"Довербальные клиенты". На стыке психиатрии и динамического подхода в психотерапии

Main ideas and concepts

• Purpose of the webinar

  • Revisit the beginning of the CM3 series to understand a “pool of clients” located at the intersection of psychiatry and dynamic/psychodynamic psychotherapy.
  • Rationale for the topic:
    • Recent changes in diagnostic framing disrupted established “client character typology,” including how neurotic/personality disorder sections are presented.
    • Repeated supervision cases where clients are described as neurotic, yet clinically behave in ways that don’t fit neurotic organization.

• Central clinical problem

  • Therapists (including experienced short-term dynamic specialists) often bring clients to supervision labeled as “neurotic.”
  • However, the clients’ behavior often suggests pre-verbal (preverbal/early trauma) organization rather than neurotic organization.
  • Therapy approaches referenced:
    • Malan–Lubavsky-style short-term dynamic therapy
      • Emphasis on contacts/countertransference difficulties, peculiar reactions, and trouble establishing contact.
    • Milan approach
      • Emphasis on conflict/triangle constructions, which can sometimes lead to disappointment when the “real problem” is different.

• Core developmental framework

  • Freud’s psychosexual development is used as a baseline for later intrapsychic conflict.
  • Freud + classical analysis
    • Client mastery of conflict depends on passing through stages (paraphrased): phallic → Oedipus/Electra → latent/genital.
  • Klein’s and related pre-verbal object relations
    • Early infancy involves partial objects (e.g., “bad/good breast”), with no full self-awareness or object-wholeness.
    • Frustration can lead to fixation; later development depends on whether experiences can be metabolized and integrated.

• Key distinction: “verbal” vs “pre-verbal” clients

  • Verbal client (generally expected by ~age 3)
    • Has emerging speech structures and can narrate emotions/experiences.
    • Forms more integrated representations.
    • Trauma can be processed verbally, remembered, and symbolized more readily.
  • Pre-verbal client
    • Experienced rejection/separation trauma before ~3 years, when verbal processing wasn’t yet available.
    • Speech/emotion labeling may develop, but the traumatic experience remains hard to access or describe as coherent narrative.
    • Objects are perceived fragmentedly (e.g., breast/hand/lips without assembling “mother as mother and father as father”).
  • Types described:
    • Trauma before verbal emergence (most severe)
    • “Two-dipole” / borderline transitional cases
      • Speech exists, but oedipal/holistic object integration isn’t fully formed.

• Why psychiatry matters here

  • Psychiatric clusters are used to map clinical manifestations:
    • Paranoid/schizoid-like, borderline, narcissistic/organized, anxious/avoidant-dependent-obsessive, etc.
  • In psychiatric terms, focusing on the ability to speak to a verbal-narrative patient may cause therapists to miss that the underlying personality organization can include strong personality disorder potentials.
  • Primary vs secondary process
    • Pre-verbal clients may show secondary-process functioning in social interaction, but primary-process surges in close relationship settings.

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The four behavioral/personality formats proposed for pre-verbal clients

The speaker frames pre-verbal clients as tending toward one of four relational strategies (not “chosen,” but arising from early development/trauma patterns), shaped by two opposing human tendencies:

• Tendency A: defense / protect a fragile narcissistic core
  • Preserve self-image/personality integrity at all costs.
• Tendency B: satisfy primary needs at all costs
  • Seek object relationships, minimize frustration, immerse in object relations.

Four formats (as presented)

1. Narcissistic disposition

   • Grandiose self-experience, but internally unstable/fragile.
   • Seeks conformity to narrow super-ego/ideal expectations to maintain self-worth.

2. Schizoid / paranoid (withdrawn, distrustful, suspicious)

   • Less need to conform to external rules.
   • Emotional coldness/distance from object relations; suspicion and devaluation of others who don’t satisfy needs.

3. Dependent/addictive type (more “socially normative” on the surface)

   • Understands norms and may appear outwardly “pseudo-normal.”
   • May develop chemical or non-chemical addictions.
   • Can show independence in relational style but still relies on compensatory attachment-like strategies.

