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PSYCHIATRY - THEORY, APPLICATIONS AND TREATMENTS

PSYCHOANALYTIC PSYCHOTHERAPY: A MODERN KLEINIAN APPROACH

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PSYCHIATRY - THEORY, APPLICATIONS, AND TREATMENTS


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PSYCHIATRY - THEORY, APPLICATIONS AND TREATMENTS

PSYCHOANALYTIC PSYCHOTHERAPY: A MODERN KLEINIAN APPROACH

ROBERT WASKA

Nova Science Publishers, Inc.


New York

Copyright 2008 by Nova Science Publishers, Inc.


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Published by Nova Science Publishers, Inc. New York

CONTENTS
Preface Introduction Chapter One Chapter Two Psychoanalytic Perspectives Concerning the Impact of Managed Care on Psychotherapy The Workplace and Paranoid-Schizoid Anxieties Chapter Three The Somatic Retreat ad te Use o Autistic Objects 1 17 33 ix xiii

Chapter Four Self-Mutilation, Substance Abuse, and The Psychoanalytic Approach 47 Chapter Five Chapter Six The Symbolic Object Paranoid-Schizoid Anxiety, Triangulation, and Oedipal Trauma Chapter Seven Growth and the Fear of Hate and Harm: Less Disturbed Patients Chapter Eight Growth and the Fear of Hate and Harm: More Disturbed Patients Chapter Nine Bibliography Index Summary Acknowledgements 103 120 121 123 131 87 73 57

PREFACE
This volume is a collection of papers written from the modern Kleinian perspective on a variety of clinical issues encountered in day-to-day psychoanalytic practice. It provides the reader a unique opportunity to step into the consulting office of a Kleinian psychoanalyst and learn about the moment-tomoment methods of working with a variety of complicated and often confusing clinical situations. The selected topics are approached from a theoretical vantage which is then fleshed out with extensive case material, allowing the reader to share in the clinical experience. Rarely does a psychoanalytic text allow the reader into the he said/she said exchange in such a close range, intimate manner. Throughout the book, the modern Kleinian approach is outlined as a vital contemporary method of psychoanalytic treatment in which analytic contact can be established with even the most difficult to reach patients, offering them a chance at psychological growth and transformation. On one hand, this volume examines very specific issues that arise in clinical practice, exploring the theoretical and technical aspects that come into play. On the other hand, each chapter is written in a manner that also invites the reader to discover the more general fashion in which the Kleinian approach is used with all patients in all therapeutic situations. In-depth verbatim case material allows the reader to learn about the psychoanalytic process of working closely with the transference, counter-transference, projective identification, and the interpretive processes. Melanie Kleins pioneering work with children and adults expanded Freuds clinical work and is now the leading worldwide influence in current psychoanalytic practice. The key Kleinian concepts include the total transference, projective identification, the importance of counter-transference, psychic retreats, the container/contained function, enactment, splitting, the paranoid and depressive

Robert Waska

positions, unconscious phantasy, and the value of interpreting both anxiety and defense. The components of the Kleinian approach have become so commonplace in the literature and adopted by so many other schools of practice that it is easy to forget Object Relations theory and technique was Melanie Kleins discovery. In broadening Kleins work to match todays clinical climate, I have developed (Waska 2005, 2006, 2007) the use of Kleinian technique with all patients, in all settings. I call this approach Analytic Contact. By analytic contact, I mean that the therapist/analyst should always attempt to engage the patient in an exploration of their unconscious phantasies, transference patterns, defenses, and internal experience of the world. Regardless of frequency, use of couch, length of treatment, diagnosis, or style of termination, the goal of psychoanalytic treatment is always the same. We strive toward the understanding of unconscious phantasy, the resolution of intra-psychic conflict, and the integration of selfobject relations, both internally and externally. The psychoanalyst uses interpretation as their principal tool with transference, counter-transference, and projective identification being the three clinical guideposts of those interpretive efforts. Viewed from the Kleinian perspective, most patients utilize projective identification as a psychic cornerstone for defense, communication, attachment, learning, loving, and aggression. As such, projective identification constantly shapes and colors both the transference and countertransference. By attending to the interpersonal, transactional, and intra-psychic levels of transference and phantasy with consistent here-and-now and in-the-moment interpretation, the Kleinian method can be therapeutically successful with neurotic, borderline, narcissistic, or psychotic patients, whether being seen as individuals, couples, or families and at varied frequencies and duration. The Kleinian method of Analytic Contact strives to illuminate the patients unconscious object relational world, gradually providing the patient a way to understand, express, translate, and master their previously unbearable thoughts and feelings. We make analytic contact with their deepest experiences so they can make personal and lasting contact with their full potential. Successful analytic contact involves not only psychic change, but a corresponding sense of loss and mourning. So, every moment analytic contact is both an experience of hope and transformation as well as dread and despair as the patient struggles with change and a new way of being with himself and others. Successful analytic work always results in a cycle of fearful risk taking, hasty retreats, retaliatory attacks, anxious detours, and attempts to shift the treatment into something less than analytic, something less painful. The analyst interprets these reactions to the precarious journey of growth as a way of steering the

Preface

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treatment back to something more analytic, something that contains more meaningful contact with self and other. The support that we give our patients includes the inherent vow that we will help them survive this painful contact and walk with them into the unknown.

INTRODUCTION
In Chapter One, the impact of managed care insurance coverage on the psychoanalytic situation is explored, using case material to show the particular ways transference and resistance may differ or not differ under this special circumstance. Managed care shapes typical areas of anxiety such as fees, schedules, frequency, and termination into riper opportunities for transference and resistance exploration. However, the so-called reality factor of an external influence easily disguises these potentialities. The analyst may unwittingly act out counter-transference feelings using this reality factor as a rational or justification for enactments that are triggered by projective identification processes. While managed care does shift the nature of the therapeutic relationship, the emphasis on interpretation of transference and resistance remains at the forefront of technique. In Chapter Two, case material demonstrates how paranoid and psychotic anxieties emerged for one patient as the result of changes in his workplace environment. Organizations can function as a temporary patch or placeholder for fragile psychological functioning. Some individuals obtain a precarious and artificial gratification in their workplace for feelings of envy and injustice, as well as sadomasochistic desires. When the group or organization goes through a structural change, this can create a disorganization in the patients internal structure. This Chapter highlights the resulting feelings of loss, spite, persecution, and entitlement as they appear in the transference and in the workplace. Projective identification, splitting, and devaluation are some coping mechanisms that the ego then employs in a rigid, excessive manner. An in-depth study of one patient is used for illustration. Chapter Three examines the way the mind and the body become fused in some more primitive psychological disorders resulting in an intense physical

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focus that defends against the severe emotional disturbance. Somataform disorders are made up of somatization, conversion, psychogenic pain, and hypochondriasis. Certain patients appear to make use of the somataform disorders as Autistic objects that protect against certain intense anxieties within the Autistic-Contiguous position. The somtaform disorders become desperate attempts by some patients to organize overwhelming Autistic-Contiguous anxieties. This Chapter provides one extensive case study to explore these concepts. Some borderline patients and some psychotic patients have a history of substance abuse and self-mutilation. Many experts, including some psychoanalytic practitioners, view these patients as especially in need of ''egosupportive'' interventions, directive and prescriptive measures, and behavioral and interactive procedures. Chapter Four shows how while these parameters to psychoanalytic technique are at times unavoidable, the psychoanalytic method is still the treatment of choice. This stance is based on the idea that self-destructive behaviors are the sum outcome of numerous unconscious phantasies. Several cases are offered to illustrate the use of psychoanalytic psychotherapy as the vehicle for reconstitution with these more primitive patients. These case examples include several derailments and failures of ''proper technique'' that seem to be inevitable in the work and valuable to analyze with the patient. In Chapter Five, the term ''symbolic object'' is introduced as a way to understand the moments between analyst and patient where ''something'' new and dynamic emerges within the dyadic relationship. The symbolic object is the bridge between the idealized, all-good object and symbolization proper. The intrapsychic atmosphere between self and object representations is in a relatively nonconflicted state during this process. By reformulating the Nirvana principle and the principle of constancy as ways in which the organism economically strives for the most organized and homoeostatic state possible, the infant or adult can be seen to be searching for the position of lowest unpleasure possible. This is the optimum balance between the libidinal and aggressive forces in the self and object representational field. These moments of ''truce'' between often highly conflicted phantasies ushers in a more refined use of projective identification as a form of intrapsychic/interpersonal communication. This is a particular atmosphere from which both parties, within the projective/introjective, back-and-forth dyadic world, can begin to co-create and rediscover assorted amalgams of self-and-object functioning. This newly awakened psychic entity is the symbolic object. This outgrowth of something fresh and new in the dyadic orbit is a mutative moment that propels the relationship into a different direction. Within the pairing of minds,

Introduction

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a novel and mutual understanding is produced. Both parties share this new symbolic object and each is shaped by it. In Chapter Six, the author proposes an early process of mental triangulation between mother and infant. A primitive triangulation is fostered by the infant's gradual awareness of self and object body parts and different aspects of internal stimuli. Libidinal and aggressive urges and rudimentary phantasies begin to bridge part-self and part-object experiences to form intrapsychic triadic transactions. These take place within an partly undifferentiated self-and-object medium, blurred by projective identification mechanisms. Trauma, deprivation, or excessive stimulation can lead the ego to adhere to this level of organization. Later traumatic experiences in the Oedipal phase trigger a regression to these patterns. This can be observed in patients who are either neurotic, borderline, or psychotic. Case material is used to illustrate these points. All patients struggle with psychological conflicts regarding love, hate, and knowledge. Some patients are troubled by phantasies of causing hurt and hatred in the object as a result of their quest for separation, individuation, and personal creativity. Success, ambition, differentiation, growth, change, and personal difference are all seen as creating injury, unhappiness, anger, hatred, and rejection in the object. Therefore, these patients rely on intense and rigid defensive patterns of submissive, subordinate, and passive relating to prevent these internal catastrophes. These defensive mechanisms are mobilized through projective identification and create frequent patterns of interpretive enactments and countertransference acting out. Chapter Seven highlights these vexing and humbling patterns of interpretive acting out we often find ourselves in as we try to reach out to patients but barely find a foothold before they slip away or before we lose our own therapeutic balance. Case material will be used for illustration to specifically examine how the defensive avoidance of certain wishes, feelings, and secret needs become part of the counter-transference and influence or pervert the interpretive process. As a result, the analyst may indeed be making helpful and accurate interpretations while also missing out on the more core aspects of the patients immediate phantasy and internal conflict. Theoretical and clinical material will be used to examine this phenomenon. Some of our more disturbed patients in psychoanalytic treatment are struggling with primitive depressive anxieties and conflicts regarding separation and individuation. They feel obligated to follow what they believe their object needs, wants, or demands while at the same time feeling restricted and wanting to oppose or reject those needs for their own ambitions and choices. However, the phantasy of rejection and punishment as well as lasting harm to their object results

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in great conflict and a sense of entrapment. The patient is left with feeling they will create hate and harm if they admit their own needs, differences, accomplishments. So, these differentiation and individuation states are cloaked and camouflaged. While working with such patients, the analyst frequently is subject to projective identification attacks in which the patients defenses against change, growth, separation, and individual choice become acted out in the interpretive field. Chapter Eight uses two cases for illustration and the need for careful counter-transference monitoring is discussed in both examples.

Chapter One

PSYCHOANALYTIC PERSPECTIVES CONCERNING THE IMPACT OF MANAGED CARE ON PSYCHOTHERAPY


As more employers offer managed care insurance benefit packages to their employees, psychotherapists are encountering more patients wishing to use managed care to utilize mental health treatment. The literature on managed care and its impact on psychoanalytic treatment is sparse. The bulk of the material deals with so-called classical psychoanalytic patients (neurotics) and insurance contracts that seem quite generous. Gabbard (1991) has written on the effects of managed care review on inpatient psychiatric care. I will be focusing on managed care=s impact on outpatient private practice psychotherapy settings. Gabbard rightly underscored patients need to attach themselves to the analyst and then work through a gradual separation and individuation. This is near impossible within the confines of managed cares push for brief interventions and quick discharge. I wish to emphasize an object relations approach to understanding the effects of managed care on the analytic situation. Specifically, this will be a Freudian view of the mind, influenced by the clinical work of Melanie Klein. It emphasizes the patients unconscious phantasies, the immediate here-and-now clinical situation, the totality of the transference, the analysis of anxiety as well as defense, and the importance of projective identification. In addition, the patients I am focusing on are more disturbed and typically involved in a psychoanalytic psychotherapy process rather than psychoanalysis proper. Rudominer (1984) has defined the task by stating the intrusion by the insurance company has to be understood in terms of all its effects, positive,

Robert Waska

negative, and uncertain, on both the analyst and patient in the analytic situation. (Pg. 774) The analyst needs to pay close notice to how the patient brings up the managed care issue, including how the patient fails to discuss its presence and impact on the treatment relationship. It is important to explore and Interpret how the patient takes (or fails to take) responsibility for the many details that are part of the managed care intrusion. These include calling to check on the status of benefits, amount of co-payment, and sending of various forms. As always, the issue of money is vital to explore. Conflicts around money are rich areas for analytic understanding. Herron and Welt (1992) have outlined the psychoanalytic study of money and its meaning from Freuds early writings to the contributions of Ferenczi, Jones, Abraham, Fenichel, and Klein. The intersection of managed care and unconscious conflict in the analytic setting seems to be the latest chapter in this rich terrain. With managed care, the co-payment is one area in which mental conflicts may emerge, creating an even more complex transference problem than usual. If a patient only has to pay five dollars for each visit because managed care pays the rest, this can provide fuel for underlying phantasies concerning manipulation, guilt, fear of retribution, and omnipotence. If the co-payment is fifty percent, some patients feel persecuted and treated unfairly by the system, which may or may not include overt negative feelings for the analyst. Narcissistic and masochistic phantasies of Awhy must I have to pay half@ can be triggered.

CASE MATERIAL
Doris presented herself as the exception to the rule. Her managed care company provided five free sessions and then she would have a co-payment. During the first few hours, her unhappiness with life began to unfold. Doris felt it was unfair that she had to work so hard at her job. She resented having to take the bus when Aeveryone else@ had a car. She felt angry with having to run errands on the weekends. Finally, she was bitter at being a wife and having to cater to her husband. At the end of her five allotted hours, she felt that paying a co-payment for additional sessions was intolerable and unfair. Doris added that she felt ripped off that I had not provided her with answers to her problems. Clearly, her unconscious phantasies became interwoven with the details of managed care. In the transference, she felt it was unfair that I asked her to think and to explore her feelings. Instead, she wanted me to perform for her and give her instant and painless answers to her dilemmas. Here, the transference and the resistance to the analysis of it came out very quickly through her focus on external

Psychoanalytic Perspectives

situations where she felt wronged. She felt above it all and thought of herself as an exception to the rule. I only became a conscious focal point of these phantasies when her managed care hours ran out. I suddenly replaced managed care as something that should be providing her with whatever she needed. I was now the someone who should be giving to her. When she was faced with the idea of giving to me, in the form of an out-of-pocket payment, the phantasies of being persecuted, misunderstood, and not properly taken care of intensified. She was unable to tolerate the anxieties and depressive feelings that came with these phantasies so she acted them out and discharged the tension by leaving treatment. Some potential patients will reject you if you are not a provider with their insurance company, rather than wondering if you could help them with their problem. Unfortunately, one rarely has the opportunity to discuss this with them as they often turn to whoever is on their provider list. The so-called preferred provider list is confusing as well. To the patient this may sound like a list of special experts rather than what it actually is: a list of therapists who are willing to work for an even lower fee than the other managed care providers who are already working for a reduced fee. To whom the managed care reimbursement check is sent and how that is handled is also of interest. Depending on the insurance contract, the managed care company automatically gives some patients the check. How fast or slow the patient turns the check over is useful information. To whom they mail the managed care check can bring up phantasies of power or impotence. The one-tothree month period it takes for most managed care companies to pay also creates fertile ground for transference and countertransference. Rudominer (1984) says, it has been my experience that policies which pay a fixed sum - $1,000 to $2,000 all told, let us say- usually have significantly less effect on the analyst-patient relationship than when 50 percent or more of the entire fee is paid by the third party. (Pg. 777) This assumes that a smaller coverage impacts the ego in a smaller way. My experience is that whether the coverage is large, which is rare, or the coverage is for three hours, which is common, the transference meaning is not necessarily any different. The patient and analyst may be able to ignore the meaning much easier if the external intrusion is quickly over, but the intrapsychic meaning is no less than the neverending policy. On the other hand, I would agree when he states, if both transference and countertransference aspects are properly analyzed, the intrusion could even facilitate aspects of the analytic process. (Pg. 778) Overall, most of the available literature seems to portray cases of quite extensive insurance coverage. In the case examples, the authors write about plans that cover up to fifty percent with no ceiling. This reflects on an era of managed

Robert Waska

care that is all but phased out. The current emphasis is on HMOs and PPOs trying to keep costs down. Nowadays, it is rare to find such generous support. Most patients are lucky to have any coverage at all. Those that do, in my experience, have policies that usually cover three to ten visits. Others typically cover up to $1,000 per year. Rudominer (1984) makes a statement directed at the managed care issue. He writes, It is my view that the conditions most likely to increase the chances of resolution and working through of the memories, feelings, and fantasies evoked by peer review (and managed care in general) are, first that a relatively classical analysis has been conducted prior to the point of intrusion; second, the patient is not a borderline or acting-out character; third, the analysis continues long enough for the issue to be resolved. (Pg. 781, my italics) I wish to disagree with his idea for several reasons. My sense is that the intrusion by managed care certainly does evoke memories, feelings, and fantasies. However, the idea of a Arelatively classical analysis@ is an unclear and questionable concept. Also, managed care intrusions occur at the beginning of treatment, not at midpoint or termination. I consider the mere existence of managed care as an intrusion. If they directly request reports or other communications, that is a second level of intrusion. Additionally, many patients seen in a typical analytic practice are suffering from borderline or character pathology. This is a trend noted as far back as 1954, during a panel of the American Psychoanalytic Association. While voicing differing views on the benefits of analyzing more disturbed patients, both Leo Stone (1954) and Anna Freud (1954) noted the increase of disturbed patients seen in outpatient analytic practices. This trend continues to the present day. Finally, research has shown that many patients stop the analytic process prematurely. Glover (1955) noted that the majority of analyses were discontinued rather than terminated. Earle (1979) reported on research that found only fourteen percent of training analyses had come to a mutually agreed upon termination. Novick (1988) writes, many analyses end prematurely or too late. (Pg. 316) Therefore, the impact of managed care, and many other issues, often goes unresolved. In short, clinical reality does not support these seemingly optimal conditions that Rudominer speaks of. The principle of the Atotal transference@ situation (Joseph 1985) is helpful in analyzing the impact of managed care. Transference is present from the beginning of treatment and involves phantasies about the analyst and the treatment in the context of a total relationship, not just in parts or pieces. We are always looking for the manifestation of the transference in every aspect of the patients associations. The apparent absence of transference is in itself a particular way the

Psychoanalytic Perspectives

patient is showing a relational reaction based in elaborate phantasies about us and the treatment. Therefore, managed care gives us yet another window into the patients phantasy life. Of course, it is also one of those situations in which we will often hear the patient say, well, this is reality, it is my insurance, it has nothing to do with us or how I feel. It is just a fact. This is a resistance to the awareness of the transference and can be dealt with as such.

CASE MATERIAL
When Rose began her analytic treatment, she assured me her managed care company could cover half my fee. Because of her modest income, I agreed to bill the insurance company for that amount and deal with them directly. After I received confirmation of her coverage, we started meeting three times a week. Two months later, I received a note from the managed care company saying that her coverage had been used up with a previous therapist and that they were denying my charges. Of course, I was angry that the company had given me the wrong information in the first place. When I informed Rose of this, her response was, oops, oh-no, oh-oh! I didnt realize I didnt= have it, now I am in debt, oops. This paralleled her entire way of being with me. She was always apologizing for what she would say to me. She also told me many stories about feeling foolish and stupid at work and home. In other words, the transference was an if it can go wrong with us it will variety. She remained in treatment and paid out of pocket. The transference material became a mix of teasing me about how much money I was stealing from her, how foolish she was for writing incorrect checks, forgetting her checkbook, Aaccidently@ bouncing her checks, and so forth. It was the continuation of a masochistic/sadistic relationship with her internal objects that emerged within the interpersonal and intrapsychic context of the transference. Managed care will sometimes just bring out one more manifestation of the transference and will be easy to notice. Other times, managed care will be a primary resistance to the transference in which the patient will cite it as simply a Areality factor@ that is somehow exempt from the analysis. Usually, the transference will have to be teased out of the more concrete details of managed care. With Rose, it was merely another area where she seemed oblivious to life; she felt that I was carried along with her on this theme of how did that happen? Of course, this gave us an opportunity to explore how it was that she related to me, herself, and life in this manner.

Robert Waska

Utilizing managed care to see a psychotherapist has the potential to stimulate or simulate oedipal transferences. The triangulation between managed care, the patient, and the therapist may evoke three-party phantasies. This can cause the analyst to make a premature oedipal diagnosis. A close examination has to be made to differentiate the patient=s more mature whole object internal relations from the more primitive part object and pre-genital internal relations. Many preoedipal patients will show a third component in much of their associations. This can turn out to be the result of a splitting defense. The managed care situation can easily represent the good or the bad aspects of the analyst in the transference. Moreover, patients can use managed care to defensively project off good or bad aspects of themselves. Analysts must then position their interpretations to these more basic states of mind. Patients and analysts can use higher level interpretations defensively, to avoid the more painful or frightening material in the room. Certainly, managed care can stimulate genuine oedipal struggles. Feelings of competition are common, with the patient siding with the analyst against the managed care company or with the patient challenging the analyst to become more efficient and perfect just like the idealized managed care model. Other manifestations include the patient feeling disappointed in the managed care company or the analyst. AI=m going to tell my managed care company about you@ and Awhy won=t managed care let me be with you@ are other clues to more oedipal struggles. Whether managed care represents triangular pre-oedipal conditions or genuine oedipal material is best judged by the moment-to-moment movement in the transference. The analysts counter-transference is also a helpful indicator. Feelings in the analyst or patient of being abandoned or wanting to compete, and feelings of being either powerful or inadequate are important to follow up on. When Halpert (1973) states, the insurance company, unlike the therapist, gratifies transference wishes; it takes care of and protects the patient, he was referring to a case in which the patient felt cared for by the managed care company. In some patients this could be a result of splitting the good aspects of the analyst off onto the managed care company. In other patients, this might represent the hoped-for good mother protecting the child from the powerful father or vice versa. Paranoid-Schizoid patients (Klein 1946) tend to brand the same details with ideas about persecution, control, and abandonment. Betty teases me with how she only pays $10 per hour as co-payment. This makes me feel controlled. She also reminds me she could easily go to someone else who is a preferred provider on her plan and pay only $6. This is a way of humiliating me when she feels I am

Psychoanalytic Perspectives

controlling her. She also hopes I see her as special but worries I could easily reject her, so she turns the tables on me. We have been analyzing her phantasies about the world being a place where one is either dominating the object or suffering under the object=s rule. Betty uses managed care defensively to threaten me and pay me back for what she feels is my unavailability and my domination.

CASE MATERIAL
Patients in the depressive position (Klein 1935) tend to infuse the details of the managed care situation, as well as the relationship to the analyst, with phantasies about loss, separation, injury, and reparation. Jenna was a woman in her forties who worked in retail sales. I saw her in twice-a-week psychoanalytic psychotherapy for her depressed moods and inability to find a boyfriend. Her funds were such that she could not afford my fee, but she had insurance coverage. She felt very bad that she was using managed care and thought it was an insult that I had to receive a lower-than-average fee and wait a month extra to receive payment. Jenna was upset that she had forced me into this less-than-optimum circumstance and therefore I must be upset and angry with her. She was routinely critical of herself about this and let me know many times over how sorry she was to impose this burden on me. This paralleled her other phantasies about burdening me with her problems. Jenna felt I was probably bored, irritated, and fed up with hearing her persistent tales of misery. As a result, she spent most of her time discussing what a pest and a loser she was. Historically, she felt she pestered her mother and imagined that neediness had driven her parents away. Her experience as a child was of loneliness and neglect and she felt this was probably due to her wanting too much and pushing her mother and father away. This was quickly replayed in the transference where she pushed me away with her insistent apologies. This proved to be a difficult treatment as she was indeed very needy and craved to be loved and taken care of. This was warded off so severely that she related to me and others as a totally self-sufficient mechanistic system that needed no one. When Jenna felt she stepped outside the strict guidelines of that system, she was horrified and emotionally flogged herself back into being a nice, tidy, independent being. One way she tried to atone for these sins of neediness was to pay me ahead of time for my fee. She clearly could not afford to do this, so it made her resent me and the therapy. As soon as she felt this anger, she took even greater steps to apologize and undo the harm she imagined I was enduring. When I declined her money and told her I would rather wait for the insurance check, she

Robert Waska

was overwhelmed with grief. She felt she had truly hurt me and could not make amends. This was an important moment in the treatment that led to a greater understanding of her internal world and the depressive phantasies that shaped her transference. This type of window into her unconscious phantasies would have probably opened up from another avenue. Nevertheless, the managed care situation provided this ripe opportunity to better understand how she functioned intrapsychically. Jackel (1981 unpublished) suggests particular clinical problems with managed care in five areas: fees, missed sessions, countertransference, confidentiality, and termination. I will take up the first three of these points. The setting of the fee is a different process when managed care has already set it. Patients will rarely bring up the fee if it is being paid for them, thus eliminating potentially useful information about their feelings for money, therapy, the relationship they are entering, and the analyst as the receiver of their money. Therefore, the analyst may have to comment on the omission of their feelings and thoughts. Struggles for control, feelings of wanting to devalue the treatment and the analyst, and fears of being taken advantage of are all given a smoke screen by the payment of fees by managed care. Rotmanns 1994 article on the German government=s role in providing managed care points to the cultural and societal collusion with patients and analysts denial of the transference. Of course, these feelings will come out in other avenues and certainly emerge when the managed care sessions run out and out-of-pocket payment is brought up. Much can be discovered about the transference through analyzing missed hours. Often, archaic phantasies concerning trust, abandonment, and power unfold. Unfortunately, most managed care companies do not allow billing for missed sessions. Therefore, the patient and analyst can be lulled into ignoring their significance. Even so, I find it still just as helpful to bring it up in the context of the therapeutic relationship and the ambivalent commitment the patient may have. Counter-transference issues are important to watch for as it is easy to be angry with the patient who routinely ignores his appointments while the analyst sits alone and unpaid. Much of this transference/countertransference material can be displaced onto managed care and the therapeutic value lost. The frequent seminars that now show up proclaiming to reveal the secrets to survive the managed care onslaught and how to save your dying practice may be the disguised and unanalyzed transference between analyst and patient being fought out and acted out through hysterical projection. Counter-transference is important to consider in exploring managed care=s impact on psychoanalytic psychotherapy and psychoanalysis. A whole range of affects are stirred up by the essentially ignorant and often arrogant managed care

Psychoanalytic Perspectives

practices. One is tempted to become rude with people on the phone who are telling us what to do with our patient whom they have never met and now are trying to apply a cookbook recipe to. We will feel discouraged about our profession in general and our practice in particular. The term not medically indicated will ring in our ears as we are denied payment or additional hours. We will find ourselves in the position of having to lie in order to obtain much-needed sessions for our patients and we will feel downgraded and humiliated by the reduced fees and lack of respect for our long-term goals. Faced with all this, we must find a way to keep our balance. When the managed care company controls us in various ways, we must be careful to not discharge our frustrations onto the patient. After spending thirty minutes playing tug-of-war on the phone with someone who has never treated a patient and is now telling you your treatment is not medically necessary, it is very easy to use the patient to feel better. Therapists can do this by becoming aggressive with the patient or by essentially demanding that patient be a sounding board and cheering squad for our frustrations. When hostile feelings are strong in the transference, managed care can be a rather easy object in which patient or analyst can hide their feelings and phantasies. Merl was an angry and sometimes intimidating man who would shout at me when he was unhappy or dissatisfied. This could be frightening at times. He had a particularly generous managed care contract that had allowed him to see many therapists prior to our first visit. When the company was restructured, he started to be denied treatment. With his managed care company now denying and limiting his treatment, it was easy to avoid the analysis of the transference by making managed care the enemy. This saved me from his threatening rage. He and I joined forces against the enemy. We acted out together to save me. Eventually, I was able to deal with my counter-transference and start to analyze his negative transference. Counter-transference problems also crop up when the managed care company asks us to provide a diagnosis and clinical write-up. Authors have pointed out the triggering of voyeuristic conflicts, including primal scene derivatives, in both patient and analyst when a report is requested. Blaming the patient for our feelings of being controlled by the managed care company is common. Halpert (1985) stated, among the most common fantasies associated with insurance coverage are fantasies of exposure . . . Still others show their concern about exposure by asking the analyst to put down the most none revealing diagnosis possible while simultaneously wondering what the analyst really thinks. (Pg. 938) I would add that when called upon to make a diagnosis, some therapists are prone to put the most non-revealing diagnosis with the

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rationalization that it preserves the patient=s confidentiality. In that sense, they are acting out for the patient. This is a complex matter. One problem facing analysts is that if they report the true diagnosis, the insurance company may stop payment. For example, many managed care companies will pay for anxiety disorders but not for personality disorders. Other companies will only pay for adjustment disorders and require medication in the place of therapy for mood disorders. Therefore, this reality factor is fuel for the analyst to feel controlled and then retaliate by lying. The other problem is the analysts fear of the patients reaction. Many physicians and mental health workers can feel more comfortable in blaming the patient=s ills on something that can be viewed as a third party. If we say the patient suffers from a biological imbalance of serotonin, then we can blame the brain cells. We can then recommend a pill to save the day and the patient sees us in a favorable light. Certainly, some patients have organic problems that require chemical interventions, but people will often blame a third party rather than face the truth and its painful consequences. Telling the patient you believe he is schizophrenic or suffering from a personality disorder is troubling to both parties. Obviously, there must be a humane way to say these things. Whether with the patient or the managed care company, this is a serious counter-transference issue. Some therapists only see patients who pay up-front and the patients are made responsible for collecting the insurance reimbursement. Many patients cannot afford to do this. In addition, many managed care contracts stipulate that the therapist cannot do this, which then is frequently ignored by the therapist for countertransference reasons. Finally, as with most arbitrary rules, this up-front payment policy becomes a manipulation and injunction that clouds the transference rather than explores it. It is also a potential power play by the therapist. I inquire if the patient can pay out-of-pocket and then recoup the money. Then I listen closely to the patients response. If the patient can pay directly, this will make it easier to focus on the immediate relationship between patient and analyst. Some managed care situations make it impossible for the patient to take charge of their affairs by requiring the therapist to personally send various forms, diagnosis, and other information back and forth. Even here, we can closely observe and comment on how much or little the patient tries to assist us in these matters. Some managed care companies do not allow the analyst to see the patient after the allotted hours. The contract requires you to refer them out. Often, managed care contracts also limit therapists from collecting any co-payment beyond the agreed-on fee. Finally, most managed care companies require

Psychoanalytic Perspectives

11

information that is clearly a breach of confidentiality. All these situations can tempt the analyst to retaliate by lying and cheating. This eye-for-an-eye dynamic invariably bleeds into the treatment setting. After a patients allotted hours are over, they may want to continue but cannot afford to at the analyst=s usual rate. This should be handled from a diagnostic perspective. If the patient needs to be seen twice a week but can only afford once a week, it would be unethical to only see that patient once a week. It would be equivalent to a surgeon taking out half of a tumor because the patient cannot afford the full operation. It seems to me that the analyst is duty bound to either see that patient at a reduced rate so the increased frequency is possible or refer that patient to a clinic or colleague who could offer the needed treatment at the rate the patient can afford. This will bring up countertransference issues such as greed, loss, and persecution and defenses such as rationalization and denial. Additionally, it will foster transference feelings such as being indebted or being special. The analyst may notice a pull to educate the patient about the benefits of psychoanalysis. This is often the result of countertransference feelings by where the analyst becomes defensive about rejection by the managed care company or the patient. Instead of interpreting the patient=s resistance, we may start to defend our belief in the unconscious as a way to convince the patient to see it our way. Now, I will discuss two cases in which managed care influenced the psychoanalytic situation and quickly became part of the transferencecountertransference dynamic. The first case reflects a struggle with paranoidschizoid anxieties and the second case shows a patient dealing with more depressive fears.

CASE MATERIAL
Mr. Brown had entered treatment to try to find a way to deal with his feelings of persecution. He felt his wife and the government were constantly trying to push him around, tell him what to do, and humiliate him. In the transference, he tried to have me be a comrade-in-arms against these forces. He projected his predatory phantasies onto the government and his wife, and projected the weak and scared parts of his ego onto me. At first, he said he felt sorry for me that I was up against the big insurance corporations. He was sure they would make my life hard. Mr. Brown said we were both struggling business men who made an honest living but were being bullied and pushed around by the government and all the cutthroat corporations.

