The borderline self and the jealous object

The purpose of this paper is to show that just as a therapist working with a borderline patient is often induced with many intense and difficult emotions, similarly, a borderline patient is induced with very intense emotions by his object, which are often experienced as foreign and ego alien to the self. As a result, these induced emotions remain repressed or dissociated from the self, but they continue to play a major role in the borderline's lifestyle. It will be demonstrated that the jealous object, and not the self, is the main factor that interferes with the borderline's growth and progress in treatment. Although a borderline patient may employ primitive defenses such as projective identification and splitting as his primary mode of coping with the bad introject as has been stated by Klein, Kernberg and other writers, I would like to suggest that a borderline patient also employs what I would call dual splittingand dual projective identificationin order to maintain a symbiotic relationship between the selfand its jealous object.     

Nameless Desire: Alexithymia and the Anorexic Patient

In this article, the author attempts to provide a psychoanalytic understanding of the anorexic patient who is disconnected from her affective experience and is considered to be alexithymic. Through her restrictive food ritual, this type of patient may organize her internal states by repeatedly creating an illusion of what it is that she needs and desires. The author asserts that the task of the therapist working with the anorexic patient with alexithymia is to be aware of his own sensation-based reverie as lived within the intersubjective arena. This will enable the therapist to assist the patient in building an affective vocabulary to accurately identify, differentiate, and label the internal signals of her body. It is suggested that the subjective emotional experience of the patient will continue to be reorganized, expanded, and enriched as the therapist and patient mutually influence one another in this unique relational matrix. A clinical vignette is provided to illustrate intersubjective treatment interventions with a difficult-to-reach anorexic patient.     

Coping with the Angry Patient

This patient is enacting two chronic maladaptive patterns. In one he alternates between the role of victim and abuser while inducing the therapist to play the counterrole. He tries to master the abuse he suffered passively as a child by becoming abusive with the therapist and having her experience what it feels like to be mistreated. My effort would be to interpret this pattern even while acknowledging and absorbing some degree of his anger. In a second pattern he acts like an angry, demanding child in an effort to extract nurturance and special treatment from the therapist. I would help him explore this posture in terms of his deprived background and its maladaptiveness in his current life. Finally, I present vignettes from my own practice to demonstrate how I work with patients' anger when it is expressed indirectly rather than in Mr. P's very direct manner.     

When Time Stands Still: The Non-Interactive Interaction in the Psychoanalytic Encounter

This paper strives to shed light on the patient–therapist encounter at times and places where emotional life has stopped, both within the patient and in the therapeutic dyad. The term non-interactive interaction is coined to describe a manner of being together that does not possess the essential features of interaction: movement, encounter, and change. The paper explores the characteristics and effects of such dead areas in one’s soul and the various motivations for the therapist’s willingness to surrender himself to such areas, both those of his patient’s and of his own. Among these, the paper suggests, are the therapist’s love and dedication to his or her patients; his deep-rooted struggle to cope with and give life to some of his own deadened and traumatic self-states; and, perhaps most important, a mythical, hubris-like, valiant, and perennial urge to fight death. Two clinical examples are presented.     

Behind the Mirror: Reflective Listening and its Tain in the Work of Carl Rogers

Although Rogerian reflective listening is considered a fundamental therapeutic practice, it is widely misunderstood. This article endeavors to dispel myths about Rogers’ reflective approach through detailed readings of his work, while also opening up a central problematic in Rogers’ thinking. Rogers struggled repeatedly with the dilemma of how the therapist can faithfully reflect the client's experience while avoiding insincerity. The metaphor of a mirror and its tain, or back surface, is used to guide a close analysis of how Rogers grappled with the tension between the therapist's reflective listening process and his or her inner experience while reflecting. It is shown that each of Rogers’ revisions of his conceptualization of reflective listening constitutes a dialectical shift that opens a different approach to the problem of the tain, eventually concluding in an interactional formulation of reflection as the provision of tentative therapist understandings designed to be amended in response to client feedback.     

