The Quest for Greatness in the Race to Not Be Forgotten.

Details from a brief psychoanalytic treatment with a disturbed and desperate patient in acute emotional crisis are used to consider the internal dread some patients have regarding separation from the object and their phantasy of eternal damnation as a result of self-differentiation. One patient's loyalty to her object as the only way to prevent abandonment is examined in depth, but also considered as a severe psychic struggle found in other disturbed patients. The nature of this pathological loyalty has to do with the internalized and projected demand for perfection as the only currency for love and acceptance. Theoretical considerations are offered from a Kleinian perspective.

The Flexible Function of the Modern Kleinian Psychoanalytic Approach: Interpreting Through the Unbearable Security of Paranoid and Depressive Phantasies.

Working to establish analytic contact (Waska, 2007) with a patient involves the verbal act of interpretation. But, how one interprets and what we try to hold in words is not the same with each patient. Each patient requires, invites, provokes and responds to a unique mixture of interpretive elements or approaches. The projective identification process that is so often the bedrock of the transference, and therefore the catalyst of the counter-transference, forms the psychological climate between patient and analyst. Case material is used to explore a Modern Kleinian interpretive approach with both a very entrenched depressive position (Klein, 1935, 1940) patient and a very primitive paranoid-schizoid (Klein, 1946) patient. Both these individuals desired relief from their symptoms of anxiety, anger, emptiness, and guilt. But, their unbearable unconscious phantasies offered pathological security that they were familiar with and therefore they preferred the known internal trauma and chaos to facing the unknown and undefined reality of self and other that change, grief, and growth would bring.

Attention deficit disorder or object detachment disorder: a brief psychoanalytic case study.

This paper follows the psychoanalytic treatment of one patient over the course of eight sessions. This patient had been diagnosed by two prior therapists as having adult attention deficit disorder (ADD). The patient had tried ADD medications and ADD behavioral treatments recommended by the therapists. Unsatisfied with the results, this individual sought out additional help. She entered analytic treatment with the mind-set of knowing what was wrong with her and what type of treatment she should receive. Nevertheless, the analyst attempted to remain open to finding out the nature of her psychological world and what might be occurring on an unconscious level to possibly cause her symptoms. In other words, the analyst held the belief that the patient's problems might be more rooted in object relational conflicts and at least wanted to offer other alternatives to the patient if there were any to be found. Ultimately, the patient was not able or willing to consider this possibility. However, in the short duration of the treatment, there were various psychological issues that were discovered that may have been at the core of this patient's struggles. The paper offers a different view of attention deficit disorder, now a very popular diagnosis. The author posits that at least some adult attention deficit disorder patients are actually suffering from an object detachment process in which they are overwhelmed with a variety of unconscious relational conflicts, which create internal and external dynamics that in turn create symptoms of inattention, difficulty in focusing, disorganization, and scattered thinking.

How the analytic process is captured and absorbed into the familiar, the feared, and the desired.

In their transference efforts to maintain psychic equilibrium (Joseph, 1989), some patients will do their best to convert their analysts into familiar, dreaded, or desired internal objects which they then react to or relate to. The interpersonal, interactional, and intrapsychic pull for the absorption and utilization of the analyst into a predesigned and pathologically limited figure creates countertransference struggles and phases of enactment that can go unnoticed, denied, or justified. Even when analysts maintain their analytic balance, the patient can manipulate, mishear, and transform words, actions, and intentions into very specific archaic objects or part objects. Case material is used to illustrate the way in which patients attempt to turn the analytic process and the therapeutic relationship into an acting out of wished for or painfully familiar self and object interactions. This method of subsuming the analytic method can be quite subtle, or it can be very obvious but still extremely difficult to shift, interpret, or recover from. Indeed, the analyst can easily be drawn into this perversion of analytic procedure and end up participating in various enactments. With such patients, the nature of the unconscious fantasies projected into the transference matrix and the intensity of the patient's object relational conflicts almost guarantee some degree of ongoing countertransference acting out. So, the ongoing and repetitive interpretive style needed with such patients is both helpful and healing as well as often becoming a contribution to the fundamental pathology the patient repeats in the clinical setting. Although the transference dynamic being examined could be understood from a number of theoretical perspectives, the author focuses on the Kleinian psychoanalytic method.