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He had a managed care policy that allowed me to ask for direct payment from him and since he could afford to do so, I requested that he be responsible for the bill. He felt enraged. Mr. Brown now felt I had betrayed him and was only another untrustworthy agent of the government structure who would abuse him. When I would not play the role of an idealized object who would take perfect care of him or a mirror reflection of his narcissistic and paranoid outlook, he quickly included me in with his wife and the government. For many weeks and months afterwards, he taunted me for the unwanted Anegative influence@ I had on him, the way I was trying to find him at fault,@ and how I was making up Amy own little rules along the way. Instead of seeing us against the tyranny of managed care as he first did, now he called his insurance company to tell them what a horrible and dishonest therapist I was.

CASE MATERIAL
Wanda came to see me for help with a Ablock@ in her ability to paint and a life-long difficulty in following through with things. She was worried that she was a burden on her husband and that she would upset him if she expressed any needs or opinions. Instead, she felt she should comply with whatever his wishes were. We arranged to meet twice weekly. Wanda made very little money at painting. She was to pay me by using her insurance plan that allowed for $1,000 a year in mental health treatment. Wanda refused to ask her husband for help with the cost of her psychotherapy, citing her sense of humiliation at having to go to treatment in the first place and repeating her fear of being a burden to him. This seemed to be a way she immediately put me in a difficult situation where she controlled me. I commented on this possibility and told her I would see her under these conditions provided we could continue to investigate her style of blocking not only her painting, but our relationship as well. Wanda then told me that she wondered about my motives in doing therapy and my possible greediness and desires for money. She also told me she worried that if she chose to leave treatment after three months, the time when her insurance would run out, I would respond by saying see, you really do have a problem with commitment. In this way, she rendered me as helpless as she felt.

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THIRD HOUR
P= (long silence) I don't know how to start. I don't know what I should talk about. I feel silly. It=s hard to know what to say. A= Those are the same feelings you have in regards to your painting, feeling stuck and like you should be doing something. P= Yes, it is the same. I was so relieved the other day when my husband told me I should take a month off and reassess my painting career and goals, to see if that is really what I want to be doing. It was such a load off my shoulders. Its funny though, as soon as I think of stopping I worry that I should be painting, but when I am painting I don't want to be doing it. But its a real relief to hear him suggest that. A= You are worried that he would be displeased if you didn't do what you imagined he wants. P= Yeah, it felt good to have his support. I have always felt these feelings of doubt in my life, like I am ashamed of whom I am and what I do, never feeling proud or ok about anything. When I was at school, I felt like a fake, just there by accident. I wish I could feel comfortable with what I am doing instead of always being in conflict with it. I guess that is one thing I want out of this. I am always doubtful about my accomplishments. (She then told me about a former boyfriend who had been abusive and how it felt good to be angry with him. She said that she had recently spoken to him in person and had been able to express her anger at him after he apologized to her for his nasty behavior. She said that expressing her anger and hearing his apology had verified her feeling of self-worth. She then apologized to me for being so Ascattered@ and talking so aimlessly. A= I think you are clear about what you are saying but you are afraid that I am confused and unhappy with you. P= Well, I do feel pretty clear, but I started to get worried that you didn't understand me and thought I was wasting your time. I am also kind of tense about this meeting I am going to have with my old friend Mike next week. He was always so mean to me when we were close. He blamed me for everything and I am afraid of how it will go. (She discusses the upcoming meeting in a very submissive manner that makes it sound as if she is going to trial for a crime she has committed, and will have to plead guilty and throw herself on the mercy of the court.) A= The way you describe the meeting sounds like you feel very meek and apologetic. P= Yes, I do feel that way. I have always felt like there is a meek side to me and then there is the real me. I want to just be the real me but when I think about

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doing it, it feels like it would be too wild or outspoken. There has always been a conflict with that. A= How so? P= Well, I know I felt like I had been a bit outspoken after I left the last session. What I said to you about your possible motives in doing therapy and how you might be doing it just for the money. I felt that way but I thought it was too rude or obnoxious to be talking that way. A= Well, I think you are bringing up an important point. In some ways our fee arrangement is a setup for you to feel taken advantage of. In three months or so when your insurance runs out, you will have to pay your own way. The pressure of having to find a way to pay out of your own pocket when you are not making much, or the pressure of seeking help from your husband is something that you may use to confirm your fears of our relationship never working out. Unless we understand these problems openly, you may indeed begin feeling taken advantage of and angry with me. P= I could end up doing it the way I always do things, bail out before it gets to overwhelming. Or I could find a new way of figuring it out, some way that would be different. Wanda did prematurely end her treatment after about six months. She had paid me out-of-pocket for several of those months, but felt very uncomfortable about it. She alternated between feeling she was cheating me by not paying my regular fee and feeling I was cheating her by taking her money and Aonly listening@ to her. A few months after interrupting the treatment, she returned and repeated the cycle. She would lament about having such Ameager@ problems and being a burden to me, her husband, and others. Underneath, she took delight, yet felt terrible remorse, over controlling me and others through her masochistic, fatalistic disguise. These particular hours reflect her phantasies of being taken advantage of, which seemed to disguise her own greedy and needy parts that she felt were hurting or even destroying her internal objects. She related to me through projective identification and denial. Again, managed care was one of the vehicles in which the transference was transported into the analytic relationship. I would agree with Gray (1973) about the analyzability of patients under managed care. When the contract remains between the analyst and the patient, the cases are just as easy or just as hard to analyze as other cases. Specifically, I am not thinking of the contract to pay, but of the relational contract to meet together to try to understand who the patient is and how they have come to the place in their life that they are. We do that through the vehicle of the transference and the interpretation of the patient=s intrapsychic phantasies.

Psychoanalytic Perspectives

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Halpert (1985) stated, the analysis of feelings and fantasies connected to the use of insurance coverage always provides another avenue for attaining insight into conflict, transference, and resistance. (Pg. 938) I would add that it adds another potential window into the patients phantasies about being taken care of, obtaining control and power, the chance to manipulate, and the presence or absence of feelings of guilt, regret, and restoration. Halpert also points out that the patient often has phantasies of corruption and theft. (Pg. 939) He goes on to mention that in reality there is a great deal of corruption on the part of both patients and therapists in dealing with insurance companies. This, like any acting out between patient and analyst, must be noticed, explored, and worked through.

CASE MATERIAL
Phil was able to accept my recommendation of a low-fee, four-times-a-week psychoanalysis after his three managed care sessions were up. He stayed in treatment for over a year, during which there was a stormy transference and some psychic change. He was able to accept the offer of analysis due to a bargain he made with opposing phantasies regarding his internal objects. He desperately wanted to be cared for and loved unconditionally to repair the chronic neglect and abuse he felt his family dealt him. On the other hand, he saw the analysis as an opportunity to seek revenge on a caretaker, use me for his own purposes, and then discard me. As the analysis progressed, he became more aware of how his own envy and greed were overwhelming the loving vision he had of me. In his mind, he began to ruin the hoped-for version of me and harm me with his craving. He felt forced to back off and leave me be, but this made him even more angry and insatiable. Phil would then redouble his efforts to use and abuse me, followed by more remorse at having depleted me. Unable to tolerate these phantasies, he fled. For Phil, managed care mirrored his complex internal object relations in which he felt righteous in receiving something he thought he deserved. However, in being restricted to three hours he felt forced again into emotional poverty, feeling denied what he wished for. As soon as he no longer had managed care to use in this symbolic way, he was forced to shift those phantasies onto his relationship with me, his analyst. This led to an unraveling of his chronic emptiness and despair that had haunted him most of his life. The type of reactions a patient has to the managed care intrusion will be helpful diagnostically. Negative reactions to managed care can be a defense against transference love and the painful resurrection of old feelings of

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competition, loss, and separation. These would be parts of phantasies indicative of more Depressive feelings. Other patients may experience managed care as more of a situation where violent power struggles ensue with someone always being right and somebody always being wrong. These phantasies would point more in the direction of paranoid-schizoid problems. In conclusion, the patients use of managed care need not compromise the psychoanalytic approach. However, the addition of managed care to the therapeutic relationship constitutes a new factor that demands understanding and analysis. Managed care is an external intrusion that is easily used to disguise or hide various transference or counter-transference material. Explicating intrapsychic phantasies concerning self and object is a goal of the psychoanalytic method. Subsequently, we should analyze any barriers or defenses that occur in that effort. By viewing managed care as yet another potential stronghold of transference and resistance, the analyst can better attempt to keep on task, rather than collude with the patient=s protective and defensive efforts. Taking nothing for granted and allowing a natural curiosity about all matters is a fundamental of psychoanalytic technique that certainly applies to the treatment of patients with managed care coverage.

Chapter Two

THE WORKPLACE AND PARANOID-SCHIZOID ANXIETIES


This Chapter explores one patients phantasy about group involvement and how this involvement provided a temporary, yet fragile shelter against primitive, unconscious anxieties. While not exploring group dynamics per say, I will be discussing how one persons phantasies about group members can influence their internal conflicts. A change in the nature of the group impacts the group members phantasies. With individuals already suffering from persecutory fears, the external change may prompt overwhelming internal anxieties. A distinction can be made between the external organization as a placeholder or intrapsychic patch and the true working through process achieved in psychoanalytic treatment. Patients have unconscious conflicts around phantasies about organizations as hoped for solutions to difficult internal problems. These struggles emerge in the transference and extra-transference associations. The unconscious cycle of envy, spite, entitlement, and loss will be explored as it occurs in the workplace and in the analytic situation. In 1921, Sigmund Freud wrote a short paper on group psychology. He discussed his idea of the herd instinct and the inborn urges in the individual that give rise to group behaviors. He felt much of group psychology could be understood as emerging from the original group setting of the family. The individuals group involvement triggers patterns of leadership and competition as well as different manifestations of love and aggression. Moore and Calder (1979) noted that between 1950 and 1975, the American Psychoanalytic Association only published one panel discussion, one book essay, and one journal paper on the topic of group phenomenon. In 1978, De Board wrote a book entitled AThe Psychoanalysis of Organizations.@ In 1979, Moore and

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Calder published a paper entitled, APsychoanalytic Knowledge of Group Processes@ which came out of a 1977 panel discussion of the American Psychoanalytic Association. Overall, ego psychology, along with other psychoanalytic perspectives, continues to be cautious about exploring this area of human experience. Influenced by the work of Melanie Klein, several British analysts have looked into the unconscious aspects of groups in various settings. Thomas Main (1946) looked at the dynamics of groups in a hospital setting, Elliott Jaques (1953) and Isabel Menzies (1960) took on social structure and the avoidance of primitive anxieties, and Hinshelwood (1987) explored collective defensiveness. Hanna Segal (1997) examined the place of group dynamics in international conflict from a psychoanalytic perspective. Jaques (1960) described the relationship between the internal, unconscious world and the external world of groups and work when he wrote,
Work is the exercise of discretion within externally prescribed limits to achieve an object which can be reality-tested, while maintaining a continuous working-through of the attendant anxiety. The capacity to work depends upon the coherence of the unconscious, and upon the integration and strength of the ego and its capacity, in the face of anxiety and uncertainty, to sustain its functions, to maintain the realty principle, and to exert pressure to make the unconscious conscious. (p. 357)

Melanie Klein extended Freud=s theories, emphasizing the nature of unconscious phantasies and internal relationships. However, she also felt the external world significantly shaped the individuals intrapsychic structure. The external world was a construct of the objective world, projections of internalized objects, and assumptions based on prior experience. Klein was interested in the impact on the objective by the subjective. Jaques (1955) writes,
... one of the primary cohesive elements binding individuals into institutionalized human association is that of defense against psychotic anxiety . . . Melanie Klein states explicitly that in the interaction between introjection and projective identification lies the basis of the infant=s earliest relations with its objects . . . all institutions are unconsciously used by their members as mechanisms of defense against these (paranoid and depressive) anxieties. Individuals may put their internal conflicts into persons in the external world, unconsciously follow the course of the conflict by means of projective identification, and reinternalize the course and outcome of the externally perceived conflict by means of introjective identification.

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Melanie Klein felt the infant was threatened by their own death instinct which lies in wait to destroy the internal world. As a defense, the infant introjects the idealized breast. Confronted with the possibility of the good object/breast becoming contaminated by the egos destructive forces, the infant projects the death instinct. Now faced with external persecutors, the ego once again introjects the threatening object. Thus, the ego creates an internal world of good and bad. Countless complex relationships emerge that are colored by anxiety, love, danger, and a quest for power and knowledge. A dynamic inner world of ego/object relations is born. By means of projective identification and splitting, a life long interplay between inside and outside, good and bad, and life and death begins. Psychoanalytic treatment uses interpretation of the transference, defenses, and resistances to work through this complicated, unconscious mire, seeking to untangle reality from phantasy. The ego plays out these intrapsychic conflicts within the realm of external reality, including group involvement. The workplace provides an organization that is easily used as a stand-in or vehicle for various positive and negative unconscious relations between internal objects and the ego. The consequences of becoming part of a group or organization are usually a combination of the organization=s collective unconscious phantasies influencing the individual and the individuals projections into the group. Bion (1961) examined the group experience and noted how the organization may become pathologically fixed into what he termed Abasic assumptions.@ These include phantasies of the organization existing to fulfill the dependency needs of the members, to fulfill aggressive desires toward outside objects, and to give hope to expectations and dreams for libidinal satisfaction. Bion was a follower of Klein and elaborated on her concept of projective identification (Klein 1946). Bion believed an essential part of normal development is the child's experience of his parents as people who can safely and securely be relied upon to act as containers for his projective identifications. I see organizations and groups being used by individuals for the same reasons, sometimes successfully and sometimes not. Some people, even when placed in the most conducive organizational setting, are unable to make constructive internal use of the group=s containing functions. In fact, they can destructively censor the loving or neutralizing aspects of the group and project poisonous and threatening parts of themselves into the group setting. As a result, they experience the organization as constantly hindering them or even plotting to attack them. These are individuals caught in a web of persecutory paranoidschizoid anxiety (Klein 1946) or depressive fears (Klein 1940). Klein felt the infant=s early development brought on persecutory fears of being annihilated by

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unbearable anxieties and fears of harming and even destroying the needed and loved object. Patients who are struggling with either paranoid or depressive tensions frequently attempt to use their workplace as a wet-nurse or emotional patch to soothe themselves. Because of their own aggressive phantasies constantly being projected into the group and because of the unpredictable nature of large groups operating within collective phantasies, these patients are eventually disappointed in a way that repeats their most basic internal conflicts. A shift in the external reality of the organization can trigger an internal shift in the individual=s psychic balance. For those with ample good objects to help contain, manage, and tolerate these changes, the experience can be one of renewal, possibility, and adventure. Change=opportunity is part of this perspective. For others with a less fortified ego structure, change can be a dramatic turn from the phantasy of a wet-nurse who finally made things right to the phantasy of a damaged or persecutory breast that transforms safety into danger. Several patients who came into treatment with work-related difficulties have made me aware of the interplay between internal and external reality and the conflict between envy and loss. These paranoid-schizoid individuals functioned reasonably well in an organization until the group or company changed in some significant way. The unconscious meaning of that change was enormous and often devastating to these patients. During my analytic work with them, I came to discover certain pathological constellations involving deprivation, sadomasochism, envy, and loss. These patients were unable to get rid of or detoxify their bad internal objects and consequently they were unable to create, take in, and maintain good internal objects. I will focus on one patient in detail, to illustrate these points. All these patients tend to be so haunted by envy, bitterness, and loss that they try to spoil and ruin their objects through manic defenses, excessive projective identification, and splitting. These defenses in turn generate more paranoid and depressive tensions, leading to even more envy and loss.

CASE MATERIAL
Arnold was a middle-aged man who came into treatment for help with anxiety and job stress. He had regressed into psychotic delusions about how the organization he worked for had become a band of tormenting persecutors.

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Arnold was the youngest of four, with two older brothers and a sister. The father was an abusive alcoholic who left the family when my patient was three years old. During most of his childhood, Arnold=s brothers would beat him and his sister. Later, they beat his mother as well. For several years, they would also have sex with Arnold and his sister. Arnold tried his best to defend his mother and sister by sacrificing himself to his brothers wrath. This masochistic offering became a way he related to the world at large. When Arnold was eighteen, one brother was killed in a gang fight and the other was sent to prison for life. As a young adult, Arnold became quite violent himself and intimidated others as he had been. His ten-year marriage to a prostitute was full of violence and drugabuse. Divorce and a series of arrests pushed him to stop using drugs. His violent approach to life shifted back to a more masochistic way of relating. He felt cheated by life and constantly used by friends. But, he loyally suffered along, always trying to be the nice guy. Arnold landed a modest job as a public relations person for a large magazine distribution company. His job was to field calls from customers who had questions or complaints. For five years he felt happy and fulfilled. The job gave him a feeling that he was providing customers protection and understanding when they felt unhappy with the company=s services. This gave Arnold a sense of mastery over his helpless childhood feelings of being at the mercy of his brothers and not being able to protect his sister and mother. In other words, he projected his vulnerable, threatened little boy parts and the weak, threatened sister and mother parts of himself into the customers and fancied himself as the watchful, good father who would intercede on their behalf. His desire to identify with an ego-ideal (himself as a good protector for mother) and his desires to be saved by an idealized father object were both gratified at his job. Overall, he also felt protected by a relatively benign organization that paid him and treated him reasonablely well. This situation was satisfying and could have gone on for many years. Internally, it proved a supportive system that somewhat diluted the pathological intrapsychic relations that created his sadomasochistic perspective on life. This was a dependant relationship that helped Arnold cope with his internal pressures and anxieties. However, it was not a transformative intrapsychic experience that shifted mental structure. In highlighting the difference between a working through process and the concept of an internal placeholder or patch, it is important to note that one is certainly more fragile and apt to fail. On the other hand, the use of a patch or placeholder shows the ego=s remarkable powers of adaptation and sublimation. This occurs by way of splitting and projective identification.

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This type of transference to an organization or group can provide some patients with an important, ongoing ego support and may even shift a portion of their unconscious phantasy dynamics. However, with patients suffering from more entrenched paranoid or depressive anxieties, the external organization can also become a vicious repetition of fragile object relations. This is an internal bond with an understanding object that provides knowledge, love, and protection but also with an object who can easily and dramatically turn into a hurt or hurtful object. Shifts in external reality influence this precarious balance, in this case a shift in the work place. These shifts can come about in different ways. Shapiro (1991) discusses the clarity of focus, reality-testing, and intergroup communication that define a work group. I think that sudden reorganizations in a company structure can quickly turn a work group into a basic assumption group. Individuals who have been having some difficulty in their work roles already, especially those with fragile object relations, can lose the company as a good, protective or nourishing, internal, container object (Bion 1962) and feel in sudden danger (internally and externally). Arnolds company took on a new project that involved major changes in customer service and a change in product line. The company anticipated a difficult transition period for the customer and in the internal workings of the organization. However, due to various factors in management and in the technical end of manufacturing, the changes were more complicated than anticipated and took many more months than predicted. This made for a steady increase of customer questions and complaints. At first, Arnold felt able to keep up with the calls and find ways of soothing the irritated customers. After a few months, he started to feel used and overworked by the company. He saw the company as abusive to the public and trying to escape scrutiny by having him cover for them. More and more, he felt he was in the middle. In other words, his unconscious phantasies about his relationship to his mother, sister, and brothers began to be repeated in his mind, now with external reinforcers. His sense of mastery crumbled and the feelings of persecution and helplessness returned. Arnold tried to sacrifice himself for the public by staying late and by taking some of his work home. He felt the troubles were somehow his fault so he struggled to solve them. Simultaneously, he saw the company as involved in a plot where management was denying the abuse that was occurring. He felt the company was profiting at the expense of the helpless victims he tried to save. He started to write letters to the president of the company outlining each abuse and how he knew it was all a cover-up. Arnold began experiencing more outright psychotic delusions in which he was the lone person fighting against the system.

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The more Arnold felt pushed around and ignored, the more he felt he was the only one who could save the suffering customers. As he felt ever more persecuted, he started to use a manic, omnipotent defense. He felt he alone knew the secret abuses of power that were going on. He told me, I am going to open the lid on this whole stinking story. The press will have a field day. This is bigger than Watergate. They wont have Arnold to kick around any more! He hated the company and he hated his department. He started to hate his boss and even his coworkers whom he saw as either part of the plot or contributing to it by their silence. Pao (1965) writes,
hatred also reflects a conflict between the ego and internalized objects . . . in hatred, influenced by the internalized object, there is a tendency to ascribe enormous status and power to the external objet, often accompanied by a feeling that one=s own existence depends on the object. (p. 258)

Albert felt compelled to stay at his job because he was dependent on the internal object it represented. He felt frightened of retribution if he left, he felt loyal to it even though he hated it, and imagined himself in a sadomasochistic bond that was essential for survival. Before the companys shift in policy, Arnold could tolerate these unconscious dilemmas because he also fancied himself as the underdog posed to become a hero, ready to save the masses, and finally be recognized for his greatness. But now, he felt he would never be thanked, let alone be appreciated. He had constructed an internal bargain with his objects that had now broken down due to a shift in external reality. Up too now, Arnold had maintained a spiteful relationship to the company and his internal objects. Boris (1986) writes,
spite can do its work of rendering the object impotent, in fantasy or fact, without requiring the sheer power required for revenge. (p. 52)

With the companys change and its unconscious meaning to Arnold, Arnold now had to resort to phantasies of revenge. He felt the organization had taken away the means to reach the breast. He felt furious and scared. In the transference, Arnold repeated his internal conflicts. At first, he seemed genuinely wanting of help and understanding. When he told me of the countless beatings and sexual traumas he suffered as a child, I felt pulled to be supportive and Aon his side.@ As long as we maintained a relationship with him as victim and me feeding him agreement and sympathy, we got along fine. This was a method of controlling me, as I had little choice but to agree with his pain and specific contentions, or be seen as against him and on the side of his brothers and his company. There were several times when he did not make his appointments and never called to say what happened. I was left with having to pursue him. He also seemed

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perturbed to have to pay his bill. I began to explore the way he treated me, as though I was there to fulfill his needs. He neglected to see me as having needs too. I suggested this was a reversal of the bind he felt at work and as a child. He could now weld the power and show me how it felt to be ignored. In other words, I interpreted the projective identification process he was using to relate to me. This process of interpretation was especially difficult with Arnold as he felt I was trying to turn the tables on him and bring him back to feeling helpless and to blame. O=shaughnessy (1992) writes,
The infants envy then distorts her (the mother=s) capacity for receiving projections into a greedy devouring of his psyche, and he misrepresents her balanced outlook as indifference. (p. 92)

In addition, the infants envy and sense of loss makes receiving the mother=s offering an unacceptable submission to a tyrant. In these ways, Arnold would not take in my comments as they felt like domination, humiliation, and attack. The paranoid aspects of Arnolds mind had resurfaced as the result of his companys shift in policy. The workplace had been helpful to Arnold as a psychic placeholder. He was, in effect, temporarily on hold from the internal demons he lived with. Now, he again felt persecuted and misunderstood. He saw himself as a savior trying to help the masses but beaten down by the devious company. In his personal life, Arnold felt people didnt like him and didnt understand him. He felt like a loser and feared peoples rejection. As a way of coping, he sacrificed himself for the good of the other. He would be a good listener, lend money, run errands, or buy a round of drinks in hopes of gaining some love and attention. When this didnt help, he regressed to thoughts of superiority. Arnold fancied himself as a renaissance man who was smarter than most. He looked down at others with contempt and felt sorry for all those who hadn=t caught up with his level of intelligence. These phantasies of grandiosity only barely saved him from experiencing the painful loss of any loving internal objects and the onslaught of internal persecutors. Arnold was a lonely and scared little boy, hoping to find a supportive, protective father. He felt deserted and betrayed, left to the cruel treatment of those around him. Arnold also felt tremendous rage and envy toward others and put them in their place with his contemptuous thoughts. These aggressive urges and acts were projected out from his ego, leaving him in a harsh internal world filled with persecutory objects and no good objects to cling to for support. When I began exploring this manic, omnipotent shell, Arnold tried to fend off the pain and humiliation by binging on drugs. This made it worse because of the shame and remorse he later felt. His treatment was difficult because of the paranoid quality of the transference. I was a soothing parent who would save him,

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I was a bully who picked on him, and I was part of the plot to make people miserable. Arnold felt these were simply facts about our relationship. Ultimately, I think he held onto these rigid and controlling phantasies to avoid feeling faced with, and controlled by, feelings of despair, loss, and anxiety. Persecution was better than chaos. Suffering was better than annihilation. Melanie Klein (1930) described the early ego=s struggle to deal with aggression at its objects. The desire to destroy the breast, the vagina, and the penis, which stand for the whole objects of mother and father, builds great anxiety. The ego wishes to hold onto its good objects and feels anxious about hurting them. Therefore, the ego begins to equate its part-objects with other things both internally and externally. Projected aggressive feelings again turn these objects into dangerous or damaged objects, so the ego again makes new and different equations. This is the formation of symbolic function, which shapes sublimation and creativity. This positive growth force is fostered by the balance between plentiful good objects and a healthy use of splitting and projective identification. These normal aspects of development can be derailed by excessive internal pressures from bad objects, intensive and unmodulated ego aggression, or a stressful external environment. Arnolds symbolic ego-functions had broken down. Without sufficient positive objects to form a feeling of safety and union and to mitigate the pain and anger he felt, he started to feel surrounded by abandoning and attacking objects. Sublimation and symbolization vanished and he believed his external objects were the same as his internal objects. This forced him to rely more on excessive and destructive forms of projective identification and splitting. When Arnold started to feel unable to conquer the company with his masochistic stance and when his manic, grandiose plans at exposing the plot failed, he turned to me for help. He now wanted me to join him in the fight and write letters for him to the president of the company. After several weeks of this, he felt so anxious that he resorted to more sadomasochistic measures. He wanted me to put him on workers= compensation so he could blame the company for his suffering and gain restitution from them. We explored these phantasies as well as the sadistic bind he was putting me in. Again, this was a projective identification dynamic in which he put his feelings of being trapped and manipulated into me and then he ruled and controlled me. I was to put him on disability as a sign of my allegiance to the cause. If I didnt, I was declaring my treason and he would retaliate by stopping treatment. In fact, he did so. He sought out another doctor who would sign the papers. I told Arnold he might be eligible for some type of disability, but that I was unqualified to do the required paperwork. I suggested he consult a specialist in

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workman compensation while continuing to see me. Arnold refused and stopped treatment. To stay with me felt like he would have to give up what felt like justifiable hate. He would have to take me in as a good object, which for him would not only feel like submitting to a dominating and persecutory object, but would bring him into the feelings of loss and grief associated with the depressive position. He wanted me to be a fellow soldier against the company or else. He didnt have a problem. The company was at fault. To Arnold, it was a black-and-white situation. In asking him to consider the companys problems as well as the emotional distress he was under, Arnold felt I was blaming him. This was the result of splitting and trying to rid himself of his own feelings of persecutory guilt. His terrible feelings of having let his mother and sister down were now transferred onto the company. Quite a few of Arnolds complaints seemed justified, although I felt his ideas for a solution were very distorted. I tried to speak with him about ways of approaching some of his dilemmas. Each time I tried to be sympathetic and help him sort out solutions, he became single-minded and defensive. If I didnt agree that the one and only solution was to force the president to admit to Ahis evils@ and to make changes according to Arnold=s plans, I was betraying Arnold. I suggested he talk to his manager, his supervisor, or the human resource department. I suggested consulting a workers compensation expert. I wondered if his union might help. I even found myself making suggestions on how to talk to the angry customers. He wouldn=t have anything to do with it. It wasnt good enough. In fact, Arnold felt I was ignoring the severity of the problem and devaluing his plight. I would talk to him about how he felt the president left him with the same horrible conflict he felt at home. He didnt have a parent to go to who would understand how horrible things were. He felt all alone against overwhelming odds. I suggested he felt I wasn=t willing to rescue him and the president was ignoring him. Arnold wanted revenge and justice. It was all or nothing. Either I sided with his psychotic phantasies or I was abandoning him and agreeing with the enemy. When I made these comments, Arnold could listen to me for awhile, but quickly went back to feeling betrayed. In the transference and at work, Arnold felt all right if he was receiving rewards for doing a noble job against difficult odds. When he was fielding calls from frustrated customers and able to imagine himself as successful go-between with them and the company, he was a contented crusader. The forces of evil were manageable and people were grateful for his efforts. This was a symbolic success at mastery. When he told me of his horrible childhood experiences and received my understanding and caring acceptance, he felt I gave him credit for having

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struggled through such adversity. However, when the company changed and when I began to explore his personality, he felt suddenly betrayed. It wasn=t so much the mounting difficulties in his day to day job activities that left him overwhelmed. It was the feeling of not being heard, recognized, or appreciated. Arnold had to have someone know how bad it was. They had to know the extent and severity of it. To Arnold that meant sharing in his mission to expose the company and get revenge. Therefore, he created a bind. There was no way I or anyone else could ever prove our willingness to help because he made impossible demands. He refused to acknowledge any portion of my attempt to help, so we didnt have a foothold from which to start. When I tried various ways of joining with him, he demanded total loyalty and concrete demonstrations to the cause. I would need to write a letter to the president or I didnt care. I needed to put him on disability immediately or I was useless. At work he used the same tactic. He refused to deal with his supervisor and wouldn=t talk to the manager. It was the president or nothing. This shows the fragility and temporary nature of the psychic patch that he had formed at work. It was a tedious internal bargain with his inner objects that broke down rather easily under change and stress. When the mechanism of projective identification creates the phantasy of an angry object poised to attack the ego, the ego then has to find ways of avoiding this persecution and potential annihilation. Arnold was constantly trying to negotiate the dangerous waters of this intrapsychic experience. All of his energy went into avoiding these fears and trying to conquer these internal demons. Stein (1990) writes,
Klein holds that good internal objects build and comprise the core of the ego and the superego, whereas bad objects, which consist of the externalized products of the child=s anxieties, become persecutors and necessitate the activation of defenses. (p. 499)

I would add that this is the hoped for healthy outcome of normal development. However, the positive object or good breast cannot gain an internal foothold if part of the ego tries to destroy the tie between the good object and the needy aspect of the ego. Out of envy, spite, and rage, Arnold managed to always fight for and fight off a supportive object. He craved to be dependent on a caring and protective object but felt compelled to be the omnipotent, independent one that others needed. Once he felt so powerful, it was as if he would have to step down in humiliation if he were to be cared for. Therefore, he suffered and played second fiddle to others in the hopes for love, all the time plotting and imagining how he was really far superior and poised for recognition. Arnold, and similar patients, cannot take in the analyst=s interpretations without feeling attacked or compromised. They crave the analysts help and love

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but resist it out of anger, envy, and spiteful sadness. Boris (1986) has discussed the reluctance to feed at one breast until feeling consoled or compensated for the loss of the Aother@ breast. This creates an unsolvable predicament that reinforces the sense of loss and persecution. For these patients, deprivation contaminates hope, rage fuels yearning, and envy magnifies hunger. Not only does the patient want an emotional feeding, but an undoing of prior injustice, a restoration of never available soothing, and a revenge for the loss of idealized objects. These feelings corrode and destroy any attempt to create or internalize a bond with good objects. Therefore, the ego is always left hunger and unable to reach the good breast. In analysis, the work is difficult and the patient feels they are being asked to give up their justifiable grudge and crusade against the bad object. Taking in and building experiences of gratitude with good objects feels like treason and intense humiliation. At his job, Arnold projected this manic, greedy self into the organization and then felt persecuted by it through the process of projective identification. He split off the needy, helpless aspects of himself and put them into the angry and hungry customers. Finally, he put himself in the middle as the long-suffering martyr who had to save the victims from the aggressors. Isaacs (1948) writes,
the difference between normal and abnormal lies in the way in which the unconscious phantasies are dealt with, the particular mental processes by means of which they are worked over and modified, and the degree of direct or indirect gratification in the real world and adaption to it, which these favored mechanisms allow. (p. 81)

Arnold used projective identification, splitting, and manic defenses to construct an internal bargain with his objects that he projected into the organization. He received enough gratification in these parts of the external world to manage a temporary psychological placeholder. This placeholder crumbled when the ingredients of his bargain were no longer available due to the shift in the organizations policies. In addition, the splitting of his mind into several separate and adversarial agencies left Arnolds mind fragmented and unstable. In the transference, Arnold put me in the role of a caring listener who would side with him and give him credit for all his suffering. Then, he tried to project the bullied and confused aspect of himself into me. He tried to be superior and point out how he was above others. When I commented on this approach and his attempt to be a Abig shot@ in order to hide his feelings of shame and humiliation, as well as a way to express his anger, he felt accused and attacked. Therefore, he reverted to the poor little boy with sad tales to tell and invited me to be by his side. In this way, Arnold tried to force my hand and demanded to know my alliance. I was either with him or against him.

