The Case of the Charmer: Shape-shifting Seduction, Lethal Splitting, and a Salvaged Treatment Using Conversational Intimacy

This paper explores the treatment arc of a case where higher order defenses and capacities consistent with psychoneurotic functioning occurred in close conjunction with regressive defenses indicative of more severe personality disturbances. Within a theoretically-grounded exploratory case study design, several notable features of the case will be highlighted, alongside illustrative transcript excerpts. First, the importance of therapist attention to capacity thresholds in the context of the patient’s unique configuration of psychodynamics will be outlined. Second, consistent with the principles of the graded format of ISTDP, we illustrate how over-threshold responses and periods of regression were addressed and ameliorated through a reduced focus on guilt-inducing torturous impulses. Third, the reader will be introduced to an adaptation of the graded approach we refer to as conversational intimacy, which we suggest facilitated progress through integrating feelings of love and hate at lower levels of intensity. Therapist self-disclosure and patient authenticity are foregrounded as primary vehicles for this integration, and generative of a titrated form of emotional intimacy. We also consider how the patient’s a priori knowledge of ISTDP may have impacted the treatment. Although the treatment approach in this case shifted focus away from major mobilization of the unconscious, it appeared to build capacity and facilitate corrective emotional experiences nonetheless. We argue that this was achieved partly through emotional intimacy developed at the conversational level, which in turn led to the course correction of a previously derailing treatment process.