The effect of therapist interventions on the therapeutic alliance with borderline patients

The authors draw attention to the problems of establishing and maintaining a therapeutic alliance in the psychotherapy of the borderline patient. They elaborate an extensive methodology designed to study the manner in which shifts in collaboration occur in response to therapist interventions. This report demonstrates how one particular borderline patient increased his ability to collaborate with the therapist in response to a transference focus in the psychotherapy. Methodological problems are noted as are directions for future research. Only a series of patients studied with this or with similar methodology will allow for a sophisticated and empirical rationale for choosing a particular form of psychotherapy for a particular kind of borderline patient.     

Incomplete mourning,betrayal, and revenge in The Prince of Tides: Erotic countertransference in the cinema

The Prince of Tidesis the characterological study of and interaction between two families, that of Savannah, the patient and Dr. Susan Lowenstein, the psychiatrist. In order to treat Savannah, recovering from a suicide attempt, fraternal twin Tom (Savannah's memory) comes to New York to assist in his sister's treatment. Tom becomes the patient relating the family dynamics in six cinematic flashbacks. These show the parental disharmony, Tom's strong Oedipal attachment, maternal betrayal and Tom's wish for revenge, his incomplete mourning for his older brother Luke, and its effects on his life. The relationship between Susan, her husband and son, Bernard, and how each interacts with Tom is also described. Susan's erotic countertransference is analyzed, and the role of the woman therapist in the cinema discussed.     

Separation and loss in psychoanalytic therapy with borderline patients: Further remarks

This paper is a continuation of an earlier one concerning borderline patients, and I can recapitulate only a few of the many areas touched upon here. The borderline individual is faced continually with the threat of loss, either of his tenuously established individual identity, through fusion with the other person, or of his fragile interpersonal relatedness, through uncontrollable flight into autism of psychotic degree. A basic theme in one's work with these persons is that of unconscious, fantasied omnipotence, variously an aspect of the patient's unconscious self-image or projected into the therapist. The acting-out which the patient does consists in his inflicting loss, deprivation, and other forms of injury upon his introjects of part-aspects of the therapist. The grief involved in the relinquishment of so-called bad introjects is discussed. The patient early in therapy is aware of his inability to grieve, and endeavors to conceal this deficiency by spurious emotionality. I give examples of patients' manifesting regressive dedifferentiation to fusion with elements of the nonhuman environment, as an unconscious defense against feelings of separation and loss. Effective therapy with these patients involves the therapist's deeper working through of his own losses. The significant losses occurred so early in these patients' lives that the therapeutic exploration of these areas may enable the therapist to gain access to comparably early losses on his own part, losses from a developmental era which many a training analysis may not have explored at all adequately.     

When the Tree Falls and No One Hears It: On Being Dropped and Learning to Hold

This case study focuses on a student therapist’s reflections upon a premature termination that occurred in her work with an adolescent male patient. The therapeutic process is traced back to the beginning of treatment, and the article delineates the extent in which the patient’s early interpersonal experiences influenced the development of the therapeutic alliance. The author addresses several themes that evolved throughout the treatment, including the patient’s experience of unpredictability and instability and his inconsistent understanding of time, and the ways in which these experiences ultimately influenced the treatment’s ending. The article describes the therapist’s development as a clinician over the course of the treatment, focusing on the various experiences that helped her consolidate a dynamic understanding of the holding environment.     

