Impervious and intrusive: The impenetrable object in transference and countertransference

The author describes an internal object that he calls the ‘impenetrable object’ which has two characteristics: being impervious to the projections from the patient and being intrusive, i.e. projecting into the patient. It arises out of an early relationship with a mother who may be generally disturbed or traumatized so that she is unable to take in or tolerate the child's projections and may use the child as a receptacle for her own projections. He links the concept of an impenetrable object with other concepts such as Williams's ‘reversal of the container–contained relationship’ and Green's ‘dead mother’. If such an object dominates the patient's internal world, it can lead to severe difficulties in the analytic process. Interpretations may be experienced as violent projections from the analyst which the patient has to ward off and the analyst may enact an impervious or intrusive object in various ways. The author describes a case in which such dynamics played a significant role. He argues that intensive work in the countertransference is required to detect subtle enactments and allow a shift in the analyst, which in turn can enable change in the patient. He gives clinical material that demonstrates such work by the analyst and illustrates the shift from an impenetrable object to a more permeable one in the patient's internal world.     

Three Phases of Treatment with Borderline and Psychotic Patients

Three distinct, yet overlapping, phases of treatment emerge when working with some borderline and psychotic patients. This are patients who test the ordinary limits of psychoanalysis, but can profit from its deep exploration. The first phase is colored by acting out, interpersonally and intrapsychically. An analytic envelope of containment is necessary to sustain the treatment. Interpretive holding and containing help the patient find a psychic receptacle capable of detoxifying violent projections. Many of these patients terminate prematurely. The second phase is centered around the patient's defensive use of the death instinct to extinguish or destroy certain parts of their mental functioning. This difficult standoff between parts of the patient's mind becomes replicated in the transference. The third phase reveals the more fundamental problem of paranoid～schizoid anxieties of loss and primitive experiences of guilt. These include fears of persecution and annihilation. Some patients abort treatment in the first or second phase and never work through the phantasies and feelings of loss. Nevertheless, much intrapsychic and interpersonal progress is possible. Given the instability and chaotic nature of these patient's object relations, the analyst must be cautiously optimistic in their work and realize the potential to help the patient even when presented with less than optimal working conditions.     

Whose Who in the Psychoanalytic Situation: Subject,Object, and Enactment in the Relational and Contemporary Kleinian Traditions

The concept of enactment, although it has probably has become an overused term in the Relational literature, is a relatively new one for the Contemporary Kleinians of London. In explicating and synthesizing these different theoretical perspectives (Relational and Contemporary Kleinians), the author's primary focus is to tackle the notion of subject and object, in the context of enactment. The author first delineates the relationship between reality and fantasy, and each theory's notion of enactment. In doing so, the author shows how these differing theories and their related notion of therapeutic action inform the kind of object the analyst sees himself or herself as. The author also addresses the technical implications related to the consequences that arise for the analyst as an object of the patient's transferences and projections, including how the analyst extricates himself or herself from the enactment. Two previously published vignettes are used for the purpose of comparison. The author argues for a complementary technical stance comprising two analytic modes: analyst as subject and analyst as object.     

Fromm's Spirited Values and Analytic Neutrality

The analyst and the patient must feel enough hope to sustain their active effort. A significant aspect of the analyst's role is inspiring hope. This seems to require that the analyst take a life-affirming position that violates traditional notions of analytic neutrality. Yet, in facilitating the patient's full self-expression, we do not want to lose the benefits of neutrality. Fromm's work can inspire us to try to integrate an attitude of spirited hope with interpretations whose content neutrally encourages the patient to reveal his whole self.     

Self-Disclosure and Vulnerability

Abstract

Based on the theoretical assumption and clinical observation that projective identification is a natural, constant element in human psychology, clinical material is used to illustrate how projective identification centered transference states create situations where acting out of the patient's phantasies and conflicts by both patient and therapist is both common and unavoidable. Because they are more obvious, some forms of projective identification encountered in clinical practice are easier for the analyst to notice and interpret. Other forms are more subtle and therefore difficult to figure out. Finally, some forms, whether subtle or obvious, seem to create a stronger pull on the analyst to blindly act out.

In some psychoanalytic treatments, one form of projective identification might embody the core transference. In other cases, the patient might shift or evolve from one level of this mechanism to another. Some patients attempt to permanently discharge their projective anxiety, phantasy, or conflict into the analyst. There is a patent resistance to re-own, examine, or recognize this projection. Some of these patients are narcissistic in functioning, others are borderline, and many attempt to find refuge behind a psychic barricade or retreat (Steiner 1993). In other forms of projective identification, the patient enlists the analyst to master their internal struggles for them. This occurs through the combination of interpersonal and intra-psychic object relational dynamics. This “do my dirty work for me” approach within the transference can evoke various degrees of counter-transference enactments and transference/counter-transference acting out.

