Orientations of psychotic activity in defensive pathological organizations

The author reviews some clinical experiences of the treatment of personality disordered patients suffering from internal domination of ego functioning by a defensive pathological organization. In particular, the function and purpose of perverse, sadistic attacks by the organization on the ego are considered and questions pertaining to technique are raised. It is suggested that different forms of sadistic, subjugating activity by pathological organizations may denote differences in intent borne of the type and severity of the psychopathology of the individual. Patients with severe narcissistic psychopathology for whom object contact has become associated with the arousal of intense psychotic anxieties seem more likely to be subjected to an invasive, annihilatory imperative by the pathological organization, the purpose of which appears to be to obliterate the experience of contact with any differentiated object, to avoid emotion and to use coercion to enforce a primitive identification by the ego with the psychotic organization in the mind. Certain patients with less severe narcissistic psychopathology, yet for whom object contact can also be associated with the arousal of psychotic anxieties due to intense or persistent conflict with the object, sometimes expressed as organized sadomasochistic clinging to a punishing and punished object (for example, in certain borderline or depressed patients) exhibit sadistic attacks that serve less to annihilate object contact and more to intrusively control and punish the object. Observations of these phenomena have been made by a number of psychoanalysts in recent decades and these contributions are discussed. This paper is addressed primarily to the implications for technique with such patients, particularly a need for triangulation of their experiences of oppression in order to loosen the controls over the ego by the pathological organization.     

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.     

The effects of a seven day camping experience on volunteer student counselors

An investigation of the effects of a seven-day camp experience with disturbed adolescents on approximately sixty undergraduate "camp counselors" was conducted. Measures of the types of reinforcement preferred and used as well as an overall attitude toward disturbed adolescents were obtained and evaluated. The results indicated that the student counselors did not use the type of reinforcement that they felt was most important and they did not change their attitudes toward disturbed adolescents as a result of experience. The limitations of the study are discussed as well as some suggestions for future research into practicum sites for programs training teachers of the severely disturbed.     

PREGNANCY: AN UNTHINKABLE REALITY

A therapist's pregnancy is bound to provoke profound conflicts in all patients, particularly those relating to envy, exclusion and loss as infantile aspects of the patient and their relation to the maternal object are revived. This paper explores the impact of the therapist's pregnancy on two patients for whom the experience was felt to be catastrophic. I suggest that in their early efforts to adapt to an inaccessible, disturbed and disturbing object who could not face reality or cope with life, these patients were compromised in their own ability to accept the facts of life and moreover to bear the frustration of exclusion, representing for them as it did, total inaccessibility. The pregnancy was so hated and distorted that it seemed to take on the meaning for them of a cruel ‘mad’ idea.     

Countertransference and containment in a patient with a psychotic mother

The importance of countertransference reactions in the treatment of a borderline patient with a psychotic suicidal mother is discussed. In such a case containment can be seriously disrupted by the violence of the patient's projections into the therapist. Where a psychotic internal object has been brought for treatment it is particularly important that the therapist be able to identify not only with the sane and mad parts of the patient but with the destructiveness and cruelty of the patient and her primary object. The difficulties of tolerating these relentless projections of madness and despair are increased by the multiple and confusing aims of the patient's excessive use of projective identification. The invasive and hostile aspects of this are often heavily disguised beneath idealization of the self and object as well as of madness itself. For the patient, attempts to interpret the idealization are moreover felt as an assault on the lost loved object, and the therapy then unconsciously becomes a persecutory experience for the patient. The therapist can thus be drawn into feeling the full force of the anger and hatred towards the real disappointing object and the sense of hopelessness about the reparative task. Although such feelings need to be tolerated, eventually some distance from the often-unpleasant fluctuations in the countertransference must develop if a useful degree of containment is to be achieved.     