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Overall, my consistent interpretation of these dynamics seemed to alleviate his anxiety and help him to reorganize his internal chaos. Temporarily, he felt less threatened and more understood. However, his fear, anger, and envy were so great that he could not use me as a good object. If I or the company did not measure up to his specific demands and acknowledge him as long suffering, justifiably angry, and deserving of reparation, he could not tolerate the relationship. Indeed, he did get me to deliver these rewards but he remained unsatisfied. Arnold felt so hurt and envious of his objects that even when he felt he gained rewards he needed more. His hunger could not be fed. His rage, envy, and spite prevented him from creating, taking in, and maintaining ties to the good breast. At his workplace, helping customers gave Arnold constant gratification of his wishes. He accomplished that by pitting them against the organization. He would tell the customers how lousy the company was and that he would work hard to help them against this mean entity. This splitting and projective identification dynamic was constant and excessive, but only broke down when the company restructured. Arnold hated his internal objects for not loving him in the right way, creating a need to be omnipotently attached to them. Grinberg, Sor, and Bianchedi (1977) write,
one of the outstanding features of the psychotic personality is the intolerance to frustration which, together with a predominance of destructive impulses, manifest itself as violent hatred of internal and external reality . . . because of the intensity of the destructive impulses, love is transformed into sadism and the conflict between the life and death instincts is not resolved . . . (the psychotic personality is) also characterized by the fear of imminent annihilation, which contributes to the specific type of object relations that are established. (p. 28)

For Arnold, these were object relations that involved sadomasochistic bargains and a hatred of the very dependence he craved. Gold (1983) discusses certain problems with inpatient hospital treatment that are equally applicable to the individual psychotherapy setting. He points out the importance for reverie and containment in the patient-therapist dyad for the detoxification of pathological projections to take place. Gold feels problems in this dyadic function are linked to lack of symbol formation, caused by excessive splitting and projective identification. This is turn prevents whole object relations. Gold attributes all of these pathological processes to the patient=s attacks on the good parts of the relationship and the healing properties that do exist in the dyad. Arnold and many patients like him seem to exhibit these elements in the transference. Specifically, they systematically find a way to destroy the good aspects of the relationship and ignore or devalue the rest. They feel such rage,

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envy, and sadness that they can=t bear to acknowledge the helpful aspects of the treatment and the moments where their relational wishes are fulfilled. The inability to take in positive possibilities or good portions of a situation make problem solving and negotiation impossible. Frustration tolerance is a characteristic of whole object relating. When an organization or group changes or restructures, it demands the individual be able to tolerate ambiguity, loss, and change of roles. Patients like Arnold cannot make this external shift because of the internal meanings it has for them. Indeed, unconsciously they refuse to. Arnold wanted to be cared for and recognized as an important soldier in the company. However, he wanted a very specific type of recognition. He was the savior for disadvantaged customers. He also felt he possessed the secret knowledge of the company=s dark side. This was a fragile sense of grandiosity combined with paranoia. When the company changed, he wasnt able to maintain this entitled position in his mind. In the transference, he wanted me to give him back this position. When I offered him a different type of experience, he could not tolerate it. He envied the analyst=s ability to live life without suffering and this envy brought on intense aggression toward the analyst. This prevented him from internalizing good aspects of the object. If his wishes for a good object came true, it reminded him of the resentment, sorrow, and loss he usually felt with his objects. Arnold, and other patients like him, are driven to destroy the good aspects of the object and refuse entrance to any evidence of good object relations. In a sense, it is a policy of destroying the present to set straight the past. Sadly, this brings about the past once again. Some patients have not experienced sufficient detoxification of their aggressive impulses and destructive phantasies by external and internal objects. They have not experienced an adequate container for their fear and despair. Consequently, they may look to groups and organizations for this function. However, this situation is often a temporary patch for their psychological difficulties. Gold (1983) writes, the concept of container intimates an object (mother/analyst) not merely a receptacle nor yet a mirror but one which has the capacity to intercept preverbal communications . . . a state of mind open to projections whether they be good or bad, whilst retaining a contact with one=s own needs and personal integrity. (p. 280) The organization may only, by its very nature, function as a mirror or receptacle for the employees projections. This gives a temporary, and misleadingly supportive, feeling of gratification. However, this placeholder

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function of the organization does not transform or translate unconscious projections. The egos envy, spite, and other destructive reactions to loss remain fixed as the primary way of experiencing the world. These pathological aspects of the ego may appear after an organization shifts its focus or mission. Many patients may continue for years in a seemingly safe and predictable feeling of mastery and fulfillment where the organization provides a soothing and gratifying transference experience. Phantasies of revenge, mutual atonement, intimacy, and security are gratified. If the organization happens to go through a marked change in policy or direction, it may impinge or destroy these phantasy fulfillments. Hope is shattered and unconscious bargains and promises between the ego and its objects are broken. This leads to significant regression to original paranoid and depressive conflicts. In other words, organizations can provide a placeholder for pathology, giving the illusion of working through without any real mourning process of the underlying phantasies of object loss or persecutory attack. The implications of Arnolds struggles for the modern company are many. Today, companies seem to routinely go through some sort of reorganization, take over, merger, or downsizing. All these changes are made for immediate profit. The old way of doing things is seen as counterproductive and not in line with modern technological streamlining. However, the old method of doing things may have been psychologically important to some workers, motivating them to be highly productive workers. Thus, a change in the company may have significant negative psychological impact on individual workers who make up the backbone of the company. This internal breakdown among strategic line-workers is usually not factored into a shift in company policy. Making sure the individual worker is helped to make the transition would insure a successful reorganization. Certain jobs might need to be reconfigured and others might need to remain the same. This might not look logical or profitable from a simple organizational chart or policy procedure manual. However, the long range benefits of making sure workers are helped to stay secure and satisfied would provide the company with an internal robustness that translates into longterm profit. For Arnold, this parent-like alertness to workers= needs during transition might have made a difference. Perhaps, he could have been relocated to another area for six months while the customer situation balanced out. Or, he might have been put on a new team designed to handle the new problems with customers. However, I think the change was too much for Arnold. His was a fragile hold on reality. I think he had found a unique spot in the company that allowed him to function and manage his anxieties. It would be hard to replicate that experience

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for him. Ultimately, he needed long-term therapy and may have needed hospitalization for that to occur. So often, the Alittle guy@ in a company works long and hard hours to create the seamless buffer between the consumer and the corporate vision. When all goes well, these are the workers who are responsible for the companys success, yet they are underpaid and underappreciated. Arnold was one such worker. Some of these individuals manage to make do in their little niche because of the deeper psychological meaning it has for them. To them, this is the important compensation. The emotional placeholder is their reward. When a major company change occurs, these types of workers are routinely plugged into another workerbee type position without allowing for their personal needs. This is disruptive at best and devastating for some. For precariously functioning individuals like Arnold, a chronic or permanent internal disruption occurs. This creates a breakdown of internal placeholders and brings on paranoid~schizoid anxieties. Novey (1957) writes,
In the neuroses, a segment of the total social institution may be incorporated into the neurotic defensive system. In so far as this happens, the social institution, intended as it is to foster sublimation, no longer serves this purpose, but is employed in the service of the non-sublimating neurotic pattern. To the degree that this occurs, it represents a defensive pattern particularly difficult to shatter, since by this manouevre the defense becomes rationalized by the neurotic as an expression of the social institution and accordingly assumes an investment of virtuosity and righteousness. (p. 82)

Arnold needed ongoing ego support to combat his persecutory internal world. Ideally this would come in the form of new intrapsychic objects that gradually would provide structural change. In Arnolds case, he had found a temporary patch in the form of an external object: the company. This worked out well until the company reorganized. This seemed to shift the sublimation Novey speaks of into a neurotic or psychotic defensive system. Because of Arnolds lack of symbolic function, the company took on a strong persecutory role and Arnold became righteous about his fight for justice. This defensive system between his ego and the external object, as distorted by his projections, made my role as analyst very difficult. In the end, the reorganization of Arnolds company triggered a pathological reorganization of Arnolds internal objects that proved impossible to work through.

Chapter Three

THE SOMATIC RETREAT AND THE USE OF AUTISTIC OBJECTS


Using criteria from the DSM-3-R (1987), the Somatoform disorder can be divided into four descriptive groups. Somatization involves multiple, chronic somatic complaints. Medical attention is usually sought with no diagnosis found. Also known as Briquet's syndrome, this is a hysteria in which the patient's complaints are general, vague, and dramatically presented. Any or all body systems are involved. Neurological, gastrointestinal, gynecologic, and cardiopulmonary complaints are common. Chronic back, joint, and abdominal pain are frequent presenting problems. Conversion disorder was central to Freud's early work. The patient displays a sudden and dramatic onset of a physical disorder that suggests neurological disease, but is not supported by medical examination. There is usually one specific symptom that results in the loss of a physical function. Seizures, loss of speech, inabilities to walk, tunnel vision, numbness of a body part, and loss of hearing are some examples. "La belle indifference" signifies the patient's unconscious gratification. The patient is oblivious to the difficulty or pain that most people would experience with the ailment. There has been an increased clinical awareness of the more subtle types of conversion disorder characteristic of personality disorders. Psychogenic pain disorder involves the complaint of pain in the absence of any physical findings. The complaint of pain is the major presenting issue. As with the other Somatoform disorders, the pain does not follow the normal anatomical distribution of motor and sensory nerves and lab tests are negative. These cases are usually seen in the medical community.

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Hypochondriasis involves the unfounded fears of having a serious illness. It is a preoccupation with body functions and the unrealistic interpretation of physical signs or sensations as abnormal. There are obsessional worries and concerns despite repeated assurances from doctors and lab technicians and these patients are often given unnecessary medical treatment. Ferenczi (1952) and Deutsch (1922) saw the Somatoform disorders as displaced expressions of repressed instinctual drives. Ruesch (1946) suggested ''body language'' was being used to communicate due to the inability to use verbal symbols. He stressed the infantile residues in the personality organization of somataform patients as a group. He felt the fragility of some of these patients during the course of treatment suggested a serious ego-weakness. Quite a few early analytic investigators believed that these patients were borderline schizophrenic. In my clinical work I have observed the somataform disorders to be defensive mechanisms equally employed by neurotic, borderline, or psychotic patients and often used as an ''autistic object'' (F. Tustin 1980). She defines the autistic object as a desperate attempt to ward off violent psychic separation from the mother. She states, For these children disillusion occurred too suddenly or too soon. Stripped of the necessary protective illusions they have had to cope with the fact of bodily separateness from the breast before their neuro-mental organization was sufficiently integrated to cope with this ordeal. The gap between instinctual inbuilt expectations and actual happenings was intolerable for them. These gaps had to be closed immediately by the over-use of bodily sensations through which the child felt he had a perfect mother always with him who gave him ecstatic and instant sensual situation. To achieve this, objects came to be used in a pathological autistic way. The pathological use of autistic objects meant that he had sensationdominated artefacts which impeded his approach to the outside world instead of gradually developing a differentiated and differentiating medium for communication and interpretation. (Pg. 31) While Tustin is including both internal representations and external real objects in her definition, I am emphasizing the use of intra-psychic and somatic experiences as the cornerstone in producing these pathological autistic objects. I will present a case in which a paranoid psychotic patient used somataform difficulties and sadomasochistic ways of relating to create autistic objects that provided a jagged psychological surface. This prevented her from falling into the endless anxieties of the Autistic-Contiguous position (T. Ogden 1989). Ogden says A(this) Autistic-Contiguous anxiety involves the experience of impending disintegration of one=s sensory surface resulting in the feeling of leaking, dissolving, disappearing, or falling into shapeless unbounded space.@ (Pg. 67)

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In 1959, Theodore Lidz stated, "the mechanisms of defense of the ego are varieties of symbolic self-deceptions that ward off recognition of situations which provoke anxiety and other disturbing emotions. Their elaboration leads to organized neuroses. Psychotic regression and withdrawal provide escape from the untenable through abandonment of reality testing. The person who is prey to psychosomatic illness has suffered serious insecurity early in life but has not erected adequate mechanisms of defense to protect against the danger. Rather, he avoids recurrence of the insecurity or trauma by patterning his life so that he will never be exposed again. The critical area of weakness is encapsulated, but the patient neither becomes desensitized nor develops mechanisms of defense to blunt its impact." (Pg.652) The (word) ''encapsulated'' trauma and (phrase) ''serious insecurity early in life'' speak to the pre-genital intrapsychic difficulties these patients experience. While Lidz says adequate defenses have not been created to avoid these early traumas, I believe ''autistic objects'' are created as precursors to actual ego defenses. These consist of early infantile phantasies of sharp and hard psychic surfaces which provide a sense of cohesion, organization, and safety. These autistic objects jar the patient from terrifying descents into feelings of annihilation within the Autistic-Contiguous position. The use of autistic objects involves intrapsychic as well as interpersonal mechanisms. Most of the Somataform patient's physical disturbances are actually communications within the Sensorimotor level of development. They are precursors to symbolic expression and forerunners to more cohesive and dynamic phantasies. At the extreme, this is a place where words and concepts do not yet exist and rudimentary desires and urges are organized and expressed via the sensorimotor system. In the psychoanalytic situation we find certain patients have either fixated at or regressed to this level of functioning and we assist them to clarify and communicate these primitive states. Vocal tone and concreteness of speech are important to consider when making interpretations. The abstraction process is often unavailable in these regressed states. No matter how correct an interpretation is, the patient must first understand it. The sensorimotor ways of experiencing the world are part of the AutisticContiguous position. The analyst can help the regressed patient by giving verbal meaning to bodily states and by example how to communicate with words. The somataform patient's attempts to deal with aggressive and libidinal urges have culminated in the use of the body as compromise. In the Autistic-Contiguous position, loss of self and object is a constant threat. Separation-individuation conflicts are usually heavily defended against as the separation is experienced as a fragmentation of the self and a loss of anchoring into the feeble sense of security

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that does exist. This loss leads to experiences of disintegration and prosecutory annihilation; one patient stated, ''I will be sucked off of the planet''. Another patient said, ''I don't want to feel this way. When I am by myself and I feel this way I start to vanish. I feel swallowed up, there is nothing, its dark, and I can't find my way. I can't even find myself''. Many of these patients also feel there is nothing between the self and the object, leaving them with a threatening engulfment or fusion. Even with predisposing genetic or constitutional factors, the somataform patient is a candidate for the psychoanalytic process. Asthmatic patients are an example. After successful treatment, these patients may still test positive for allergies, but will not experience asthmatic attacks in stressful situations as severely as they did before. Otto Fenichel (1945), in his book, "The Psychoanalytic Theory of Neurosis," explicates the origins and dynamics of somatic symptomology so clearly that I will quote him at length: ''the behavior of a person is continually influenced by his conscious and unconscious instinctual needs. Whereas the oscillations of conscious drives are regulated automatically through instinctual actions, wardedoff impulses, which cannot find an adequate outlet but over and over seek to find discharge and to produce derivations have less obvious and more lasting effects. Attempts at substitute outlets are continued or repeated, and this may eventually produce physical alterations. A simple example: A habitual forced clearing of the throat, kept up over weeks and months, has a drying effect upon the throat and may eventually result in a pharyngitis. Or the habit of sleeping with the mouth open also dries the throat and may cause a pharyngitis. Both habits at times may have organic causes; at other times they certainly are an expression of unconscious wishes. There are many kinds of behavior that provoke common colds. Various authors have illustrated occurrences of this kind in detail. To summarize: An unusual attitude, which is rooted in unconscious instinctual conflicts, causes a certain behavior. This behavior in turn causes somatic changes in the tissues. The changes are not directly psychogenic; but the person's behavior, which initiated the changes, was psychogenic; the attitude was intended to relieve the internal pressure; the somatic symptom, which was the consequence of the attitude, was not sought by the person, either consciously or unconsciously." (Pg. 239) This close relationship between unconscious conflict and actual behavior will be evident in the case material. Specifically, the patient=s overeating, scalp picking, and bowel problems were manifestations of internal conflict that became organic problems as well. If the patient has a stable premorbid history, absence of major psychiatric syndromes, and a significant current external trauma to which they are reacting,

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the general prognosis is quite positive. These patients are usually not so fortunate, and more typically they have underlying, preexisting conditions such as a syntonic personality disorder or latent psychosis. Patients are usually reluctant to accept the possibility that their problems are psychological. In the transference, the persistent focus on physical symptoms is used as a resistance and defense against the crippling anxieties of the Autistic-Contiguous position. With gradual insight into their psychological functioning, the patient can shift from experiencing life in primitive and frightening ways to more reciprocal yet autonomous ways. Interpretations focus on the primitive phantasies which the patient's body both defends against and expresses. A gradual working through leads to less reliance on projective identification and splitting. Analytic treatment of Somatoform illness also results in a gradual shifting to higher levels of psychological coping mechanisms, away from the somatic precursors to phantasy into symbolic and verbal mechanisms. Theodore Lidz stated in his 1959 paper in the American Handbook of Psychiatry, ''fortunately, effective therapeutic work with (these) patients does not depend upon knowledge of how emotional conflicts are translated into physiologic malfunctioning or upon resolution of problems concerning specificity. The physician who orients treatment to the patient rather than simply to the disease and who can utilize the doctor-patient relationship therapeutically can often alleviate emotional problems and ameliorate the physical illness. The general principles which guide psychotherapeutic efforts with patients suffering from psychosomatic disorders are similar to those used in other psychiatric conditions." (Pg. 654) Here he points to the analysis of the transference as the central vehicle for change rather then the goal of symptom reduction. While these patients make for particularly difficulty and lengthy treatments, the standard psychoanalytic approach is, I believe, the treatment of choice. By this, I mean to say the analysis of the transference and the resistances provide the best vehicle to restitution of the ego functions.

CASE MATERIAL
The autistic object can be defined, in part, as the defensive use of certain states of mind to create a place of safety an internal experience of hardness, sharpness, and definition as a shield against the formless, internal void of the Autistic-Contiguous position.

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Mrs. E was a patient who made extensive use of autistic objects to ward off the Autistic-Contiguous position. Ogden (1989) states, the Autistic-Contiguous organization is associated with a specific mode of attributing meaning to experience in which raw sensory data are ordered by means of forming presymbolic connections between sensory impressions that come to constitute bonded surfaces. (Pg. 49) Mrs. E used various somatic experiences as autistic objects into which she projected unbearable internal object relations and affects. The analysis of the transference was frequently a threat to these autistic objects and she defended herself through regression, projective identification, and a variety of psychotic processes. Mrs. E was a 50yr old, lower middle class woman who had two prior marriages with no children. Mrs. E demonstrated all four categories of the Somataform diagnosis. She had chronic and varied physical complaints, a rather dramatic conversion disorder, psychogenic pain, and multiple hypochondriacal worries. ''Job stress'', depression, chronic anxiety, and vague physical complaints were her reasons for seeking treatment. She was a paranoid psychotic who seemed to exist within the AutisticContiguous position and would find expression and organization for her primitive internal states through somatic disturbances, bulimia, and sadomasochistic relationships. She used these states as autistic objects to gain a temporary defensive footing into the Paranoid-Schizoid (H. Segal 1974) position and a shortlived mental respite from the extreme anxieties of the Autistic-Contiguous mode. Mrs. E loved her father, but did not have a great deal of contact with him while growing up. Her mother always told her to ''beware of the evil man." During treatment, Mrs. E interpreted that her mother used her as an emotional waste dump, depositing all her rage, fear, disgust, and confusion into her. Tustin (1980) states '' The frustration of unbearable disappointment means that instead of the creation of healthy illusion and hallucinations which lead on to dreams, fantasies, and ideas, the infant begins to manipulate autistic objects in an excessive way. These being tangible, sensation-dominated and ever-present, keep the child stuck at a primitive level of over-concretized mental functioning.'' (Pg. 32) Mrs. E experienced massive disappointment as a child and managed to recreate this loss in her adult life, prompting the need of autistic objects to psychologically steady herself. Mrs. E remembered her mother routinely caressing her genitals and painting them with ''medicine'' through ages 2-6yrs. She feels her and her mother found this sexually satisfying, in a sadomasochistic sort of way. Her parents would tease her about her ''fat body'' and her physical changes during adolescence. In her forties, she was extremely depressed and sought

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treatment with me. She would spend days in bed incapable of caring for herself and often thought of suicide as the ''merciful relief'' that would cure her misery. On and off over the years, Mrs. E picked her scalp to the point of causing bleeding and irritation. This was based on a vague worry she had about head lice and other scalp problems she thought she might have. She also gorged herself on sweet foods, breads, and candy, causing obesity. This bulimia was based on a misunderstanding of certain emotional states as physical sensations of ''starving to death''. She would miss seeing me and feel very lonely. She would experience these feelings as a physical emptiness and then gorge herself on sweets and breads. Throughout her life, she routinely met with dozens of chiropractors, homeopathic healers, ''energy specialists'', shamans, physical therapists, massage experts, and other ''practitioners'', all in an effort to alleviate a broad spectrum of physical complaints. She was truly a regular fixture at the local hospital and would often be in bitter disputes with the staff. She would become angry that they ''didn't know what they were doing'' and she would then proceed to ''show them'' or tell them the ''correct'' way to practice medicine. In the transference, she often criticized me for not knowing how to ''correctly'' practice psychoanalysis and wold then tell me the ''right way'' according to her beliefs. From the time we began therapy to well into the second year of treatment, she had a loss of bowel control. She would have a bowel movement in her pants several times per week to several times a day. It was a fully formed stool, unlike the diarrhea that came with her earlier Crohn's disease, which was then in remission. Extensive medical tests were negative. She had to make sure she was never far from a bathroom and her whole life became organized around this. She was seen by several psychiatrists and neurologists for depression, back ache, and lack of bowel control. While the tests showed no serious physical pathology, she did receive disability for major depression. She would stay in bed for days at a time in a highly disorganized state. After several months, she began a schedule of walking for her health. At the same time, she had been gorging on food for months and gained 100lbs. We explored this as a desire to self-sooth and provide her with a sanctuary from the prosecutory agents of the world. Mrs. E had many physical problems when she entered treatment. Some of these steadily lessened or completely stopped during the course of analysis. The picking of her scalp was a symptom that would typically begin when she felt anxious and unsure. We discussed how she used the feelings created by her bleeding and irritated scalp as a spot to focus upon, organize herself, and feel contained and contented. It was an autistic object. In 1986, Tustin stated

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'''Hardness' is a characteristic feature of most autistic objects. This gives the child the feeling that they keep him safe. Autistic children, because they lack experience of civilizing relationships with other human beings, feel constantly threatened with being attacked and hurt. They feel that their helpless bodies are a target for savage and brutal attacks. ----- The main purpose of autistic objects is to shut out menaces which threaten bodily attack and ultimate annihilation.''(Page 107) This seems to have been true with Mrs. E, who was haunted with phantasies of brutal attack as well as terrifying abandonment. The intensity of each physical worry, pain, complaint, or conversion shifted depending on her inner conflicts. Mrs. E sought out numerous and complex medical procedures for her lack of bowel control. These investigations included a spinal tap, MRI, CAT scan, blood work, GI tests, change of diet, and consultations with surgeons, psychiatrists, and numerous other specialists. All of these tests showed that the patient suffered from back difficulties, obesity, and chronic and severe psychiatric problems. However, there were no physical indicators that would explain her lack of bowel control. This was a frustrating process for both of us, yet it motivated us to double our efforts at understanding the psychological dynamics involved. Her way of focusing all thoughts and energy on medical tests and physical symptoms was the creation of another reliable autistic object that provided definition and purpose for her otherwise formless and terrifying mental disorganization. When she felt more secure with me and felt less persecuted, her bowel movements would lessen. When she felt alone and confused, she would imagine the world, including myself, to be quite dangerous and the bowel movements would increase. After two years of these bowel movements occurring ''without warning'', her condition changed. They decreased from up to six per day to once per week during the second year of treatment and then ceased all together after thirty months of treatment. While her weight remained at 250 pounds, her food gorging lessened. I interpreted these changes as part of her increased trust in our relationship, her view of herself as more worthwhile, more realistic expectations of her relationship to her mother, and fewer phantasies regarding predatory, ''mean mother'' attacks from myself and others. She had less need for the somatic method of organizing her psychic world. In a deeper sense, her need for autistic objects to provide balance and stability lessened as her internal object relations became less prosecutory and as she felt she could trust me. During those first two years of analytic work, we had discussed her lack of bowel control many times. I had focused on her inability to hold onto anything hopeful or soothing, her desire to expel the hatred and evil that she felt dwelt inside of her, and her perception of her body as an outside force that controlled

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her. We also explored how organizing her life around the prevention of and cleaning up after the bowel movements somehow gave a focus to everything. It was only gradually that I understood this to be the creation of autistic objects that provided a supportive mental surface to cling to, a prototype of sanity and reality which she felt some degree of control over. In the following years, she had no more loss of bowel control. She did nevertheless retain the somatic retreat as a defense. When she had to shift from working three days a week to four, she was very anxious and woke up the morning of her new shift with her eye swollen shut. The same type of fragmentation occurred during our shift from three to four times a week treatment. Due to her persistent attendance at a local diet center and our examination of what food meant to her, her weight dropped from 275lbs to 175lbs. She was successful in losing the weight, yet still maintained a sadomasochistic relationship with the diet center and myself. She still had relapses into gorging and we were usually able to trace these to her feeling abandoned or neglected by people, including myself. Her relationship with food was multi-determined. It provided a reliving of the sadomasochistic relationship with her mother, created a soothing experience of security, and was an autistic object that gave her a textured mental surface to hold on to during times when she felt as though she was sliding off a cold glass like surface into a bottomless pit. She would say, ''I start to go to this place where there is nothing. I can't move, I don't feel anything, and I have no purpose to my life. I start to go away and that is when dying seems like it would be a welcome place because at least it would be something I would know. Today I suddenly just found myself at the store buying donuts and ice-cream, like it is totally out of my control. I feel better after though --- like I need to eat or think about dying to feel better''. In her despair, suicide felt as though it would provide a hard and helpful mental surface that she could ''know''. At these times, she would also pick at her scalp until it bled as a method of creating an autistic object that she could hold on to, focus on, and feel companionship with.Four or five months later, she once again weighed 270lbs from chronic gorging and was struggling with multiple physical complaints. She had been involved in numerous situations with her boss which paralleled the transference. She felt massively wronged and wanted ''justice'' and went about demanding it in a way that was brutal yet pathetic. Embedded in this way of existence was an extreme rage that was difficult to access. She saw her anger as justified given the ''terrible victimization'' that she ''endured''. This lifestyle of chronic crisis and sadomasochistic relating provided her with an extremely dependable hard mental surface to cling to. She created an autistic object that was a pitifully crippling and dried-up breast to hang onto, yet was much better then no breast at all. Tustin (1986) states ''--in the

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therapeutic situation, this replacement of needed people by autistic objects which help the child to feel impenetrable and safe leads to behavior on the part of the child which, to the outside observer, appears idiotic, but to the child seems essential, and by entering and understanding his world, that we can help him.''(Page 115) The treatment with Mrs. E was a constant and difficult task of trying to make sense of the meaning of her otherwise ''crazy'' ways of living. In many, if not most, of the sessions Mrs. E appeared to be extremely anxious and not present. On occasion, she was comfortable and wanting of my help but mostly she was distant and very reluctant to be close. When I gave interpretations that seemed to be a close fit with the transference, she would immediately fall to sleep or become numb and unable to think or talk. If I directly commented on Mrs. E's fears she would fall right to sleep or ''space out''. This seemed to be the result of excessive splitting and projective identification mechanisms and led to her appearing naive, stupid, or ''shell-shocked''. She would routinely ''accidentally'' lock the outside front door to my office, preventing any other patients from entering. I mentioned there might be some meaning to these acts which we could explore together. She looked bewildered and astonished and said, ''oh my, I am so sorry --- I never realized --- I am sorry -- I must look out for that --'' and seemed to be literally shook up at the seams. She took any unconscious meaning as a threat to be wary of. She responded in such a concrete manner that it was near impossible to have a joint exploration into what may have been taking place on a psychological plane. Tustin (1986) remarks ''during the period when these children felt protected by their autistic objects they were impenetrable to my attempts to help them''. (Page 103) When I interpreted her fear of losing me if she didn't lock others out, she became sleepy and ''spacey''. I found that interpretation of the intra-psychic aspects of projective identification were far too threatening and in fact we seemed to make the most progress when I interpreted the interpersonal aspects instead. This was in part, I believe, due to her experience of my intrapsychic interpretations as robbing her of the autistic objects that she was desperately clinging to. The interpersonal interpretations allowed her to keep her autistic objects and in fact use my comments as a relational connection from a safe distance. In the transference, Mrs. E felt manipulated, controlled, neglected, and ignored. She also felt that I was always angry, on the verge of getting rid of her ''for good'', unwilling to support her, and generally expecting too much. Her method of dealing with these transference states was with withdrawal into silence, sleep, dissociation, and by attacking me ''back'' with various accusations.

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She was angry that, in her recollection, I never once commented on or was concerned with her food problems and weight gain. These feelings were in contrast to her other feelings of being understood, supported, and accepted about other topics. We discussed this as a feeling of being ignored and abandoned by her father and the sense that I somehow wanted her to be fat so I could ridicule her for it. This led to her discussions of how her mother would encourage her to eat ice-cream and cakes for desert as both a child and adult, but then tell her that she could never expect to be a success as long as she remained so ''fat and ugly''. This was a clear example of double bind that left her in a psychological plane so void of stability, meaning, or connection that she had to resort to the construction of autistic objects to attach herself. After losing another job due to paranoid delusions, she had to relocate some forty minutes from my office. She became convinced, more then ever, that I was an unsupportive and cold father and a blaming and prosecutory mother. Her phantasies at that point included terror of hurting me by leaving, my subsequent rage, and the revenge that I would then seek. She expressed her desire for my love and the wish that somehow we could continue to be together, yet once she felt she had my caring and love she became terrified that ''the other shoe would drop''. All these intense and intimate feelings had surfaced many times before, but the move brought them to a rather brittle focal point. On one hand, there was some working through of these feeling. On the other hand, she became convinced that I truly was her father and that I was very angry with her for leaving me. It seemed useful to interpret this as a defense rather then to see it as an ego deficit. This transference psychosis was an autistic object that provided her with a temporary footing into the Paranoid-Schizoid position, rather then the terrifying anxieties of the Autistic-Contiguous position. It was safer to fear me and have to fight me off then to feel totally abandoned and helpless. The transference paralleled her work patterns in that she was chronically late to her sessions, didn't show up for many of them, was consistently late in paying her bills, and was always in some sort of personal dispute with me. Time after time, she became disorientated on her way to my office and often ended up at a local airport some fifty miles away. She felt I not only ''made her'' lose her way, but deliberately caused her stress, humiliation, and frustration. When I would give her the monthly bill, she felt I had, ''out of the blue'', dealt her a crushing blow right at the point where she was ''at her lowest''. While the fact that she felt this way each and every month seemed like a ripe opportunity to explore her feelings, my comments were always taken as fresh and volatile attacks that had no link to anything else.