4. Borderline traits/pattern

   • Unable to maintain stable compliance with internalized norms (role-playing/compliance is too costly).
   • Seeks intense contact/object presence; frequent switching/splitting (good/bad therapist/object).
   • High relationship volatility; identity disturbance and emptiness.

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Diagnostic and therapeutic “signs” emphasized

A) Why these clients are hard to diagnose

• They may initially look neurotic, especially early in therapy.
• Over time, they create very tough difficulties, such as:
  • Hard-to-establish contact.
  • Strong demands regarding which therapy tools will “work.”

B) Signs that indicate pre-verbal experience

• Very high basic anxiety
  • Triggers cause anxiety to spike rapidly.
• Paroxysmal episodes
  • Sudden, sharp surges.
• Unstable self-esteem
  • Warning: don’t assume narcissists have simply “high self-esteem.”
  • Often inflated externally but low internally (“shuttle self-esteem”).
• Impulsivity and intense affect
  • Narcissistic-type: anger; may include sexual/relational acting out.
  • Borderline-type: rage, splitting, suicidality risk, identity fragmentation.
  • Schizoid/paranoid: suspicion, jealousy, aggression/devaluation patterns.
• Frequent primary-drive distortions
  • Sexual perversions, eating-disorder patterns, or other deviations framed as “primary drive” related.
• Envy
  • Often denied indirectly (“direct denial” rather than neurotic repression).
  • Envy may generate control attempts through relational mimicry.

C) Contact and countertransference notes (practical implications)

• Therapists may feel:
  • Over-cautiousness, fear, or sudden “intuitive self-preservation” impulses.
• The speaker frames these as a meaningful countertransference signal:
  • The client’s anger/overwhelm can feel dangerous to confront directly.
• Verbal pressure phenomenon
  • Some clients “drown” therapy with information; meaningful content arrives late.
  • Therapists should avoid superficial analysis of all data and focus on what is therapeutically relevant.
• Warning about mislabeling
  • A client might appear alexithymic/somatic (“psychosomatic profile”), but the core issue may be inability to access trauma verbally—so they express it through bodily reactions rather than narrative processing.

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Borderline clients: specific features and treatment framing

Core features described

• High and persistent suicidal ideation
  • Shifts between active and less active forms; attempts occur frequently (statistics are mentioned).
• Identity disturbance
  • Including severe ambiguity around gender/sexual identity.
• Affective instability resembling bipolar patterns
  • Difficulty distinguishing bipolar disorder from borderline-related states.
• Impulsive behaviors
  • Dependence/co-dependence, alcoholism/drug risk, promiscuity/circulation-type behavior.
• Core emptiness
  • “A hole inside me,” with repeated attempts to fill it through object-relating.
• Splitting
  • Therapist/object perceived as entirely good or entirely bad; inability to maintain holistic perception after dissonant moments.

Therapeutic approach emphasized

• Focused transference/countertransference therapy
  • Therapy operates through ongoing transferential dynamics (relational-experiential spirit).
• Focus on:
  • Why the therapist’s responses change suddenly in the patient’s lived experience.
  • How the patient splits into “good/bad,” and how therapist continuity can be used therapeutically.
• When emotions become too intense:
  • Dissociation-like shutdown (derealization/depersonalization), including possible “absence-like” pausing.
• Anxiety regulation:
  • Use of chemicals or rituals is described as common.

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Schizoid and paranoid clients: Klein’s “fragmented objects” model

• Klein’s developmental sequence
  • Early psychotic core associated with the schizoid/paranoid position.
  • Progression toward “depressive position” resembles more neurotic-like integration (linked by the speaker to the development of secondary process).
• Fragmented object perception
  • “Bad breast” vs “good breast” ambivalence.
  • Failure to integrate can sustain paranoid tendencies:
    • omnipotence/idealization,
    • devaluation of others,
    • aggressiveness toward non-satisfying objects.
• Schizoid characteristics (as described)
  • Withdrawal from object relations; self-focused fantasies/solitude.
  • Social norms matter less because pleasure is mostly internal.
  • Low empathy; praise/criticism has reduced impact.
  • Externally low interest in sexual contact (internally posited as hypersexuality).
• Paranoid characteristics (as described)
  • Suspicion, hyperscrupulousness about status, jealousy, perceived special significance.
  • Sometimes conspiracy/mystical themes.