Community care for the kibbutz chronic psychiatric patient

After over 15 years' experience with a very structured community care program for kibbutz chronic psychiatric patients, the author is convinced that these severely disturbed patients show improved psychosocial adjustment and a highly significant reduction in recidivism and rehospitalization as compared to their records before the institution of the community treatment program.     

Community care for the kibbutz chronic psychiatric patient

After over 15 years' experience with a very structured community care program for kibbutz chronic psychiatric patients, the author is convinced that these severely disturbed patients show improved psychosocial adjustment and a highly significant reduction in recidivism and rehospitalization as compared to their records before the institution of the community treatment program.1981, Fall     

Multiple labels for objects in conversations with young children: parents' language and children's developing expectations about word meanings

Children sometimes seem to expect words to have mutually exclusive meanings in certain contexts of early word learning. In 2 studies, 12- to 24-month-old children and their parents were videotaped as they engaged in conversations while playing with sets of toys (sea creatures, vehicles, doll clothing) in free-play, storytelling, and categorization contexts. In both studies, parents demonstrated a reliable preference to provide just 1 label for a given object. Importantly, parents' violations of this preference were usually accompanied by clarifying (or "bridging") information that either indicated the relation between the 2 labels or suggested that 1 of the labels was appropriate. Further, in some contexts, parents' tendency to use multiple labels and to provide bridging information for multiple labels was correlated with children's productive vocabulary. It is argued that these findings support a socio-pragmatic hypothesis about the origins of children's early beliefs about word meanings.     

The Entropic Body: Primitive Anxieties and Secondary Skin Formation in Anorexia Nervosa

This paper develops a metapsychological view of anorexia nervosa, including not only its symptomatic presentation but also its etiology and characteristic psychic and relational styles. Because patients with anorexia are understood as not having internalized maternal comforting functions in the period of separation-individuation, they are unable to digest trauma experiences of infancy. I argue that the anorexic patient’s disturbed relationship with food reflects distortions in transitional object usage. Lacking the ability to contain intense anxieties about disintegration and falling apart, patients with anorexia must find other ways to hold themselves together. The fear of getting fat expressed by these patients is one way that this fear of disintegration is expressed. Furthermore, the almost addictive experience of emaciation holds the personality together. Elaborating this idea, I develop the notion of the entropic body, a particular version of the false body (Goldberg, 2004) employed by patients with anorexia nervosa in an attempt to compensate for absent maternal comforting functions. This body-state (Petrucelli, 2014), which develops against a background of profound early trauma, eschews hunger and dependence in favor of omnipotently controlled protection.     

Craving,longing, denial,and the dangers of change: clinical manifestations of greed

Greed is the unrelenting and unrealistic search for all the good an object has to offer and, via identification, all the good one can produce and provide. In phantasy, and sometimes in the patient's early developmental environment, the object and the ego demand more from each other than either have to give. Some patients cannot contain their urge to possess all and to be all, so it becomes a part of the interpersonal and psychological relationship with the analyst rather quickly. These patients feel something is owed to them, and they demand to be fed immediately. Other patients try and hide these greedy phantasies by being the opposite of greedy. They strive to be independent and charitable, while having great conflict over deeper desires to be dependent and in possession of an idealized giving object, an all-providing breast. Case material was used to explore these ideas.     

‘I am not crying. I am rubbing my eyes’: Annie and the hollow object

This article explores the relationship between the development of severe eczema and asthma in an eight-year-old girl and her difficulties with experiencing psychic pain and conflict. The author focuses on the transference dynamics that preceded and surrounded the psychosomatic reaction in the session. The observations in this case may explain why patients, despite feeling taken over by intense physical sensations, can display flatness and superficiality of affect giving the appearance that they are emotionally ‘hollow’. The author proposes that these patients experience an emotional sense of emptiness in themselves and in their objects that is the result of a very early defence of dissociation caused by overwhelming anxieties of annihilation that are lived out in and through the body. The appearance of a psychosomatic symptom during the session can follow the emergence of sudden and intense raw hostile feelings towards the primary object, accompanied by a sense of danger and profound anxiety, as the hated object is also desperately needed for the subject’s own physical/emotional survival. The analyst can contribute to triggering these episodes by failing to contain the patient’s projections, which may lead to the patient feeling forced to re-introject unprocessed and unbearable ‘psycho-physical’ emotions. This article discusses the different degrees – and forms – of symbolic functioning in connection to this girl’s experience of her eczema and asthma and their manifestation in the transference relationship to the therapist.     