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She stopped attending after six years in treatment, citing the unbearable pressure of having to travel to my office across the ''dangerous and frightening'' highways where ''people seemed to be angry and pushy''. She also said the inability to pay me brought up thoughts of being in a ''vice like debt'' and the thoughts of me actually being her father terrified her. She kept me appraised of her life circumstances by way of long and rambling sadomasochistic phone messages. One month after the termination, her boss fired her due to chronic lateness, unreliability, and inability to perform her job duties. I invited her back into treatment many times over the months but Mrs. E refused, again citing money and travel time. I suggested there were other components to her ambivalence, but she maintained it to be a ''practical matter.'' However, she would say that ''for some strange reason'' she felt unsure and uncomfortable with coming to see me. While unemployed and on disability, she fell down and injured her knee and began extensive visits to various specialists at the local hospital for tests and treatments. She then began a series of tests on her gastrointestinal system to investigate vague ''spasms'' and painful gas. These tests included barium enemas, x-rays, and upper and lower G.I. track procedures. It seemed she had rapidly retreated to the use of somatic experiences as autistic objects to focus upon and organize herself around. Indeed, I had been an autistic object to her for years. When I was able to articulate the transference climate, she lost me as an autistic object and felt she was falling into oblivion. This is the difficult and paradoxical nature of the working through process with these patients. Both the somatic focus and the sadomasochistic way of relating were also paradoxical in that she ultimately created the autistic void she so feared, yet at the same time created such a jarring and terrifying experience as to develop a sandpaper like psychic surface of autistic objects that would at least temporarily save her from this frightening experience. It became a bizarre world of various autistic objects that were used to defend against other autistic anxieties as well as against frightening Paranoid-Schizoid phantasies. When she was not be able to organize her internal state through the use of autistic objects, she was limited to staying in bed for days at a time. Mrs. E used splitting and projective identification in an intense and rapid fire manner that was very difficult to keep up with. She was angry with me for the feelings of craving she had, both for food and for my love. She was angry that she was a ''charity case'' but felt very guilty about her anger because she also felt I ''lovingly'' reduced her fee throughout the treatment. She was overwhelmed with loneliness when she couldn't see me but hated me when she arrived. This rage was

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an autistic object that protected her from the terror of being rejected by me when she felt so vulnerable. Her physical problems created an abrasive surface onto which she could cling to and focus rather then fly into endless black mental space. Indeed, when she was having daily bowel movements in her pants, she was maintaining a job and carrying out many responsibilities. The bowel movements gave her a predictable bodily experience that she could trust and actually use to bind her deeper anxieties. She would often have a bowel movement in my office bathroom, leaving a horrible odor in the general area. She would leave the bathroom in a state of messiness with water all over the place, toilet paper unrolled onto the floor, and so forth. This seemed to be both a chronic internal disorganization which she externalized and a sadistic lashing out which provided some degree of subsequent organization. Again, this was a type of autistic object with which she literally ''marked her territory'' like an animal to prevent a feeling of loss and fragmentation. When she ended treatment with me, she was on a hormone treatment, antidepressant and anti-anxiety medication, and pills for leg cramps. Every month or two, she would forget to fill her prescriptions, facilitating a crisis. This seemed to give her an external project to focus on and to become agitated and desperate about, all of which generated an internal experience that was a wedge in what would otherwise be an overwhelming void and vacuum. She was seeing a massage therapist, an acupuncturist, a psychic, a ''polarity worker'', a psychiatrist, and a physical therapist at that point. She complained of ongoing neck pain, back pains, vague abdominal discomfort, leg cramps, headaches, tingling of the extremities, and various other concerns. She also had fears of developing cancer of the brain, lungs, stomach, and rectum and was at times convinced that she was dying of AIDS, cancer, uterine ''problems'', and ''environmental poisons''. Mrs. E kept creating states of somatic distress and externalized chaos to avoid the perils of not only the Autistic-Contiguous position but the dangers of phantasy as well. When she became more in touch with the symbolic nature of phantasy, she met up with the frightening aspects of the Paranoid-Schizoid position. While she previously defended herself from more global, sensory dominated terrors of collapsing, disintegrating, and becoming fragmented and immobile, she now had a more symbolic plot to her ongoing anxieties. Prosecutory phantasies and fears of destroying her objects with hatred and neediness began to dominate her inner world. This lead her on a search for a precarious and narrow psychological ledge to balance upon to avoid as much of these two danger zones, Autistic-Contiguous and Paranoid/Schizoid, as possible.

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Tustin (1986) states ''The pseudo-protection of autistic objects prevents the child from using and developing more genuine means of protection. In particular, it prevents him from getting in touch with the caring human being around him who would help to modify his terrors. It keeps him trapped in a bereft state beset with fantastic terrors with no authentic means for these to be alleviated and modified.''(Page 108) Mrs. E wanted me to save her from the numerous internal terrors she lived with. However, she was unable to become vulnerable enough to reach out or accept my love due to her extreme anxiety and because of the autistic objects that not only protected her but blocked off any connection with me. The severe nature of her somatic retreat, her overwhelming reliance on primitive defenses, and her psychotic functions all made for a grim prognosis. The chief resistance was not only the transference itself, but her terrifying view that my interpretations were going to rob her of the autistic objects with which she was so loyal to. She had become an expert at producing an endless and hopeless array of internal and external experiences that at best validated her worst fears. This is a sadly paradoxical situation in which the autistic object that seemed to save her from the jaws of disintegration actually delivered her there by a more ''scenic'' route. She managed to defeat herself and those around her in a colorful sadomasochistic circus, fueled by intense and fantastic parts of herself that were constantly being traded about through projective identification. This resistance was extremely difficult to approach, as she felt it to be a series of autistic objects that keep her afloat in a deadly sea of nightmarish threats to her existence. I was therefore seen as a threat to her precarious balance on reality. Somataform disorders are made up of somatization, conversion, psychogenic pain, and hypochondriasis. Certain patients appear to make use of the somataform disorders as Autistic objects that protect against certain intense anxieties within the Autistic-Contiguous position. A case was used to illustrate the defensive use of somataform disorders as autistic objects. This case involved a woman who ''successfully'' used the somatic focus to ward off intense psychotic anxieties. It was ''unsuccessful'' in terms of leaving her in a viciously repetitive cycle where she traded one set of terrifying perceptions for another set of destructive phantasies. Aspects of the transference and the difficulties with resistances were explored.

Chapter Four

SELF-MUTILATION, SUBSTANCE ABUSE, AND THE PSYCHOANALYTIC APPROACH


The general public and a wide sector of psychiatry tend to view self mutilation as the act of disturbed patients who are not treatable from a psychoanalytic perspective. Alcohol and drug abuse, while socially more acceptable, also carry a stigma. Alcoholism counselors tend to see these patients as having behavioral "addictions" that need to be extinguished with pragmatic approaches. Favazza (1987) discussed multiple ways to understand the internal meaning of these destructive actions. He stated: ''Self-mutilation by mentally ill persons {is} a private, solitary act that often temporarily alleviates pathological symptoms. This remedial effect is extremely rapid. The most common pathological condition is tension and anxiety, often accompanied by self-anger and feelings of powerlessness. Another commonly stated pathological condition is a perplexing feeling of numbness, strangeness, and unreality in regard to one's body, thoughts, and emotions as well as to persons and objects in the environment. The sensations of pain and the presence of blood not only interrupt the monotony of depersonalization but also indicate that the cutter is, indeed, alive and that the body's border of skin is intact and in place. Self-mutilation may also be therapeutic because of the symbolism associated with the formation of scar tissue; scar tissue indicates that healing has occurred. In times of desperation because of loneliness, perceived rejection by others, and fears of separation, personality disordered persons may receive solace from self-mutilation. Sometimes self-mutilation can be a manipulative ploy to gain attention or to coerce others.'' ( Pgs. 192-98)

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Favazza is pointing out that the observable behavioral symptoms of self-harm can be conceptualized as linked to deeper, often unconscious, conditions and are in fact motivated by these deeper conflicts. Psychoanalytic theory proposes that all human behavior has meaning. Specifically, self-destructive acts can be understood as resulting from and symbolizing certain intrapsychic phantasies involving wishes, fears, and compromises. From this standpoint, the analysis of the transference provides the optimum vehicle for the resurrection, clarification, and modification of archaic internal self and object representations. The psychotherapy process does not have to focus solely on the symptoms of self-harm or alcoholism for the patient to improve. The welfare of the patient and the public are crucial and may warrant an initial detoxification, hospitalization, or other method of containing the destructive action. However, an emphasis upon the analytic process can begin from the moment the patient enters treatment. I will present four case examples, all women, in which patients presented symptoms of self harm and/or substance abuse. In noticing how the majority of such patients are women, I wondered about the nature of how sadistic and masochistic impulses are projected, externalized, and otherwise communicated according to gender. Space does not permit a full exploration of those valuable questions. In working with these patients, I try to cultivate a mutual psychoanalytic curiosity in the treatment, as best as permitted, while allowing for some parameters when necessary or unavoidable. Parameters are only deviations from ''standard analytic technique'' when they are not analyzed within the context of all other transference/counter-transference material. As with all patients, but particularly with these types of individuals, I found myself falling into various reproductions of unconscious historical material and realized I was involved in multiple violations of sensible technique. It seemed most helpful to talk to the patient about these events and see if we could use them as clues in our ''analytic search''.

CASE #1
Miss A, a mentally retarded borderline woman, did not present symptoms of alcohol abuse, drug abuse, or self-mutilation until some time into the therapy. After about ten months, she began to say, "I've started to hurt myself. I cut myself and started to bang my head against the wall. You made me so angry last time that I had to." She would also threaten me by saying, "I need to see you another time this week and I will hurt myself if I can't.'' While A was not prone to excessive drinking, she started telling me, "I got drunk last night instead of feeling my

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feelings." The patient would frequently blame my vacations and schedule changes for pushing her to self-destruction. She began threatening suicide and calling local crisis hotlines who then would call the police to investigate. This would go on several times each weekend. I told A the treatment would be discontinued if she was not willing to work on controlling her behavior. While she did test these limits several more times, the technique was successful. By successful, I mean that the focus was no longer exclusively on extinguishing "crisis" situations and that instead we could struggle with exploring the transference meaning of her acting out. For example, we tried to understand how I frequently was invited to be the ''sheriff'' in our relationship. In 1980, Kwawer stated: ''the therapeutic stance during the period of inpatient treatment discussed emphasized consistent reinforcement of boundaries and limits in order to facilitate a mutual exploration of the interpersonal context in which {the patient's} symptoms emerged.'' (Pg. 205) These boundaries and limits are equally important in outpatient treatment, which is where most of these patients seek help. While these power struggles and several hospitalizations for actual suicide attempts did move the locus away from an analytic process, in the long run they were not impediments to the psychoanalytic orientation. While a treatment can be forced into being predominately, crisis oriented a treatment can also be kept on an analytic plane even though emergencies and power struggles are constantly present.

CASE #2
Miss B was a young woman with a higher level of ego functioning than Miss A, but still within the borderline range. She had transient psychotic periods in which she would see a ''floating head'' that would warn her of vague dangers. She had not been in treatment before and came for help with intense anxiety and depression. She quickly formed a transference in which she was distant, entitled, and provocative. She treated me in a seemingly careless and invasive way. She had grown up with a detached, yet caring father who was seldom present to create rules, offer protection, or give advise. The mother was verbally abusive and alcoholic. The patient had five brothers and was left unsupervised with them much of the time. This led to exposures to group sex play between the brothers and their friends. After the parent's divorce, B lived between the ages of four and six with the mother while. The mother's chaotic lifestyle resulted in the child's early molest, in which mother literally gave her five-year-old daughter to a group

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of adult men who shared the same house. The patient's first remembered incident of intercourse was the result of a high-school "date-rape." After two years of therapy, she recalled having oral and genital sex with her father when she was between 8-12 years of age. In her adult life, she was sexually promiscuous, had many unstable relationships, drank excessively, and cut herself with a razor. She usually felt anxious and dissatisfied. It is interesting that many of her friends pierced themselves in the nose and nipples and would "carve" the logo of heavy metal music bands into their skin. Miss B was referred to me after previously having seen two female therapists. When she mentioned that she "cuts and drinks," they immediately referred her out as a "dangerous alcoholic in need of more professional help." The fact that B felt rejected and misunderstood by these two women was helpful to explore, given her feelings of being misunderstood and abandoned by her mother. Also, the idea that she had been handed over to a man by a mother figure was interesting to consider. The first two to three months of treatment consisted of mostly clarification and confrontation. In the transference, she felt I was unsupportive, a potential sexual threat, and a judgmental parent figure. At the end of the third month, B was attending Alcoholics Anonymous and building a new set of friends. Without the blur of alcohol and drugs, her interpersonal problems could be better examined and the transference was easier to explore. The changes in the treatment and in the patient-analyst relationship created by suggesting she go to AA had to be examined many times over. This was similar to how my manipulation of the transference with A had to be discussed and analyzed repeatedly. B would relapse into drug and alcohol abuse or self mutilation. When she discussed a relapse of blackout drinking, she told me ''how exciting'' it was to not know how she made it home from a distant bar. I proposed an idea that arose from the seductive and provocative way she had told the story, which fueled a seductive and provocative part of me. It was a projective identification mechanism operating between us. Based on what I knew of her history, I asked: ''did you have to perform oral sex again, in exchange for a ride?" She replied, "Well, that is something I have done many times before," as fear and sadness flashed across her face. She began to cry. I said, "I guess another word for 'excitement' is terror. You learned from your mother to do whatever you had to in order to survive. She exposed you to very harsh circumstances with which you had to struggle. Today you remain loyal to her in your mind by providing the same type of vicious situations for yourself." We also explored the way in which I had made a scary and invasive comment, recreating her early object relationship experiences.

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During the course of therapy, B worked through some of her internalized trauma and shifted the way she related interpersonally. She elected to end treatment after almost four years. At that point, she no longer cut herself nor drank. She was much more aware of how she reacted to internal stimuli and felt more at peace with herself and others.

CASE #3
Miss C was a middle-aged woman with a history of cutting and burning herself as well as poly-drug abuse. She commented one day that she had recently cut herself with a razor, in order to deal with the threat of internal anxieties. "I started to cut myself when I felt like my life was going nowhere fast," she said. We had already discussed the practical dangers of infection, scars, and accidental artery or vein damage. Unconsciously enacting a seducer/slut way of relating, I asked her where she had cut herself. She stood up and raised her blouse up to her breasts, showing a few minor cuts on her chest. At the same moment, she unzipped her jeans to show me another cut by her groin. We spent the rest of the session discussing boundaries and the implications for such provocative actions. I asked her thoughts on how I had invited such behavior and how she then complied, leading to a repetition of certain childhood experiences. She associated to her difficulty in following her ''gut reaction'' to interpersonal situations and to her feeling used by men and then blaming herself. She discussed a ''void of loneliness'', relating it to different events and emotional climates in childhood. I interpreted that she probably felt lonely with me when I didn't appear to be aware of her need for privacy or personal boundaries. We also explored why she chose to cut herself close to her sexual organs. I often find myself drawn into various replications and personifications of internal phantasies with these patients. It usually becomes clear at some point in the analysis that I was participating in a mutual projective identification mechanism. Investigating the details of that mechanism, in both its interpersonal and intrapsychic detail, helps in understanding the patient's phantasies. From an economic view, Novotny (1972) states, ''it {the symptom of selfmutilation} persists because it requires the least amount of energy necessary to cope with conflicting impulses. The clinical data seems to indicate that the symptom brings about a certain degree of reconstitution of ego functions, in this way making possible, at least temporarily, a better adaptation to the environment'' (page 511-12).

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The management of affect is part of the economic motivation behind "slashing." In a very controlled and predictable fashion, pain is produced. Since affective experience for these patients has generally been chaotic, externalized, and prosecutory, the idea of self-generated affect is quite novel. It is a step toward self-creation, a building of identity. This is a sad and paradoxical situation for the patient because this is affect that is physiologically based and regressive. The more pain produced, the more pseudo identity is formed. It is a false self based in masochistic isolation and externalization. C remarked, "It gives me pain and that is better than no feelings at all." She was defending herself from intense feelings of abandonment and disintegration. In 1991, Shapiro wrote: ''self-destructive behavior can be an attempt to reverse self fragmentation or breakdown secondary to feeling overwhelmed by unbearable affect. Therapeutic attention to blocks in the development of affect integration may help individuals process painful feeling states more efficiently, thus dealing with tension states more constructively'' (pg. 370) C told me that she initially started to cut herself as a ''fun experiment''. I interpreted this as the novelty of experiencing emotion and the novelty of finally feeling in control of her internal and external environment. For her, it would be a chance to experience an affect other than depression or anxiety and on her own terms. C was committed to the role of slave. She often felt and acted like a victim, at the mercy of others. There was little sense of self-ownership. She agreed to this idea and said, ''yes, it's true, except that I feel the pain when I cut and it is my pain." I interpreted this to be a primitive reintegration of very split-off fragments of herself that she felt had been stolen or lost. Self-mutilation is a repetitive masochistic state that is paradoxically counterrelational. Much of the self-harm is a last ditch effort to ward off terrifying phantasies of losing the object or a desperate attempt to restore or repair an impaired internal object. However, the actual results are frequently contrary. Miss C was fascinated by the blood that dripped from her small and delicate wounds. She entered a trance state of suffering and wonderment that involved temporary loss of reality testing. This powerful self-hypnotic state can serve as a resistance or impasse unless explored and interpreted. It became an autistic retreat that made her inaccessible to my care or connection. She was able to only mildly explore the displacement of her transference wish for union and warmth with me onto the external relationship with blood. Therefore, even though it was a primitive attempt to be with me, the internal mechanism she used barred me from helping her. Certainly, this patient might have been more accessible to a better trained analyst or an analyst who created a different sort of analyst/patient match. We work with what we have.

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Self injury is also a defense against feeling out of control. The act of cutting provides very focused control over otherwise frightening feelings of abandonment or merger. It can "cut off" frightening affective experiences. At the very least, it helps to distract the patient from other painful feelings in the moment. Miss C would often return to burning herself after she felt rejected in dating men or by me in the transference. After two years, C's self-harming ceased. The exploration of its meaning continued. Setting of limits in and out of treatment was critical. However, a non wavering focus on her internal dynamics and on and the transference meaning of her behavior was pivotal. After three years, C ceased to drink or use drugs, stopped burning and cutting, and no longer sexually acted out. In fact, she applied to a university and began a stable and committed relationship to a young man her own age.

CASE #4
Miss D, a psychotic woman in her twenties, had scratched and clawed at her body from the ages of nine to fifteen. She felt this was her expression of rage at her mother and father ''turned inwards''. In her later teen years, she would stop taking her antidepressant medication in the wish to hurt herself and ''show them''. Early in her now ten-year treatment with me, I hospitalized her for a suicide attempt in which she slashed her wrists. D was raised in a home where her mother was a long-suffering martyr who seemed to delight in her power as a ''unrecognized saint''. D's father, a violent alcoholic, had left the family when D was three years old. Soon after, her mother married a man who was mean, provocative, and controlling. While he established a highly sexualized relationship with D, he made it clear that she should act proper with all other men and be mindful to protect herself from their ''lecherous ways''. After many years of full-scale denial of any feelings about me or about the therapy, D gradually began talking about her transference feelings. This would cause great anxiety and she would regress into obsessive rituals and paranoid ramblings. One way D organized herself was by reducing much of her internal life into a sharp division of ''warm and cuddly'' versus ''dirty and nasty'' or ''religious and pure'' versus ''slutty and mean''. In the transference, she wished for a pure love with me that would last forever, but was terrified that I would leave her broken hearted. She also wished to be part of a sexy and provocative relationship with me

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but feared it would collapse into a mutual rape and a chaotic destruction of all that matters. As mentioned, she defended against acknowledgment of either state of mind as well as any other feelings our relationship. As a result, she appeared much younger than her age, like a naive adolescent who seemed to lack the capacity for any emotion, intellect, or common sense. The extreme splitting of both thoughts and feelings left her with no ability to negotiate conflict, until she felt pushed to extremes and then would feel forced to act it out. Although she wanted a raise at her job, she was unable to really have the wish for more money because it meant she was too ''greedy or dirty''. Therefore, she didn't tell her boss she needed and wanted a raise. Projecting her own infantile superego onto her boss, she began thinking he was refusing her a raise because she ''didn't deserve it''. She was so angry with him for this perceived withholding that she began to plot to kill him. Luckily, our talking about it and understanding these dynamics reversed the psychotic process and she ultimately asked for a raise. In a recent session, she told me she was going to have her tongue and nose pierced and was going to get a tattoo. This was particularly striking because of her innocent choir-girl persona. She explained that she felt no one understood she had other parts of her personality that were different then the ''good little girl'' image she usually maintained and everyone knew her by. She said she was sick of having to keep these other more ''direct'' parts of herself quiet and had decided to finally let everyone know ''who she really was'', even if it meant losing her job. Her job required a strict dress code. I told D that she was, of course, upset at feeling restricted to being the nice girl and now was going to rebel, but that she seemed to have wanted to come and talk it over with me first, because she hadn't done it yet. She agreed and said she wasn't' sure what I would think of her idea. I suggested this was a projection of her own ambivalence. She thought that was probably true and went on to say how ''fed up'' she was living a ''secret life''. I said she was probably tired of having so many feelings she would like to share with me, but also was tired of feeling she was dangerous, dirty, or too provocative. I suggested that since she felt unable to talk to me about her strong emotions about various matters due to feeling so ''ugly'' on the inside, she felt compelled to act out by making herself ugly on the outside. Finally, I proposed that the tattoo and piercing were a form of self harm that she was going to use to punish herself for all these ''outlawed'' feelings she had inside. I said that despite her fears, we could probably bear to talk of these things if we did it together. She then told me how she envied her coworkers for being ''brave'' and outspoken with how they felt. D wished she could break out of her self-imposed

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shell. She gradually noticed how she was going to use this counter-phobic self mutilation strategy to mask her intense wish to share herself fully with me and others. She feared that I would either use her vulnerability for my own ''evil needs'' or be so disgusted by her ''true identity'' that I would leave her forever. Although she never went through with the tattoo and the piercing, it is interesting to consider the compromise she made. She had planned to get a tattoo of a round, happy, smiling face. To her, this innocent symbol would have been the equivalent of getting a Hells Angels tattoo.

DISCUSSION
While self-injury and substance abuse are difficult symptoms for both analyst and patient to cope with, and relapses are frequent, the emphasis does not have to be on managing crisis. The initial ego support and therapeutic boundary setting in these difficult cases must be matched by psychoanalytic exploration. In working with these patients, I find that through mutual projective identification processes, the analyst and the patient are frequently resurrecting certain aspects of the patient's archaic phantasy life as defined by various self and object representations. Therefore, the continuous analysis of the transference and the countertransference is certainly essential. However, the additional willingness on the part of the analyst and the patient to explore the frequent and mutual interpersonal/intrapsychic acting out is paramount.

Chapter Five

THE SYMBOLIC OBJECT


This Chapter proposes that paranoid-schizoid patients (Klein, 1946) traverse a developmental bridge between the use of idealized objects and the depressive functions of true symbolization and whole object relating. This in-between, intrapsychic domain forms dynamic structures that I call symbolic objects. Psychoanalytic treatment requires a relationship in which matters that are usually left unsaid are spoken, clouded thoughts are deliberately clarified, and ordinarily dismissed affect signals are brought to bear as primary relational currency. The patient's personality, and the internal conflicts that color that personality, create a vast set of potential intra-psychic relationships (Kernberg 1976) which the analyst encounters within the transference. The analyst=s own complex internal object relations also are brought into each hour. The analytic pair, therefore, consists of converging dynamic worlds that are constantly evolving within themselves and within a dialectical matrix. Analyst and patient first encounter this morass when beginning a treatment and continue to experience it throughout the analysis. Introjection builds up an internal world that only partly reflects the external world. Projections of intrapsychic affect and phantasy color the perception of that external world. Trying to defend themselves, human beings try to impose their own inner world onto the external world and then reinternalize that world. Through projective identification, these projections are subsequently controlled, defended against, and reintrojected as a basic method of coping with uncertain psychic experiences with unknown entities. The ego achieves an elementary form of communication we now call projective identification. This creates a safer internal environment. Predatory and persecutory phantasies are traded about and defended against in this way. In essence, infants (and later adults) create their own

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world (Klein, 1975) and the external object is important in how it modifies the projection rather than as an object in itself. The shadow of the ego falls upon the object. (Grotstein 1982) Melanie Klein and W. R. Fairbairn are two influential figures in object relations thinking. While the literature has often polarized them, they are compatible in their analytic stance. Both have helped to form the now wellaccepted vision of an inner world of object relations and the related mechanisms of projection, introjection, splitting, and projective identification. Fairbairn discussed ''objects'' that are internal mental experiences with structure and dynamic properties. These objects are capable of acting as independent agencies within the mind (Fairbairn, 1944). This is remarkably similar to the Kleinian idea of phantasy. Fairbairn considered objects not merely static internal figures or mental representations, but agencies capable of psychological activity. His theory examined the interrelationship of parts of the ego to various internalized objects. Clinically, he noted how these intrapsychic relationships actively function and manifest themselves in relationships with external objects. Both Fairbairn and Klein placed primary emphasis on the internal world of object relationships, the resulting interactions of this "endopsychic situation," and the eventual encounter with the external environment. These fundamental ideas concerning internal and external reality help explain what takes place within the patient-analyst collaboration. Analyst and patient struggle to understand the difference between the external reality of the past or present and the internal reality of the past, present, and perceived future, as well as the correlation between the two. Psychological mindedness is not a given in the patient or analyst, but can be cultivated within the therapeutic relationship from the analysis of transference and countertransference. Counseling or supportive psychotherapy can be defined as the exploration of the external, fixed, and concrete view of the supposed objective world, with only an occasional venture into the exploration of the subjective experiences of each party. This would naturally mean a minimum of attention to the transference. J. Oremland (1991) states that supportive, or what he terms "interactive" psychotherapy is psychotherapy Awhose mode uses transference in directive, suggestive, and manipulative interventions, with modeling and selective transference interpretations, to produce changes largely according to the psychotherapist's evaluation.@ (pg.133) On the other hand, psychoanalytic psychotherapy and psychoanalysis are methods of understanding, organizing, and transforming the patient's internal,

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fluid, and subjective experiences. Psychoanalytic treatment only rarely includes these supposedly objective ventures into the concrete interpersonal world. The paradigms of Fairbairn and Klein compliment the Freudian concepts of drive and defense. While transference and countertransference are central to the treatment, Klein=s notion of phantasy is the collective, unconscious "ghost" that brings together these dynamics. It is only within the analysis of phantasy that patient and analyst find the underlying conflicts within the timeless, dynamic unconscious. Within the complex, multidetermined, and usually quite confusing nature of transference phantasies, analyst and patient constantly seek a deeper articulation of the specific spirit that moves through the analytic relationship. This involves coming to know the particular nature of the patient's self and object representations and how those dynamics interact with the self and object representations of the analyst. In the psychoanalytic situation, this is done through the examination of the transference, countertransference, and projective identification processes. Some patients show a violent resistance to the acknowledgment and acceptance of their own subjective world. They have anchored themselves into the external and concrete for attempted safety and control and they frantically use displacement or projection to organize their shaky internal experiences. Interactive counseling colludes with this defense. To analyze one's phantasies is a movement toward mastering developmentally mutated and often fixated aspects of internal self and object representations. For some patients this feels dangerous. As the result of early infantile experiences, the self can be experienced as a poisonous and painful place to be avoided and the object can be felt as the enemy. Manic defenses, splitting, and projective identification usually follow. The Nature of Working Through Structural change occurs within the realm of phantasy. The ego gradually masters the internal and external surprises, recollections, challenges, and varied intonations that life brings. Change is the transformation of ancient ghost-like phantasy relationships in the unconscious mind. As Karush (1967) states, (aspects of working through) Aare reorganization and assimilation of newly learned truths, altered balance among defenses, neutralizations of resistances, formation of new identifications, and reconstructions of the ego ideal.@ (pg. 377) For some patients, the assimilation of new truths is a particulairly frightening threat to the familiar phantasies they usually exist in. Morton Shane (1979) has examined the shift between interpretation, insight, and change as the arena of the working-through process and has identified four

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crucial steps: letting in and comprehending the new insight, trying out the new awareness to construct new abilities, experiencing of oneself differently because of the emerging capacities, and mourning and accepting the loss of old self and object representations. The analyst is always a participant~facilitator of the working through process. The analytic relationship forges a new entity that is at first the result of both parties, then becomes more then the sum of the two. The analyst allows for the possibility of personal insight, which he or she can then be transmitted to the patient. The analyst tries out new-found ways of perceiving the patient and the analytic relationship. As these new developments take place, the analyst must be able to experience him or her self within the emerging new relational context and consequently begin to mourn the loss of the way both parties formally related. Intra/interpsychic mental relationships include various states of desire, fear, conflict, and compromise that all occur within phantasy states. Affect, intrapsychic self and object relations bridge cognition and somatic sensation. Clinically, the investigation of how these overlapping experiences manifest within the transference bring on transformational analytic experiences. The analytic culture, consisting of the dialectic process between analyst and patient within interpersonal and intrapsychic planes, must be able to expand and contract while still containing and articulating these elements. Therefore, the working-through process evolves within, and emerges from, the transference. There is an intimate sharing which produces something new. There are many internal conflicts that the ego can=t resolve without help from another object. These are dyadic points of negotiation within the intrapsychic structures of one individual. Without the phantasy of the other, the mind becomes brittle and fragments. There is always a need for the other and under certain circumstances such as the analytic situation, a new psychic construct is forged within that connection. Much of the time, relations between self and object representations are predominantly either defensive or offensive. However, during the periods when these internal relationships are quantitatively more or less non defensive and non offensive, an atmosphere is created that is conducive to the forming of an entirely new relational entity. A mutative moment takes place. Externally and interpersonally, we may call it ''a meeting of the minds'', ''having something in common'', a ''shared cause'', a ''friendship'', or ''love''. Analytically, it is the intrapsychic and interpersonal creation of a new element, within the orbit of two unconscious systems. Conflict can facilitate growth. However, the product of conflict is different then the culmination of a relatively harmonious intrapsychic bond.

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The idea that new psychic structure can be the result of relatively peaceful affective bonds is in contrast to Kernberg's idea (1987) that core self and object representations are created by extreme pain or pleasure. It is important to consider that while different types of intrapsychic experiences can produce similar phantasies, different types of intrapsychic experiences can produce equally significant yet different self and object representations. Reformulating Freud's Nirvana principle (Freud 1920) and the principle of constancy (Freud 1915) will be used to better view these ideas. Giovacchini (1987) states, ''other than proposing an innate tendency toward low levels of excitation, we can think of an inherent striving toward equilibrium'' (pg. 65). I believe we can see non-excitation as meaning the seeking out of the lowest level of unpleasure. It appears, therefore, that the striving for non-excitation or homeostasis is a striving toward a particular type of relational experience. This would be contrasted with the relational matrix that occurs during periods of tension or conflict. The principle of constancy and the nirvana principle can also be understood as an expression of the stress between the urge to individuate and the urge to return to an idealistic union with the primary object. This symbiotic state is always being sought out, while simultaneously the subject strives for increased autonomy and differentiation. The desire for symbiosis establishes an altogether different medium in which new psychic structure can emerge. The unique, complementary relationship between drives, internal object relations, and the interpersonal expression of drive derivatives produces a matrix from which a particular way of being with the other will unfold. This way of being will either tend to create and foster or negate and destroy the potential creative space that could occur between subject and object.

THE SYMBOLIC OBJECT


I think there is a type of intrapsychic and interpersonal climate found in the analytic relationship that often is not thought or spoken of, let alone addressed. There is a ''place'' where the analyst and patient meet and interact. The workingthrough process within each interpretation, each analytic hour, and each psychoanalytic treatment can be seen as the co-creation of new psychic structure shaped by the orbit of the two participants. To understand how the analytic relationship fosters structural change, we must understand how that relationship comes about, its properties, and the ways those properties function. Interpretation can be a powerful instrument to study these unknowns. The process of interpretation is not simply knowledge that is

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created through the uncovering of what was there all along. Interpretation also can be the kindling for an evolution of a shared reality where new psychic structure is formed and both parties are affected. Kubie (1955) seemed to point in these directions when he asked:
What are these situations in which effective interpretative communication can be nonverbal? What are the situations in which effective interpretations can be approximate and general? What are the situations in which effective communication depends upon the unique and precise word? (Page 298)

During an ''on-line'' panel discussion (1996), O. Renik stated a similar thought:


It seems to me that what makes successful analysis is not the 'correctness' of an analyst's interpretations, but the analyst's willingness to engage the patient in connection with what the analyst perceives to be the patient's crucial struggles.

In the same panel discussion, E. Wolfe (1966) stated:


Perhaps both analyst and analysand stumble into corrective experiences on the basis of unconscious motivations. But the analyst's understanding retrospectively of how they stumbled into it can become a conscious guide to converting the stumble into a small piece of cure.

A. Furlong (1992) had his own thoughts on how the most fundamental aspects of a relationship can be understood:
Lacan (1953-4) viewed the ego as the place of the other, a precipitate of alienated identifications. In his conception, the psychoanalytic relationship is necessary of an inherently dialectical nature, reflecting the fact that it is only through the other that the ego can recognize itself in a distorted and reversed way. The Other always precedes and defines the subject. ---- The mother desires that the infant need her and confirms Aulagnier's argument that the offer of the other precedes the subject's demand. ---- The maternal offer, to be desired as a mother, exists before and give meaning to the infant's chaotic and unformulated demand. Thus the infant first introjects a trait which belongs to the maternal unconscious, i.e., a 'signifier' of her unconscious desire. This desire emanating from another is metabolized by the infant psyche as its own. ------ a logical residue both of the infant's biological dependency and of the inevitably dialectical interplay of unconscious identifications. (Page 708)

To complement these ways of viewing the ''something'' that goes on in the intimacy of the analytic relationship and in the mother/infant dyad, I wish to introduce the term ''symbolic object''. In many analytic relationships, there are moments in which both patient and analyst experience a sudden outgrowth of something new between them and within themselves. This paper attempts to understand some vicissitudes of that new and shared creation. It is an attempt to explicate the working through process as it happens moment-to-moment.

