The unreachable object? Difficulties and paradoxes in the analytical relationship with borderline patients

The author investigates the main difficulties the analyst encounters in borderline patient analysis, focusing on the specific way in which such patients put the analyst's mental functioning to the test and highlighting the most salient elements of the transference-countertransference dynamic. The author picks out several of the paradoxes that characterize the analytical relationship with these patients, who are constantly seeking contact with the object, which is inevitably traumatic for them. On the basis of highly detailed clinical material, the author demonstrates how - no matter which theoretical-clinical model is adopted - a specific technical problem with these patients is how to manage their intense destructiveness. With these patients, countertransferential difficulties are inevitably predominant because of the looming threat of the destruction of the analytical relationship. Maintaining a balance between the recognition-legitimization of primary narcissistic mirroring needs and the recognition-control of narcissistic demands and attacks on the analytical link is as crucial as it is complex. The paper examines the most important therapeutic and anti-therapeutic factors, highlighting the importance of countertransference analysis and self-analysis as ways of accessing as yet unrepresented elements of the patient and analyst respectively. Particular attention is given to the role played by the analyst's subjectivity and to the enactment.     

Exploring a patient's shift from relative silence to verbal expressiveness: Observations on an element of the analyst's participation

By tracing a portion of close process of a patient's shifts from a relatively silent and inhibited stance to one in which he is beginning to verbalize more about his experience and fantasy, I will illustrate some tensions between the analyst's role as facilitating expressiveness and as occupying a place in the patient's internalized world. Since the analyst's functions as facilitator and as internal object (often an obstacle to the patient's expressiveness) are sometimes in conflict with one another, it is important for the analyst to be able to work internally with this conflict as he works with his patient. Splitting processes between these two functions may provide the analyst with cues related to the patient's and the analyst's resistance to understanding the patient's communication of unconscious conflict and the patient's recruitment of the analyst into the patient's internalized world.     

The hero, the anima and the claustrum: anality and idealization

Joe Redfearn's (1979) classic paper 'The captive, the treasure, the hero and the anal stage of development' is recognized as seminal to the development of Jungian thought about anality, particularly its integration with mainstream (Freudian, Kleinian) psychoanalytic perspectives. This paper develops such an approach through drawing on contributions from Meltzer, Green, Bion, Chasseguet-Smirgel and Kernberg. More specifically, it is argued that over-investment in hero and anima archetypal configurations may represent an attempt to replace the resource of the internal parental couple that, at the level of unconscious phantasy, has been destroyed by the aggrieved child's attack on the primal scene. Unless this usually dissociated sadism can be integrated, the creative epistemophilic instinct may remain blunted, giving rise, through projective identification, to the adoption of a pseudo-adult identity based on appropriation or assertion. This in turn may lead to manic attempts to reach authentic ('animating') experience through the (often erotized) excitement of heroic endeavour. Consideration of both Redfearn's and the author's own clinical material demonstrates how close attention to process as well as content is fundamental to revealing and addressing such likely-to-be dissociated scenarios.     

“You touched my heart”: Modes of memory and psychoanalytic technique

Abstract

With the concept of procedural unconscious processes, contemporary psychoanalysis goes beyond Freud, who did not know of implicit memory and the resulting procedural relational dynamics. Today, lack of mentalization and symbolization is regarded as another mechanism besides repression constituting the psychodynamic unconscious. From that theoretical background, the manifestation of early pre-reflexive archaic experience can be conceptualized as procedural transference and handled in a way that takes care of the specific functioning inherent to the underlying archaic states of mind. Using material from the analysis of a narcissistic patient, the merging of episodic and procedural modes of transference and how this affected the psychoanalytic technique are demonstrated.     