Projective identification,containment and sojourn in the psyche: Clinical notes on a specific type of transference-countertransference interaction

Abstract

This paper suggests that the interplay between transference and countertransference is considered to be a valuable channel of communication. The author puts an emphasis on the containing function of the analyst. The patient strives for an experience of an object (analyst) that tolerates and copes with the patient's projections. There are some moments when analysts feel themselves to be invaded, controlled or abused by their patient's products. As Bion has postulated, this situation takes the form of a sojourn in the analyst's psyche. Clinical vignettes are given to provide support for the ways in which the analyst contains and elaborates the projections of the patients in his or her own mind and the therapeutic role that these processes have.     

The body one has and the body one is: Understanding the transsexual’s need to be seen

The transsexual individual confronts the analyst with a disturbing otherness. How this otherness is understood, that is, how the analyst ‘looks’ at the patient through her distinctive theoretical lens impacts, in turn, on the patient’s experience and what transpires between them. In this paper the author outlines a developmental model rooted in attachment and object relations theory to provide one alternative way of ‘looking’ at some of these patients’ experiences in the clinical setting. It is suggested that in some cases of transsexuality the primary object(s) did not mirror and contain an early experience of incongruity between the given body and the subjective experience of gender: it remains unmentalized and disrupts self‐coherence leading to the pursuit of surgery that is anticipated to ‘guarantee’ relief from the incongruity. Through an account of work with a male to female (MtF) transsexual who underwent surgery during her five years of psychotherapy, the author explores how a focus on the transsexual’s experience of ‘being seen’, that is, of being taken in (or not) visually and mentally by the object in their state of incongruity, affords another window through which to approach the transsexual’s experience in the transference–countertransference dynamics.     

A Mixed Bag: The Realities of Psychoanalytic Practice

For a variety of reasons, psychoanalytic training is done in somewhat of a vacuum. It teaches a theory and a way of practicing that does not always translate well to day-to-day private practice work. The clinical realities of psychoanalytic practice prove the psychoanalytic method to be one that provides help to a wider audience than classical psychoanalytic training programs might suggest. The psychoanalytic approach offers the analyst many special opportunities to work with and help a wide variety of patients. Analysts who accept both the limitations as well as the wide application and broad benefits of the psychoanalytic approach may have a more fulfilling experience than their training experiences might foster. At the same time, the analyst's level of therapeutic skill, the patient's diagnosis, and many multiple external factors create different limitations in the practice and outcome of psychoanalytic work. Extensive case material is used to show the broad range of patients who are helped by the psychoanalytic method. The clinical material also shows the less than perfect, but often good enough outcomes of these difficult cases with often severely disturbed patients.     

Losing a father all over again: the termination of an analysis of an adolescent boy suffering from father loss

Criteria for beginning and conducting the termination phase of psychoanalysis have provoked debate and confusion from the early days of psychoanalysis. Gabbard (2009) has recently pointed to the field's tendency to cling to idealized versions of these criteria as a way to deal with disagreements. The situation becomes more complicated for child and adolescent psychoanalysts because their patients are in the midst of a developmental process at the very time they are engaged in a psychoanalytic process. The termination phase of an adolescent male suffering from father loss is presented in depth in order to provide clinical data toward further consideration of the vexing questions surrounding termination in psychoanalysis. His termination is used to examine the relative importance of losing the analyst as a transference object as against a developmental object; the meaning of action during termination; the complicating role of trauma vis-à-vis termination; and the importance of the post-termination phase of analysis. It is suggested that his termination phase demonstrates that a "good enough" termination involves the development of a self-analyzing capacity that continues to evolve and develop after termination.     

