Treatment of narcissistic and borderline disorders in marital therapy: Suggestions toward an enhanced therapeutic approach

This paper examines a psychodynamic model of marital therapy that has been found to be useful when one or both partners suffer from disorders of the self. The theories of Heinz Kohut and recent self psychologists give insight into ways of understanding and treating each partner's narcissistic vulnerabilities. Some specific aspects of borderline and narcissistic disorders are described and discussed within the context of a marital relationship. This method of marital therapy not only helps couples to learn how to be selfobjects for each other, but also may facilitate rebuilding of damaged structures of the self. A case example is provided along with a discussion of why certain specific therapeutic interventions were made.I have no hesitation in claiming that there is no mature love in which the love object is not also a selfobject. Or, to put this depth-psychological formulation into a psychosocial context: There is no love relationship without mutual, self-esteem enhancing, mirroring and idealization (Kohut, 1977, p. 122).     

DEPRESSION IN MATURE MARRIAGES: IMPACT AND IMPLICATIONS FOR MARITAL THERAPY

Recent reviews of MFT literature have shown a failure to address mental health issues of the aging. Chief among these issues is depression, one of the most common psychological disorders found in older people. Although the relationship between depression and aging is a well-researched topic, few studies approach this common problem from a systemic perspective. Using data from a national survey of preretirement- and retirement-aged couples, this paper discusses the association between depression and marital quality in mature marriages as well the possibility of mediating variables such as the personality construct hardiness. Implications for marital therapy with older couples experiencing depression and future research are discussed.     

Reconsidering Therapeutic Neutrality

In recent decades, with the emergence of postmodern philosophies and of relational psychoanalysis, therapeutic neutrality has come under challenge as being both an impossible and an undesirable analytic stance. This article explores recent understandings of transference and of therapeutic neutrality; the position of those relational psychoanalysts who posit that explicit use of intersubjectivity is the central treatment vehicle of psychoanalysis; and presents material from the treatment of an individual with a borderline personality disorder, using the developmental, self, and object relations approach of James Masterson, to illustrate some potential dangers of abandoning a neutral stance when treating such clients.     

African American and European American Women's Marital Well‐Being

Using a sample of 247 African American and European American women in their 3rd year of marriage, this study compared the predictors of marital well‐being for each group by focusing on the influences of individual, interpersonal, and social and economic resources. Regression analyses revealed that emotional health (individual), trusting one's spouse (interpersonal), and feeling underbenefited in the relationship (interpersonal) were significant predictors of marital well‐being for both groups of women. Physical health (individual) and in‐law relations (social and economic), however, affected the marital well‐being of only African American women. Findings from this study suggest the need to examine marital well‐being within the context of race.     

Anxiety Disorders and Family Therapy

The role of family therapy in anxiety disorders is controversial. Empirical data exist only in relation to agoraphobia and obsessive compulsive disorders. Experienced clinicians, generally working with complex cases, regard marital and family conflict as central to many cases, which require a family approach for optimal therapy. In contrast, research workers generally regard marital and family factors as irrelevant to treatment. This is because complex cases are usually excluded from empirical research. This leaves mainly uncomplicated cases without significant family conflicts, for which a family approach is rarely necessary. Techniques for treating anxiety disorders in a marital/family setting are outlined.     

The Functional Approach to Using Dreams in Marital and Family Therapy*

This paper presents a process based method for using dreams as an adjunct to marital and family therapy. Based on the functional orientation in psychology, this approach identifies and emphasizes personality and life area strengths rather than weaknesses. Dreams are viewed as pictures of feelings and as guides to the emotional dynamics operating for each individual in a family system. The process variables of expression, feeling, clarity, activity, and contact levels are emphasized. A case study illustrates the application of this approach in the treatment of a disturbed family system.     

The borderline/schizoid marriage: the holding environment as an essential treatment construct

The borderline/schizoid marital constellation is the prominent constellation among borderline patients on a long-term inpatient unit. Treatment of this marital constellation, in which each spouse has a severe personality disorder, requires application of the concept of the holding environment as an essential treatment construct, with the therapist as manager of the holding environment. This paper explicates the means of management. With the proposed treatment approach and a long-term treatment orientation, seemingly hopeless cases can improve.     

The nature of preferences: An exploration of the relationship between economics and psychology

Ordinal utility theory begins with the assumption of a consumer of given preferences, therefore, we must go beyond economic theory in order to investigate the nature of preferences without becoming circular. The approach here is to use interpersonal theories of personality development to investigate the formation of the preferences of the individual consumer. To establish a methodological relationship between economics and psychology, a common ground of analysis and an integrative framework must be provided to bring the contributions of psychology into economics into a systematic way. This is explored by using specific psychoanalytic theories of the internalization of interpersonal relations, and by relating this to a more general theory of personality development based on the significance of interpersonal relations. The objective of this study is a broader understanding of the behavioral foundations of the economic theory of the consumer, and a greater appreciation for preference structures which do not conform to the concept of the rational consumer of economic theory.     