Another form of projective identification, common in the clinical setting, is when a patient wants to expand the way of relating internally, but is convinced the analyst needs to validate or coach the patient along. This is why such a patient may stimulate transference/counter-transference tests and conduct practice runs of new object relational phantasies within the therapeutic relationship. Over and over, the patient may gently engage the analyst in a test, to see if it is ok to change their core view of reality. Depending on how the analyst reacts or interprets, the patient may feel encouraged to or discouraged from continuing the new method of relating to self and object. The patient's view of the analyst's reactions is, of course, distorted by transference phantasies, so the analyst must be careful to investigate the patient's reasoning and feelings about the so-called encouragement or discouragement. This does not negate the possible counter-transference by the analyst in which he or she may indeed be seduced into becoming a discouraging or encouraging parental figure who actually voices suggestions and judgment.

All these forms of projective identification surface with patients across the diagnostic spectrum, from higher functioning depressive persons to those who are more disturbed paranoid-schizoid cases. Whether immediately obvious or more submerged in the therapeutic relationship, projective identification almost always leads to some degree of acting out on the part of the analyst. Therefore, it is critical to monitor or use the analyst's counter-transference as a map towards understanding the patient's phantasies and conflicts that push them to engage in a particular form of projective identification.     

Developing a Psychoanalytic Practice

Abstract

This paper examines two methods of developing a psychoanalytic practice. The first is an “internal” approach that helps a patient make the transition from therapy to analysis with the same analyst. This may be accomplished by attenuating the patient's unconscious fears of analysis as a facilitator of an anticipated regressive loss of control and as a reactivator of feared desires and impulses. Increased motivation for analysis may also result from a therapy that leads the patient to an awareness that an ongoing level of distress is internal, together with the experience of a deepened therapy and of the analyst as safe and potentially providing relief. The second method of developing an analytic practice is an “external” approach that provides others, such as analytic, mental health, medical, and academic colleagues, an experience of the analyst as person and some idea of the type of work he or she does.     

THE PATIENT'S OBJECTS IN THE ANALYST'S MIND

In every analysis, the analyst develops an internal relationship with the patient's objects—that is, the people in the patient's life and mind. Sometimes these figures can inhabit the analyst's mind as a source of data, but at other times, the analyst may feel preoccupied with or even invaded by them. The author presents two clinical cases: one in which the seeming absence of a good object in the patient's mind made the analyst hesitate to proceed with an analysis, and another in which the patient's preoccupation with a “bad” object was shared and mirrored by the analyst's own inner preoccupation with the object. The use and experience of these two objects by the analyst are discussed with particular attention to the countertransference.     

On the process of the psychoanalytic psychotherapy with the borderline depressive patient

Abstract

A certain subgroup of borderline patients often presents depressive symptomatology (either chronic or periodic) and an underlying borderline personality organization.

In this article, the effort is directed at elucidating the psychoanalytic psychotherapeutic process of these borderline depressives by presenting clinical fragments of several psychotherapeutic cases.

The process goes through periods of activation of the patient's depressive or primitive mental functioning, which also reflects on the therapist's countertransference.

The capacity of the therapist to tolerate and elaborate on his patient's projections, facilitates the development of the therapist-patient communication and plays a significant role in the therapeutic outcome itself.     

Incognito or not? the patient's subjective experience of the analyst's private life

This paper examines the meaning for the patient of the analyst's personal life and personality which are ostensibly banished from the consulting room. The therapist has a not‐always‐so‐secret “secret life”; that the patient is supposed to “not know”; about. Yet, more or less unconscious perceptions, impressions, and fantasies about extratherapeutic aspects of the analyst are omnipresent and significantly color the psychoanalytic enterprise.

Moreover the analyst as a person generally plays a critical and underacknowledged role in the patient's experience of the endeavor. Constructing multiple overlapping images of the analyst and of the analytic relationship, the patient discovers himself or herself in the matrix of these relationships with various images of the analytic other. The analysand is motivated to make sense of the analyst as wholly as possible, the better to place into context the analyst's interventions. The patient's resulting view of the analyst's subjective experience acts as a lens that filters and subtly alters the meaning of the analyst's communications.

I illustrate these points by relating my work with a patient whose dreams uncannily picked up on a (consciously) unknown aspect of my private life—my having a handicapped son. The treatment thereafter centered on the patient's identification with my child (as someone “disabled") and on the meaning of her having dreamt something so personal about her therapist.     