Emotional Communication in the Case of Antonio

ABSTRACT

In describing her work with her traumatized patient Antonio, Dr. Jane Lewis focuses on Barthes’s (1981) notion of a photograph as having the symbolic linking function of an umbilical cord, and emphasizes the notion of the punctum, the specific personal wounding detail in an image that connects to the viewer’s experience. This article discusses these ideas, which appear mystical to Lewis, in the contexts of the theory of multiple coding and the referential process, as well as recent advances in the fields of social neuroscience and embodied communication. In the early Arousal phase of the referential process, emotion schemas associated with painful events of the past are activated for both participants, in subsymbolic, embodied form. Antonio is largely mute and frozen; Lewis also feels herself freezing and disappearing. In the Symbolizing phase, Antonio begins to connect to dreaded experience of his past, and to tell memories, fantasies and dreams. Memories and images of her past, related emotionally to Antonio’s experience, are awakened for Lewis as well. Through their embodied communication and shared imagery, the therapist’s ability to find emotional meaning for her own painful experience appears to support the patient’s beginning to provide some meaning for his pain and dread. Related observations by Bollas and Arlow, and parallels to a case reported by Ogden are discussed.     

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.     

Rebirth fantasy and the psychoanalytic process

In this paper, Jungian and Freudian perspectives on the fantasy of rebirth are explored and a brief review of the literature on the theme is used to show how that the rebirth fantasy seems to be a universal fantasy in the human mind, connected with the experience of both destruction and creation. In the psychoanalytic process the rebirth fantasy is connected with initial hopes for a better life, but is also a vehicle for creating the analytic pair and for separating from the 'totalitarian object'. An account of clinical work with a patient is given to illustrate the mutual and parallel process of rebirth in both the patient and the therapist. For the patient, the therapy was experienced as an awakening or a birth. The therapist was initially doubtful about the patient's capacity to engage in the analytic process but his involvement and interest were 'born' during the early sessions, enabling the patient to rely on him to lead her out of the claustrophobic power of the totalitarian object.     

Warriors,authors and baseball coaches: the meaning of metaphor in theories of family therapy

This article examines the metaphors family therapists use in their theories to reveal aspects of the theories which are not explicitly stated, using Whitaker's symbolic experiential therapy, Minuchin's structural therapy and White's narrative therapy as examples. Such examination, drawing on social constructivist understandings of metaphor and meaning making, reveals that Minuchin's metaphors of family as organism and therapist as artist and warrior emphasize the family as relatively holistic and the therapist as relatively interventionist. In contrast, Whitaker's metaphor of family as ecological system or team and therapist as coach emphasizes the interdependence and context sensitivity of the family and relative powerlessness of the therapist to impose change. Finally, White, reflecting his explicitly post‐structural commitment, uses the metaphor of therapy as a journey undertaken with a map and as therapy as an act of re‐narrating a story.     

Parting gifts: termination rituals in group therapy

A patient's termination from group therapy is a powerful experience for the departing patient, the therapist, and all group members. Unless the feelings evoked are channeled into constructive expression, they may undermine this potentially valuable phase of both the departing patient's group treatment and the life of the group as a whole. A termination ritual, styled by a particular patient according to his or her own need, therapy goals, and personality may help the patient achieve a more clearly defined sense of self. The authors suggest that the group therapist's careful attunement to and thorough exploration of the significance of any termination ritual or gift will help to extract maximum therapeutic benefit for the departing member and the group as a whole.     

The Angry Patient: Case and Session Presentation

Responding to patients who become angry at the therapist is difficult for many clinicians. In the case and session presented, the patient is not only angry, but devalues the therapist by not paying while asking for more frequent sessions. The therapist loses it, states she is angry, and remains insistent on the patient keeping his bills paid or reducing the frequency of sessions. The therapist is conflicted over confronting the patient with what she believes has to change in order for his symptoms to diminish—the irrational beliefs, life style, and sense of entitlement related to the personality disorder of this patient, but likely to drive him away from treatment. The therapist engages in a risky confrontation and remains unclear about the eventual benefit of this response.     