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The symbolic object is a dialectic that is developmentally grounded in the earliest relationship between infant and mother. It is the creation of a mental space or surface by one or both of a dyad, from which there can be a shared organizing and defining of somatic and psychic experiences. While phantasy is fostered and creatively enriched, the reality principle is equally promoted. The nature of the symbolic object is that of a seed which, when provided with the sufficient surroundings, can lead to psychic individuation. It is the birth and maintenance of a balanced, relational, yet separate set of psychological structures. While the process of projective identification produces the symbolic object, it is not so much a defensive posture or attacking maneuver. The symbiotic object is, therefore, a product of the nirvana aspects of projective identification processes. This is a stage of ego development that is certainly shaped by the earliest prey/predator phantasies encoded in all of us, but is primarily made up of the relational space and tension between these two phantasy states. Bion (1957) and Rosenfeld (1983) have already explored some of this territory in their writings about the communicative aspects of projective identification. These concepts are in some ways close to those discussed by other authors. I hope to expand on their ideas. O'Shaughnessy (1983) has spoken of the ''interaction of patient and analyst at an intrapsychic level'' (page 281) and Green (1975) has written about the ''analytic object''. Thomas Ogden (1992) has written of the ''analytic third'' and spoken of ''the nature of the interplay of subjectivity and intersubjectivity in the analytic setting'' (page 62). He says this ''analytic third'' is a product of a unique dialectic generated by/between the separate subjectivities of analyst and analysand within the analytic setting'' (page 64). He goes on to state:
the analytic process reflects the interplay of three subjectivities: the subjectivity of the analyst, of the analysand, and of the analytic third. The analytic third is the creation of the analyst and the analysand, and at the same time the analyst and the analysand are created by the analytic third. (page 93)

The symbolic object is a developmental situation that comes alive or dies within the analytic situation, just as it first came alive or died between the mother and the infant. Most important, it is a developmental situation that thrives or perishes within the intrapsychic world of object relationships. A particular distinction, or different emphasis, between the symbolic object and the analytic third is the nature of the internal environment in which it comes forth. Specifically, the symbolic object is the result of the nirvana aspects of projective identification, a state that momentarily holds a ''truce'' between the more intense libidinal and aggressive urges of both subject and object. I define this as the lowest level of conflict and tension within the intrapsychic self~object exchange.

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It is the point of balance between the predatory/prey and love/hate forces where there is a moment of peace, followed by an intrapsychic union and a complimentary tracking of somatic and psychological states. Therefore, the difference between the symbolic object and the analytic third is more quantitative than qualitative. The new term seems justified as a way to discuss the importance of the intrapsychic truce between affect and phantasy states, creating a near conflict-free relational atmosphere. Also, projective identification is the core dynamic underlying the symbolic object. This is not always the case with the analytic third. Developmentally, projective identification is the original and primary state from which the infant experiences and defines the world. The infant begins life in various neurological states of flux, psychological and physical tensions, somatic and cognitive stimulations, and complex interfaces with environmental experiences. From the very start the infantile organism seeks out the object and the phantasy of the object to cause a subjective sense of understanding as well as discharge of drive states. At first this is in more primitive ways and later with more sophisticated expression and intent. These states of mental and bodily need are innate and if chronically unmet grow to unbearable proportions. The extreme of this would be the death of the organism as reported by R. Spitz in his investigation of marasmus (1965). The internal needs of the self, if unmatched, begin to shift into internal anxiety states that in turn develop into crippling, fragmentation experiences that begin to destroy the organism. This broadens Freud's idea of the death instinct (Freud 1920). Projective identification consists of an intrapsychic phantasy, brought to bear upon the internal object representation and the external object. An interpersonal situation is fostered that breathes life into the phantasy. This intrapsychic and interpersonal relationship is cultivated within a state of blurred self and other representations, yet the normal outgrowth is a healthy differentiation and individuation of the self and the object within the mind's representational field. While the symbolic object includes drive states, persecutory fears, predatory urges, and other object related conflicts, it is primarily a shared mental space founded in moments between such conflicts. This fosters more creative then defensive autonomous mental functions. The symbolic object signifies the most fundamental aspects of the mind's attempt to relationally organize and structure external and internal experiences outside the realm of fight or flight phantasies. The infant's primary method of communication is projective identification and it is the main vehicle for mastering inherent struggles toward homeostasis. It operates as a rich method of relating, designed to maintain a general cohesion of the organism. The symbolic object is a product of ''nirvana moments'' within these

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dynamics. Projective identification communicates the infantile needs, be they annihilation anxiety or simple nutritional urges. This is both an intra-psychic maneuver and an interpersonal contact. Spoken language is unavailable so, along with physical activities such as gesturing, excreting, and mouthing, an unconscious, pre-wired language is put to use. While development brings additional internal and interpersonal coping mechanisms, projective identification continues to be a primary communication effort throughout the life cycle. Maturity fosters other psychic methods of relating, which makes for a richer rather than fragile or narrow flavor to the projective identification endeavor. Projective identification, nevertheless, remains at the forefront of all normal as well as pathological unconscious relational efforts throughout the life cycle. The nirvana aspects of projective identification and the creation of symbolic objects can stall or fail entirely, leading to autistic and psychotic disturbances. In the psychoanalytic endeavor, there is a continuous establishing or re-establishing of symbolic objects. Simultaneously, the symbolic object is the sum of all intrapsychic and interpersonal phenomenons that occur on a shared surface and an outgrowth of a new entity from both parties. Naturally, the transference becomes a vehicle for the patient=s struggles with the symbolic object. While projective identification is the most basic of pre-wired coping methods with which the infant communicates, the psychic ability to use this tool in infancy is fragile. Evolution has prepared the infant both to send and receive internal and interpersonal messages. However, the organizing, linking, and detoxifying functions of a receiver are psychological abilities that develop over time. The infant is stressed beyond psychological and neurological capacities if taxed, especially in a chronic and aggressive manner, to be the primary receiver and translator of projective identification messages. I believe the infant is designed through evolution to be primarily a sender rather then a receiver in the beginning of life and if this balance is offset, a severe psychological conflict and mental catastrophe can result. The sheer pressure and force of the parental need to use the infant for gratification can thwart the infant=s normal projective efforts. The infant's developing ego cannot take in and process the object=s excessive projective identification. It creates a structural disintegration. Eventually, the infant feels forced to retaliate and send back both its own rage as well as the parents= unprocessed affect. The child or patient then has the phantasy of causing a poisonous situation within the mother or analyst's mind. To ward off the terror of being responsible for causing such damage, the ego establishes narcissistic defensive structures. This is an illusion of power and omnipotence as a defense against the horror of hurting the source of love and life. In this context, there is

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also an acute denial of the enraged and offended parts of the self that want to destroy the object for causing so much pain. These feelings must be quieted for the sake of self-survival and produce the beginning emergence of a hidden grandiose self-representation. The nirvana component of projective identification is an innate, speciesspecific potential. While susceptible to defensive or aggressive conflicts, it for the most part serves as a more creative non-combative bonding. The libidinal and aggressive urges are still present, yet the conflictual aspects of these drives are economically at rest. External somatic manifestations of this are periods of satiation in the baby after feeding, or periods of contentment before and after sleep. This idealized state of union with the object and the pleasurable feelings of continuity and integration create the symbolic object. This is an ideal object full of knowledge and magical powers. This power, when internalized, becomes the creative ability to transform conflict into symbolic solution. The analytic relationship is always defined, enhanced, or limited by the nature of the projective identification situation. Whether or not the projective identification mechanisms are being interpreted forms the extent of what is analytic. How the analyst interprets these processes leads to an expansion or destruction of the symbolic potential.

PART TWO
Interpretation is a process based on the systematic gathering of data from the patient's associations. However, at times it is an intuitive leap, based on a prior affective history within the transference and countertransference. Insight can be an outgrowth of something new in the patient's mind or something that emerges independently in the analyst's mind. Insight also can be a collaborative effort on an unconscious level. Even when insight emerges predominantly from one person in the pair, dyadic phenomenon still shapes it. These are intrapsychic exchanges between self and object representations that leak out into the interpersonal realm. Thus, it is a mutual enterprise, though at times a more passive experience for one party than for the other. With lower functioning patients, the symbolic object often will first come forth through the analyst and later become a shared mental space. This is the result of projective identification mechanisms. The patient projects the symbolic object into the analyst and then relates in particular ways. As an example, Mr. W was a chaotic and reclusive borderline patient. He felt extremely ambivalent about our relationship and wasn=t sure how to feel comfortable with me. As was typical,

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W was silent for thirty minutes and then began to talk in a halting and anxious manner. ''Just speaking to you is difficult. I feel like I am getting really dependant on you and to talk to you means I am becoming more dependent and helpless. I love having you here with me but it blocks my independence and it keeps me addicted to you. I need you and crave you and feel so dependant on you. I feel so terrible all the time. I can't seem to even get out of bed most of the time. These feelings are crippling. I try to desperately look for something positive in life but the darkness haunts me and the bad feelings follow me like leaches or vultures hunting me down. I can't get rid of them, they are always there and never go away. This crap goes on and on and on, just like me. I drone on and on and on. I'm sorry. I want to keep talking with you and come to see you more often. At the same time, I can't stand to be here and hate the fact that I need you or therapy at all. I am sorry to bother you with all this crap, I really appreciate that you listen. Maybe I could come in more often.'' I began interpreting the intense splitting. I am the longed-for nutrition he craves to bathe in, yet I turn into the dominating leach-like monster that will never let him think for himself. As the hour continued, I noticed myself feeling bogged down and even bored by my interpretation. It slowly occurred to me that I was feeling discouraged in the same way he was describing himself. A new thought came. He was keeping these split-off parts of himself separate because if he didn't, he would drain me, dominate me, and harm me. While this was certainly not the first time I presented these ideas to him, it felt new, fresh, and alive. When I related these ideas, he too seemed to come alive in a frightened, yet interested way. We began to move together in a way that felt different and the material began to have a more integrated and cohesive tone. It was the beginning of a symbolic object. He felt he might hurt his idealized object by wanting too much and being destructive. This was the beginning of a struggle with depressive anxieties that his paranoid-schizoid fears usually hid. Now, he was more able to consider the plight of his object. This was the result of a non-combative form of projective identification. At this point, the largest part of the interpretive task had to be carried by the analyst. With the more regressed patient, there is usually more time spent with the analyst being the vehicle for the symbolic object before mutuality takes hold. This is the result of the developmental and evolutionary vicissitudes of projective identification. In the early stages of the dyadic relationship, the mother/analyst must be the chief organizer and translator of the projective identification mechanisms. The infant gradually takes over that role more and more until it is a reciprocal process.

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CASE OF MR. V
The following are notes from an analytic hour with Mr. V. During the end of the hour, the patient interpreted the sadism that brought havoc into our relationship. Mr. V created a symbolic object in which we shared our experience. This is particularly striking given that he is a person who has always felt the world owes him and therefore he is reluctant to share any part of himself with me. V: Laying on this couch makes me think of how I want to get an Easy Boy recliner for my living room. I've been thinking about your comment last time, about how I tend to see things as either really good or really bad, kind of polarized. I was looking for a cheap tailor to alter my suit. I always try and find a good deal. I thought I had found the cheapest tailor around and I got my suit done but now I'm not pleased with it at all. It fits so badly that I had a hard time getting the jacket on and the pants are way too big. I have looked for years for the perfect tailor who will do exactly what I want for what I want to pay. Yesterday I got really down on myself for trying to save money and having it backfire so bad. I felt very depressed. I don't know what to do. If I value the way I look, maybe I should be willing to pay for it.
Analyst: The way you search out a bargain seems curious. V: Yes, that's it. I end up paying twice as much in the end because I have to have it redone. I am very anxious about how I look so I want a nice fitting suit but it backfires. Analyst: The way you bargain hunt seems like a way to control people, but you then end up feeling controlled yourself. V: Maybe, although sometimes I am able to find really great deals. (He tells me a story of several ''great bargains' he has found in the past.) I would have paid twice that if I had bought it at the regular store! Analyst: I think you feel a bitter anger behind all this bargain hunting. V: Well, its payback time goddamn it! Analyst: Yet then you feel re-injured when it backfires; maybe that's connected. V: My mother was exactly like that. She always felt cheated and poor. It's all overblown. As I'm talking, I am feeling myself deflate. I felt this way yesterday about my suit and the cost and how dissatisfied I was. I felt so anxious, unfocused, and deflated. Analyst: When payback time doesn't work you collapse? V: I think I realized how little it takes to make me feel such turmoil, totally fragmented. My moods shift quickly and unpredictably, I am starting to see that. I feel really sad. At work the other day I was noticing that Joe has an office with a nice sunny window and I started to think about how I am stuck in my little office with no window. I thought to myself, ''shit, shit, shit''.

The Symbolic Object


Analyst: You felt ripped off. V: Yes, and I feel like I put myself in those positions somehow like I did with my suit. Analyst: Maybe you are really angry and hungry to get what you think you deserve, but then you feel very uncomfortable if you get it. So you put yourself down. V: I can see that. When I went on vacation last year, I thought I had found the best deal on a hotel in the entire state. It ended up having those cockroaches in it. So it ended up not such a great deal after all. Analyst: Perhaps you get blinded by your hungry anger. V: I think I come from this place where I feel I can't ever afford regular things so I have to get the special deals, but then it all becomes a hassle. Maybe I just need to go to a regular tailor. Analyst: You started out telling me about your angry payback time but now you switched to the idea that you just need to go to a regular tailor. V: I feel very out of sorts. When I felt this way in my marriage, my wife would try and comfort me or suggest things. I think something is happening here where I am saying ''help me'' and then you can't. That's the game I am playing. A perverse pleasure in frustrating your efforts to help me. I have done it with many people I feel close to. I set you up. Analyst: After you get your payback, your left with a bad suit and no connection with me. V: Yes. I get rejected by my behavior. I never used to understand that before. (Crying) I don't like it. I don't want to do this. Analyst: The perverse pleasure is mixed together with misery and loneliness. V: I feel shitty and want to take it out on those I am close to, or try to. But it only makes it worse. Analyst: Yesterday you felt so disappointed and angry with yourself so today you try and dump that onto me. But that makes you feel even worse and more alone because you think I will hate you for it. V: Well, it worked in the past. There is an odd sadomasochistic flavor to the whole thing and I think I am very envious and jealous. I know I was very envious of my wife and I know I am with my friends and coworkers. I envy you too. I have lots of rage and anger and that is a way it comes out. Analyst: You try and deal with those envious feelings by playing a cat and mouse game with me? V: Yes. I wouldn't have put it that way, but yes. I think part of it is that I feel others get so much more in life than I do. If my tailor is charging me more per hour than what I am getting paid, I find that intolerable. I think this is a part of me that has been around for a very long time. I take my anger out on others. Analyst: Perhaps the low fee you pay me is a way to be angry and get payback too. (I see him four times a week on the couch, for a low fee)

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V: Yes, I know that is true. Yet with you it is also conflicted. This is hard to look at, I feel so embarrassed (crying), more than embarrassed, so terrible (sobbing) Analyst: Ashamed? V: (crying heavily) Yes! Analyst: Perhaps the conflict is over how much you care about our relationship and still have all these feelings of rage and envy. V: (crying) Yes. I am hoping our time is up. I can't take much more of it. I feel so terrible. When I see you, I find all these parts of myself that I have been trying to hide for my whole life, parts of me that I am so ashamed of. Mr. V was able to create a symbolic object by revealing that he was playing a sadistic game with me in which he wanted to frustrate my efforts at helping him. This led to a different type of feeling in our relationship during the hour and he began to produce material that was new and exploratory. He brought me into a new level of his thinking that neither of us had been able to access before. This seemed only possible when he felt a truce in his internal relationships. In the calm, he could see us in a new light, and begin to imagine new possibilities for himself.

Case of Mr. XMr. X, a psychotic patient I had worked with for several years, was often scared of being killed by snipers. Feeling we were getting close triggered these states of persecutory panic. Throughout X=s treatment, there were many moments where a symbolic object emerged in the transference. During one hour, something happened which produced the spontaneous emergence of a symbolic object within the transference matrix. We were discussing how he felt angry about me wanting a relationship with him and how he also felt he couldn't survive without me. At that moment, a nearby car backfired. He ducked down and I blurted out, ''they missed!'' He said, ''yeah, they did'' and we both laughed with relief. Through the process of projective identification, he had infused me with the fears and phantasies about a gunman. When the car backfired, we had a moment of symbolic attunement, a shift to a non-conflictual form of projective identification, that created a symbolic object. This was a mutual achievement of something new that solidified our trust, as well as our efforts to work through these terrifying persecutory phantasies.

CASE OF MRS. H
During this analysis, there were times where we created a symbolic object. These were always significant crossroads in the working-through process. Mrs. H was a woman who had been the only girl raised in a foster home with five other

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boys. She had a very close relationship with the foster father, but felt the foster mother hated her and was always very mean. During the course of her treatment, we both noticed that we engaged in ''locker-room@ banter. We called it this because we would begin chatting in a very crude, erotic, and ''chummy'' way. Again, this was a spontaneous and equally shared interpretation of the transference/countertransference. From this mutually formed symbolic object, she went on to explore memories of fond yet fearful ''locker-room@ relationships with the boys and her foster father. She also noticed the duplication in the transference of her identification with these important male figures. The excitement, closeness, and fearful tension of those relationships had been reproduced in our relationship. The mean mother aspect of her internal world also came alive in that she felt I was ''forcing her into scary sexual talk''. The breakthrough of shared insight into our relationship was the common symbolic object. Some readers may feel that my case examples are of so-called enactments. First of all, it seems to me that every treatment consists of countless enactments occurring at many levels. The symbolic object is an intrapsychic phenomenon that produces a specific interpersonal climate. Hopefully, both patient and analyst are able to discover and understand that climate as well as its origins. This climate stimulates the awareness and subsequent interpretation of the enactments.

SUMMARY
The term symbolic object has been introduced as a way to understand the moments between analyst and patient where something new and dynamic emerges within and from the matrix of the dyadic relationship. The intrapsychic tension between self and object representations is in a relatively non-conflicted state during this process. Reformulating the Nirvana principal and the principle of constancy as ways in which the organism economically strives for the most organized and homoeostatic state possible, the infant and adult can be seen to search for the position of lowest unpleasure possible. This is the optimum balance between the libidinal and aggressive forces in the self and object representational field. These moments of truce between often highly conflicted phantasies usher in a method of intrapsychic communication within the nirvana moments of projective identification. This is a particular dyadic atmosphere from which both parties, within the projective~introjective world, can begin to co-create and mutually uncover the various amalgams of unconscious phantasies that shape the transference relationship.

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The symbolic object is a product of the dyadic relationship, yet is greater then the sum of the two. This outgrowth of something so fresh to the dyadic orbit is a mutative moment that propels the relationship into a different direction. A pairing of minds produces a novel and mutual understanding. Both parties share this symbolic object and each is shaped by it.

Chapter Six

PARANOID-SCHIZOID ANXIETY, TRIANGULATION, AND OEDIPAL TRAUMA


Certain patients, more than others, are theoretically challenging and therapeutically difficult. Their transferences seem to be centered around Oedipal dynamics, but careful examination reveals a pre-oedipal profile prone to primitive triadic conflicts. Oral and anal struggles predominate within an apparently Oedipal organization. I believe these patients are exhibiting a trauma-induced regression to an early state of paranoid-schizoid (Klein 1946) triangulation. This more undifferentiated state, in turn, has usually been the sight of prior overstimulation, deprivation, or attack from the internal and external environment. Melanie Klein (1952) brought attention to the infant's emerging triadic phantasies when she said,
... early stages (of the oedipus complex) are characterized by the important role which part-objects still play in the infant= mind while the relation to complete objects is being established.... Powerful oral desires , increased by the frustration experienced in relation to the mother, are transfered from the mother=s breast to the father=s penis. (Pg. 78)

Klein goes on to quote Abraham who points out how the penis is regularly equated to the breast and that other body parts can stand for those two organs in the infant=s mind. These could be a finger, hair, urine, mouth, and so forth. I am proposing that within the paranoid-schizoid position, the infant builds precursors to paternal body parts by establishing crude triadic relationships between internal and external experiences and the subsequent phantasies about those experiences. The infants early experiences with paranoid-schizoid and depressive (Klein 1935) anxieties bring on fears of and concerns for the object. This object is at first

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quite undifferentiated from the ego and is in parts, blurred and divided up by the mechanisms of splitting, projection, and introjection. Klein (1958) writes,
The young infant would be in danger of being flooded by his self-destructive impulses if the mechanism of projection could not operate. It is partly in order to perform this function that the ego is called into action at birth by the life instinct. The primal process of projection is the means of deflecting the death instinct outwards. Projection also imbues the first object with libido. The other primal process is introjection, again largely in the service of the life instinct; it combats the death instinct because it leads to the ego taking in something life-giving(first of all food) and thus binding the death instinct working within. (Pg. 85)

Through introjection, the infant becomes more and more aware of ''other then self'' phenomenon. Some of these are simply external events that create a primitive marker between self and object. Internally, however, there are numerous somatic and psychic stimulations, phantasies, and conflicts that bring about a sense of individuation from the object and an impression of a somthing other than self. This ''other'' is the element which naturally comes into play as the result of the frustration or gratification of libidinal and aggressive urges within the only vaguely differentiated dyad. The interaction of two part or whole objects is experienced as a semi-differentiated third element in the mental landscape. To the early ego, there is Ame@, there is Ayou@, and there is Aus@. Simultaneously, reliance on projective identification maintains a cloudy state of con-fusion within a symbiotic union of ego and part objects. Situations during the first months and years of life start to be organized into triangulated systems. Groupings such as self-milk-mouth, eye-bright light-pain, mouth-arm-thumb, nose-itch-finger, and mother's smell-mother-self come together as mental triads that emerge within the domain of more symbiotic perception. These are primitive triadic relationships organized by phantasies and shaped by the developmental characteristics of the paranoid-schizoid position. The difficulties, frustrations, and fears of this period lead to emerging triadic phantasies. This is in line with Klein=s (1928) statement,
Oedipus tendencies are released in consequence of the frustration which the child experiences at weaning, and that they make their appearance at the end of the first and the beginning of the second year of life; they receive reinforcement through the anal frustrations undergone during training in cleanliness. (Pg. 167)

Repetitious physical experiences such as hunger, the milk traversing through the mouth and down the throat and often back out the nose, ''goose bumps'', sweat, and teething are examples of somatic episodes that lead to a feeling of ''something other then self''. It is only through the development of cognitive functions, maturing of perceptual abilities, ongoing exposure to stimuli, and the intrapsychic/interpersonal ''translating function'' of the mother that the infant

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begins to understand them all as part of the self or part of the mother rather then disjointed, foreign entities. They begin to be assigned meaning. As the result of these somatic impressions, a primitive mental triangulation begins to develop within the psychic structure. The ''third'' component of the triad is often the affective response to the dyadic interaction. Later, the affect becomes a linking bridge between the self and object representations, but within the paranoidschizoid position it is experienced as a separate and non-integrated ''third party''. Only later in the depressive position, do these phantasies emerge in the form of whole object, internal oedipal relations. States of fusion and states of differentiation are in constant fluctuation during this period. Therefore, self-mother-environment is experienced as one and the same yet different and unique. For example, the infant can feel overwhelmed by the mother who feeds too much, too fast, and without a sense of the baby's actual needs. The desired food becomes a fearful burden because of the over gratifying mother. The mouth, the food, and the mother's hand therefore become triangulated in a painful battle. In these sorts of phantasies, there is a paranoid-schizoid triad that begins to have oedipal shading. A part of the self or object is felt to be a withholding, welcoming, or attacking third that either prevents or gratifies the desired access or union with another part of the self or mother. Laplanche and Pontalis (1973) note that
Freud remarks that even when the relation with the mother is dominate the father is still present as a 'troublesome rival'. Melanie Klein holds that the father intervenes very early on in the relationship with the mother, as shown notably by the phantasy of the father's penis being kept within the mother's body. (Pg. 329)

I am hypothesizing that an even earlier sense within the dyad emerges: if there is an ''us'', there must be a ''them''. This is the birth of triangulated phantasies. There are particular situations which bring on an increase of libidinal and aggressive investment in the ''third''. This then leads to gradual shifts from dyadic connections to more triadic forms of integration and relating. When the infant attempts to organize and fulfill their physical and psychological needs, he or she meets invariable frustrations. When attempted gratification leads to frustration, particular affects and phantasies emerge. If these frustrations are not excessive, they become precursors to the reality principal (Freud 1911) and precursors to full triangular intrapsychic relations. When the infant tries to reach out and grasp a toy, there is a sense of the hand being a ''part of me'' as well as a foreign object. If the hand is unable to grasp the toy, then the ''not a part of me'' hand is experienced as a frustrating and tantalizing object, the ''part of me'' hand as a powerless or undependable portion of the self, and the toy

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as a yearned for yet unavailable desire that the hand denies. The infant projects their love or hate desire onto the object and proceeds to try and interact with that desire. The struggle that ensues, and the positive or negative outcome, is perceived as a relationship between part objects which are in a hurtful or helpful relation to the self. Therefore, each dyadic endeavor naturally produces a ''third'' object which pushes the dyadic phantasy into a more triadic phantasy.Trauma experienced within paranoid-schizoid triadic precursors can create a psychic tilt toward con-fusion and conflict about self, the nature of the object, and the form of the ''third''. Conflict and deficit are dual outcomes of early trauma and have a synergistic relationship with one other. These early traumas create varying degrees of fixed intrapsychic phantasies and self/object representations that all influence future development. In particular, the oedipal phase will be weighted more toward regressive, symbiotic con-fusion. Therefore, the separation/individuation process of building a more autonomous ego structure, the establishment of whole objects, and the ability of the ego to make intrapsychic and interpersonal boundaries can be compromised. Oedipal trauma which corrupts the natural separation and individuation process will bring on a regression to this paranoid-schizoid triangulation period as well as a reappearance of the particular traumatic conflicts historically fixed within it. The paranoid-schizoid triadic process takes place within a mental arena where affect, somatic sensation, and phantasy define the infant's life. Therefore, the phantasy of ''the third'' is not so much that of an actual object but the manifestation of somatic experiences and libidinal or aggressive impulses that coalesce into phantasies of separate, ''not me'' entities that are located within either the mother or the self. My ideas about early triadic phantasy formations are fundamentally different from some other articles on pre-oedipal triangulation. Other authors, such as Rupprecht-Schampera (1995), Abelin (1971), or Sharpless (1990), focus on the importance of the actual father as facilitator of various psychological needs. I am exploring the creation of an internal third, a sort of precursor to the importance of an external figure other than mother. While cognitive perception of the physical father is of course possible at an early age, it is an interaction between external and internal. I am focusing on the significance of a triadic relationship that is shaped internally by internal factors. Later, external trauma can lead to mutations within the internal triadic groupings. These Anot-me@ part aspects of self, and at times part aspects of the mother, are encountered as foreign specters. Even the predictable sequence of wish-fearconflict is experienced as a triangulated battle between three separate yet fused ''bodies''. The self is associated with one aspect, the mother with another, and

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another part of self or mother with the third. Implicit in the third is the notion of competition, power, and control that is characterized by libidinal or aggressive charges. Klein (1958) writes,
The superego - being bound up with te good object and even striving for its preservation - comes close to the actual good mother who feeds the child and takes care of it; but since the superego is also under the influence of the death instinct, it partly becomes the representative of the mother who frustrates the child, and its prohibitions and accusations arouse anxiety. (Pg. 86)

The good mother aspect of the superego, the bad mother aspect of the superego, and the ego itself also form an early oedipal type triangulation, embodied by conflict, competition, and danger. Hanna Segal (1974) has provided better understanding of this primitive dawning of Oedipal dynamics. She states,
When the mother is perceived as a whole object, there is a change not only in the infant's relation to his mother, but also in his perception of the world. (Pg. 103)

The word ''when'' indicates the important distinction of not so much a totalistic moment where all is different from then on, but more of a shifting back in forth for a while, until the quantitative back and forth gives way to a qualitative move into a more integrated ego supported by, yet separate from, whole objects. Segal goes on to say,
the infant becomes aware of the important link that exists between his father and his mother. This sets the stage for the Oedipus complex. A splitting between mother and father may occur, one parent becoming ideal, while the other is felt as a persecutor. This last form of splitting may closely resemble a genital, oedipal situation, except for the extreme idealization of the desired parent and extreme hatred and persecution experienced in relation to the rival parent. The very early stage of the Oedipus complex - is characterized by the acuteness of the ambivalence, the predominance of oral trends and the uncertain choice of the sexual object.

In regards to a part-object world of paranoid-schizoid triangulation, she states,


To both boy and girl infant the first object of desire is the mother's breast, and the father is perceived to begin with as a rival. But, in view of the persecutory and depressive anxieties experienced by the child in relation to the mother and her breast, the father's penis quickly becomes both to the little girl and the little boy an alternative object of oral desire to be turned to away from the breast. (Pg. 103)

I would add that the persecutory anxiety felt with the breast can be projected into the penis, turning the breast into a safe haven to run to for shelter. This is a way to magically repair the breast and infuse it with the love the infant so

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desperately needs. Both situations, the bad breast/good penis and the good breast/bad penis, will be illustrated in the case of AR@. Case MaterialR was a woman in her late twenties who came for help with anxiety and agoraphobia. She was a paranoid schizophrenic who dressed out of the norm and had a peculiar accent and mannerism of speech. These slightly ajar ways of being with me were not a result of any cultural influence but represented externalized parts of her ajar internal world. She was very anxious and needed to make sure she was protected at all times from phantasized physical ills and other catastrophic terrors. My experience was of being with a person from a different land, with both of us awkwardly trying to find a way of relating with each other. R appeared to have undergone internal and external trauma within the paranoid-schizoid position, leading to a build-up of pathological precursors to the Oedipal juncture. Later, when she participated in both acute and chronic oedipal trauma, she regressed to this prior level of de-differentiation and to con-fused states of internal mother, father, and self representations, all organized within a paranoid-schizoid experience. From what R was able to reconstruct, her mother and father fought bitterly and exposed her to many primal scenes activities during the first five years of her life. At first, R tried to tell me this was a result of their ''artistic temperament'' and something she could be proud of. Gradually, she was able to explore the deeper feelings of anger and fear surrounding these conditions. R's father left the family when R was five years old. He moved away after R's mother underwent a psychotic breakdown. R continued to live with her mother until she left as a young adult to marry. R's mother had odd ideas about food and how it should be sparingly used. This led to my patient being diagnosed with malnutrition in her latent years and anorexia in her adolescent years. The mother was prone to physically and verbally abuse R as well as neglect her. Through the years the mother engaged in many sexualized behaviors with R that were masked as acts of parental care. When the father did visit, he would use the mother as a sexual object. R remembers her father coming by to ''visit'' every month or so, giving her mother money, and then dragging her mother into the bedroom to have ''loud sex''. R's mother told R to work in the local massage parlor as a receptionist so that she could help with the family finances. One of the prostitutes helped R leave that job when she was fifteen. In high-school, R took acting lessons and did quite well. This pursuit was quite suited to her hysterical style. As an adult, she never worked at any job, part time or full-time. During the course of treatment, she began to volunteer as a helper to a disabled elderly woman, but often felt persecuted by her and thought that she ''may have been a Nazi SS officer who escaped Germany''. R was married

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for ten years to a caring and helpful man. Most of the time, he has been able to contain her frequent bouts of panic, agoraphobia, delusion, and depression. When she began to see me, her daily routine had been established for years. She woke up at 10:00 a.m. If she could not have an immediate bowel movement, she became terrified about her physical health and would lie on the bathroom floor for hours. She told me that the coolness of the floor tiles provided her some sense of security, prevented her mind from ''scattering'', and helped her fight the thoughts about the ''poison'' inside her. R was fearful of going out of the house or socializing for any reason. Many of her worries were of being attacked, raped, and cut up into little pieces. Our relationship was two fold. On one hand she was sterile and aloft. She treated me as a professional from whom she purchasing services. On the other hand, she was quite seductive and had intense and excited worries that we would somehow become ''involved''. She was disturbed by thoughts of me sexually manipulating her and emotionally harming her. I interpreted this as a projection of sadistic and untrustworthy mother part-objects that were mixed together with conflicts and confusions about her feelings with her father. Over the first year of treatment, we contended with a transference that was based on the mother's psychotic and sexualized methods of parenting. R gradually worked through some of her feelings of hate for her mother and was able to come to somewhat of a compassionate understanding for her mother's mental illness. This became an identification. She had originally identified with many aspects of her mother's craziness. Now, by feeling compassion toward her mother she now also could see that she too had mental problems that could be compassionately understood. She also felt murderous rage toward her father and his neglect. What appeared to be an Oedipal conflict with fears of incestuous urges slowly unfolded to be a more undefined amalgam of paranoid-schizoid (pre-oedipal) and depressive (oedipal) struggles. The sexualized relationship with her mother, her oedipal phantasies, and her primal scene memories were mingled with other self/object representations in de-differentiated triadic units. The initial bad-mother transference defended against a more primitively fused father-mother-child internal family unit. Her inability to distinguish from mother or father or self was best highlighted in the transference. It was often unclear to her who was who. We at times were like a sketchy, unidentifiable mass. The hours would then seem totally scattered with both of us unsure of what we were trying to accomplish. The clearer thoughts and feelings about her mother who had been so abusive and invasive had defended her from the more terrifying experiences of being with a father and a mother who seemed, unpredictably, to turn into a predatory mother-father-self blur.

