Interpretation as Shaped by Projective Identification

How to make interpretations during the course of psychoanalytic treatment is a recurring clinical question. Certain aspects of the analysis serve as helpful signposts along the way. Patients have particular interpersonal ways of presenting themselves. The unique intrapsychic manner the patient has of relating to us (transference) and our feelings (countertransference) to these matters give us clues to study. Our understanding of these situations may lead to the development of a hypothesis we may or may not choose to share with the patient. Projective identification is a complex mental mechanism that can often shape the content and manner of an interpretation.     

Gone but not forgotten: A new look at difficult cases

Many treatments never seem to get off the ground. They end almost as quickly as they begin. These are often treatments of borderline, narcissistic or psychotic patients. While it is easy to dismiss these cases as failed, or unanalysable, they are valuable to study. One such case is presented.     

Greed and the Frightening Rumble of Psychic Hunger

Many patients are desperately struggling with feelings of envy and greed. For some, greed is experienced as a constant hunger, a feeling of being empty and alone. This type of patient can be aggressive or resentful in the way they feel and act. They are determined to take what they feel is rightly theirs. Other such patients are much more conflicted about their greedy phantasies and striving. This paper focuses on patients who are fearful and anxious about the greedy urges that shape their inner world. Case material is used for illustration.     

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.     

The Ideal Patient and the Realities of Clinical Work

As candidates, and later as practicing analysts, we filter the idea of what patients, analysts, and the analytic process should look like through our own ego ideal. Literature that is often stilted toward a theoretical ideal further muds the picture. Finally, we are often confused by the quest for the perfect patient who meets the criteria for analyzability outlined by our training institute, our supervisors, our teachers, and our own demanding superegos. This paper examines several cases of clinical work that falls far short of any ideal. However, these realistic snapshots of day-to-day clinical work are too important to be ignored as simply failed cases with unanalyzable patients. Often, even the briefest of clinical encounters enrich the analyst's understanding of human functioning and occasionally benefits the patient as well. If the analyst uses the analytic stance with all of his patients, a useful analytic discourse may take place with some of them. These cases are not standard or complete analytic treatments, but the results are often valuable to the practitioner and potentially helpful to the patient.     

The clinical notion of working within

Clinical material is used to illustrate the Modern Kleinian approach to and within a patient’s defensive system and their particular transference profile. Rather than embrace the traditional concept of the working-through (WT) process, the author focuses on the analytic here-and-now of working within a patient’s unconscious phantasy world, the transference, and any pathological organizations that are relied upon. This is a more holistic and comprehensive method of working analytically, based on working within a patient’s internal object relational experience, which hopefully leads to growth and transformation. A summary of the first two analytic sessions with one patient, material from a psychotic patient in treatment for 6 months, and a higher functioning patient seen for more than a year are presented to show the utility of working in this manner with all patients regardless of their level of psychic organization.     

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.     

WHEN PATIENTS FACE THE DUAL THREAT OF DEPRESSIVE AND PARANOID PHANTASIES

A number of patients enter psychoanalytic treatment appearing to suffer from depressive anxieties in which they fear harming their objects, so they try to make amends and find a peaceful solution to perceived conflicts. However, over time these same patients reveal a deeper and darker form of internal chaos in which they are experiencing a combination of paranoid and depressive phantasies of an overwhelming nature. Primitive experiences of loss combine with persecutory feelings to bring about unbearable states of mind. Projective identification and splitting are used defensively but also increase this pathological internal situation. Attempts at reparation fail, leaving the ego to eternal loss and life without forgiveness. Dead and destroyed objects return for revenge, replacing hope with dread. These patients have an immature foothold in the depressive position while still struggling with paranoid conflicts. Rather than finding refuge in pathological organizations or regressing from one position to another, they face the constant threat of both paranoid and depressive experiences without any reliance on good internal objects to sooth, save, or guide them. Melanie Klein's theoretical discoveries in this area are discussed and clinical material is used for illustration.