PROJECTIVE IDENTIFICATION IN COMMON COUPLE DANCES

This paper integrates the object relations concept of projective identification and the systemic concept of marital dances to develop a more powerful model for working with more difficult and distressed couples. This integrated model explains how some couples use the defenses of splitting and projective identification to externalize and transpose internal conflicts into interpersonal conflicts in five common marital dances. The author suggests how object relations techniques can be used to interrupt the projective identifications, help clients to reown their disowned and projected affects and resolve the conflict on the intrapsychic level so that the marital dance is no longer necessary to resolve the intrapsychic issues.     

The Intersubjective Experience of the Physical Body in the Clinical Setting of Eating Disorders

This paper will illuminate one dimension of self-disclosure as it relates to the inescapable presence of the body in treatment, and the female clinician’s ability to bring her physical body into clinical discussions during an encounter with a female client with an eating disorder. Although the clinical literature on eating disorders validates that transference and countertransference issues are particularly powerful, it generally neglects the exploration of these issues specific to the body’s physical presentation. Since body dissatisfaction is increasingly normative for women today, female clinicians need to have a theoretical road map on which to rely when they encounter a shared body experience. Thus, in order to encourage discussions of the therapist’s body in clinical social work practice, the body needs to be situated in a larger theoretical framework within which it can be explained and located; this framework is object relations theory viewed through an intersubjective lens. Concepts from object relations theory will demonstrate the importance of the body in the clinical exchange by highlighting the parallel between Winnicott’s ‘good enough’ mother and the ‘good enough’ therapist’s body. When the therapist is able to judiciously invite discussions of her body into the clinical arena, the client is given the opportunity to move from object relating to object usage. A case presentation exemplifies how this conceptual framework can be applied to clinical social work practice, strengthening the relationship between knowing and doing.     

THE EFFICACY OF MARITAL AND FAMILY THERAPY: AN EMPIRICAL OVERVIEW, CONCLUSIONS, AND RECOMMENDATIONS

Based primarily on the contributions to this Special Issue of JMFT, this article provides an overview of the empirical research on the efficacy of marital and family therapy for the following disorders and problems: schizophrenia; affective (mood) disorders; slected externalizing, internalizing, and pervasive developmental disorders of childhood; adolescent conduct disorder; marital distress and the prevention of divorce; alcoholism; adult and adolescent drug abuse; and various chronic adult, adolescent, and childhood physical disorders. Convincing scientific evidence supports the efficacy of broadly defined marital and family therapy for the treatment of many disorders, as well as its superiority to standard and individual treatments for certain disorders and populations. We conclude with recommendations for future research as well as for collaborative initiatives between marital/family therapists and other professionals working in the marriage and family field.     

Some Observations on the Use of TA in Marriage Counseling*

Most marital difficulties are seen as a function of childhood problems leading to childhood solutions. This paper emphasizes the symbiotic aspect to marital problems both in terms of the individual's existential position and his racket/ racketeering behavior. The goal of treatment is to have the individual utilize his resources for himself and to negotiate these resources for his mate. A group of spouse and non-spouse members, coupled with a Transactional Analysis orientation, is seen as the most useful approach to effect change in a person, as well as in his relationship to his spouse.     

An Empirical Study of Personality Disorders Among Treatment-Seeking Problem Gamblers

The primary aims of this study were to examine the prevalence of personality disorders in problem gamblers, to explore the relationship between personality disorders and problem gambling severity, and to explore the degree to which the psychological symptoms highlighted in the biosocial developmental model of borderline personality disorder (impulsivity, distress tolerance, substance use, PTSD symptoms, psychological distress and work/social adjustment) are associated with problem gambling. A secondary aim was to explore the strength of the relationships between these symptoms and problem gambling severity in problem gamblers with and without personality disorder pathology. Participants were 168 consecutively admitted problem gamblers seeking treatment from a specialist outpatient gambling service in Australia. The prevalence of personality disorders using the self-report version of the Iowa Personality Disorders Screen was 43.3 %. Cluster B personality disorders, but not Cluster A or C personality disorders, were associated with problem gambling severity. All psychological symptoms, except alcohol and drug use, were significantly higher among participants with personality disorder pathology compared to those without. Finally, psychological distress, and work and social adjustment were significantly associated with problem gambling severity for problem gamblers with personality disorder pathology, while impulsivity, psychological distress, and work and social adjustment were significantly associated with problem gambling severity for those without personality disorder pathology. High rates of comorbid personality disorders, particularly Cluster B disorders, necessitate routine screening in gambling treatment services. More complex psychological profiles may complicate treatment for problem gamblers with comorbid personality disorders. Future research should examine the applicability of the biosocial developmental model to problem gambling in community studies.     