Barely here to begin with and not-so-goodbyes: keeping the faith when working with turbulent patients.

Some patients are unable or unwilling to step into the difficult and uncharted explorations that psychoanalytic work entails; in this paper the author shows how the effort to establish analytic contact with each individual can provide a level of valuable support, containment, and growth for many patients. Such patients may display great resistance to the challenge of psychoanalytic treatment, subtly inviting the analyst, through projective identification processes, to succumb to countertransference acting out. These turbulent patients often leave treatment in very abrupt and unprocessed manners. It is suddenly all over and that is that. This abrupt dismissal is usually a continued expression of the remaining pathology and conflictual phantasies that had been played out in the transference throughout the span of the analytic process. We cannot always prevent this. Rather than seeing this as a complete failure, we can try to maintain ourselves within the depressive position by realizing we are being used by turbulent patients as provisional placeholders and temporary containers. This is a model of grieving in which we acknowledge and accept what we cannot have, what we are not, and what should be but is not. Struggling with these issues in the countertransference is critical to our ability to help such patients because these are the exact issues the patients cannot bear in their lives. And, if we cannot bear them, then the patient has no hope of ever surviving them.

Striving toward useful interpretation while managing countertransference enactments: encounters with a thick-skinned narcissistic person.

Narcissistic patients tend to push the analyst to work harder than usual to contain, understand, translate, and utilize their countertransference states. This is because of the unusually extreme reliance on denial, devaluation, projective identification, and control that these individuals exhibit. Defenses against loss, envy, greed, and dependence create difficult transference states in which symbolic or creative material is flattened, stripped, and neutralized. Feelings are out of the question. This clinical paper explores the narcissistic lack of connection to self and other that endures in the transference as well as in all aspects of these patients' lives. With thick-skinned narcissistic patients, there is a subtle lack of engagement, an underbelly of control, and a complete uncoupling of feeling or link between self and object. Envy is often a cornerstone of such difficult clinical problems and is part of an internal desolation that fuels an emotional firebombing of any awareness of interest in self or other. Detailed case material is used to show how confusing, alarming, and demanding such narcissistic patients can be, trying the very essence of the analytic process. They enter treatment looking for help, wanting a quick fix to their suffering, but resist the deeper understanding, learning, and change that psychoanalytic treatment offers.

O Modo de Vida “Como-Se” versus o Modo de Vida “Como-ɔ: confusões entre o servo, o mestre e o Eu / El Modo de Vida “Como Si” versus el Modo de Vida “Como Es”: confusiones entre el siervo, el maestro y el Yo / The As-If Way of Life Versus the As-Is Way of Life: confusions between servant, master, and self

Questões de idealização, inveja, instinto de morte e ciclos patológicos de identificação projetiva podem se cruzar para produzir uma busca constante e desesperada pelo conhecimento total e pelo amor perfeito, sendo seguidos de constantes decepções e rejeições. O material explora o caso de um paciente que tinha a intenção de se tornar o farol ideal para seu objeto, fornecendo a combinação perfeita para os desejos deste objeto, e para isso esvaziou-se tão profundamente a ponto de sentir-se oco, exceto pelos ventos de desprezo e solidão que permaneciam. Aceitar a si mesmo “como-é” e apostar na posição depressiva que mescla amor, ódio e conhecimento pode significar perda e diferença, e ser insuportável para alguns pacientes, resultando em uma dependência da personalidade de defesa “comose”, na qual o objeto é seduzido com falsidades e controle. Uma busca maníaca por amor imediato e por provas de singularidade é o efeito colateral do vício. Ao contrário da definição clássica do personagem “como-se”, que tenta manter tudo completamente estagnado, essa variante de conflito interno envolve um esforço maníaco de prevenção de um colapso iminente, de rejeição e de perda. O tratamento psicanalítico comprovadamente oferece alívio e transformação, independentemente da frequência, desde que uma meta consistente de contato analítico e de interpretação da transferência seja mantida