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Addictions: criteria, link to pre-verbal dynamics, and treatment posture

Addiction vs “bad habit” (criteria list as given)

1. Pronounced need/necessity for regular use
   • For non-chemical addictions: substitute “substance” with the object of addiction.
2. Use regulates emotions
   • Substance/object becomes the main method for controlling emotional states.
3. Impaired control
   • Can’t control onset, dosage, and termination.
4. Increasing costs
   • More time/financial/physiological cost over time to obtain use and recover.
5. Withdrawal symptoms
   • Hangover/withdrawal pattern.
6. Tolerance
   • More is needed for similar (or sometimes reduced) satisfaction.
7. Degrading alternative interests
   • Social life narrows; relationships center on the addiction.
8. Continued use despite harm
   • Repeated unsuccessful attempts to stop.

Addiction and attachment

• Attachment theory (Bowlby/Ainsworth mentioned) is invoked to relate attachment patterns to later addiction behavior.

Alcoholism subtype classification referenced

• A typology distinguishing:
  • social drinkers,
  • stress-reactive “reactive drunks,”
  • neurotic drinkers (framed Oedipally),
  • alcoholics/addicts with deep regression.
  • (One author-name is unclear due to mistranscription.)

Core psychoanalytic claim about addiction (as presented)

• Addictive need is framed as related to annihilation anxiety and shame, becoming a pathway to contact.
• The “object” of addiction becomes, under regression, like a maternal/child-object replacement.

Treatment note

• The speaker says they don’t rely on psychoanalysis alone for addictions.
• For some patients (already exposed to refusal, 12-step programs, and with more social readiness), therapy can be approached “as for verbal ones,” with collaboration from addiction specialists.

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Detailed methodology/instruction content (as presented)

Methodological workflow implied by the lecture

1. Reassess “neurotic labels” from intake/supervision
   • Watch for mismatches between “neurotic” descriptions and actual behavior in close work.
2. Use developmental markers to decide verbal vs pre-verbal
   • Approximate timeline:
     • Before ~3 years: likely pre-verbal trauma risk.
     • After ~3 years with speech structures: more likely verbal-trauma processing.
3. Identify the likely pre-verbal personality format
   • Narcissistic vs schizoid/paranoid vs dependent/addictive vs borderline-pattern.
4. Diagnose based on lived relational behavior
   • Look for:
     • spikes of basic anxiety,
     • splitting into good/bad,
     • envy-driven control dynamics,
     • primary-process surges in relationship mode,
     • dissociation/shutdown under overwhelming emotion,
     • addiction patterns as emotion regulation and shame-based contact.
5. Adapt technique accordingly
   • For borderline/pre-verbal patterns:
     • work with transference/countertransference,
     • allow the therapeutic “game” to develop rather than interpret prematurely.
   • Maintain boundaries (avoid mutual seduction/eroticization).
6. If trauma can’t be verbalized
   • If primary-scene access fails, consider collaboration with somatic/body-oriented or trauma-phase approaches (one option mentioned: MDR) to reduce anxiety before analytical engagement.
7. For addictions
   • Treat addiction as more than habit:
     • evaluate diagnostic criteria as a whole,
     • integrate shame/attachment dynamics conceptually,
     • coordinate with addiction medicine/12-step contexts when needed.

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Main speakers/sources mentioned

Theoretical/clinical references

• Sigmund Freud
• Melanie Klein
• Sabina Spielrein
• Donald Winnicott
• Sándor Ferenczi
• Michael Balint
• John Bowlby
• Mary Ainsworth
• Otto Kernberg (referenced indirectly)
• Carl (Gustav) Jung
• Carl Rogers (referenced as “Roger”)
• Bowlby/Ainsworth mentioned for attachment
• An alcoholism typology author is referenced, but a name is unclear due to mistranscription
• MDR therapists/colleagues (unspecified)

Therapy approaches/figures referenced

• Malan–Lubavsky short-term dynamic approach
• Milan approach (triangle/conflict mapping)
• Focused transference therapy (transference/countertransference focus as described)

People appearing in the video

• The main lecturer/speaker (not named in subtitles)
• Supervisors/supervisees (not individually named in the subtitles)