Group psychotherapy of the characterologically difficult patient

A broad range of characterologically difficult patients present for treatment in psychotherapy groups. Despite different clinical presentations, including features of the schizoid, borderline, and narcissistic personality disorders, these patients share a common developmental failing. Specifically, these individuals have failed to attain object constancy and the associated stable internalization of tolerably ambivalent representations of the self, and of the other, in relationship with one another. Splitting mechanisms predominate over integrative ones, as primitive defenses are utilized to deal with the individual's powerful needs and fears related to engagement and intimacy. These maladaptive interpersonal styles are clearly illuminated in group therapy, but often to the exclusion of the latent, intrapsychic derivatives of this behavior, with detrimental effects. This paper examines the group therapy of such patients from the perspective of object relations and self psychology theories, models that provide the essential link between the interpersonal and the intrapsychic worlds.