Psychoanalytic identity and the external world: Interaction between psychoanalysis and health service systems in Sweden

Abstract

This paper continues the exploration of the clinical phenomenon of analytic contact. The author demonstrates, through case material, the essential ingredients of psychoanalysis to be not frequency or use of the couch, but rather the moment-to-moment analysis of the patient's transference state and phantasies of what it means to establish relational contact with their objects and with themselves. The nature of the treatment can be shaped, prevented, perverted, or fostered by the patient's phantasies and unconscious conflicts into something more analytic or less analytic. Interpretation needs to include the exploration of the patient's attempts to change the treatment into something that is often a replica or a repetition of archaic object relations. The typical patient in psychoanalytic treatment is struggling with rather profound pathology and as such tends to create a significant stand-off with the analyst when analytic contact is forming. Analytic contact is often threatening to these patients in very primitive and alarming ways that must be gradually understood and interpreted if the treatment is to survive and remain a primarily analytic journey rather than be transformed into a more supportive counseling or a pathological re-enactment of conflictual phantasy states.     

Dissociation,the Analyst's Vulnerability,and the Body: Review of Awakening the Dreamer: Clinical Journeys by Philip M. Bromberg

This review praises Bromberg's rich and evocative new book for its clinical and theoretical usefulness and elaborates on three broad themes: the analyst's personal role in traumatic enactments, dissociative/addictive uses of the body, and the distinction between life-threatening and developmental trauma. Extending Bromberg's formulations, the author argues that in successful work with trauma survivors, the analyst must be actually (temporarily) traumatized as actual, personal vulnerabilities of the analyst are necessarily engaged. The analyst's vulnerability serves as an internal contact point, opening up a process of unconscious empathy with the patient and providing crucial validation of the patient's experience. The review also explores how bodily processes are used to further dissociation with eating disordered patients and how they become the source of treatment difficulties. When the patient's states of desire have been “detoured” into the body (where they are ruthlessly controlled or attacked) as well as into the relationship with food (where they are temporarily gratified), they are not as available to be mobilized in the analytic relationship. The review also questions Bromberg's assumption that the underlying dissociative mechanisms are the same for life-threatening trauma (or Posttraumatic Stress Disorder) and developmental (or relational) trauma.     

CONTAINING,TRANSLATING, AND INTERPRETIVE ACTING OUT

In analytic treatment, when patients project unspoken aspects of their internal self and object world, the analyst has to find ways to understand and communicate those expelled phantasies without the patient feeling accused, seduced, or persecuted; even when we do our best at interpreting such inner conflicts, the patient may experience our interpretations as assaults, forcing them to give up themselves or their hope for reconnecting with an object. The patient will resist or fight our efforts through the use of projective identification. Caught up in patient's projections, the analyst in turn may enact some of these phantasies by becoming the object rather than translating its presence in the transference, by overemphasizing one side over another of the patient's conflict, or by interpreting accurately but prematurely. These issues are illustrated in two case presentations and discussed in relation to the views of contemporary Kleinian writers on transference and countertransference.     

Tactics and empathy: Defences against projective identification

In this paper the author argues that interpretations made when the analyst has not done the emotional work of recognising and bearing what kind of object she has become in the patient's psychic reality will be experienced as empty tactics – even lies – rather than interpretations of integrity. However, interpreting from a position of bearing the truth of the patient's perception will be technically difficult and indicate turmoil as the analyst struggles to take in the patient's view of her. If the analyst avoids integrating her own picture of herself with the patient's picture (despite giving voice to the patient's picture) the split inside the analyst will be felt and intensify the patient's need to split. Vignettes demonstrate how the analyst, believing she is trying to understand, may become a projective‐identification‐refusing object and the issue of the analyst's disclosure of her countertransference is examined. Ultimately, the author argues, a capacity to receive and bear projective identification requires empathy with both patient and analyst‐as‐patient's object, engaged in a process about which both are ambivalent.     

Terminating Without Fatality

The psychoanalytic relationship is unique among intimate relationships, in that its ultimate goal is separation. After termination, the analysand mourns the loss of the analyst and while feeling vulnerable and bereft, faces demanding emotional tasks alone. The post-termination phase is a precarious time during which the hard-won gains of an analysis may be threatened or even lost. Given the analysand's vulnerability, it is disturbing that many of our common termination practices may undermine the patient's leave-taking and harm the positive internal images of the analyst and the analytic relationship that have been forged during the analysis. Findings from recent research about the patient's experience after analysis are presented and implications are drawn for practice regarding the termination and post-termination phases. The author recommends that our theory and technique of termination should be reexamined and revised in light of new research and within the context of contemporary two-person theories of psychoanalysis.

In real life, only death and hostility bring a libidinal relationship to an end. The kind of termination psychoanalysis demands is without precedent.

