: BORDERLINE PERSONALITY DISORDER
5 PERSONALITY DISORDERS OF INTERMEDIATE AMENABILITY TO PSYCHOTHERAPY: OTHER PERSONALITY DISORDERS
6 PERSONALITY DISORDERS OF LOW AMENABILITY TO PSYCHOTHERAPY: BORDERLINE PERSONALITY DISORDER
7 PERSONALITY DISORDERS OF LOW AMENABILITY TO PSYCHOTHERAPY: OTHER PERSONALITY DISORDERS
8 PERSONALITY TRAITS AT THE EDGE OF TREATABILITY
9 UNTREATABLE PERSONALITY DISORDERS
AFTERWORD
INDEX
	A
	B
	C
	D
	E
	F
	G
	H
	I
	K
	L
	M
	N
	O
	P
	Q
	R
	S
	T
	U
	V
	W
                        
Document Text Contents
Page 139

130 PERSONALITY-DISORDERED PATIENTS

A 46-year-old man was referred for psychotherapy because of trouble on
two fronts: severe marital conflict and a crisis in his business. Both troubles
stemmed from a common source—his explosive temper and its impact on
all the people whose lives intersected with his. A handsome man with a pow-
erful athletic build, he was a formidable ladies’ man and even more formi-
dable as a competitor in business. The business he owned took him to many
countries, and, like Mozart’s Don Juan, he had liaisons with women in
whichever country he visited. These affairs had led to the downfall of his
two previous marriages but were not the main issue with his current wife.
The problem was his temper. He had few complaints about his wife, but he
hated his in-laws. If she dared to take their side on any issue, he would ex-
plode in anger, call her disloyal, and sometimes hit her. At other times, he
took out his frustrations about work once he got home, and he might over-
turn the dinner table or smash down a door. He could be cordial, even
complimentary, to his employees who performed well. Those whose per-
formance displeased him, however, were subject to his rage and humiliat-
ing remarks.

He was given to mood swings, with mild hypomanic episodes that al-
ternated with occasional but deeper depressions. This pattern was compat-
ible with a diagnosis of bipolar II disorder. His symptoms were not very
responsive to mood stabilizers. In other respects he showed the features of
malignant narcissism (Kernberg 1992, p. 77). Ordinarily cheerful, with a
breezy sense of humor (he referred to his medications as his “M&Ms,” be-
cause they didn’t seem to have much greater effect than those candies), he
could suddenly descend into a profound sadness, crying with remorse if he
had struck his wife the day before.

After he had been in treatment with me for half a year, his tendency to
extremes of mood intensified. He was in the midst of selling his firm, which
offered the possibility of a comfortable retirement if the sale was made or
of more years of ungratifying work if it failed. On one occasion he came
home after a frustrating day with the prospective buyers and lost control
with his wife, hitting her in the face and giving her a black eye. He threat-
ened to kill her, as he had threatened on other occasions, but this time she
was quite frightened. I scheduled an emergency meeting with both of them.
I insisted he live apart for a few days in a kind of cooling-off period, which
he was reluctant to do. I asked his wife to leave, so I could talk with him
alone in the hope of getting my point across. The dialogue went this way:

Patient: Why do you say I have to go somewhere else? I just lost my tem-
per. I could never kill her. She’s my only friend, even though I hate her at
times.

Therapist: You know what? I don’t know you could “never” kill her. You
gave her a black eye. You scared her out of her wits. You smashed the kitchen
door. You’ve been way out of control. And you don’t have to go “somewhere
else.” You can sleep in your office for three or four nights, get hold of your-
self, and then we’ll see.

Patient: I can’t do it. I feel lost without her. Even three days alone.…
I promise I won’t lay a hand on her.…

Therapist: She’s gotta know she’s safe. That’s the first thing. Three days

Page 140

Intermediate Amenability: Other Personality Disorders 131

without her—that’s a small price to pay for making sure nothing bad hap-
pens. You’re a 220-pound weight lifter. She’s a 100-pound woman. You
could accidentally kill her, not even meaning to. They find a married
woman murdered—what do the cops know? Ninety percent of the time it’s
the husband; 5%, it’s the ex-husband. The trial is window dressing. They’d
know it was you. And you’d be looking at 20 years of bad food and no
women. Do the 3 days. If you get lonely, call me.