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In her childhood, she had focused on hating her mother as a way to avoid this terrifying and disorganizing triad. In the treatment, she tried to use the same defense. Gradually, we managed to move past that. Once she let go of this paranoid, hateful defense, she often would be confused as to who said what, who was the patient, who was the analyst, and who was in danger of what. It slowly became obvious to us that she was actively working through this undifferentiated father, mother, and self state of paranoid-schizoid triangulation in the transference and in the safety of her frequent dreams. We came to notice that the dreams, as well as certain interpretations I made regarding this symbiotic blur, led to her feeling more safe, ''clear headed'', and independent. In other words, it was less frightening to hate one bad object then to feel lost and blended in with three (selfmother-father). When I said she felt we were becoming a lost and scary family blur, she would regain her footing in reality, feeling less anxious. I will present four of R=s dreams that showed a working through of these oedipal and pre-oedipal concerns and de-differentiated paranoid-schizoid relationships. These and other similar dreams unfolded during the second year of treatment.In the first dream, there was a general store where people were casually buying goods. All was well. There was a back room with a bed and R was a child, laying on the bed. She felt relaxed and began to look about the room. Staring at the ceiling, she noticed a large bag attached to a rope that hung over a rafter. There was a small hole, tear, or opening in the corner of the bag from which began to emerge what R first thought was an eyeball. Suddenly, it seemed a snake started to crawl out, dangling above her and the bed. At this point, R realized that what was actually emerging from the bag was a large penis. The jolt of being passively under this wiggling, descending, snakelike, phallus was too much. She woke up. Exploring the dream, R associated to her childhood. As a child, R routinely witnessed her father dragging her mother from the known regularity of the living room (general store) into the bedroom (backroom) where scary primal scenes took place. We also were better able to understand her worried thoughts concerning my possible seduction or attack. We talked about her mother's sexual activities with her as different then her father's sexual activities with mother as different from her own impulses and wishes with father, mother, or myself. At first glance, this dream appears to be about oedipal wishes and fears. Closer inspection revealed much more. First of all, she was clearly terrorized when telling me the dream and reliving it. The more we discussed it the more that she felt very frightened at how fragmented she had become in the dream and in retelling it. The Oedipal material consisted of her desiring to take mother's place in the marital bed and also to be laying in my analytic ''bed'', receiving my

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affections. However, this more integrated phantasy barely shored up a fragmented nightmare of reliving certain actual memories that had become fused with more primitive phantasies. As a child she had been a witness and participant to countless primal scenes. In the dream the curious child suddenly became a vulnerable participant in a primal scene where she merged with a raped mother who was attacked by her father/mothers' penis. The de-differentiation of this primitive triangulation left her feeling overcome by annihilation anxiety rather then oedipal guilt. The dream represented her struggle with being a part of, yet separate from, a scary union between self, mother, and father. At times, I was now a part of that internal fused family unit. During this period of the analysis, R experienced less fear and fewer hallucinations outside the sessions. Our relationship felt less of a brittle and askew too. The ongoing work in the transference was being replicated in her dreams and both seemed to be easing her anxieties. The second dream was a long and complex story with many subplots and twists. This alone seemed to reflect a growing shift from the paranoid-schizoid position into the depressive position, even if for temporary moments. Her struggles to master paranoid-schizoid panic were well illustrated in this dream. R was being chased through the woods and up and down a mountain by her father. His clear intention was to capture, rape, and kill her. ''Somehow'', she said, ''he had the look of my mother, even though he was my father''. R would fluctuate between the age of five and fifteen years, the age span she had lived with her mother. At one point she was able to flag down a passing car and while she was greatly suspicious she accepted the help. I was driving the car. We talked about how this was a reference to the growing trust in our relationship. She was still very cautious of me and my motives, but had begun to feel safe enough to share both her chaotic and vulnerable parts of herself with me. The nature of the father/daughter relationship alluded to the increased differentiation of self and other. Developmentally, she was separating the father, mother, and self states of pathological fusion into more of an oedipal phase dilemma. However, the chasing father was also a chasing predatory mother and I was the hoped for rescuing good mother. These were also projected aspects of her self that stood for the evil raping self and the healthy to-be-trusted self. While the paranoid-schizoid position was still her predominate internal experience, she felt more in ownership of her body and mind. This increased feeling of self-agency was evident in the dream and seemed to slowly leak out into the interpersonal aspects of the transference. In the third dream, R found herself in bed with me. I had convinced her of the importance of having a session in bed, without any clothing. She had agreed with the stipulation that she remain clothed. We talked as we usually did and there was

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no sexual contact. As after the other dreams, we were more able to discuss it in terms of our relationship. She felt I was a father like authority figure whom she was attracted to, yet felt prone to be submissive with. The sexual desires and fears relating to her father and me were now quite clear to her and she was able to discuss and explore them. Developmentally, she was gaining a degree of separation and assertion that was evident first in the dreams but now in the transference as well. Threads of a more differentiated and integrated oedipal transference were emerging from the de-differentiated, triadic father-mother-self state. However, this was all still a conglomeration of paranoid-schizoid, triangulated, internal and external experiences mixed with more mature Oedipal phase conflicts. In this particular dream, she had been able to say no to my request for nudity and boldly remained clothed. The fact that we then proceeded to have a "normal session" seemed to indicate her ability to create a safer environment with increased boundaries between self and others. She was able to partake in a portion of her oedipal wish while preventing it from becoming an oedipal tragedy. She was able to have a phantasy about her father-analyst without it becoming a nightmare with a father-mother-self-analyst. The content of the fourth dream and the way she told it to me reflected an evolution within the transference. Interpersonally and intrapsychically, her former shy, cautious, and submissive manner was giving way to a more direct, confident, and mutually relational style. She was still coy and seductive with me, yet also more capable of and interested in a mutual, ''team approach'' exploration of her difficulties. R dreamed that she arrived for her regular hour and walked up the stairs toward my office door. There I stood, leaning casually and seductively against the door jam, wearing a loose fitting terry cloth robe with a towel draped suggestively over one arm. I said in a sexy tone, "would you like to conduct today's session in the shower?" The less forceful manner of my question was a clue to the gradual transformation of the object representation from a sadistic and pushy one to more of a separate and equal other with whom negotiation was possible. She replied, "no, I want a 'regular session'." This demonstrated her increased mastery of ambiguous internal situations with untrustworthy objects. We then proceeded, in the dream, to conduct a normal analytic session. When R discussed this last dream, she expressed delight in her ability to be in control of the situation. She was also quite insightful when trying to find meaning in the dream. At the end of that hour, she told me in a half kidding and halfserious way, "remember, no robes next week." I felt this revealed her still ambivalent yet prospering individuality but also the wish for and fear of Oedipal

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intimacy which had not yet been totally analyzed or worked through. Also, the anxiety she felt with these wishes had to do with the still at times fused nature of the core father, mother, and self representation. She longed for a pre-oedipal, symbiotic closeness with her father and mother but was terrified that if she allowed herself to be vulnerable to that, the good loving parent would switch to the abusive and rejecting parent or that she would turn into the seductive and destructive parent. Intrapsychically, closeness would deteriorate into sex or sex would become a form of destructive intimacy. She would be harmed or she would harm me. All terrors were possible and constantly shifted back and forth into an overwhelming and combined danger. For example, this would take the form of phantasies in which she became a whore-like temptress with all men. At other times, she became furious with me and wanted to hurt me or my office furniture.When I would draw her attention to how she acted seductive or provocative with me (wondering if we could have an ''affair'', wondering if I needed my feet rubbed, or wondering if she could leave her husband to be with me), she would at times agree and be able to explore those wishes as well as her fears about those desires. This would certainly seem to indicate more neurotic structure. At other times, my same comments would push her into frankly paranoid and dissociative states where she thought I was going to attack her, rape her, and ''force her'' to ''admit to being dirty''. She would become delusional and want to run out of my office or ''call the authorities for help''. These were times when she regressed to fearful feelings of being a fused child-mother who was about to be attacked by a sinister mother-father. She hoped the good mother-father-authorities would come to save her. The Oedipal phantasy of replacing her mother so as to be closer to her father-analyst brought with it terrorizing feelings of being taken over and merging in a harmful way. Her internal objects were not solid or whole and the boundaries were overly permeable. Therefore, my interpretations would sometimes lead to a traumatic, paranoid-schiziod triangulation experience instead of a more individuated and integrated, depressive state of mind. On the other hand, my comments would sometimes bring her back into a more secure and clarified state of mind. This is the very con-fusing condition these types of patients are in, where their internal objects are not quite fully formed and separate yet not totally de-differentiated or fragmented. Diagnostically, this indicates a constant shifting of structural gears between a psychotic and borderline character structure. I believe this is due to the trauma in the paranoid-schizoid, early triadic stage of development, followed by trauma within the oedipal period. These two developmental impairments then seem to pathologically influence one another. The result is a contradictory and often

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bizarre transference that looks neurotic, borderline, or psychotic at any given time. Countertransference is especially important to monitor in these cases since the analyst is usually left feeling chaotic and prone to act out uncomfortable anxieties. Many of these terrifying conflicts were played out every day in R's bathroom. She would try and have a bowel movement, which meant she was going to have a good day where she was ''in harmony with the world'' away from the poisonous self-mother-father internal family unit. If she couldn't have a soothing bowel movement where she became separate from the stool, she became disorganized and panicked and turned into the ''poisonous crap''. She then was visited by the violent and unavailable internalized parent(s). At that point she sought refuge with the cool reassuring floor tile parent(s) that brought relief and comfort and a brief respite from the terrifying de-differentiation of herself and these various internal objects. Many patients present with transferences that fluctuate and overlap during the treatment. This is due to the phenomenon of splitting and the frequent reality of two very different yet pivotal parental influences upon the developing infantile ego. Second, when there are two significant introjected relationships, one is often manifested as a overt transference while the other is kept hidden. It is true that there will be overlap and spillage from one to the other but the analyst can often be unaware of one of these transferences even up to and through the termination phase. The more covert transference is sometimes worked with by the patient within dreams. The patient can use dream work to pass through some of the more fearful transference states. R was able to not only use her dreams to work through some of her Oedipal and pre-oedipal conflicts, but was also able to bring these experiences into the transference and thereby work them through in another modality. When R stopped the treatment, she said she still hated her father. I pointed out that this indicated she still had many unresolved feelings about me and our relationship. At the same time, the quantitative shift she had made from her prior mistrust, ambivalence, and con-fusion with me and other internalized objects gave her a better mental cohesion. R applied for a part-time job at the local library and began to do the weekly household shopping. Only during several days of the month, usually at the time of her period, would she need the reassurance of the cool bathroom floor tiles. She acknowledged that she still ''had alot of work to do'', but choose to break off the treatment and engage life a bit more then ever before.

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SUMMARY
The interaction of strong aggressive and libidinal drives, various primitive intrapsychic phantasies linking somatic sensations, body parts, ego, object, and the effects of early environmental stress and trauma all produce a potential crisis in the paranoid-schizoid period of development. Certain innate methods of understanding somatic experiences as well as the interaction between internal and external reality lead to a unconscious triangulation of part objects. A frustrating, stimulating, or punitive ''third'' which blocks, nullifies, or over gratifies certain wishes then emerges as a pivotal object in the internal landscape. During the paranoid-schizoid, triadic process, there is a fluctuation between separation/individuation and de-differentiation/fusion. If the early triangulation process has been either exceedingly frustrating or overly stimulating in regards to ''reaching the third'' or ''warding off the third'', the infantile ego is fixed by aggressive and libidinal forces to de-differentiation experiences rather then to more separate and individuated ways of relating. Therefore, the later oedipal stage will be colored by excessive oral and anal conflicts and will be weighted on the side of primitive maneuvering based on splitting, projection, and introjection. When the child (and later adult) becomes involved in Oedipal situations marked by stimulation or frustration of triadic drives, there can be a regression to the earlier paranoid-schizoid triadic period. A case study was presented in which a patient struggled with a partial working through of these conditions in dreams and in the transference. This pulled her more in the direction of a differentiated Oedipal conflict and whole object functioning.

Chapter Seven

GROWTH AND THE FEAR OF HATE AND HARM: LESS DISTURBED PATIENTS
From a Kleinian perspective, all patients struggle with psychological desires and conflicts regarding love, hate, and knowledge. Some patients are troubled by phantasies of causing hurt and hatred in the object as a result of their quest for separation, individuation, and personal creativity. Success, ambition, differentiation, growth, change, and personal difference are all seen as creating, injury, unhappiness, anger, hatred, and rejection in the object. Therefore, these patients create intense and rigid defensive patterns of submissive, subordinate, and passive relating to prevent these internal catastrophes. These defensive mechanisms are mobilized through projective identification and create frequent patterns of interpretive enactments and counter-transference acting out. This chapter will highlight these vexing and humbling patterns of interpretive acting out we often find ourselves in as we try to reach out to patients but barely find a foothold before they slip away or before we lose our own therapeutic balance. Case material will be used for illustration to specifically examine how the defensive avoidance of certain wishes, feelings, and secret needs become part of the counter-transference and influence or pervert the interpretive process. As a result, the analyst may indeed be making helpful and accurate interpretations while also missing out on the more core aspects of the patients in the moment phantasy and internal conflict. Theoretical and clinical material will be used to examine this phenomenon. Patients come to us with very complex and troubling emotional struggles and we do our best to assist them in untying the mental knots and understanding how they may be continuing to tie themselves up. However, along the way in helping them learn and change, it is common if not predictable and unavoidable, that we

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face failure in our efforts. We come to find a wide spectrum of destructiveness in our patients internal world yet we step in to help them learn about it and find resolve and integration. We encounter difficult moments at every turn and often have to pick up the pieces as we go. Counter-transference and projective identification are always found in conjunction with the transference and therefore make for sticky and chaotic clinical situations that can cause various forms of acting out between both parties but also can lead to a new clarity and internal shift. It is common to be nudged, seduced or invited in subtle unconscious and interpersonal ways to be the spokesperson for the patients unwanted aggressive, erotic, competitive, or defiant feelings and phantasies. In this forms of enactments, the analyst ends up making interpretations that basically voice the unwanted or sinful experiences for the patient, taking him or her out of the spotlight and taking on the risk or shame. This occurs through projective identification and counter-transference cycles that produce patterns of acting out or enactments by the analyst. So, a patient who is scared of being put in his place by the phantasy of a strict father might describe a situation in which he wanted to leave work to go play a game of basketball with his buddies, but he would describe it as a situation in which he felt he probably should stay late at work because after all, lots of people are depending on him for this important project. The analyst would be, through projective identification and counter-transference patterns, become the holder and now spokesperson for the patients defiant and guilty wishes. So, the interpretive enactment might be that the analyst says, You really wanted to toss work to the side and head out to the courts. It was time for fun! But, you feel guilty about it. Here, the interpretation would be correct, but the patient has projected his guilty phantasy into the analyst and has the analyst voice this indulgence for him, thus avoiding the risk and not having to take responsibility for it. Due to projective identification and counter-transference, the excitement and defiance resides in the analyst not the patient. Often in our best attempts at interpretation, we end up still emphasizing one side of things and neglecting other sides. This is unavoidable since there are always many facets to the patients conflicts. However, the patient may be inviting us or pushing us in one direction or another and through our own countertransference wishes or fears, we may side with the patients defensive strategies and end up interpreting one aspect of their phantasies over another. As I mentioned in the short example, we often end up interpreting the conflicts our patients have because we have been tricked into being the voice for their id impulses and they then avoid their potential superego punishment. In other situations, our own counter-transference of defiance, rebelliousness, or empathy

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for the underdog pulls us into making interpretations that are basically routing the patient on to do what he or she wants to but feels some superego judgment about. I believe this is the more common mistake that we interpretively make and the easier one to notice as the combination of projective identification and countertransference is a fairly predictable and obvious one to eventually notice.

INTERPRETIVE ENACTMENTS AND THE PROJECTIVE DEFENSES AGAINST DIFFERENTIATION


In this paper, I will use case material to show the more difficult to notice interpretive enactments that occur with patients who use projective identification and how our counter-transference can be clouded to over interpret the shy, weak, or in need of protection side of the patients phantasy and we end up ignoring, denying, or minimizing the more aggressive, independent, and separate aspects of their phantasies and feelings. Since these feelings tend to be saturated with guilt, anxiety, fear, and ownership of these desires is felt to be toxic or dangerous to both self and object. So, the patient unconsciously wants and hates their own independent desires, struggling to promote their own ambitions and hopes as wells as attacking them at the same time. Therefore, when counter-transference is colored by projective identification of these intense conflicts, the analyst can have a blind spot to these phantasies because he wants to protect the patient from that self judgment and hate or wants to avoid conflict with the punitive object. These clinical moments in which we slip and fall into a variety of enactments with our patients are not fatal to the treatment but cause momentary friction or detour in the analytic process. The contemporary Kleinian approach embraces the clinical idea that projective identification and counter-transference often combine in unavoidable ways to nudge the analyst to subtly or strongly act out certain object relational phantasies with the patient. Previously (Waska 2006), I have written about how the interpretive process is a frequent stage for these moments in which we make interpretations that are both correct and helpful but also an aspect of counter-transference guilt, hostility, collusion, desire, or defense. Specifically, I have noted in other publications how often one side of the patients conflict is acted out by the analyst. Often, it is the role of guide, permissive parent, soothing caretaker, or encouraging coach for the illicit, censored, unwanted, or prohibited feelings and thoughts the patient struggles with. So, the analyst ends up doing the dirty work and interprets the very thing the patient wishes to say or do but doesnt want to risk. Therefore, I have previously

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examined this hidden, projected side of the patients phantasy. In this paper, however, I will outline a similar situation, but one that has more to do with the patients projection of core defensive judgments and decries than the projection of raw impulses or rebellious protest. The case material will show the analysts temporary collusion with the patient defensive structure and self-hatred of change, differentiation, or growth.

CASE MATERIAL
Interpretive slips or clinical fender benders are often temporary, but sometimes ongoing, moments that are unnoticed or denied by the analyst in which the patients pathological organization (Rosenfeld 1971 Steiner 1987) or psychic retreat (Steiner 1993) is shared by the analyst. My patient David had spoken many times over his two year analysis of feeling stranded on Mount Everest without a jacket. This phantasy would come up whenever he revealed hidden wishes, forbidden anger, or strong desires to be different rather than pleasing or conforming to the object. So, in the transference, he imagined I would be disapproving if he wanted to go fishing on the weekend instead of staying at home with his family or if he asked me to change our meeting time so he could go to the gym during his lunch break. When David revealed these sorts of forbidden feelings and censored thoughts to me, he felt extremely exposed and vulnerable. Hence, he associated to being stuck on Mount Everest without a jacket, facing the icy winds alone on this desolate peak. For the first year of treatment, I interpreted this image as him risking showing me a more masculine, striving side of himself but then feeling scared and alone, against the icy wind of my possible judgment and rejection. This was based on counter-transference feelings and a counter-transference impression of him as a vulnerable little boy, passive and hoping for my aid and care. Now, I believe this was and is true and that my interpretations of his phantasy was helpful in exploring this scared little boy flexing his new muscles but unsure of how father would respond. He wondered whether I would encourage him or disapprove and would I love him or hate him for having his own identity. David wanted my protection and encouragement as well as my reassurance that it was not bad or dangerous to be himself. He wanted to know that I wouldnt leave him there to freeze to death on the mountain top for his sins. But, I eventually realized I had been in collusion with David on another level. There had been a fender bender. While I think I was accurate and helpful in pursuing the fear and punishment angle of his exposing a more strong, personal,

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and opinionated side of himself, I had been missing another side of his conflicts and phantasies. Both of us had focused on the scary and submissive side of being on Mount Everest without protection and we had avoided or hidden the more dominate, exhibitionistic, and proud aspect of the phantasy. So, during one session he was telling me about going fishing on the weekend and catching several decent size trout! Then, he expressed how guilty and worried he was about the fallout from his family. I mentioned he might also worry about my opinion and would I be proud of his big catch or upset that he wasnt a responsible family man. He said, Yes. After I tell you about it, I feel I am up there on a ledge, on Mount Everest without a jacket fighting the elements with the snow in my face. At that point, I reflected on my own counter-transference associations of what he was describing. I pictured a masculine mountain climber boldly conquering Mount Everest with a bare chest and success in his eyes. This image, a counter-transference phantasy formed by what my patient was not saying but possibly feeling and then needing to eject through projective identification, helped me realize there was more to the picture than just his fear and guilt. There was also hidden pride, aggression, and virility. So, I also noticed how we had both participated in this cloaked secret, only illuminating one side of his personality. Now, I was able to make more balanced interpretations. I said, I think you want to emphasize the scared and guilty feelings and hide the side of you that has conquered the mountain. After all, you are on top of the tallest and most difficult mountain in the world, single handedly making it to the top. You feel like a strong successful man, but are trying to hide that from me. David paused and then said, I havent ever thought of it that way. But, I see what you mean. I think that is right. I do feel like a real success some times and I want to wear that. But, I am not sure you want that or will allow it. So, after a prolonged interpretive impasse or what I call a therapeutic fender bender, we were now able to work on a new and much more important aspect of Davids phantasy life and his inner conflicts. This was not an instant transformation in the treatment but it did begin a very successful period in which he began to work through his anxieties around being competitive, equal, different, and opinionated. He hated this side of himself less and less. David was more able to work on how and why he needed to camouflage his pride and desire with masochistic submission and guilt. We were more in touch with how he liked to flex his muscles rather than how he felt punished for flexing them. He was gradually more able to work with my interpretations regarding how he hid his more phallic side by controlling me with this more needy, exposed image of a helpless junior climber in need of a jacket. I said, You dont think I can handle

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you being a man, as if I will be shown up as weak or you will feel like we are in competition. You dont like to have us be two men hanging out together. With this gradual shift in my interpretive direction, we were more able to better address the wider view of Davids internal world. This therapeutic fender bender had caused some minor damage or delay to the analytic procedure but now we were more involved in an integrative process and were better able to maintain analytic contact (Waska 2007) in a creative and healing manner.

DISCUSSION
Betty Joseph (1988) has suggested that object relations theory should be constantly rediscovered and refreshed within the clinical situation by analysts focusing on not just what is being communicated by words but by what is being lived out in the transference. I would extend this idea to include an ongoing focus on what is being lived out in the counter-transference and in the interpretive process. This has much to do with the nature of the projective identification climate within the analytic situation and how those projections make up the core transference phantasies. As Joseph (1988) has noted, these projections can stimulate and provoke the analyst to act out the patients phantasy life. I believe this often occurs through the interpretive field in which the analyst ends up making interpretations in either a defensive or anti-defensive mode, based on what elements are being projected. In this paper, the case material illustrates interpretive enactments in which the patients defensive stance was embedded within the interpretation, thus temporarily acting out the projective identification dynamic. Hinshelwood (1989) explains how the analyst, when being projected into, will respond with one of two counter-transference feelings. Either he will experience the anger, guilt, excitement, or whatever the patient is projecting or he will experience the patients defenses against them, such as denial, manic triumph, guilt, anxiety, and so forth. Brenman (1985) has also noted a similar idea. He describes how patients are fairly attuned to the analysts mind and tend to selectively project into certain aspects of the analysts mind, including the analysts defensive system. The clinical material will continue to show how this occurs within the purview of the analysts interpretive function, distorting and deadening the analysts ability to interpret in a whole object manner and instead selectively interpreting in a manner that colludes with the patients own defenses against certain dangerous feelings and phantasies.

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CASE MATERIAL
The patients projective identification dynamics can coerce the analyst to act out, via interpretation, various roles in the patients unconscious phantasy life. Counter-transference sensitivities may increase the chance of this occurring. This interpretive acting out may be subtle and passive or more aggressive and active. If not monitored, contained, and understood, it can be destructive to the therapeutic envelope. We can become seductive, persecutory, guilt-inducing, or withdrawing by noting one aspect of the patients internal issues in our interpretations and not another. When interpretively acting out, the analyst may end up participating actively or passively within these pathological cycles. All these types of acting out are inevitable but must be constantly monitored and worked through with the aid of the counter-transference. If properly handled, these therapeutic fender benders can shed important light on otherwise hidden aspects of the patients internal struggles and conflicts that are up to that moment only accessible through a projective identification process. While these moments of interpretive acting out can coincide with uncorrupted interpretive work, the overall analytic contact (Waska 2007) can suffer. While such acting out is probably unavoidable, the quicker the analyst can notice, contain, and understand such deviations, the better chance analytic contact can be reestablished and maintained. Sarah was raised with her two sisters by parents who were very strict and critical. Sarahs father was particularly demanding in that he constantly told Sarah what she should be doing with her life and always added how she was failing his expectations. She loved him and felt they had some degree of resolution in their relationship before he died five years ago, but she still views her parents as never really understanding her and quick to find fault. It was hard for them to ever imagine what I might be going through, whether it is positive or negative. During her career as a hospital manager, Sarah was frequently told she was too slow and disorganized. Part of this was the result of her emotional struggle with authority, in particular with men, and feeling the need to take on everything so she could please the authority she also resented. But, taking on everything meant she was always overwhelmed and did a sloppy job as a result, displeasing her bosses. At the same time, she always felt very fatigued. During a routine physical examination, it turned out she had a neurological disease which would only get worse over time. She went out on disability about the same time she began her psychoanalysis. Now in her fourth year of analytic treatment, Sarah is doing much better in many ways. She is not as severely depressed or anxious and she has reduced her

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self-sabotaging patterns. Her difficulty relating to men remains. She has not had a boyfriend or had sex for almost ten years. There is a theme within the transference that was prominent from the beginning and remains a central thread. Sarah sees me as an intimidating male authority that she wants to receive fatherly guidance from but imagines this will always be given alongside of judgment, sternness, and anger. There is a unique way she relates to me that pulls me into that role. I will make various interpretations that are fairly on the mark, regarding a wide variety of topics. But, soon enough, she will start to say something that either makes her sound nave, lazy, or forgetful. I will take it up as a matter of common sense and ask her for details. Then, Sarah will offer more details that make her look clueless, stupid, or immature. At that point, I will sometimes end up making some comment about how it seems obvious that she should have done it this way or that way instead of how she did it. Sarah will respond by telling me that she didnt think of it or that she forgot. Again, this leads me to feel hopeless about her intelligence and frustrated about her motivations. Indeed, sometimes she tells me she just didnt feel like it or I dont care if it was my fault. I guess I am just lazy. Depending on how she says it, I might feel empathic, want to hear more about it and help her find the solution to whatever the problem was or I might feel like she is being a lazy little brat and want to lecture her on the correct way of proceeding. So, I was caught up in either being an attentive, gentle, guiding father or an irritated, lecturing father. Grinberg (1962) has noted how when put off balance by projective identification, the analyst, can become passively led into acting out various archaic roles within the patients internal landscape. By exploring and examining this transference and counter-transference pattern, certain things came to light. It often turns out that Sarah in fact knew exactly what to do in the situation she was describing or indeed had already taken care of whatever it was, but failed to include that detail in her story to me. Exploring this, we have come to see how she successfully provoked me, teased me, or invited me to be like a nice teacher ready to help but easily tipped over into a scolding, impatient teacher. We have explored how this is a repetition of her childhood experience and memory of her father combined with her wish for a different experience or memory. In analyzing this, we have come to realize that it is now her who can be judgmental, impatient, and disappointed with either herself or others and that in the transference she puts me in that role as well. At the same time, she wants to be with a new, more loving man but she feels she must be a helpless, nave little girl to do so, which then shifts the object back to being a critical and scolding father with her feeling like a disappointing daughter.

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More specific to this interpretive enactment pattern with Sarah is the way in which I was duplicating her own defenses and conflicts against seeing herself as competent, independent, and successful without me. The submissive daughter who was linked to me as a faithful father through criticism and expectation was a familiar internal struggle. This was easy to use to defend against and hide from the scarier and unknown relationship of grown woman and man together as equals with her showing her own strengths and opinions. Over time, by consistently examining and monitoring my countertransference and my occasional lapses into interpretive acting out, I have been more able to reduce my enactments. And, as we work to learn, understand, and change her fatherchild phantasies, there is much less provocative and teasing transference from her to draw me in. In fact, because I have been more aware of the defensive projections that I was interpretively acting out, we both are more open now to her previously warded off feelings of competence and individuality. Sarah now exhibits much more maturity, confidence, and pride. Her stories about her week are much more prone to be about her successes and how she solved various problems. In working through my own counter-transference and projective identification based acting out, I helped Sarah to have less investment in her defensive stance. Now, Sarah is less conflicted when considering herself as a more independent and vibrant woman linking to me as more of a proud, understanding father who respects his daughters autonomy and personal choice. Recently, I interpreted that she seems not yet ready to see us an equal adults because she worries she might have to give up all of the nice father/happy daughter gratification she has with me if she becomes a mature, separate woman. Sarah responded by saying, I am getting there, but even if I can see myself as stronger and more able, the fact is that I still need your help. Sometimes, that feels like a good thing and I like depending on you. Other times, I resent it and feel bad because it reminds me of how much I am still struggling with my life. In this way, we are having more genuine, important exchanges and less acting out on both sides of the equation.

CASE MATERIAL
A similar fender bender occurred in my working with Tom. He had been in analytic treatment, on the couch, for several years. He was continuing to explore his pattern of caretaking a woman he had known since high school who was very erratic and was drug addicted. Tom told me he wanted help in breaking free of

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this way of being and find a new way of living my life and finding a real girlfriend. This woman was the only girl he had ever had sex with and he felt so poorly about himself that he couldnt picture another woman ever wanting to be with him. So, I interpreted his sense of power and control over this woman and how he pictured that he alone could rescue her and prevent any harm from coming to her. Genetically, we have linked this to his early experiences with a depressed mother who was institutionalized several times after the death of her second child. Tom recalls how the family reacted with stoic silence and that everyone said nothing and just pretended everything was ok. We didnt want mom to sink into that dark place again. No one in the family ever talked about their feelings. I thought it was best for mom if I acted nice and made everything smooth. I added, Or, you might be too much for her, hurt her, and make her depressed. He said yes. One way this fear and guilt of hurting the object and his need to cater, care, and please the weak, sickly object came into the transference was around the Christmas holiday. A week before the holiday, we were scheduled to meet. He told me he was thinking of going skiing that week and said he assumed I would be taking it off. I told him I would not, that I would be working. When he attended that session, it came out that he didnt really want to be there, but realized I must be working because I really need the money. You probably need the cash to pay your bills and buy presents for the family. So, out of guilt and obligation, Tom attended the session so he could pay me and prop me up in my desperate financial situation. I interpreted that he saw me as yet another broken down mother who needed protection and care. He told me he was also worried I or the girlfriend would be angry with him and reject him if he didnt do what he should to meet both of your needs. He added that she might kill herself if I draw my limits and make my own way. Over time, I had also been interpreting that he was using her in that he saw her as the one source of sex he could go to and sometimes manipulate into having sex if she felt lonely or was drunk. Here, I was partly exploring his more controlling, sadistic or opportunistic side but also bringing up the level of his desperation and his phantasy of not having access to anyone else due to his conviction of being too ugly, not masculine, and not a skilled sexual person. One of the issues that came to light after the first year and after Tom working through a great deal of shame and embarrassment was his chronic masturbation. He tended to masturbate everyday, calling them his trainings. In these trainings, he tried to escape all the obsessive worries he had about his defectiveness and inferiority. So, by masturbating properly and successfully, he tried to prove to himself that he was hard enough, could last long enough, had a long enough penis,

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had properly sized and properly dangling testicles, and that his ejaculations were powerful enough. He had a great deal of worry about all these matters and obsessed about being a failure in every category. This anxiety sometimes grew to near psychotic level in which the anxiety become somatic and somewhat delusional. So, he sometimes ended up going to specialists or even to the emergency room to make sure something wasnt medically wrong when he thought his testicles were not proportional or if there appeared to be a blemish on his penis. So, recently Tom was telling me about how he was masturbating to a porn site on his computer and how he felt anxious, pressured, and guilty about lasting long enough since he was masturbating to a porn star and she would want it to last a long time. This was an interesting window into the intense phantasy he lived in which sometimes eroded reality to a severe degree, leaving him feeling like he was literally with this porn star and having to literally please her or face the consequences. At first, I was drawn into commenting on his slavish need to please the porn star to avoid her rejection as well as to avoid hurting her feelings and leaving her to become a depressed mother. Again, as with all my previous interpretations that were in line with this theme, I believe I was accurate and helpful. But, I was also missing out on the other side of his conflict, the other aspect of his phantasy. In this way, there was a fender bender. I was pulled into siding with his more masochistic way of relating and his need for me to see him that way. What was being hidden and not noticed or emphasized by either one of us was his sense of power, control, and dominance. So, I found a way out of the fender bender by interpreting that he was telling me how anxious he was to last long enough to please the porn star but at the same time he was hiding from me the fact that in his mind he was indeed having sex with a famous porn star. In other words, I was now drawing attention to his phantasy of power and sexual success. I interpreted that Tom normally tried to only show me his scared impotent side and now we were discussing his hidden porn star side. Tom replied, I feel embarrassed, but you are absolutely right. I do have that side but I keep it hidden and secret. But, I have lots of phantasies like that. I asked for details. He told me that a reoccurring image he masturbates to is the picture of a crowd of people around him watching him have sex with a woman and the crowd is amazed at how sexually powerful he is. They are practically cheering him on. And, the woman is begging for more of his incredible sexual prowess. The next session, Tom reported two dreams. In the first one, he had his cheering crowd and he was the sexual stud. In the second one, he had been rejected by a woman and felt like a sexual loser. I interpreted that he was very

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anxious about having exposed this more prideful, masculine side of himself to me and now he was feeling unsure and guilty. In other words, he showed off in front of me in the session and in the dream, but then he had to quickly devalue himself and put himself back down in this inferior place just in case I might be upset with him acting too potent. Tom agreed and talked about feeling like it was wrong and foolish to think of himself so arrogantly, even though it felt good at the same time. So, now that we were beyond the fender bender, we were able to explore and work on a much fuller, richer portrait of his inner life.