The framework of psychoanalytically oriented psychotherapy with traumatised patients and the institution

Abstract

Lindbom-Jakobson M, Lindgren L. The Framework of Psychoanalytically Oriented Psychotherapy with Traumatised Patients and the Institution. Int Forum Psychoanal 1997;6:217-224. ISSN 0803-706X.

Psychotherapies performed at multidisciplinary institutions will be influenced by the ongoing dynamics and inevitable group processes of the institution. The difficulties of these processes become extremely hard to handle when the patient category is a severely traumatised one. The prerequisite of psychoanalytically oriented psychotherapy, the illusion of the sealed room and fixed framework, gets disturbed by the information flow in an institution. The institutions for these patients tend to become stages on which the patients as well as staff can perform and repeat their intrapsychic and interpersonal conflicts, non-adaptive defences and disturbed object relations. The predominant dynamic that arises around tortured refugees as a patient category is sado-masochistic relating.     

The marriage checkup: An indicated preventive intervention for treatment-avoidant couples at risk for marital deterioration

Prior to dissolution, it is likely that couples that become severely distressed first pass through an at-risk stage in which they experience early symptoms of marital deterioration but have not yet suffered irreversible damage to their marriage. It is during this “at-risk” stage when couples might benefit most from early intervention. In response to this need we have developed an indicated intervention program called the Marriage Checkup (MC) based on the principles of motivational interviewing. The current randomized study provides preliminary evidence for the attractiveness, tolerability, efficacy, and mechanisms of change of the MC.     

Race, culture, and psychotherapy: transference to minority therapists

We present observations on the use of racial and cultural stereotypes in psychoanalytic psychotherapy with patients from the majority culture and with those from minority backgrounds. Earlier work has centered on black/white patient dyads and has not taken other possible combinations into account. "Race" and "culture" have sometimes been used synonymously. Our clinical experience indicates that there is some overlap in the themes of transferences to us as members of different racial minorities. We note, however, that for the African-American therapist, projections are more often based on racial stereotypes, whereas for the Chinese-American therapist, projections are based more on cultural assumptions. When careful attention is paid to the manifestations of racial and cultural stereotyping, much can be learned about the patient's inner life, to the benefit of the analytic work.     

A group-centered object relations approach to group psychotherapy with severely disturbed patients

This paper discusses how the application of object relations theory to clinical intervention has extended the application of psychoanalytic group psychotherapy to more severely disturbed patients. The author suggests how to structure the group based on individual and group needs. Clinical issues are presented, including the group as a container, communication peculiarities, and psychotic response to separation, sexuality, and interpretation.     

Attitude accessibility,attitude-behavior consistency,and the strength of the object-evaluation association

Two experiments were conducted in order to examine the accessibility of attitudes from memory as a function of the manner of attitude formation. The findings of the first experiment indicated that subjects could respond more quickly in a response-time task to inquiries about their attitudes when the attitudes were based upon direct behavioral experience with the attitude objects than when they were based upon nonbehavioral experience. It was suggested that, relative to indirect experience, behavioral experience may facilitate the attitude formation process and increase attitude accessibility once the attitude is formed. A second experiment found support for both of these notions. Two additional experiments indicated that repeated association of the attitude object and the attitudinal evaluation enhanced both attitude accessibility and attitude-behavior consistency. It was suggested that the strength of the object-evaluation association is a critical determinant of accessibility, which, in turn, acts as a central factor in the process by which attitudes affect later behavior. It was further suggested that the manner of attitude formation affects attitude-behavior consistency because direct experience produces a stronger object-evaluation association and, hence, a more accessible attitude than does indirect experience.