Another key component of the psychodynamic approach is that the clinician treats the person and not just the illness. In practice, that perspective means taking the personality into account in every case. The interface of the biological and the psychosocial is particularly apparent in the area of personality. The psychobiological model of personality developed by Cloninger et a/.(22> recognizes an equal contribution of biological and environmental factors (see Table 2). The four dimensions of temperament are roughly 50 to 60 per cent heritable independently of one another. They all manifest themselves early in life, and they involve preconceptual biases, habit formation, and perceptual memory. They include the following:
Table 2 Development of personality
1. novelty-seeking, characterized by active avoidance of frustration, quick loss of temper, impulsive decision-making, frequent exploratory activity in response to novelty, and extravagance in the approach to cues and rewards;
3. reward-dependence, characterized by sentimentality, social attachment, and dependence on the approval of others;
4. persistence, which refers to the capacity to persevere despite fatigue and frustration.
Certain of these temperament dimensions appear to correlate with specific types of personality disorders. The cluster A personalities in DSM-IV, for example, are strongly associated with low reward-dependence. Cluster B personality disorders have been shown to be high in novelty-seeking, while cluster C personality disorder patients tend to rate high in harm-avoidance.
The other component of personality in this model is character. While temperament is genetically based, character is shaped by environmental experiences, such as family relationships, peer relationships, trauma, and neglect. These dimensions appear to make up about 50 per cent of personality. There have been three dimensions of character identified that appear to mature in adulthood. These dimensions influence social and personal effectiveness by insight-learning about self-concepts. The three character dimensions are self-directedness, co-operativeness, and self-transcendence.
Self-directedness is a developmental process with several aspects:
1. acceptance of self-responsibility for the choices one makes instead of externalizing or blaming others;
2. identification of personally valued goals and purposes versus a lack of direction or goalessness;
3. development of confidence and skills in problem-solving (resourcefulness versus apathy);
4. self-acceptance versus self-striving;
5. congruent second nature versus personality distrust.
The second dimension of character, co-operativeness, refers to the extent to which a person is agreeable, on the one hand, or hostile and self-centred, on the other. It, too, has several aspects associated with it:
1. social acceptance versus intolerance;
2. empathy versus social disinterest;
3. helpfulness versus unhelpfulness;
4. compassion versus vengefulness;
5. pure-hearted principles versus those based on self-advantage.
Individuals who are uncooperative regard the world as adversarial and hostile, while those who are high in co-operativeness view themselves as involved in compassionate and mutually supportive social networks.
The third dimension of character, self-transcendence, also has several aspects:
1. the capacity to lose or forget oneself versus self-conscious experience;
2. identification with transpersonal values or goals versus self-differentiation;
3. spiritual acceptance versus rational materialism.
Low self-directedness and low co-operativeness are associated with all categories of personality disorder in the DSM-IV system. (2Z> Self-transcendence, on the other hand, does not differentiate patients with personality disorders from those without personality disorders.
Self-directedness and co-operativeness reflect two fundamental tasks in personality development as defined by Blatt et al.(28): the achievement of a stable, differential, realistic, and positive identity, and the establishment of enduring, mutually gratifying relationships with others. These two dimensions evolve in a dialectical and synergistic relationship to one another throughout the lifecycle. Patients with character pathology tend to divide into two groups: introjective types, who are primarily focused on self-definition; and anaclitic types, who are more concerned about relatedness.
The character dimensions readily lend themselves to typical psychodynamic constructs. The self-directedness dimension is closely linked to what are often called ego functions or self-structures. The dimension of co-operativeness is a direct measure of a person's characteristic pattern of internal object relations as they are externalized in relationships with others. In one's assessment of a patient's personality, the transference-countertransference dimensions of the clinical interaction provide a privileged glimpse of the typical patterns of relatedness that cause difficulties in the patient's outside relationships. (29) The patient is involved in an ongoing attempt to actualize certain patterns of relatedness that reflect various wishes in the patient's unconscious. Through the patient's behaviour, he or she subtly tries to impose on the clinician a certain way of responding and experiencing. (39
An individual internalizes a self-representation in interaction with an object representation connected by an affect through a series of repetitive interactions in childhood. This pattern ultimately leads to an internalized set of self- and object representations in interaction with one another. The adult individual repeats these patterns again and again as an effort to fulfil an unconscious wish. Even abusive or painful relationships involving a 'bad' or tormenting object may be wished for because of the safety and affirmation such relationships provide. In other words, a child who has been abused has internalized a highly conflictual abusive relationship as a predictable and familiar pattern. Having an abusive object may be preferable to having no object at all or being abandoned. Many patients with histories of an abusive childhood become convinced that the only way to remain connected to a significant person is to maintain an abuser-victim relationship.
The repetitive interactions seen in patients with personality disorder may reflect actual relationships with real objects in the past, but they may also involve wished-for relationships, such as those often seen in patients with childhood trauma who seek a rescuer. Clinicians who are influenced by the patient's interpersonal pressure to respond in a particular way may unconsciously accept the role in which they have been cast. When this phenomenon occurs, it is often referred to as projective identification.(11) In other words, the patient may 'nudge' the therapist into assuming the role of an abuser in response to the patient's 'victim' role, and the therapist may feel countertransference hate or anger and begin to make sarcastic or demeaning comments to the patient.
In addition to this pattern of object relations, the other major component of character, from a psychodynamic perspective, is the particular constellation of defence mechanisms that characterizes the individual patient.(31) While defences were traditionally regarded as intrapsychic mechanisms designed to prevent awareness of unconscious aggressive or sexual wishes, the current understanding of defence mechanisms has been expanded far beyond Freud's dual-drive theory. We now understand that defences also preserve a sense of self-esteem in the face of narcissistic vulnerability, assure safety when one feels dangerously threatened by abandonment, and serve to insulate one from external dangers through, for example, denial or minimization.
Different personality types or disorders use characteristic sets of defence mechanisms. For example, the paranoid personality may typically use projection as a way of disavowing unacknowledged feelings and attributing them to others. Patients with obsessive-compulsive personality disorder may use defensive operations such as isolation of affect, intellectualization, and reaction formation to control affective states that are highly threatening. In the relationship with the clinician, as noted previously, these defences will manifest themselves as resistances. Hence, if a patient with an obsessive-compulsive personality disorder uses intellectualization as a defence against painful affects, when the patient comes to treatment, intellectualization will be used as a resistance to avoid getting at feelings in psychotherapy.
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