Dramatology in life,disorder, and psychoanalytic therapy: A further contribution to interpersonal psychoanalysis

Abstract

Action and interaction, and emotion and thought as the inner wellsprings of action, play a central role in the lives of individuals, families, and society, spanning the continuum between everyday life and disorder. Until now, the narrative tradition has been the main methodology for portraying and formulating human action and interaction, and little has been written about the dramatic approach to life, disorder, and therapy. Since the essence of drama is action, dialogue, character, and emotion, it is time to give drama its due. The author proposes a methodological concept – dramatology – analogous to narratology, to highlight the dramatic method of investigating action and interaction in life, disorder, and therapy. Breuer and Freud presented both aspects of dramatology: dramatization in dream and fantasy, and dramatization in act, focusing on the person. This approach was elaborated by psychoanalysts with an interpersonal orientation, focusing on the person and speech as action. Dramatology is applied to exploring ongoing patient–therapist interactions as reality and as transference. Analyzing unconscious and latent dramatization in dream, fantasy, and enactment with free association is enhanced by utilizing clarification and confrontation, focusing on the manifest and mutually observable expressive form and style of actions and enactments, defenses and resistances, and the discharge and meaning of emotions. Dramatology puts forward a new paradigm for psychiatry, psychotherapy, and psychoanalysis.     

Expressive disclosure to improve well-being in patients with amyotrophic lateral sclerosis: A randomised,controlled trial

Amyotrophic lateral sclerosis (ALS) is a terminal neurological disease associated with progressive paralysis, loss of communicative ability and functional decline. Expressive disclosure may help people with ALS, particularly those who are emotionally or socially inhibited, meet psychological challenges associated with the disease. People with ALS (N?=?48) were randomised to expressive disclosure about their disease or no disclosure. Psychological well-being (affect, depression and quality of life) was assessed pre-intervention and also three and six months later. Results of multi-level models indicated that the group that disclosed thoughts and feelings about ALS had higher well-being than the control group at three months post-intervention, but not six months. Ambivalence over emotional expression (AEE) moderated three-month post-intervention well-being. Those low in AEE had higher well-being than those high in AEE regardless of condition. Those high in AEE, who disclosed, had increased well-being from pre-intervention, whereas controls had decreased well-being from pre-intervention. Expressive disclosure may be helpful for people with ALS, but only those who have difficulty expressing emotions. In addition, the intervention had only temporary effects; the dynamic challenges of ALS progression may mean that the effect of processing thoughts and feelings about the disease in one stage may not generalise to later stages.     

Transferences in parent–infant psychoanalytic treatments

In parent–infant treatments, babies sometimes exhibit symptoms such as screaming, clinging, and fearful gaze avoidance of the analyst. The paper investigates if such phenomena may be regarded as transference manifestations, and if so, if they appear both in younger and older infants. Based on three case presentations, it is concluded that some babies are capable of forming both brief and enduring transferences. The term “indirect infant transference” refers to when a baby reacts emotionally to the analyst as long as the parent's transference remains unresolved. “Direct transference” refers to when a baby reacts in a non‐mediated way to the analyst. The necessary tool of investigation for discovering these phenomena is a psychoanalytic method with an explicit, though not exclusive, focus on the baby. Discerning them in the clinical encounter may help us understand the baby's predicament and when and how to address the baby or the parent. These treatments constitute an empirical field awaiting more extensive clinical and theoretical investigation. Already now, they suggest that transference may be rooted in, and may appear during, very early developmental stages. The paper's positions are compared with those put forward by other parent‐infant clinicians.     

‘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.     

Psychological wellbeing and quality of life in amyotrophic lateral sclerosis: A review

Amyotrophic lateral sclerosis is a fatal neurodegenerative disease with a progressive and rapid course that, so far, cannot be stopped or reversed. The psychological impact of the disease is huge, on both patients and caregivers. This review summarizes studies that have investigated quality of life, depression, anxiety, pain, spiritual and existential issues, hope, and hopelessness in the ALS field, with attention to both patients and their caregivers. Psychological support and the possible role of psychologists in the ALS field are also discussed.