Cajoling him in this way, I was able to persuade him to spend 4 nights
in his office, by the end of which he had regained his composure and re-
turned to his wife with much better self-control. This was a time of crisis,
and I felt an exhortatory comment—a distinctly supportive intervention,
laced with humor to make it more palatable—was needed. During the sev-
eral years between that crisis and this writing, he and his wife have been on
consistently better terms, and he has kept his promise not to get “physical”
with her, no matter the situation. The outcome at work was not nearly as
good. He remained a tyrannical boss, until he finally did retire, which re-
duced his explosive temper by eliminating the chief source of irritation.

There are many ways of making sense out of this patient’s approach to
life and many concepts derived from various theories of personality devel-
opment that render his behavior understandable. His early years were
marred by a mother who was forever belittling him for being merely a top
student, not the top student. She urged him to be a lawyer and put down his
preference for a business career. In addition, his mother much preferred his
sister and looked down on her husband as “weak” because he earned only
a modest living. The patient grew up forever trying, always in vain, to earn
his mother’s respect, and trying—with success—not to end up in “medioc-
rity” like his father. From a psychodynamic viewpoint, these experiences
could be identified as the seeds of his narcissistic defenses. One could also
see in his philandering—using his charm to seduce women whom he then
emotionally wounded by dumping them and going on to another—an end-
less cycle of getting women to care about him, as he could never do with
his mother, and of then exacting his revenge on these mother surrogates (as
he unconsciously regarded them).

But I am also drawn to an explanation in the language of cognitive-
behavioral schema theory, as set forth by Jeffrey Young et al. (2003). In their
understanding of narcissistic personality, they draw attention to three
prominent schemata: the lonely child, the self-aggrandizer, or the detached
self-soother. As the “lonely child,” the narcissistic person struggles against
emotional deprivation and comes to utilize a coping style of overcompen-
sation accompanied by feelings of entitlement, which leads such persons to
“demand much and give little to the people closest to them” (Young et al.
2003, p. 374). These authors went on to say that narcissistic persons typi-

Page 277

268 PERSONALITY-DISORDERED PATIENTS

Prognosis, and amenability to
psychotherapy, 70–74

Psychic murder, 250–252
Psychoactive substances, 3
Psychoanalytically oriented therapy,

51
Psychodynamic psychotherapy, 52,

119
Psychological mindedness, 41
Psychopathic personality, 25, 27, 221–

244, 222
evaluation of treatment, 239–240
treatability factors, 258

Psychopathy, 222
genetic predisposition to, 231

Psychopathy Checklist—Revised. See
PCL-R

Psychotherapies for personality
disorder, 119

Quarrelsomeness, 201–203

Resistance, 103–104
Reward deficiency syndrome, 110
Reward dependence, 28
Roman emperor syndrome, 232

Sadistic personality, 27, 237–239, 258
Sadistic personality disorder, 230
Sangfroid, 55
Schizoid personality, 26, 119
Schizoid personality disorder, 49,

121–123
Schizotypal personality

dream analysis with, 70
relevant literature, 119

Schizotypal personality disorder, 49,
118–121

Self-centered narcissistic patients, 179
Self-defeating personality, 50, 88–92,

125, 127–129. See also Depressive-
masochistic personality

Self-destructive behaviors, 56
in BPD, 51–52

Self-directedness, 28, 29
Self Psychology approach, 51
Self-transcendence, 19, 20–21, 28
Semantic memories, 153
Sensation-seeking, 203–205
Serial killers, 232, 233–240. See also

Murderers; Parental factors in
psychopathic personality; Sadistic
personality; Tyrants

Serotonin system, 82
Seven Deadly Sins, 20
Sexual trauma, 24–25, 106–107, 114–

115
Short-term therapies

relevant literature, 119
“Skinheads,” 196, 239, 259
Soul murder, 247, 250–252
Spectrum of treatability, 220
Spirituality, 19–22, 41–42
Spitefulness, 205–208
Splitting, 33
Substance abuse, 140, 145–149
Suicidality, living circumstances and,

32
Suicide gestures, manipulative, 50
Supportive-expressive therapy, 57
Supportive therapy, 51
Symptom disorders, 38–40, 42, 110
Symptoms, 3, 82

Temperament, 8–9, 28
Therapist factors

with BPD, 54–59, 140
“clicking,” 140
with paranoid patients, 171–172

Traits. See Personality traits
Transference, 100
Transference-focused approach, 51,

177
Trauma, 24–25, 164–166. See also

Sexual trauma
Treatability factors

in BPD patients, 102–103, 138–
166, 139

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