DISCUSSION
Segal (1977) has noted how the patient projects into the analysts mind, affecting the analyst in certain ways. I would add that the patient attempts to install, infect, control, or reshape the analysts mind in particular manners that are aggressive, defensive, and reparative. Joseph (1975) has noted how helpful the counter-transference can be in teaching the analyst about how and why the patient is attempting to draw the analyst into various roles and enactments and how and why the patient wants to have a say in the functioning of the analysts mind. Joseph (1985) has reported on how patients draw us into their defensive systems. This paper has examined this phenomenon as a byproduct of intensive projective identification in which the analyst unwillingly makes interpretations based on this distorted counter-transference experience. Spillius (1988) and Schafer (1994) have pointed out how various Kleinian thinkers including Rosenfeld (1987) have clinically found how patients hope for the analyst to be able to have the capacity to remain stable and dependable when confronted with projections. However, these same patients usually are very anxious about the analysts ability to remain stable, neutral, and integrated so the patient may retreat, repair, or altogether avoid putting the analyst in the dangerous position of having to contain their projections in the first place. One way this occurs is that the patient projects their defensive system into the analyst as a way to help the analyst avoid being toppled or injured or overwhelmed when encountering the true self of the patient. This also protects the patient from feeling potential persecution or guilt from inserting their various conflicts and phantasies into the analyst. The case material has illustrated how some patients project various levels of defense and denial into the analyst to protect both self and object from more individual, independent, and successful aspects of the self as well as difference, disagreement, or separation and growth. At times, the analyst can be drawn into acting out these defenses systems by interpreting only one aspect of

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the patients dynamics rather than other aspects. The inferior or immature aspects of the patient can become over emphasized rather than the growing, challenging, or superior feelings and phantasies. In this way, both analyst and patient collude in a defensive role relationship designed to focus on old, pathological ways of being rather than new, transformative ways of relating. By monitoring the counter-transference and the interpretive acting out that occurs in these situations, the analyst can begin to regain analytic balance, disengage from therapeutic fender benders, and come back from these projective identification based countertransference detours onto the road to change and emotional clarity. The day to day work that the psychoanalytic endeavor demands on both patient and analyst typically involves an ongoing series of successes and failures with various ups and downs. There is clarity and mystery within each session as well as over the course of an entire treatment. Hopefully, these breakdowns and breakthroughs are mixed together and balanced more toward the gradual working through and transformation of unconscious conflict and psychological suffering. Often, there is more of a murky series of confusing detours that often bring us to something helpful and important, but with a great deal of entanglements along the way. Most of our patients in private practice or clinic settings are fairly disturbed and coping in a fairly raw, slippery, or confusing manner. It is common to become involved in counter-transference acting out and temporarily lost in intense projective identification cycles in which the patient subtly or dramatically pulls the analyst into a variety of roles. Sandler (1976) has noted that the concept of transference should be broadened to include not just the projections of archaic figures from the past, but all the patients attempts to manipulate or provoke certain role relationships with the analyst. Sandler goes on to say that the patient unconsciously scans the analysts reactions to their projections to assess if the analyst can handle it or not and to see if the analyst is choosing to take up a certain side of things over another. The patients ability to accurately perceive this is of course distorted by the hopes and dread of their unconscious phantasy. The patients examined in this paper are scanning the analyst to see if the object is capable and willing to accept and tolerate the more independent and assertive side of their phantasies. But, because of intense internal convictions regarding the frail, rejecting, angry, or disapproving aspects of the object, the patient is quick to assume rejection or collapse. So, they are quick to project certain defenses against the side of themselves and emphasize or promote the view of themselves as quite opposite. These are what Sandler calls the defensive role relationships that are constructed to manipulate the analyst away from these areas perceived as dangerous to either

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self or object. Once the analyst takes on a part of this defensive construction, the counter-transference, the counter-transference reactions are played out in the manner in which interpretations are given. Even thought the bulk of the interpretive process may still seem on target and helpful in assisting the patient to work through many different conflicts, it is also a one-sided approach and is a blind spot of sorts in which the analyst is now avoiding the same feelings or transference anxiety that the patient is avoiding. Now, one could say the interpretive acting out is a sign of therapeutic failure. On the other hand, Money-Kryle (1956) has noted that it is common for the analyst to fail in their function as a container. But, the specifics of how he fails can be very informative. Thus, the ongoing monitoring of how countertransference and projective identification is contaminating the interpretive process should be a regular part of the analysts evaluation of self and object. The manner in which the interpretive process has gone astray or askew points to the area of the patients mind that is manipulating, hiding, rebelling, or retreating. Another way the patient may draw the analyst into a defensive structure that only illuminates certain aspects of their personality while cloaking others is to carefully strip away the knowledge and insight from the analysts interpretations. Joseph (1989) has noted how this can stimulate more of a sadomasochistic transference and counter-transference situation in which the patient denies more and more of himself which provokes interpretive attacks or devaluations from the analyst. Therefore, neither party has to acknowledge the more positive, growth orientated, or differentiated aspects of the patient. The motive for this projective identification driven defensive stance can be to prevent or escape either paranoid (Klein 1946) or depressive (Klein 1935; 1940) fears. Grinberg (1979) notes that when under the passive sway of intense projective identification forces, the analyst can become drawn into various roles affects and phantasies which he may play out with the patient in different ways. Grinberg goes on to describe a classification of projective identification states that include specific aims, contents, and effects on others. Central to the patients I am examining in this paper, Grinberg notes the controlling and evacuative and defensive aims combined with the superego functions that have confusioning and defensive effects on the analyst. The patients presented in this paper are representative of those individuals who are haunted by paranoid (Klein 1946), pre-depressive (Bicudo 1964; Grinberg 1964), and depressive (Klein 1935; 1940) anxieties regarding separation, differentiation, growth, and change. For these individuals, change equals danger (Waska 2006). Torras De Bea (1989) has noted how differentiation is from birth the essential element in projective identification that is based around unconscious

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self to object communication. However, when this natural and pervasive communication is distorted or perverted by anxieties regarding unacceptable, to self and/or object, acts of differentiation, massive defenses are brought up and become the core of projective identification. The elements of projection shift from more of a communication process to a rigid defensive maneuver designed to hide or destroy any evidence of change, challenge, separation or growth. Of course, this enters the realm of masochistic camouflage, the death instinct, and various forms of negative therapeutic reaction. The analysts interpretive function must be restored in order to begin reestablishing analytic contact (Waska 2007) and to begin helping the patient deal with the anxiety they are defending against. Once the counter-transference reaction becomes less of an acting out via interpretation and more of an informative toll, then the analyst can start to investigate the unconscious elements of the patients projective identification efforts. Heimann (1950) has noted that the analyst needs to always be curious about why the patient is currently, in the moment, doing what to whom in phantasy, to either self or other. All transference interpretations come forth from this equation. This paper has outlined the ways the analyst can be caught up in the projective identification cycle of defensive maneuvers that create counter-transference induced interpretive blind spots. Riesenberg-Malcolm (1995) has discussed the core importance of the transference relationship as the what, the paranoid or depressive level of conflict as the where, and the when being the verbal integration of interpretive elements at a particular moment when things gel in the mind of the analyst. These critical interpretive ingredients are all susceptible to this projective identification and counter-transference blind spot. In particular, the analyst may be drawn into one aspect of the patients internal conflict while avoiding another, therefore only aware of a lopsided picture of the transference relationship. As a result, it might appear to be a paranoid or depressive problem when it is not necessarily so. Finally, these fake or only partly true clinical facts will prevent, distort, or rush the moment when pre-interpretive elements gel in the analysts mind. Joseph (1988; 1989) has shown in her extensive clinical focus the way the analyst is almost always drawn into playing out a role in the patients phantasies. If the analyst can maintain an observing stance and not be pulled too deeply into these interpretive enactments (Steiner 2006), the analyst can be better informed as to the patients defensive structure and the conflicts he has regarding his object relational world. Our job involves being the willing recipient of the patients ongoing projections which by definition clouds our ability to reason and think. However, it is imperative to our ability to contain and translate to be able to think on our feet. So, there is always a difficult and confusing place we must reside,

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trying to understand rather than act, yet the patients projections constantly pull us toward action. Joseph (1989) has discussed the concept of psychic equilibrium and how the patient strives to maintain what may appear to be a malfunction and pathological system of coping to avoid a lack of psychic balance with their internal objects and a shift into an internal state of unknown difference and change. Projective identification can be utilized to maintain this rigid equilibrium and to keep those objects, including the transference object of the analyst, from seeing any evidence of ambition, differentiation, or psychological growth. Joseph (2003) and Steiner (2006) have both written about the enactment process as it takes place within the interpretive field. Steiner (2006) points out the limiting or even destructive effects interpretive acting out can have on the patients ability to develop their own thinking and judgment. He goes on to point out how the analyst has to keep his feelings under control, remaining both involved and separate, in order to be engaged, but also able to observe and assess. This paper has illustrated both the limiting effects of interpretive acting out as well as the informative and therapeutic aspects of examining, exploring, and utilizing the unconscious foundation of these often unavoidable dynamics.

Chapter Eight

GROWTH AND THE FEAR OF HATE AND HARM: MORE DISTURBED PATIENTS
Heimann (1950) was among the first in the Kleinian school who emphasized the utility of counter-transference as opposed to viewing it as a personal liability. She explained that one of the benefits of our own analysis is being able to sustain our feelings as opposed to discharging them like the patient does. In sustaining our feelings, we can examine them in relation to what the patient is saying, feeling, or doing and begin to expand our understanding of the internal conflicts our patient is working with. Money-Kyrle (1956) and Bion (1959) discussed the importance of acting as a container for the patients projections by tolerating them and by putting those projections into words. I see this process as becoming a psychic translator and psychological filter for the patients unknown, unwanted, and unthinkable thoughts, feelings, and phantasies. Through this way of working and Kleins (1946) concept of projective identification, the analyst was now able to make intra-psychic interpretations of the interpersonal interactions in the clinical moment, bringing insight into the total transference (Joseph 1985). Due to these Kleinian discoveries and advances in clinical technique, the analyst is now able to better assist the patient with his anxiety and psychological confusion. The analyst takes in the intra-psychic meaning of interpersonal interactions, using the counter-transference as an organizing tool to decode the interactive projection, and then eventually interprets the core conflicts that make that interaction up, offering the patient a potentially mutative experience. Of course, in using counter-transference to better understand the patient, the analyst has to become acutely aware of how he reacts to the patients projections. A common reaction to various forms of aggression, envy, demand, separation,

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individuation, loss, or seduction is to move away defensively. The standing task in examining counter-transference is to determine if that defensive reaction is the analysts own personal retaliation or the patients unique personal defensive structure that is being pushed into the analyst. The patient may be quite anxious about the analysts view of usually hidden parts of the self, convinced the analyst could feel the same judgment that the patient harbors about certain aspects of his own personality which are normally kept hidden, repressed, or split off. So, the patient can become very anxious, either in a paranoid-schizoid (Klein 1946) or depressive (Klein 1935, 1940) manner, about what will happen when the object realizes the patients true identity, mindset, or affect state. Therefore, it is very common for the patient to use projective identification to push various forms of defense into the analyst which becomes embedded within how the analyst acts or interprets. Then, the analyst can end up colluding with the patient to deny, avoid, or minimize what the patient imagines to be offensive, toxic, taboo, or unwanted. The two cases in this paper will illustrate how the analyst can become over focused on one aspect of the patients transference or phantasy state as part of a defensive acting out of this type of projective identification dynamic. The analysts interpretations are only helpful or mutative when the analyst works to contain himself and translates his counter-transference feelings in a way that makes himself separate and different than the patients archaic internal objects (Elmhirst 1978). Projective identification influenced counter-transference acting out commonly occurs in the interpretive process when the analyst holds on possessively to the projections or tries to discharge them prematurely. When acting out the patients defensive dynamics against certain transference anxieties, the analyst is frequently over emphasizing or prematurely interpreting one side of the patients transference, phantasy state, or internal conflict, while withholding and underemphasizing other aspects. Pit stops: A Momentary Break Before Diving Back Into the Fray Pit stops are those clinical situations in which patients come to see us for a brief period, usually in a state of external crisis which is a reflection of intense internal crisis. They desperately want help, hope for immediate change, and seek fast relief. But, they are captured within intense inner conflicts and rigid projective identification systems in which they cry out for the object, flee from the object, grieve for the object, and move to attack and fight the object. The anger, guilt, loss, and fear towards themselves and others seem at unbearable levels and rapidly vacillating cycles. These shifting phantasies regarding love, hate, and knowledge make for chaotic, short, and taxing treatments. Like fender benders,

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the analyst may play some counter-transference role in enacting various pathological phantasies with the patient. However, even when the analyst maintains or regains a balanced and measured analytic stance, this group of patients are very difficult, hard to reach, and prone to fragmentation and flight. If we realize that these momentary brushes with the analytic process is all that the patient can handle or will allow at that given period in their life, we may be able to help them to some modest degree. This may be to bring them back to a pathological state they are used to before they entered the current crisis or it may be the chance to establish analytic contact long enough to given them a taste of internal choice, peace, or freedom which they have never before experienced. Even if this is only fleeting, it still may act as a seed for some point later in time where they might make another pit stop or fender bender in which they might find some degree of healing and growth.

CASE MATERIAL
Liz came to see me after feeling on the verge of a breakdown at her new job of six months. She was the youngest of several children raised by loving parents who have always been there for us. Liz described an upper-middle class lifestyle of boarding schools where she excelled in her studies and as a member of the track team where she trained everyday for several hours and helped the school win various awards. She said her parents were loving and attentive but that when her father had taken to drinking he was angry and impossible to talk with for much of my early teen years. Liz is now twenty-six years old and still very close to her family. She relies on them for guidance and help in most matters. Her father gave up drinking years ago so they have a very good relationship now but Liz still gets fed up with him sometimes. In college, Liz excelled at her classes and was on several sports teams. She told me she could see looking back how she worked very hard and was extremely focused but that it was all for something she believed in and enjoyed so it didnt seem like a burden. After graduating with high marks in her business degree, Liz was offered several prestigious jobs. One was locally, near her family, working with local charity organizations to help develop new approaches to serving the poor. Liz wanted to take the job and said it felt right and was very exciting. I would be really hands on taking my business skills to the streets and actually making a difference. The other offer was from a major corporate law firm across the

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country. She was also excited about this opportunity but was unsure what to do. Lizs father and several other family members told her to Go for the big bucks. It is a perfect career with enormous earning potential. She felt they were probably right and they said they would help me out in whatever way I needed so to just try it out and know the family is backing you. So, six months ago Liz moved out to the West Coast to begin her new corporate job. She had no friends or relatives in the area and had only met a few executives at the company during the interview process. She began working in a highly demanding, high stress environment in which a typical day was 12-15 hours with no real lunch break. Very soon, she was taking home at night and coming into work on Sundays. When I asked about this, in response to her telling me things were pretty stressful, she immediately told me that type of schedule is pretty standard in the industry, everyone does it. Liz told me about being tired all the time and never having any time to herself. She was looking more exhausted and depressed. Thus, pulled by my counter-transference of not feeling like I would ever put up with this situation and therefore neither should she, I asked her about what was so difficult about setting limits. Here, my question was important and relevant but it would have been better if I had interpreted how she was presenting all the tired stories but never adding anything about wanting limits and therefore she seemed to want to have me step in and set them for her. Instead, I was playing out a projective identification based transference phantasy. Another way of viewing this dynamic is that I was quickly part of an Oedipal triangle in which there was the job, Liz, and I. She would show allegiance to one and then the other. I found myself fighting against one for the benefit of the other. I felt pulled to be a good father stepping in to set limits on her behalf, teach her how to say no, and encourage her to take care of herself instead of be a slave to her job. But, when I acted this out in a modest degree, I noticed that Liz now turned away from her despair and exhaustion to a multitude of concrete reasons why she had to work under those conditions, how it was normal, and how everyone did it. So, one interpretation was to point out how she wanted me to be the good, soothing father who would set limits for her. Now, I also interpreted that she was reacting to that wish and turning into a stern, matter of fact father who was explaining to me how there is work to be done and that is just the way it is. At one point, she turned to talking about trying to do her best and not let anyone down. This last statement was a masochistic rise to excellence that had to occur regardless of how tired or unhappy she was. I interpreted her want to please me, her boss, and her father no matter what and she was going to show us all what

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a hard working good little girl she was even if that meant sacrificing her own needs. So, very quickly in Lizs analytic treatment, she illustrated her need to use work and performance in general as a retreat from her worries of judgment and her never ending struggle to win over her objects. Up to the point of this new job, it appeared that Liz had successfully used excelling and doing her best as a defense against various depressive anxieties and some more primitive paranoid fears. In her mind, over achieving had always left her feeling accepted, loved, and victorious. But, the demands of this new career and her lack of interest in the work itself created a fragile psychic retreat that was springing multiple leaks. She tried to shore these up by working harder and increasing her level of denial about her true feelings and instead justifying her focused dedication with logic about industry standards. Lizs object relational conflicts were intense. On one hand, there was her desire to please her father and not fail what she saw as her obligation to follow his guidance. So, when I tried to be compassionate and helpful, Liz heard that as me encouraging her to disappoint her father/boss. When I made this interpretation, she felt able to speak about the other side of her conflict. She told me how she was angry with her father for always telling her what to do and then expecting her to like it and excel at it. After she discussed this for awhile, I interpreted that while this may be true, it also looked like she was now being her demanding father all by herself, exacting long hours and no time for personal enjoyment. For a moment she reflected and took this in and told me she thought it was accurate and useful. But then she said, But I want to know what exactly to do to begin working on this problem. I pointed out that she in a bossy, demanding way was now making me into her boss/father and wanting my instructions on her next assignment. This sort of interaction led me to think she was very unsure of what would happen if she gave up this fixed, strict approach to life. I interpreted that she did not want to give up the chance to be the best but hated that she had no choice in the matter when under her own strict fatherly demands for excellence. To give herself a chance and see what she might want instead felt like a frightening disappointment to her objects and a turning toward an unknown new way of being where she felt no control and no one to turn herself over to. Liz said she thought she wanted to try this out but wasnt sure what the right decision was yet. The stress of trying to please this projection of a highly demanding and never satiated father object left Liz collapsed and depressed. She lost weight, looked haggard, and developed stomach problems. Now, she spend what little free time she had either going to gastro specialists for tests or trying to rest. This was

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difficult as she was working fifteen hour days now. Finally, the physical manifestations of her cruel and constant demand on herself took its toll. She was so exhausted and sick that she had to take two weeks off and stayed in bed most of the time except to see me or her other medical specialists. Again, she separated this problem out in a concrete fashion and saw it as a stomach problem not related to either her job, her father, or her emotional conflicts. Over the next month, the stress of her psychological issues created even greater problems. Liz became increasingly depressed and anxious under the burden of tolling away at something she felt she had to excel at even though she didnt really see the point of most of the work, it is boring and repetitive. At one point, Liz said she hated it was close to quitting. But, at the same time, showing the degree of internal conflict she struggle with, Liz told me she didnt want to disappoint her boss. She continued reacting to her desire to quit by saying, maybe I just need to get into the swing of things, put my head down, and stop complaining. I should realize life is not supposed to be a bowl of cherries. The bit about not wanting to disappoint her boss rang a bell for me as Liz had mentioned several times how she felt obligated to go with whatever her father recommended and not let him down. She said he is always very supportive and freely gives me advise. Liz said she is often unsure about how to proceed in life so she will ask him what to do and always takes his suggestions. I interpreted that she wants his love and approval and has decided she should do what he says and not disappoint him or she will loose this precious commodity. But, that puts her in a spot of having no choice of her own without feeling very guilty. So, she has to become an angry victim to what she now sees as either his unreasonable demands or her own pathetic incompetence. I interpreted that she has a mind of her own and some ideas of what she wants to do, but is anxious that if I find out I will be disappointed or disapprove. She would be turning away from me and father, leaving her feeling guilty, lonely, and scared of reprisal. So, she doubles her efforts to be the best and please me, her boss, her father, and her own internal slave driver rather than to be herself and cause trouble and face the consequences. Here, I was interpreting the core anxiety behind the projective identification defenses she was utilizing. Liz responded, I am very angry with my father. He always tells me to go for it, do whatever it is, like moving out here and taking this job. He says he will always be there for me and support me. But, I feel totally left alone. I did it for him in a way and now I regret it sometimes. But, I dont want to be a quitter. What do I do?! Here, Liz was able to access and share a formally split off conflict around her relationship with father. She wants to please him and wants to feel his supportive love in exchange. But, she feels he has betrayed her and she in

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turn is sick of doing what he wants instead of what she wants. As soon as she expresses this warded off feeling, she becomes conflicted and guilty. She sees herself as a quitter if she stops catering to father. But, she wants to feel more independent as well. Then, she jettisons the conflict into me and demands, what do I do? Here, she wants me to become her father and tell her what to do. I made that interpretation and Liz said, I see what you mean, but I dont want to have to make the decision myself. I interpreted that she uses me as a father to avoid and the guilt and anxiety of being her own boss but then would feel trapped by my fatherly advice. I said, from everything you tell me and how you describe your work, it seems clear you want to quit and find something you will enjoy instead of trying to appease your father, your boss, and myselt. But, you are such a taskmaster that you feel guilty and like a quitter so you dont want to admit wanting more freedom and independence. You would rather have me tell you to quit your job than face your own desires about it. Here, I was interpreting the projective identification process that shaped her transference. Instead of acting out her projected defenses in the form of interpretive enactment, I was able to clearly spell out her unconscious struggles and fears around love, hate, and growth. Liz responded by telling me she should just find a way to be more efficient and work smarter. Everyone else in the office doesnt seem to have a problem. I should stop whining. I said, You are suddenly reacting to my idea that you have your own feelings and wishes. You are saying you are simply lazy and need to work harder. Now, you are acting like how you see your father and you want me to fight him and disagree with him. So, I was now interpreting her rapid cycling between being the demanding father, the desperate child, and the stubborn child who will prove she can do it. At the same time, Liz was shifting her phantasy view of me in accordance to each self/object perspective. Unfortunately, Lizs health continued to deteriorate and she became more depressed. Her coworkers noticed and her boss suggested she go on a medical leave. I think she took this as her father giving her permission to stop working at a job she hated. So, she informed me by phone that she was leaving the next week to be with her family for several months and thanked me for my services. While her treatment was short and rocky, I believe we did accomplish something positive given the circumstances. While I initially was pulled into an interpretive acting out of some of Lizs defenses against differentiation and growth, I was able to find my therapeutic footing and help her address some of her core conflicts and internal anxieties. Many patients show up to our offices in similar states of crisis, anxiety, and urgency. They leave fairly soon afterwards for various reasons. But, if we strive to make and maintain analytic contact with them, there can be a degree of help,

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integration, or change. Perhaps we can only offer a mild support and balance for them but this may be all they can take in at that time. We can still help them learn about themselves and create a sense of hope or curiosity. Some of these short term cases take a quick pit stop on our couches before resuming the precarious race they are in. For others, this pit stop is the first step in realizing they have a choice to step out of that race and into something new and nourishing, something they can author instead of feeling passive and victimized. We strive to illuminate the patients unconscious object relational world, gradually providing the patient a way to understand, express, translate, and master their previously unbearable thoughts and feelings. We make contact it their deepest experiences so they can make contact with their fullest potential.

CASE MATERIAL
Edward was told by his company to seek therapy and find out why he always stayed at work past the time when everyone went home, why he kept garbage and old food containers around his desk even though his manager asked him to not do that, and why he insisted on doing certain projects for the company which no one ever asked for. This last point was also part of a conflict in which Edward insisted he knew what was best for the companys wellbeing and felt compelled to take action on these projects even when no one asked or even if someone said not to. He was caught sleeping at his desk several times because of how late he stayed there everyday. From what I could gather, he had been with the company for so long that they tolerated his odd behavior for many years but a new manager would not tolerate it. In fact, it sounded like the company was trying to fire him and actually they did tell him if he continued with his current behavior they would. Edward appeared disorganized and low functioning, but intellectually sharp. He was obese and disheveled, with his underwear hanging out the back, his shirt untucked, and three pairs of glasses hanging off his neck. Over the next few weeks, I noticed he wore the same clothes every time I saw him. Every pants pocket, shirt pocket, and jacket pocket was crammed full of envelopes and pieces of paper. I asked him about that and he told me it was his filing system and that he kept his mail, mostly unopened, in this filing system. Edward was extremely anxious and scattered as he talked and was prone to rambling and unlinked topics. He told me how stupid his manager was and how the manager doesnt realize by making me waste time coming here I am not at work making sure everything runs smoothly.

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While Edward was definitely functioning at a psychotic level, he was also extremely smart and knew how to figure out certain systems and projects at work that made him a valuable worker for many years. He company had tolerated his odd ways for many years but now a new manager and tough economic times meant Edward was seen as a liability to be gotten rid of. Over a period of several months, I listened to a pattern of feelings and thoughts that I attempted to interpret. The main theme I interpreted was that Edward tried to keep his company going on, functioning properly, no matter what. He stayed there till midnight many nights and came back at 6am. As a result, his apartment was so unkempt and full of debris that his landlord was ready to evict him. In fact, that is what happened to his last apartment. I felt, in the countertransference, that he was desperately trying to keep the company alive, with a sense of single handed power and control and desperation, as if he was the sole lifeguard on a treacherous beach which he had to guard 24/7. I made this interpretation and he responded very concretely, agreeing that yes, this was the case. When I began hearing about Edwards upbringing, this pattern made some sense. He told me, Your type, the psycho doctors, like to hear about the mother and the father. Well, I am not sure I want to trust you. It has never been helpful to trust anyone as far as I can tell. History is a showcase for reality. I would rather seek out the outer world and the edge of the grid as it is called by the survivalists. They seem to have some genuine ideas of how to live and avoid the traps. But, right now I have to work and save money so I could do that one day. If I get fired, I may do that. But, for now, I must make sure the company stays intact, for their own good. They dont know they need me but if I was gone they would quickly see what a mess things become. No one seems to ever care until it is too late. Where was I? Oh. You may want to know about my family but will you only stare at me like all the rest? I said, You are sure I will judge you. Maybe the things you want to share make you anxious and guilty? Edward said, If you judge me, it will be a secret you put in your little book. People seem to either keep their thoughts hidden or they come right out and feel they can call themselves superior. I was surprised when they spit on me in high school but no one else seemed surprised. I dont have a good feeling about this. I said, You are starting to share something very difficult, painful. Lets take it slow and talk about what you are feeling. Slowly over time, Edward told me about being one of two children raised by an alcoholic and psychotic mother. He said, Sometimes, she would go crazy and beat us. Other times, she was super depressed and suicidal. I came home from school one day and found her in a puddle of blood after she tried to kill herself.

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Later, my father yelled at me for not keeping a good watch on her. He wanted me to always keep an eye on her and make sure nothing bad ever happened. He told me I had failed and it was my fault. I asked where his father was when all this was happening. Edward replied, He was always at work and never home so we had to take care of everything. Here, I listened closely and interpreted, that was so painful and scary. You did your best to care for her but it was never enough. You were a kid, she had severe problems, and you ended up feeling responsible for her health. Maybe that is what you are feeling at work, trying to keep the company alive too. Edward responded, Yes. I am, they need me and no one else knows all the ends and outs. So, he replied to my interpretation of his emotional repetition of caretaking his suicidal and out of control mother with a very concrete view. Edward seemed to fluctuate between trusting me and then seeing me as a part of the system, pieces of a puzzle destined for collapse because of manipulation and blind ambition. When he relaxed a bit and saw me as on his side, he shared his real knowledge of the true layers of life. He told me he was in touch with many hidden messages and signs that appear in life if you know how to notice them. He told me he had been sent certain messages, probably from certain Gods, maybe a Goddess. These messages came before the 9/11 terrorist attacks and he didnt recognized them completely or their significance. Therefore, I said, So, you must feel terrible that you could have maybe stopped the attacks but you didnt realize the essence of the messages. He agreed and said now, looking back, he can see that he was being used as a conduit for certain celestial bodies, perhaps the Greek goddess I mentioned, who provides a window into time and space for reasons that are important to the individual and humanity as well. I interpreted you must feel a great burden to have to hold all that important information and thought to myself that this was similar to him having to take care of the company and similar to his phantasy of wanting to predict, prevent, avoid, and heal his mothers suicidal and aggressive behaviors, but ending up feeling to blame somehow. After a few sessions, I asked Edward if he was dating anyone. He laughed and said, After that bitch, how could I ever get near anyone. I just want to get away from people, that is my mission in life. He told me, I know you are just waiting for this, it is what they train you to do. How will you react? I dont know if I can trust you but you probably wont stop asking. I said, This is very difficult. Tell me what you can and also tell me why it is so hard to trust me. Edward then proceeded to explain how from ages 10-18 years old his mother preyed on him sexually. She would come into his room at night to fondle him, masturbated him in the car, and kissed him inappropriately before he went off

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school in the morning. He was clearly anxious telling me this and said, She was like a mechanical vulture, flexing her metal claws and biting into me with a sharp seriated beak. The way he said this gave me a sudden scare as if he was changing into something dangerous. This was a difficult moment in which I believe projective identification threw me off balance, giving me a taste of mother becoming psychotic and aggressive. He was in a momentary psychotic fusion state with mother and I was pulled along for the ride. The sexual trauma left Edward with very distorted and contorted images that provided a primitive method of understanding the frightening objects that he was populated by. An example was when he told me about the Greek myth of a sexy woman who was found out to be a murderess. She seduces you and then turns on you, ripping you apart and leaving your entrails for the wolves. I interpreted, feeling your mother turned from someone you wanted to look up to and love into a monster is very disturbing. Edward replied, I have spent my life trying to escape people and only want to be left alone in peace. I said, It is hard to trust me. You want to but you think I might judge you. He said, I dont want to just quit my job and let everyone down. I would be lying to them just like people lied to me when they said to just ignore them spitting on you, picking on you, and calling you names. Edwards idea of a special woman, who was a goddess and might be either good or bad, but held great power, was part of his thinking in many ways. He told me he thought there were important clues that are left throughout time for those who can recognize and believe. He told me he has noticed in certain news stories over the years and in certain novels he has read of a pattern or theme regarding a certain type of woman who is special and may be linked to important world situations. Besides work, Edward did almost nothing. He did not socialize or go out. But, he had a few specific interests. He told me he liked to read comic books and was currently very interested in following a series of stories about a seemingly ordinary girl who seems very regular and peaceful. But, we are starting to find out, only slowly and somewhat ominously, that she has a certain shadow life. It is turning out that she may actually be the mysterious anti-hero who slays dragons at night. There is no concrete evidence that she has killed a dragon yet, but it is starting to point in that direction. Here, I thought he was telling me about his internal confusion about his objects. Were they normal and peaceful, were they suddenly turning into something else, and was that something else wonderful and protective or sinister and deadly. Also, I thought he wanted to grow out of his ordinary self into a stronger person who could stand up against the dragon but he felt anxious. He might be a hero or he might be a villain killing off an innocent

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dragon. Here, I thought he might feel this was the dangerous urge he had to be independent and separate, to differentiate, or to express his angry feelings instead of always being the helper. In general, Edward felt he had always been taken advantage of by all the authorities he had ever looked up to. I interpreted, I wonder if it is just a matter of time before you see me that way. Or, is there a way for us to build some trust? He replied, I am still assessing that. I interpreted that he was trying to make sense out of his mothers crazy behavior, trying to repair her in his mind, and control things at the company that seemed out of control. He felt he had to stand watch over mother and work. He said, That is an interesting way of thinking. I like that. I will consider it. During one session, he told me, I feel good about sharing with you; it is a new experience even though I dont really think much of the process. Later in the same session, he said, I dont know how this could ever help. It is useless. I interpreted his fear of exploring these painful and frightening feelings and memories and trying to trust me. He agreed to keep trying it for awhile. Unfortunately, Edward was fired from his company and then told me, I am not coming back. I dont want to spend my money on this. I may look for another job or I may just see about moving away, somewhere far away like the survivalists who live off the land, maybe to Montana or somewhere else where there is no one to bother me. Thus, Edward ended his pit stop with me. He had spent his life trying to survive a vicious external world and trying to find his way through a vicious internal world. He survived but at a great price. His pit stop was not voluntary. Perhaps his next one will be of his own choice. Edwards struggle with feeling persecuted by the world was in part the result of his primitive depressive guilt and anxiety over separating and turning away from what he saw as the incredible needs of his job and his mother. He wanted to take care of himself for a change but didnt want to abandon his job/mother for fear of causing hurt and hate. For a bit, I fell into his defenses against these anxieties by interpreting his sense of burden and guilt, rather than interpreting his desire and fear of differentiation, growth, and change. Both interpretive directions were accurate, but the first was more of a collusion with his projected defenses against intense paranoid and depressive phantasies and the second was more his core conflict and desire.