Altruism and Boundary Violation

ABSTRACT

The desire to help others is a common motivation for becoming a therapist, and boundary crossings are an expectable part of psychotherapeutic work. However, progression to boundary violation is rare. The concept of an altruistic boundary violation is presented and illustrated with detailed clinical material drawn from the analysis of Mrs. A,¹ a generally ethical therapist, whose violation of the therapist/patient boundary with her patient, M, began as an altruistically motivated enactment and boundary crossing. In Mrs. A’s case, and arguably in all similar altruistic boundary violations, a specific fit existed between patient and therapist. The intense need to rescue this particular patient was fueled by Mrs. A’s history of early physical and abandonment trauma, which increased her vulnerability to overidentification with her traumatized patient. The stress of relocation to another city and closing her practice further magnified her susceptibility. The complex clinical, professional, ethical, and legal issues inherent in consulting on such a case are discussed. I describe my countertransference and my parallel enactment, an initial crossing of the boundary between the roles of supervisor and therapist.     

Clinical differentiation of borderline syndromes from the psychoses

The discrimination of borderline syndromes from the psychoses is often a difficult task clinically. The problem most often arises in the acute setting in which a crisis has arisen--the typical example being that of acute hospitalization. The clinician's task is to assess the patient's apparently psychotic symptoms and behaviors to determine whether they are the manifestations of an underlying psychotic process, or whether they reflect a more or less transient regression from a somewhat higher level of habitual functioning. Some discrimination between these categories is possible even in the acute presentation, since borderline patients only exceptionally demonstrate Schneiderian first-rank symptoms or any other discriminating indices of psychosis. While the differentiation may be clear cut between the psychotic and the higher-order, better functioning borderline, there may be less precision in discriminating between the lower-order borderline forms or transient borderline states and psychoses. We have focused on this area of differentiation in this study. The discriminating indices are both short- and long-term. The differentiation cannot be adequately made without longer-term evaluation of the patient. Nonetheless, on a short-term basis, evaluation of the patient's behavior can point the diagnosis in one direction or other. The presence of a clear precipitant; the presence of intense (often verbalized) anger; the patient's attempts to engage the therapist in an intense, dependent, clinging and demanding relationship, usually in manipulative fashion; the partial, fragmentary, often circumscribed and ego-alien quality of the patient's psychotic productions; the marked tendency to act-out feelings, particularly anger, in a way that gains increased attention and concern from doctors, family, friends, or hospital staff; the persistence of some degree of reality testing and areas of significant realistic functioning; the transient nature of regressive manifestations and the ready reversal of regression in structured environments and with appropriate therapeutic management, particularly adequate limit-setting--all point toward a borderline diagnosis. Moreover, these factors carry an accumulative weight so that the more of these factors that can be validated, the more secure the diagnosis of borderline psychopathology. On a longer-term basis, beyond a few days, one would expect the above indices to be better discriminated. In addition, there is greater opportunity to study patterns of patient behavior--both his interaction with staff and other patients and with the therapist.(ABSTRACT TRUNCATED AT 400 WORDS)     

The effects of teaching experience on levels of alienation

This study was designed to measure the levels of alienation among American student and full-time teachers, based on the length of their experience with the public school organization. One hundred seventy eight subjects, including 113 full-time teachers and 65 student teachers, were administered the Dean Alienation Scale. Analysis of the data indicated that student teachers had significantly higher levels of alienation, isolation, normlessness, and powerlessness, than did full-time teachers. The less experience the teacher had, the higher were his or her levels of total alienation and powerlessness.     

Movement,Stagnation, and Renewal of Movement in the Therapeutic Session

This article examines the term potential space in the therapeutic session and the pathological situations in which this space collapses. The article suggests that such failures occur in the weaving of transference and countertransference between patient and therapist. The potential to free and repair this space can be found in emotional thinking that occurs between the therapist and the patient. When the object-therapist can play or dream, the infant-patient can do so too. Thus, a new shared experience may be created in the therapeutic session and in the patient's mind. This article reviews the different types of collapse of the potential space, as suggested by Ogden, and offers a new additional type.