Tuesday, September 24, 2013

Candidates discuss effect patients have on them

In discussing Slochower’s ‘hateful borderline patient’ paper one candidate, Dimitris Tsiakos, summarized as follows:

The patient who maintains an intensely and unremittingly hostile stance toward the analyst inevitably evokes strong countertransference feelings… It might be suspected that the patient who finds it necessary to relentlessly attack the analyst has failed to develop confidence in his capacity to make a real impact on a real object, and probably also deeply doubts the possibility of receiving a genuine response from the object. Such a person has failed to internalize a stable, alive object world. In this sense, the hateful borderline patient may be attempting to establish a relationship with an object who is alternately experienced as external, and thus capable of destroying and being destroyed, and as a projected aspect of the patient's own hate. 

The last line here, speaks well to Winnicott’s ideas of the necessity of the analyst’s survival, and to the paradox in the transitional space of playful relations between what is real (external) and what is fantasy. Tsiakos goes on:

I have found that many times a borderline patient tries to involve me within his sadomasochistic pattern by making me adapt from one the strict - authoritarian figure that holds the frame and for the other by scaring me to impose something that make him angry…. There is a big question between the necessary patience of the therapist in terms of tolerating the hostile and angry feelings in order to transform them into introjected representations and the collusion to a "masochistic" state where he [the analyst] is forced to tolerate any kind of behavior [from the patient].

thereby bringing up a very important discussion about ‘When does survival cross the line to masochism?’  This very line is different for each dyad, of course. No matter where the line, an analyst may make use-- sometimes, to avoid enactments, must make use-- of feelings evoked by the patient so as to better negotiate the relationship between the two, and to help the patient, and analyst, see the impact and the projective identifications more clearly.

This very question came up at the most recent, local Society meeting when the guest speaker noted that her patient, from Europe, continued to insult Americans, including the analyst, and American education. Having been repeatedly disparaged for over a year with these invidious comparisons, the analyst finally asked him why he did not just go back to Europe then. A couple of ego psychologists in the audience seemed quite pleased that the patient got his comeuppance and that the analyst had put an end at last to the patient’s sadistic behavior. Had the analyst heretofore been masochistic? Had she felt abused and felt that she had to take it? She thought so. The analyst’s self protection is an important part of the treatment for both analyst and patient. And it is to the analyst’s feelings we look when locating the ‘line’ (dare I say "red line"?).  To wait to address what was going on between them may indeed have been masochistic (I was not there) on the analyst’s part but, unless the question was in playful paradox where both participants knew the analyst meant-and-did-not-mean banishment, her question may also have been perceived as retaliation, a failure to survive, as if she had ‘had’ it and now needed to say so. Failure to survive runs the risk of not engendering a capacity for concern but instead further relegating the patient's aggression to the Not-me.

Some kinds of self protection, just as is our masochism, are more costly than others.  Sometimes it models behavior that a patient might choose to consider for himself. If we withdraw by not explicitly addressing what is going on between us, that, too, is a failure to survive.  Once, when a patient was yelling his aspersions, I got an instant headache. Not one prone to headaches, I found it distracting. I told the patient it was important he continue saying what he needed to say, but, because I had a headache, I would appreciate he tell me in a reduced volume, which he did, seething his insults through his teeth. My headache dissipated soon after and I could listen again.  

A good outcome might be when, later, we may come to know that the patient's paramount intent was not to attack us, but was part of the process of finding us and communicating their desperate need to do so (find us). Regardless of how and in what circumstances we grapple with survival and masochism, Slochower lets us know how very difficult relentlessly attacking patients can be, as well as speaks to theories that help vitiate our failure to survive.

Fosshage, too, offers food for thought when he re-conceptualizes the classical distortion model of transference as a patterning to organize experience, assimilating or accommodating new with the old. The classical model seeks to resolve transference via interpretation and sees transference as a product solely of the patient’s psyche. Contemporary models recognize the co-creation of transference-countertransference in which each participant brings and triggers unique aspects of the self and other.

Slochower, J. (1992). A Hateful Borderline Patient and the Holding Environment. Contemp. Psychoanal., 28:72-88.      
Fosshage, J.L. (1994). Toward Reconceptualising Transference: Theoretical and Clinical Con... Int. J. Psycho-Anal., 75:265-280.

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