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DISCUSSION
Hinshelwood (2003) has noted that the Kleinian understanding of countertransference and the Kleinian technical approach has been greatly influenced by Bions (1959) concept of containment. Hinshelwood outlines the three possible outcomes in that process. In the first level, the analyst/mother reacts to the intensity or forbidden nature of the patients projections by becoming rigid or unaccepting, causing the projection and the patients internal experiences to become formless, meaningless, or unprotected. Bion (1959) has explained how the analyst/mother needs to be to a degree disturbed in order to be able to acknowledge the disturbance in the patient, but not so disturbed as to reject the patients anxiety or desire. The second level of containment is the more ideal result. The analyst/mother becomes a flexible, accepting container who is affected by the projections but only in a way that is beneficial to both parties. Initially, the analyst does feel the dread, guilt, persecution, and confusion in unison with the patient or even in isolation after the projective discharge, but hopefully sustains their greater ability to integrate, understand, and ultimately teach via returning the modified projection through the vehicle of interpretation. The third possible result of projective identification is when the projection overwhelms the analyst and the container function collapses or becomes fragmented and splintered. Hinshelwood (2003) notes that failure to properly contain is to be expected but an ongoing effort to regain and maintain a mental balance is critical. When the analyst becomes confused or overwhelmed by the projection of the patients defensive system, he is likely to become rigid, critical, or even soothing in an artificial, carbon copy or echo sort of way that does not really soothe, heal, or support because it is in fact a collusion with the patient against certain taboo ways of thinking, feeling, or acting. These taboo states tend to be focused around individuation, growth, difference, and separation. Segal (1975) has noted how important it is for the patient to internalize a new object who is capable of containing and transforming their anxiety. I would add that it is vital, especially for the type of patients outlined in the case material who are worried about the implications of their independent, individual strivings, to be able to introject a new version of the object who is not only capable but willing to accept, contain, and transform. I think many of our patients, such as the two outlined in the case material, do not trust that we are willing to take on their hidden desires for change, difference, separation, and challenge so they chose instead to project a variety of defenses that block, cloak, or obscure these wishes

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and thus protect themselves and the object from possible retribution, injury, loss, or disappointment. In conclusion, there are times when the patients over reliance on projective identification brings both patient and analyst into a mutual defensive position that feels comfortable and repetitive. This pattern of mutual avoidance comes forth in the analysts ongoing interpretive acting out of certain object relational phantasies that take the focus away from other more conflicted aspects of the patients internal world. While Kleinians view projective identification as involving elements that can be solely within the patients unconscious phantasy world, they also have delineated ways in which projective identification becomes part of the interpersonal and interactional situation by which both patient and analyst act out various projected roles. This paper has described how counter-transference acting out can cause the analyst to interpret only selective aspects of the patients desires or fears and avoids or denies others, thus colluding with the patients basic defenses against these uncomfortable states of mind. The analyst process and the successful establishment of analyst contact (Waska 2007), create the potential space for new knowledge and understanding which can create dependence and union as well as independence and separation between internal links of self and other. This potential psychological change can be extremely threatening in the mind of the patient, who is filled with paranoid-schizoid and/or depressive anxieties for self and object. Therefore, to eliminate this intolerable and unbearable state, the patient may resort to intense projective identification in which he draws the analyst into a mutual defensive acting out. The analysts part in this unfolds in a series of one-sided interpretations (Feldman 1991) If the analyst is in fact made guilty, anxious, or angry by the patients projection of separateness, difference, and division, he may be more susceptible to enacting a common or mutual defensive posture against them. The analyst can escape his own embarrassment, shame, or judgment by ignoring, denying, or camouflaging his reactions and turning to another focus instead. This becomes a transference/counter-transference union in flight against certain other elements of the patient that were split off with projective identification. The mutual defense reassures both parties, at least temporarily, that all is ok and that the object is not angry, destroyed, or lost. Joseph (1988;1989), Oshaughnessy (1992), and Carpy (1989) have all pointed out that enactments, including the interpretive variety examined in this paper, are inevitable, but if properly handled can provide valuable clinical information about the patients struggles with self and object. Once the analyst recovers his analytic balance, he can find the freedom to allow the patient to be

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different in his own mind. This provides a new type of object for the patient to introject, one that accepts and allows new, different, and separate ways of thinking and feeling that can exist without damage to or attack from self and/or other. Of course, this will feel refreshing, relieving, and supportive to the patient but also alarming, unfamiliar, and alien. Therefore, the initial anxiety and mistrust of this new object can provoke yet another cycle of defensive projective identification that is pushed into the analyst for aggressive, protective, and reparative reasons. Once again the analyst will need to work through the paranoid and depressive counter-transference reactions to this, especially as they affect the interpretive arena. The consistent working through of this cycle is necessary in the overall healing and transformation the psychoanalytic process can provide patients.

Chapter Nine

SUMMARY
This volume has covered a wide range of issues that arise in the practice of psychoanalytic psychotherapy. Each chapter has taken an indepth view of specific clinical problems form both a theoretical and a technical vantage. The reader has been brought into the actual verbal and emotional interaction between analyst and patient, as the nuances of transference and counter-transference are played out in the analytic situation. While each chapter has brought clarity to very dense and often perplexing psychoanalytic issues, this volume has also taken the reader into a better understanding of ow the general practice of intensive psychoanalytic psychotherapy actually unfolds. The wealth of verbatim case material has illustrated just exactly what the analyst says when working to establish and maintain analytic contact. This very candid approach to writing about the nuts and bolts of the Kleinian method provides the reader a way to understand the very difficult therapeutic road the analyst must travel when striving to enter into a patients private psychological world and truly sort out their unique internal experience. By examining a wide variety of technical issues with a wide variety of patients, this volume also shows the ability of the psychoanalytic method to help not only neurotic patients but also borderline, narcissistic, and psychotic individuals. The Kleinian system and in particular my own Kleinian hybrid of analytic contact is well suited to find the often well hidden and well defended core emotional conflicts each patient suffers from. Then, a slow, often complicated and uncharted journey can begin in which the analyst can assist the patient to face often previously unbearable phantasies and feelings about self and other.

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Then with hard won moments of working through, learning, and acceptance, a gradual internal transformation can be set in motion. As illustrated throughout the book, this Is not always easy and not always successful. In fact, the modern psychoanalytic approach, as pioneered by the Kleinian school, has discovered the clinical value of understanding counter-transference enactments and projective identification and interpretive acting out that is fairly common, especially when working with more disturbed patients. So, many of our cases are a mixed bag of results, with a great deal of turbulence along the way. However, even in these more chaotic and less than optimal clinical situations, we can still provide a new way of understanding life, a path through anxiety and mistrust, a healing of devastating guilt, a way to accept loss, a method of repairing broken images of self and object, and a path ot experiencing life and relationships as bearable, full of potential, creative, and desireable. The promise of loving and being loved can be reached. This book has shown that by using the psychoanalytic approach, all these changes are possible, one session at a time. The steady, regular investigation of transference, counter-transference, and projective identification by the use of the interpretive process combine to reach the deepest aspects of our patients psychological experience and in doing so we give them back choice, clarity, and identity.

ACKNOWLEDGMENTS
I wish to thank my patients for sharing their lives with me and choosing to expose their most vulnerable feelings to me as we struggled together to learn, repair, and change the difficult problems that have prevented them from living life to the fullest. As a result of the analytic encounter, I find myself brought into greater awareness of how the mind functions. In this way, each patient helps me help the next patient. All clinical material has been disguised, censored, or changed to protect the confidentiality of the patient. I am always conscious of the great contribution my wife Elizabeth provides. She is my foundation in my personal and professional life. As I have mentioned in my previous books, my love for her has only grown in the past few decades. Finally, I wish to extend my gratitude to the following journals for allowing previously published material to appear in this volume. I thank the Journal of Psychoanalytic Social Work for allowing use of material in Chapters 1 and 5(1), the American Journal of Psychotherapy for material in Chapter 4(2), the American Journal of Psychoanalysis for material in Chapter 6(3), and Novoscience Press for material in Chapters 7 and 8(4).

(1) Waska, R. (1999) Psychoanalytic Perspectives Concerning the Impact of


Managed Care on Psychotherapy, Journal of Psychonalytic Social Work, 6:2, 61-77 Waska, R (2000) The Symbolic Object, Psychoanalytic Social Work, 7:2, 25-44 (2) Waska, R. (1997) Self-Mutilation, Substance Abuse, and the Psychoanalytic Approach, The American Journal of Psychotherapy, 52:1, 18-27 (3) Waska, R (2000) Paranoid-Schizoid Anxiety, Triangulation, and Oedipal Trauma, The American Journal of Psychoanalysis, 60:2, 163-176

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(4) Waska, R (2009) Do You Hate Me? Have I Hurt You? Defenses Against Growth, Separation, and Individuation that Create Interpretive Enactments, Part One: Fender Benders and the Shared Defensive Systems of Less Difficult Patients, in Handbook of Hate, Novascience Publications, in press Waska, R (2009) Do You Hate Me? Have I Hurt You? Defenses Against Growth, Separation, and Individuation that Create Interpretive Enactments, Part Two: Pit Stops and the Shared Defensive Systems of More Difficult Patients, in Handbook of Hate, Novascience Publications, in press

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INDEX
anger, 17, 27, 34, 49, 52, 53, 54, 70, 74, 77, 103, 104, 115, 125, 129, 131, 133, 147 annihilation, 49, 52, 54, 62, 63, 68, 98, 118 abusive, 34, 44, 46, 80, 117, 121 anorexia, 115 accidental, 82 antidepressant, 74, 85 achievement, 105 antidepressant medication, 85 activation, 52 anxiety disorder, 29 acute, 100, 115 argument, 95 adaptation, 45, 83 artery, 82 adjustment, 30 articulation, 91 adolescence, 66 artistic, 115 adult, 17, 44, 66, 72, 80, 81, 107, 115, 116, 124 assignment, 150 adults, xi, 90, 135 assimilation, 92 affective experience, 83, 84 assumptions, 41, 42 age, 68, 81, 83, 85, 86, 113, 119 atmosphere, 16, 93, 97, 107 aggression, xii, 40, 49, 55, 130, 146 attachment, xii aggressive behavior, 155 attacks, xiii, 18, 55, 63, 68, 69, 72, 140, 155 agoraphobia, 115, 116 authority, 119, 133 aid, 129, 132 autonomy, 94, 135 alcohol, 79, 81 avoidance, 18, 40, 125, 158 alcohol abuse, 79, 81 awareness, 17, 24, 60, 92, 106, 163 alcoholism, 78 alertness, 57 alternative, 114 B amalgam, 117 ambiguity, 55 back pain, 75 ambivalence, 73, 86, 114, 123 backfire, 102 ambivalent, 28, 101, 121 bail, 35 American Psychiatric Association, 165 barium, 73 analysts, 25, 28, 29, 40, 131 barium enema, 73 barriers, 37

132

Index
classes, 148 classical, 19, 22, 23 classification, 141 cleaning, 69 clouds, 30, 142 cockroaches, 103 cognition, 93 cognitive function, 111 coherence, 40 cohesion, 62, 98, 123 colds, 63 collaboration, 90 collective unconscious, 42 collusion, 28, 128, 129, 157, 158 commodity, 151 communication, xii, 17, 45, 61, 90, 95, 98, 107, 141 community, 60 compassion, 117 compensation, 49, 50, 57 competence, 134 competition, 25, 37, 40, 113, 114, 131 complement, 96 components, xii, 73 conception, 95 concrete, 24, 51, 71, 91, 149, 150, 155, 156 concreteness, 62 confidence, 134 confidentiality, 27, 29, 31, 163 confrontation, 81 confusion, 66, 145, 156, 158 construction, 72, 140 consulting, xi, 50 continuity, 100 contracts, 19, 30, 31 control, 26, 27, 36, 67, 68, 69, 70, 84, 91, 103, 113, 120, 135, 137, 138, 143, 150, 154, 155, 157 conversion disorder, 60, 65 conviction, 136 corporations, 32 correlation, 90 corruption, 36 costs, 22 counseling, 92

basketball, 126 behavior, 34, 63, 70, 78, 79, 82, 83, 85, 104, 153, 157 beliefs, 67 bell, 151 benefits, 20, 23, 31, 57, 145 benign, 44 binding, 41, 110 birth, 96, 110, 112, 141 blame, 30, 47, 49, 79, 155 blaming, 30, 50, 72, 82 bleeding, 66, 68 blind spot, 128, 140, 141, 142 blocks, 83, 101, 123 blood, 68, 77, 84, 154 body language, 60 bonding, 100 bonds, 93 borderline, xii, 16, 17, 22, 23, 60, 79, 80, 101, 122, 161 bowel, 64, 67, 68, 69, 74, 116, 122 boys, 106 brain, 30, 75 breakdown, 57, 58, 83, 115, 147 broad spectrum, 67 brothers, 44, 46, 47, 80 buffer, 57 bulimia, 66, 67 burning, 82, 84, 85

C
cancer, 75 carbon, 158 cardiopulmonary, 59 care model, 25 caretaker, 36, 128 case study, 16, 124 catastrophes, 18, 125 celestial bodies, 155 chaos, 49, 54, 75 cheating, 31, 35 cherries, 151 childhood, 44, 51, 82, 117, 118, 134 children, xi, 60, 65, 68, 71, 147, 154

Index
courts, 126 craving, 36, 74 creativity, 17, 49, 125 credit, 51, 53 crime, 34 criticism, 134 crying, 104, 105 cultural influence, 115 culture, 93 curiosity, 37, 78, 152 currency, 89 customers, 44, 46, 50, 51, 53, 54, 55, 57 cycles, 126, 132, 139, 147 cycling, 152

133

Diagnostic and Statistical Manual of Mental Disorders, 165 diarrhea, 67 diet, 68, 69 differentiation, 17, 18, 94, 98, 111, 115, 118, 119, 122, 123, 125, 128, 141, 142, 152, 157 disability, 50, 51, 67, 73, 133 disabled, 116 disappointment, 66, 150, 158 discomfort, 75 disorder, 59, 60 displacement, 84, 91 disputes, 67 dissociation, 71 distress, 75 distribution, 44, 60 D division, 85, 159 divorce, 80 danger, 41, 43, 45, 61, 75, 110, 114, 117, 121, doctor-patient, 64 141 doctors, 60, 154 dating, 84, 155 dominance, 137 death, 41, 54, 67, 98, 110, 114, 129, 135, 141 downsizing, 57 debt, 24, 73 dream, 118, 119, 120, 122, 137 defenses, xii, 18, 31, 37, 41, 43, 52, 53, 62, 75, drinking, 79, 81, 148 92, 131, 134, 138, 140, 141, 151, 152, 157, drug abuse, 77, 79, 82 158, 159 drug addict, 135 defensive strategies, 127 drugs, 44, 48, 81, 85 defensiveness, 40 drying, 63 deficit, 72, 112 duplication, 106 definition, 61, 65, 68, 142 duration, xiii deflate, 103 duties, 73 delusion, 116 delusions, 43, 46, 72 denial, 28, 31, 35, 85, 100, 131, 138, 149 E depersonalization, 77 depressed, 26, 66, 103, 133, 135, 137, 148, 150, ears, 28 ego, 16, 17, 22, 32, 40, 41, 43, 44, 45, 46, 48, 151, 152, 154 49, 52, 53, 56, 58, 60, 61, 62, 65, 72, 80, 83, depression, 65, 67, 80, 84, 116 87, 90, 92, 93, 95, 96, 99, 110, 113, 114, deprivation, 17, 43, 52, 109 122, 123 derivatives, 29, 94 elaboration, 61 desert, 72 elderly, 116 destruction, 86, 100 emotion, 83, 86 detoxification, 55, 56, 78 emotional, 16, 37, 42, 50, 52, 58, 64, 66, 67, detoxifying, 99 82, 126, 133, 139, 150, 155, 161 devaluation, 16 emotional conflict, 64, 150, 161

134
emotional distress, 50 emotional state, 67 emotions, 61, 77, 86 empathy, 127 employees, 19 employers, 19 encapsulated, 61, 62 encouragement, 129 energy, 52, 67, 68, 83 entanglements, 139 enterprise, 101 entrapment, 18 environment, 15, 77, 83, 111, 120, 148 equilibrium, 94, 142 evil, 51, 66, 69, 87, 119 evolution, 95, 99, 120 excitation, 94 exercise, 40 exposure, 29, 111 external environment, 49, 84, 90, 109 external relations, 84 externalization, 83 eyeball, 118 eyes, 130

Index
food, 67, 69, 71, 74, 110, 111, 115, 153 forgetting, 24 fragility, 51, 60 fragmentation, 62, 69, 74, 83, 98, 147 freedom, 147, 152, 159 friction, 128 friendship, 93 frustration, 54, 66, 72, 109, 110, 111, 112, 124 fuel, 20, 30 fulfillment, 56 funds, 26 furniture, 121 fusion, 63, 110, 111, 112, 119, 123, 156

garbage, 153 gas, 73 gastrointestinal, 59, 73 gel, 142 gender, 78 glass, 70 glasses, 153 goals, 28, 33 government, 27, 32 greed, 31, 36 F grief, 27, 50 group involvement, 39, 41 failure, 126, 136, 140, 158 family, 36, 39, 44, 85, 115, 117, 119, 122, 129, groups, 40, 42, 56, 59 growth, xi, xiii, 17, 18, 49, 93, 125, 128, 138, 130, 135, 136, 148, 152, 154 140, 141, 142, 147, 152, 157, 158 family members, 148 guidance, 133, 148, 150 fat, 66, 71 guidelines, 27 fatalistic, 35 fee, 21, 22, 24, 26, 27, 31, 34, 35, 36, 74, 104 guilt, 20, 36, 50, 118, 127, 128, 130, 131, 132, 135, 138, 147, 152, 157, 158, 162 feeding, 47, 52, 100 guilty, 34, 74, 126, 130, 136, 137, 151, 152, fees, 15, 27, 28 154, 159 feet, 121, 142 gut, 82 fire, 74, 153 fishing, 129, 130 flavor, 99, 104 H flex, 130 flight, 98, 147, 159 hallucinations, 66, 119 floating, 80 hands, 148 fluid, 91 hanging, 131, 153 focusing, 19, 20, 68, 113, 131

Index
hardness, 65 harm, 18, 27, 36, 78, 84, 87, 101, 121, 122, 135 harmony, 122 hate, 17, 18, 46, 50, 97, 101, 104, 112, 116, 117, 125, 128, 129, 147, 152, 157 head lice, 66 healing, 55, 78, 131, 147, 160, 162 health, 67, 152, 155 hearing, 26, 34, 59, 154 heavy metal, 81 helplessness, 46 high school, 135, 154 highways, 73 hip, 84, 98 HMOs, 22 homeostasis, 94, 98 hormone, 74 hospital, 40, 55, 67, 73, 133 hospitalization, 57, 78, 80 hospitalized, 85 hostility, 128 household, 123 human, 40, 41, 50, 68, 75, 78, 89 human behavior, 78 human experience, 40 humane, 30 humanity, 155 humiliation, 33, 48, 52, 53, 72 hunting, 101, 103 husband, 21, 32, 33, 35, 121 hybrid, 161 hypnotic, 84 hypochondriasis, 16, 76 hysteria, 59

135

I
ice, 70, 72 idealization, 114 identity, 83, 87, 129, 146, 162 illusion, 56, 66, 99 images, 156, 162 impairments, 122 impotence, 22 incestuous, 117

independence, 101, 152, 159 indicators, 68 individuality, 121, 134 industry, 148, 150 infancy, 99 infants, 90 infection, 82 inferiority, 136 injunction, 30 injustice, 15, 52 insecurity, 61, 62 insight, 36, 64, 92, 100, 106, 140, 145 inspection, 118 instinct, 39, 41, 98, 110, 114, 141 institutions, 41 insurance, 15, 19, 20, 21, 22, 23, 24, 25, 26, 27, 29, 30, 32, 33, 35, 36 insurance companies, 36 integration, xii, 40, 83, 100, 112, 126, 142, 152 integrity, 56 intellect, 86 intelligence, 48, 133 interaction, 41, 96, 110, 111, 113, 123, 146, 150, 161 interactions, 90, 145, 146 internal environment, 90, 97 internalizing, 55 interpersonal communication, 17 interpersonal contact, 98 interpersonal interactions, 145 interpersonal relations, 98 interview, 148 intimacy, 56, 96, 121 intimidating, 29, 133 intrusions, 23 invasive, 80, 82, 117 investment, 58, 112, 134 irritation, 66 isolation, 83, 158

J
jobs, 57, 148 judge, 154, 156

136

Index
mask, 87 mastery, 44, 46, 51, 56, 120 maternal, 95 matrix, 89, 94, 105, 106 meanings, 55 measures, 16, 49 medication, 30, 74 medicine, 66, 67 memory, 134 men, 32, 80, 82, 84, 85, 121, 131, 133 mental health, 19, 30, 33 mental illness, 116 mental processes, 53 mental representation, 90 mentally ill persons, 77 messages, 73, 99, 155 middle class, 65, 147 middle-aged, 43, 82 milk, 110, 111 mirror, 32, 56 misunderstanding, 67 modality, 123 modeling, 91 money, 20, 24, 27, 30, 33, 34, 35, 48, 73, 86, 102, 116, 136, 154, 157 mood, 30 mood disorder, 30 morning, 69, 155 mothers, 118 motion, 162 motivation, 83 motives, 33, 34, 119 mouse, 104 mouth, 63, 109, 110, 111 movement, 25, 67, 74, 92, 116, 122 MRI, 68 muscles, 129, 130 music, 81 mutations, 113 mutuality, 102

judgment, 127, 128, 129, 133, 142, 146, 149, 159 justice, 51, 58, 70 justification, 15

K
killing, 156 knots, 126

L
land, 115, 157 language, 60, 98 law, 148 leach, 101 leaches, 101 leadership, 40 leaks, 149 learning, xii, 162 libido, 110 life cycle, 98 life instinct, 110 lifestyle, 70, 80, 148 links, 159 listening, 35 locus, 80 loneliness, 26, 74, 78, 82, 104 loyalty, 51 lungs, 75 lying, 30, 31, 156

M
maintenance, 96 major depression, 67 malnutrition, 115 management, 45, 46, 83 manic, 43, 46, 48, 49, 53, 131 manipulation, 20, 30, 81, 155 manners, 138 manufacturing, 45 marriage, 44, 104 marriages, 65

N
narcissistic, xiii, 32, 99, 161 natural, 37, 113, 141

Index
neck, 74, 153 neglect, 26, 36, 115, 117 negotiation, 55, 93, 120 neurological disease, 59, 133 neuroses, 58, 61, 166 neurotic, xii, 17, 58, 60, 121, 122, 161 nonverbal, 95 normal, 42, 49, 52, 53, 60, 98, 99, 120, 149, 156 normal development, 42, 52 novelty, 83 nudity, 120 nurse, 42, 43 nutrition, 101 nuts, 161

137

parenting, 116 parents, 26, 42, 66, 99, 132, 147, 148 passive, 18, 101, 125, 129, 132, 141, 153 paternal, 110 pathology, 23, 56, 67 patterning, 61 peer, 22 peer review, 22 penis, 49, 109, 112, 114, 118, 136 perception, 69, 89, 110, 113, 114 perceptions, 76 permit, 78 personal life, 48 personality, 29, 30, 51, 54, 60, 64, 78, 86, 89, 130, 140, 146 personality disorder, 30, 60, 64, 78 pharyngitis, 63 O phone, 28, 73, 152 physical health, 116 obese, 153 physical therapist, 67, 74 obesity, 66, 68 physicians, 30 obligation, 136, 150 play, xi, 30, 32, 80, 109, 110, 126, 141, 147 observable behavior, 78 pleasure, 93, 104 omission, 27 poison, 116 on-line, 95 poisonous, 42, 92, 99, 122 oral, 81, 109, 114, 123 poisons, 75 orbit, 17, 93, 94, 107 polarity, 74 organic, 30, 63 police, 79 organism, 16, 97, 98, 106 poor, 53, 103, 148 orientation, 80 posture, 96, 159 oscillations, 63 poverty, 37 out-of-pocket, 21, 28, 30, 35 power, 22, 28, 30, 36, 37, 41, 46, 47, 80, 85, outpatient, 19, 23, 80 99, 100, 113, 135, 137, 154, 156 overeating, 64 powers, 45, 100 ownership, 84, 119, 127 pragmatic, 77 president, 46, 49, 50, 51 pressure, 35, 40, 63, 73, 99 P prevention, 69 pain, 16, 47, 48, 49, 59, 60, 65, 68, 75, 76, 77, privacy, 82 private, 19, 77, 139, 161 83, 84, 93, 100, 110 private practice, 19, 139 pairing, 17, 107 problem solving, 55 paradoxical, 73, 76, 83 profit, 57 paranoia, 55 prognosis, 64, 75 parental care, 115 property, vii parental influence, 122

138

Index
remission, 67 repair, 36, 84, 115, 138, 157, 163 reparation, 26, 54 resentment, 56 residues, 60 resistance, 15, 21, 24, 31, 36, 37, 64, 75, 84, 91 resolution, xii, 22, 64, 132 responsibilities, 74 restitution, 49, 65 retail, 26 retaliation, 146 retribution, 20, 47, 158 rewards, 51, 54 righteousness, 58 risk, xiii, 126, 128 robustness, 57 role relationship, 139

protection, 44, 45, 75, 80, 127, 129, 136 prototype, 69 pseudo, 75, 83 psyche, 48, 95 psychiatrists, 67, 68 psychoanalysis, 20, 28, 31, 36, 67, 91, 133 Psychoanalysis, vii, 40, 163, 165, 166, 167, 168, 169, 170, 171 psychological states, 97 psychology, 39, 40 psychosis, 64, 72 psychosomatic, 61, 65, 168, 170 psychotherapeutic, 64 psychotherapy, vii, 16, 19, 20, 26, 28, 33, 55, 78, 91, 161 public, 44, 46, 77, 78 public relations, 44 punishment, 18, 127, 129 punitive, 123, 128

sadism, 54, 102 sadness, 52, 55, 81 safety, 43, 49, 62, 65, 91, 117 range, xi, 28, 57, 80, 161 sales, 26 rape, 80, 86, 119, 121 satisfaction, 42 reality, 15, 23, 24, 30, 36, 40, 41, 43, 45, 47, 54, 57, 61, 69, 76, 84, 90, 95, 96, 112, 117, scalp, 64, 66, 68, 70 scar tissue, 78 122, 123, 137, 154 rebel, 86 scattering, 116 rebelliousness, 127 Schizophrenia, iii, 170 receptacle, 56 school, xii, 34, 80, 116, 135, 145, 148, 154, recognition, 52, 55, 61 155, 162 recollection, 71 search, 75, 79, 103, 107 rectum, 75 searching, 17 recurrence, 61 secret, 18, 46, 55, 86, 125, 130, 137, 154 reflection, 32, 147 secrets, 28 regression, 17, 56, 61, 65, 109, 113, 124 security, 56, 62, 70, 116 regular, 35, 67, 103, 104, 120, 140, 156, 162 seed, 96, 147 reimbursement, 21, 30 self-destruction, 79 reinforcement, 79, 111 self-destructive behavior, 16, 83 reinforcers, 46 self-mutilation, 16, 78, 79, 83 rejection, 17, 18, 31, 48, 78, 125, 129, 137, 140 self-worth, 34 relapses, 69, 87 sensation, 61, 66, 93, 113 relationships, 40, 41, 66, 68, 81, 89, 90, 92, 93, sensations, 60, 61, 67, 77, 123 96, 97, 105, 106, 110, 118, 122, 140, 162 sensorimotor system, 62 relatives, 148 sensory data, 65

Index
sensory nerves, 60 separateness, 61, 159 separation, 17, 18, 19, 26, 37, 60, 62, 78, 113, 120, 123, 125, 138, 141, 146, 158, 159 series, 44, 73, 76, 139, 156, 159 serotonin, 30 services, vii, 44, 116, 152 severity, 50, 51 sex, 44, 80, 81, 116, 121, 133, 135, 136, 137 sexual activities, 118 sexual contact, 119 shame, 48, 53, 126, 136, 159 shape, 107 sharing, 51, 93, 157, 163 shelter, 39, 115 shoulders, 33 shy, 120, 127 sign, 50, 140 signals, 89 signs, 60, 155 skills, 148 skin, 78, 81 sleep, 71, 100 smoke, 27 social structure, 40 somatic complaints, 59 somatization, 16, 76 sounds, 34 species, 100 specificity, 64 spectrum, 67, 126 speech, 59, 62, 115 spinal tap, 68 sports, 148 stability, 69, 72 stages, 102, 109 standards, 150 sterile, 116 stigma, 77 stomach, 75, 150 strategies, 127 strength, 40 stress, 43, 51, 65, 72, 94, 123, 148, 150, 151 subjective, 41, 91, 97 subjective experience, 91

139

subjectivity, 96, 97 substance abuse, 16, 78, 87 suffering, 23, 26, 30, 39, 45, 46, 49, 53, 54, 55, 64, 84, 85, 139 suicidal, 154, 155 suicide, 66, 70, 79, 80, 85 suicide attempts, 80 superego, 52, 86, 113, 114, 127, 141 superiority, 48 supervisor, 50, 51 surgeons, 68 survival, 47, 100 sweat, 111 sweets, 67 symbiosis, 94 symbiotic, 94, 96, 110, 113, 117, 121 symbolic, 16, 37, 49, 51, 58, 61, 62, 64, 65, 75, 89, 96, 97, 98, 99, 100, 101, 102, 105, 106, 107 symbols, 60 sympathetic, 50 sympathy, 47 symptom, 59, 63, 65, 68, 83 symptomology, 63 symptoms, 64, 68, 77, 78, 79, 87 syndrome, 59 synergistic, 112 systems, 59, 93, 110, 138, 147, 153

T
tangible, 66 taste, 147, 155 teaching, 138 technicians, 60 temperament, 115 tension, 21, 77, 83, 94, 96, 97, 106 territory, 74, 96 terrorist, 155 terrorist attack, 155 theft, 36 therapeutic relationship, 15, 28, 37, 90 therapists, 21, 29, 30, 31, 36, 81 therapy, 27, 30, 33, 34, 57, 67, 79, 80, 82, 85, 101, 153

140

Index

thinking, 35, 86, 90, 102, 105, 136, 142, 156, 157, 158, 159 third party, 22, 30, 111 threat, 62, 65, 71, 76, 81, 82, 92 threatened, 41, 44, 54, 68 threatening, 29, 41, 42, 63, 71, 79, 159 threats, 76 throat, 63, 111 tin, 75 tissue, 78 tolerance, 55 toxic, 127, 146 tracking, 97 training, 23, 111 transactions, 17 transformation, xi, xiii, 92, 120, 130, 139, 160, 162 transition, 45, 57 transition period, 45 traps, 154 trauma, 61, 62, 64, 82, 109, 112, 113, 115, 122, 123, 156 traumatic experiences, 17 travel, 73, 161 travel time, 73 treason, 50, 53 treatable, 77 trial, 34 triangulation, 17, 25, 109, 111, 113, 114, 117, 118, 121, 123 triggers, 39 trout, 130 trust, 28, 69, 74, 105, 119, 154, 155, 156, 157, 158 tumor, 31 turbulence, 162

V
vacation, 103 vacuum, 74 vagina, 49 vehicles, 35 vein, 82 victimization, 70 victims, 46, 53 violence, 44 violent, 37, 44, 54, 60, 85, 91, 122 vision, 36, 57, 59, 90 voice, 126, 127 voicing, 23 vulnerability, 87

W
walking, 67 war, 29 water, 74 weakness, 60, 61 wealth, 161 wear, 130 web, 42 weight gain, 71 welfare, 78 wellbeing, 153 wells, 128 wind, 129 withdrawal, 61, 71 women, 78, 81 woods, 119 work roles, 45 workers, 30, 49, 57 workplace, 15, 39, 42, 48, 54 worry, 33, 66, 68, 130, 136 wrists, 85 writing, 24, 161

U
uncertainty, 40 unfolded, 117, 118 unhappiness, 17, 21, 125 urine, 109

X
x-rays, 73