Issues of idealization, envy, the death instinct, and pathological projective identification cycles can intersect to produce a constant and desperate search for total knowledge and perfect love followed by constant disappointment and rejection. Case material follows one patient who was intent on becoming the ideal beacon for the object, providing the perfect match for the object’s desires, only to empty himself out so profoundly as to feel hollow except for the winds of contempt and loneliness that remained. To accept the self as-is and gamble on the depressive position mixture of love, hate, and knowledge that can mean loss and difference is too unbearable for some patients and results in their reliance on an as-if personality defense in which the object is seduced with falsehoods and control. A manic search for immediate love and proof of one’s uniqueness is the vicious side effect. Unlike the classic definition of the as-if character who tries to keep everything quite stagnant, this variety of internal conflict involves a manic striving to prevent an ever looming collapse, rejection, and loss. Psychoanalytic treatment is shown to offer relief and transformation, regardless of frequency, as long as a consistent goal of analytic contact and transference interpretation is maintained

Cuestiones de idealización, envidia, instinto de muerte y ciclos patológicos de identificación proyectiva pueden cruzarse para producir una búsqueda constante y desesperada por el conocimiento total y por el amor perfecto, siendo seguidos de constantes decepciones y rechazos. El material explora el caso de un paciente que tenía la intención de convertirse en el faro ideal para su objeto, suministrando la combinación perfecta para sus deseos de ese objeto, y para eso se vació tan profundamente a punto de sentirse hueco, excepto por los vientos de desprecio y soledad que permanecían. Aceptarse a uno mismo “como es” y apostar en la posición depresiva que mezcla amor, odio y conocimiento pueden significar pérdida y diferencia, y ser insoportable para algunos pacientes, resultando en una dependência de la personalidad de defensa “como si”, en la que el objeto es seducido com falsedades y control. Una búsqueda maníaca por amor inmediato y por pruebas de singularidad es el efecto colateral del vicio. Al contrario de la definición clásica del personaje “como si”, que intenta mantener todo completamente estancado, esa variante de conflicto interno implica un esfuerzo maníaco de prevención de un colapso inminente, de rechazo y de pérdida. El tratamiento psicoanalítico comprobadamente ofrece alivio y transformación, independiente de la frecuencia, desde que se mantenga una meta consistente de contacto analítico y de interpretación de la transferencia

Slippery when wet: the imperfect art of interpretation.

When pursuing a line of psychoanalytic interpretation, there are many factors that need to be considered. Interpretation is always a provisional exercise in which the analyst's proposes something to the patient to consider and then wait to see his or reaction. Whether or not the interpretation is correct is not as important as the patient's reaction to it. Does it cultivate insight, does it spur defensive reactions, does it feel helpful, does it leave the patient hurt or misunderstood, or does it aid the patient in facing their anxieties and exploring them in a way that might facilitate change? These are just some of the possibilities when analysts voice their opinions about what might be happening at an unconscious level in a patient's immediate experience. Interpretations may be correct and address the patient's phantasies and transference state, but they can also be part of a pathological projective identification system. In other words, it can be a collusive acting out that not only helps patients to grow but also serves their defensive structure and thus helps them to retreat at the same time. The author explores clinical moments in which interpretive enactment or interpretive acting out occur. The constantly shifting emotional states produced by transference, countertransference, and the dynamics of projective identification make the interpretive process prone to instability, fallibility, and uncertainty. The unavoidable pros and cons of interpretive acting out are examined through the lens of one complex psychoanalytic treatment.

Session-by-session report of low frequency Kleinian psychoanalysis: establishing analytic contact with a borderline patient.