A REVIEW AND EVALUATION OF MARITAL AND FAMILY THERAPIES FOR AFFECTIVE DISORDERS

Although the efficacy of individual treatments of affective disorders has been well-documented, there are also significant limitations to existing treatments. In the last decade attention has focused increasingley on the interpersonal context of affective illness, and on marital and family relationships in particular. As a result, a number of approaches have been developed which directly involve family members in treatment. In this article we evaluate the current status of marital and family therapies for affective illness. We begin with a discussion of several lines of research bearing on the relationships between family processes and affective illness. The available treatment outcome data evaluating the efficacy of marital and family interventions are then reviewed, with particular attention paid to predictors of treatment success and cost efficacy issues. Finally, we suggest several priorities for future research.     

The Social Ecology of Marriage and Other Intimate Unions

This article provides an interdisciplinary framework for studying marital and other intimate relationships. Three levels of analysis are distinguished: (a) the society, characterized in terms of both macrosocietal forces and the ecological niches within which particular spouses and couples function; (b) the individual spouses, including their psychosocial and physical attributes, as well as the attitudes and beliefs they have about each other and their relationship; and (c) the marriage relationship, viewed as a behavioral system embedded within a larger network of close relationships. The discussion focuses primarily on the interplay between the spouses and their marriage, emphasizing the importance of distinguishing, both analytically and operationally, the individual from the dyadic (or group) levels of analysis. It is also argued that in order to appreciate how marriages work, social scientists must understand not only how these 2 levels of analysis interpenetrate each other but also how macrosocietal forces and the ecological niches within which couples live impinge on partners and their marital relationship.     

A nursing-centered treatment team in inpatient medical psychiatry

1. Nurses have the most extensive direct contact with their patients, yet in the traditional physician-centered model, they are often excluded from decision making. We have developed a new model of patient care with the nurse as the primary therapist and contact person, as well as the individual who cares for each patient's physical needs. 2. Out team approach improves efficiency, integration of care, and staff unity, which can be especially helpful for patients with personality disorders. 3. Patients appreciate the approach and are better able to increase focus on treatment when the physicians are not present in the ward.     

Silenced Reality: Power Relations between Marital Blueprints in Israeli Marriages

In this study we examined the effect of job insecurity on couples' relationships in the context of recent macro‐level economic changes in Israel. Based on Hajer's discourse interaction approach, we conceptualized marital relationships and particularly the marital conversation as contested terrain reflecting power relations between social forces and their related discourses. We interviewed seventeen couples in which at least one of the partners suffered from job insecurity in order to trace forms of emotion work and silence in their marital interaction. We found that couples experienced a decreased ability to speak with each other. In their accounts of this experience, gendered “story lines” that we interpreted as “new” to the relationship emerged. Women's emotion work was indicative and halted change‐directed marital negotiation. The possibility that authoritative gendered relationships are reinforced in Israeli marriages during times of job insecurity is thus supported.     

Relational resources, gender consciousness and possibilities of change in marital relationships

Investigating the possibilities of change in marital relationships, we argue, involves examining the interplay of gender consciousness, relational resources and material circumstances in their concrete, interactional manifestations. The attempt to address this interface is grounded in the idea that understanding gender relations necessarily involves both institutional and interactional dimensions. While much research has been devoted to the influence of material or structural resources on indicators such as the domestic division of labour, relatively little direct attention has been given to the issue of differing ‘relational’ or interpersonal resources. We use a multi-method approach based on interviews with women in different occupations to analyse possibilities of change in marital communication and the domestic division of labour in relation both to women's material and to their relational resources. We conclude that a combination of increased gender consciousness and the development of particular inter-personal skills facilitates negotiation and change in the boundaries regulating both communication and the domestic division of labour within the marital relationship.     

FAMILY INTERVENTION IN A CASE OF MULTIPLE PERSONALITY

The authors report a case of multiple personality in which therapy was directed at the marital couple, rather than focusing on the multiple personality per se. The symptoms of the individual are seen as a disturbance in the family homeostasis and were treated from that standpoint. The functions of the symptom in the areas of impulse discharge, superego operation, boundaries of closeness-distance, and self-object representations for the couple and family are discussed.     

An exploratory investigation of marital functioning and order of spousal onset in couples concordant for psychopathology

Individuals with a psychiatric disorder are significantly more likely to have a spouse with a clinical diagnosis--marital concordance. We used a community sample of 304 couples concordant for either major depressive disorder (MDD) or substance use disorders (SUDs) to examine the relationship between marital functioning and gendered patterns of mental health diagnosis onset. For SUD concordance, couples in which wives onset before husbands--despite typical later onset for men--reported lower levels of marital satisfaction compared with couples in which the husband onset first. For MDD concordance, couples in which husbands onset with depression before wives--despite typical later onset for men--reported lower levels of marital satisfaction. These results suggest that for couples concordant for mental diagnoses, it is most problematic for marital functioning for one partner to have an atypically early onset. Implications for treatment targets in marital therapy are discussed.