—Martin Bergmann (1997, p. 163)     

At Death's Door: Therapists and Patients as Agents

This paper explores the interrelationship between patients' exercise of will to make advances in an analysis and their readiness to forgive their analysts for their human limitations. There is a thin line between idealization of the analyst, probably a necessary component of the process, and resentment of the analyst for his or her privileged position in the world and in the analytic situation itself. The patient's “progress” emerges as a kind of reparative gift, one that implicitly overcomes the patient's tendency to withhold such change out a sense of chronic, malignant envy. Particularly poignant in terms of its potential to elicit the patient's reparative concern is the situation in which the analyst is struggling with his or her mortality because of aging or life-threatening illness. In this essay two clinical vignettes are presented to illustrate some of the issues that this situation poses. One begins with an elderly patient appearing at the door of the analyst's (the author's) home the day of his return from the hospital after coronary bypass surgery. The other begins with an analyst who is terminally ill appearing at the door of a patient who is threatening suicide. The two stories are compared in terms of their implications for human agency, the exercise of will, and the coconstruction of meaning in the face of mortality in the analytic process.     

Self‐disclosure,trauma and the pressures on the analyst

This paper argues that self‐disclosure is intimately related to traumatic experience and the pressures on the analyst not to re‐traumatize the patient or repeat traumatic dynamics. The paper gives a number of examples of such pressures and outlines the difficulties the analyst may experience in adopting an analytic attitude – attempting to stay as closely as possible with what the patient brings. It suggests that self‐disclosure may be used to try to disconfirm the patient's negative sense of themselves or the analyst, or to try to induce a positive sense of self or of the analyst which, whilst well‐meaning, may be missing the point and may be prolonging the patient's distress. Examples are given of staying with the co‐construction of the traumatic early relational dynamics and thus working through the traumatic complex; this attitude is compared and contrasted with some relational psychoanalytic attitudes.     

A Century of Psychoanalysis: Critical Retrospect and Prospect

Abstract

The distinction between having mode and being mode would seem to be the basis of the Frommian clinical approach, which finds its main application in the “center-to-center” relatedness between analyst and patient. The analyst can understand the patient because he/she experiences what the patient experiences. The dialogue is based on emotional and conceptual responses and reactions which are reciprocally communicated; both identities come into play. Psychoanalytic treatment which is not inspired by biophilia can only compile an inventory of data upon data, imposing interpretations and reconstructions. Biophilia makes psychoanalysis an art because it is applied to living things. The psychoanalytic session can save itself from the having mode by addressing the patient's living memory, which represents the past relived in the present, according to the being mode. The author comments on a psychoanalytic session.     

Food and violence: Childhood violence and emotional abuse as complicating factors in the inpatient treatment of eating disorders

SUMMARY

This paper considers the treatment, on an inpatient eating disorders ward, of patients who have suffered violence and emotional abuse during childhood. The complex web of relationships surrounding these patients is discussed, and it is suggested that there are multiple transferences — to the institution, to various members of staff, and to other patients — and that splitting of these transferences is inevitable. Staff experience powerful countertransference feelings, related to the patient's violent history. A central task for the staff team as a whole is to understand and contain the patient's disturbance — taking on, tolerating, and processing the projections. This demands the close working-together of the members of the multidisciplinary team, so that staff can together openly examine the patient's interaction with them and their own emotional responses to the patient and to other members of staff. If these responses are not understood by the ward staff, they can lead to conflict and inappropriate decisions. On the other hand, if the staff team together can build up a picture of the patient's relationships on the ward, and their meaning for the patient, this picture, like a particular projection of the world in an atlas, provides a ‘map’ of the patient's inner world. This ‘map’ can be used by the staff team in navigating their interactions with the patient. It can also assist the psychotherapist in her work to help the patient recognise and, eventually, own the split-off parts of herself.     

Altruistic love in psychoanalysis opportunities and resistance

Many patients manifest a desire to help the analyst. This is usually understood as being derivative of defensive aims or in the service of other primary motivations. This paper argues for the developmental and clinical importance of primary altruistic aims, which are often warded off by the patient because of his or her fears of exploitation or rejection. Several pathogenic beliefs and varieties of psychopathology result from the failure of the patient's caretakers to allow the child to contribute to their welfare, to “take”; the child's “help.”; Similarly, some patients require tangible evidence that they are having a positive impact on their analyst. Ordinary “good‐enough”; technique often reinforces the patient's view that he or she has nothing to offer. A full appreciation by the analyst of the importance to patients of having their altruistic gestures and concerns recognized and accepted can open up possibilities for analytic progress and therapeutic growth. Various sources of resistance to and misunderstanding of these dynamics are explored, ranging from ethical concerns to certain traits that cluster in the personalities of analysts.