There is virtually no literature regarding the psychoanalytic treatment of patients with less than three times a week frequency other than those articles that include the word psychotherapy in the title. Even though more lenient positions are taken in public forums and between colleagues, there is still a vast political distance between what is considered kosher psychoanalysis and "that other procedure." The leading publication for psychoanalysis worldwide, the International Journal of Psychoanalysis, now includes articles on psychoanalytic psychotherapy. It is remarkable, but never mentioned, to notice how the cases and clinical process written about are usually indistinguishable from the cases and clinical process in all the other articles concerning psychoanalysis. This author presents material based in the belief that if a consistent pattern of transference analysis has taken place along with regular exploration of phantasy and defense, then, regardless of frequency, analytic contact can take place. This treatment is then regarded as psychoanalysis. In other words, psychoanalysis becomes defined by clinical process rather than external criteria. This article examines the establishment of analytic contact with a borderline patient within a twice-a-week, on-the-couch, Kleinian framework.

Using countertransference: analytic contact, projective identification, and transference phantasy states.

The influence of projective identification is an integral aspect of most psychoanalytic treatments, not only with patients who are more disturbed, but also with individuals are higher functioning and have neuroses. Projective identification involves both internal relational phantasies of self and object as well as external interactions with the environment. Both elements shape the transference. Continuous projections distort the ego's image of the object, causing introjections that bring increased guilt, anxiety, and envy onto the ego, creating even more radical projections. Consequently, the countertransference is repeatedly stimulated in an evolving or devolving manner (Clarkin, Yeomans, Kernberg, 2006). The case material has illustrated the constant interplay among projective identification, transference, and countertransference as well as the utility of countertransference in making the most helpful interpretations. The concept of analytic contact (Waska, 2006; Waska 2007) was noted as the vehicle of optimal psychological transformation. Rather than an emphasis on frequency, diagnosis, use of couch, or mode of termination, the focus is more on the clinical situation and the moment-to-moment work on internal conflict, unconscious phantasy, destructive defenses, analysis of the transference and extratransference anxieties, and the gradual integration of core object relational experiences. Regarding a more clinical rather than theoretical definition of psychoanalysis, Sandler (1988) states that what truly defines a treatment as psychoanalytic is the analyst's attitudes towards his patient, his willingness to contain and make the effort to patiently understand the patient's unconscious conflicts and reactions to internal phantasy states, the humane detachment and lack of judgment, and the maintenance of a comfortable and safe setting in which the transference can unfold. This definition is certainly similar to the elements of analytic contact. Use of the countertransference is crucial in finding a path into the patient's projective identification processes, which in themselves often hold the core phantasy states with which the patient most struggles. These phantasies shape his experience of the analyst and the world around him. Melanie Klein thought that phantasy was an essential aspect of the mind from birth onwards, with love, hate, and the quest for knowledge being innate, yet influenced by external events that then recast the phantasy and the patient's reaction and perception of those external situations (Spillus, 2007). Klein's belief that phantasy is the bedrock of human experience has led the Kleinian school to conceptualize the transference as being constant and all pervasive, and therefore, not something that arises at only selected times in the treatment. There is no differentiation between the transference and the working alliance. If the analyst is consistently on the alert for manifestations of the transference, he or she may be able to help the patient identify and work through phantasy conflicts. However, the transference, through a constant phenomenon, may elude the analyst for many reasons. Projective identification dynamics are often the culprit because transference phantasies are hidden, discharged, communicated, acted out, camouflaged, or traded off in projective identification interactions with the analyst. It is here that the countertransference, a likewise constant element in the treatment setting, can be most useful in relocating the transference phantasies. The analyst can begin to explore them, rather than be a part of the patient's denial, destructive acting out, or gratifications. As the countertransference is better understood, the analyst can begin to more properly contain, translate, and ultimately interpret the core phantasy states to help the patient feel more in control of them. It is this ongoing emphasis in working within the transference/projective identification/countertransference matrix that gradually brings clarity to the analyst who can share that knowledge as an interpretive proposal. Then, the patient may use it to build greater psychological freedom, emotional stability, and personal choice.

The search for knowledge and the avoidance of knowledge.

In the psychoanalytic setting, patients can develop a strong reaction to the therapeutic opportunity to gain new knowledge about themselves. This reaction to knowledge is manifested in the patient by walling it off, splitting it off, or attacking it and erasing it from one's internal experience. The avoidance of knowledge can be the result of various phantasy states that bring on defensive postures. Knowledge can be experienced as a persecutory threat to be avoided and defended against. Knowledge can also elicit depressive concerns of loss and separation. Issues of dependence and autonomy can be equated with knowledge and therefore learning must be warded off. As a result of any or all of these internal threats, the ego can instigate a moratorium on thinking and creativity, a shutdown on feeling, thinking, and learning. As will be shown in the case material, wanting to know can be offset by a greater defensive need to not know. Through projective identification cycles, knowledge is placed into the analyst and experienced as dangerous, unobtainable, or a gift one deserves to be given rather than earned. The patient in the case example demonstrates a more paranoid experience of knowledge and a more paranoid avoidance of learning and change. When paranoid phantasies drive the patient to destroy object-relational links between self and analyst, the transference becomes colored with the phantasy of knowledge being equal to dangerous dependence that leads to destruction of either self or object. Therefore, curiosity and learning are to be avoided. Change is no longer a safe option. Psychic change can only occur when past and current knowledge are allowed to be part of the ego's self<-->object world. In other words, Psychic change is possible when the ego is less restrictive and open to new self<-->object experience. Therefore, the ego must tolerate conflicted feelings and thoughts about the self and others for knowledge to be allowable and accessible. This is the core struggle for many patients and must be identified through interpretation of transference and phantasy for gradual working through to become a viable possibility.

Psychoanalysis or psychoanalytic psychotherapy? Shifting the debate from theoretical to clinical with the concept of analytic contact.

There have been numerous books, papers, panels, and debates over the years regarding the differences and similarities between psychoanalysis and psychoanalytic psychotherapy. This article shifts the often circular and political argument from a theoretical tug-of-war to a clinical focus. The author provides clinical material to show that frequency, diagnosis, or use of couch are at best external enhancements to a process of analytic exploration. The case material illustrates the concept of analytic contact, in which the aim of treatment, regardless of setting, is to establish an ongoing investigation into the patient's defenses, phantasies, and internal conflicts that come out of the patient's object relational experiences. Analytic contact is evoked, established, maintained, and protected by the consistent interpretation of transference and extra-transference experiences that occur in the treatment relationship. External issues and life circumstances cannot be avoided and must be given equal focus, but always in the pursuit of understanding their associated underlying object relational phantasies. Clinical matters must take precedence over theoretical ideals in the struggle to establish analytic contact. The analyst consistently seeks, sometimes failing and sometimes succeeding, to understand how the patient either builds on genuine analytic contact or seeks to dismantle it.

Addictions and the quest to control the object.

Most patients come into psychoanalytic treatment engaged in some form of repetitive, destructive behavior that is an externalization or projection of their internal struggles. One form of this object relational acting-out is the addictions, be they to alcohol, gambling, drugs, sex, procrastination, or other variations. The patient's experience is a "must do-can't stop" one that leaves them both desperate and relieved. Patients come to us wanting help in refraining from these addictive patterns. Sometimes, they are attending a 12-step program or are in a day treatment recovery program but need additional assistance in remaining free from their addictive behaviors. Others seek out psychoanalytic treatment while still involved in their addiction, but wish to stop the behavior and build a more positive plan for their lives. This paper examines the deeper object relational issues that lie behind the addictive process. The transference is often colored by acting-out, by sadomasochistic dynamics, by projective identification, and by fantasies of persecution and loss. Case material is used to explore these specific problems as well as the patient's general difficulties with paranoid-schizoid and depressive functioning.

A case study of borderline anxiety and the process of analytic transformation.

Borderline patients present particular treatment problems and require close, devoted understanding of their often chaotic and shifting intrapsychic conflicts. Many of these patients act out, making it difficult to maintain an analytic process. In fact, many terminate early on. When they do stay for longer periods, they exhibit particular constellations of defense, anxiety, and conflict. One extensive case report is used to examine the overlapping cycles of treatment with this population. Frequently, self-destructive acting-out is present in the transference and extra-transference. This acting-out is often followed by the self-destructive, anti-change attitude of the death instinct. These ways of relating to the self and the object are mobilized within the vehicle of projective identification and are best understood as primitive defenses against core fantasies of loss and persecution. These issues of loss and fear are the final and vital phase of treatment with borderline patients, who are often able to make major fundamental changes in their internal sphere, but only if patient and analyst can tolerate and understand these three levels of intrapsychic experience.

Symbolization and the good object.

Some patients struggle with the acceptance of, connection to, or identification with a good object who provides a containment-symbolization function. This is manifested as a standoff, a resistance, and a denial of the good object and, therefore, of the symbolization process that is part of healthy development. This is usually due to troubled family histories and a destructive projective identification process. The ego defensively blocks acknowledgment of any symbolizing capacity within the self and within the maternal object out of envy, fear of rejection, and dread of persecution. Destruction of symbolization and the experience of goodness within the self or in the object provides an artificial respite from the threat of annihilation, yet quickly brings on even greater levels of internal chaos and anxiety. Case material is used to illustrate these points.

Greed and the frightening rumble of psychic hunger.

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

Fragmented attachments: the paranoid-schizoid experience of loss and persecution.

The author discusses paranoid-schizoid patients who have yet to deal with whole-object depressive fears of harming one's object. Their paranoid-schizoid anxiety is more a combination of dread, paranoia, and fear of destroying one's object with neediness, envy, and other oral desires. In this part-self and part-object world, destruction is absolute. Ego functions and object relational capacities such as guilt and grief are not yet fully consolidated. The part-object is not only destroyed but is also equally capable of magically resurrecting itself to seek revenge. Fear of annihilation of the self and object, as well as desperate attempts at keeping each other alive, are the primary focus of this early anxiety state. These infantile fears are at the root of certain difficult treatment situations. Within the transition from paranoid-schizoid to depressive, the ego struggles with highly exaggerated and distorted fantasies of persecution, loss, and primitive guilt by resorting to crude and often self-destructive mechanisms. These include splitting, projective identification, and idealization. During the course of analytic treatment, three overlapping phases are distinguishable. Acting out is the main theme of early treatment. As this externalization of internal conflict is analyzed and contained, a second phase of intrapsychic struggle emerges. The patient exhibits a paralyzing battle between certain ego-object ties and the striving of a defensive death instinct. If the analytic relationship is able to withstand passage through these difficult phases, the patient begins to work through more core issues of persecutory loss and annihilation. Case material is used for illustration.

A mixed bag: the realities of psychoanalytic practice.

For a variety of reasons, psychoanalytic training is done in somewhat of a vacuum. It teaches a theory and a way of practicing that does not always translate well to day-to-day private practice work. The clinical realities of psychoanalytic practice prove the psychoanalytic method to be one that provides help to a wider audience than classical psychoanalytic training programs might suggest. The psychoanalytic approach offers the analyst many special opportunities to work with and help a wide variety of patients. Analysts who accept both the limitations as well as the wide application and broad benefits of the psychoanalytic approach may have a more fulfilling experience than their training experiences might foster. At the same time, the analyst's level of therapeutic skill, the patient's diagnosis, and many multiple external factors create different limitations in the practice and outcome of psychoanalytic work. Extensive case material is used to show the broad range of patients who are helped by the psychoanalytic method. The clinical material also shows the less than perfect, but often good enough outcomes of these difficult cases with often severely disturbed patients.