Barely Here to Begin with and Not-So-Goodbyes: Keeping the Faith When Working with Turbulent Patients

Introduction

Patients with whom we have difficulties typically have spent their lives cultivating, maintaining, and then enduring intense internal and interpersonal turbulence through excessive reliance on destructive projective identification processes. As a result, the analyst must be constantly aware of these shifting and complex dynamics. Turbulent patients, by definition, create a vicious internal cycle of projecting toxic mental conflict, reacting to it as if it is an outside force were threatening them, and then creating more defensive projections to protect themselves.

In the Kleinian approach (Segal & Britton 1981), the understanding of projective identification has led to a greater attention to the interaction between analyst and patient. Historically, this has added to those sources of information already available for interpretative use, such as the patient’s verbal and nonverbal behavior. Now, interpretation can include the analyst’s perception of himself through his patient’s view, his own emotional experience of the session in the countertransference, and both his and the patient’s tendencies to action. Often, the core of the transference with such patients will be projective based phantasies that pull the analyst into very narrow roles the patient expects, desires, and fears. The case presented in this paper illustrates many moments of this type of uncertainty, a misstep on the analyst’s part, and the struggle to regain balance.

Slow-to-thaw patients, such as the one followed in the clinical material, struggle with enormous levels of anxiety concerning conflicts about love and hate and the psychological meaning of knowing more about themselves or their objects. For example, the patient in this paper unconsciously felt that knowing more about his mother and learning about his own feelings toward his mother were very dangerous and, therefore, to be denied, avoided, or eliminated.

In response to these internal threats regarding knowledge, love, and hate, these patients tend to excessive and destructive methods of projective identification, manic denial, and splitting, which provides temporary psychic shelter or pathological retreats (Steiner, 1993). These methods of relating and reacting create intense transference and countertransference climates. Joseph (1978) pointed out how the more the patient uses primitive defenses against anxiety, the more the analyst is used by the patient unconsciously, which, turns the analysis to a scene for action rather than understanding. I like to think Joseph meant this was a threat to both parties, so that the analyst must constantly watch for the ways he and the patient might try to act out rather than to understand, think, feel, and know. By working within the complete countertransference (Waska 2011) and the total transference situation (Joseph 1985), the analyst has a chance not to be overcome by the demons to which the patient has succumbed and gradually, to interpret the nature of the patient’s unconscious conflicts. As a result, the patient has a new opportunity to work with the paranoid and depressive visions of self and other and possibly find some degree of emotional freedom and peace of mind.

Case Material

F. had seen me for therapy for nine years when he suddenly stopped attending sessions. Now, this sudden termination was not entirely a shock; throughout the duration of the analytic treatment, F. had often questioned “why I am still coming in here when I feel just fine”. His “feeling fine” states were often fairly short lived and followed by a return to a marked depression. Through our working together, F. would realize he was in a manic state of denial and then begin to face a variety of feelings and conflicts about which he felt less than fine. At that point, anxiety and claustrophobia about owning these less-than-perfect feelings would overtake him, and he would project his critical judgments and controlling desires onto me. Then, he would struggle with “whether he really cared enough about all those issues to work on them,” or “was … just facing normal problems everyone has and therefore, has no need for help,” or “… just being bullied into staying when [he] really wanted to quit but felt guilty that [he] wasn’t working hard enough,” or “… hurting my feelings by stopping and leaving me hating [him] as a bad patient?” Along with these transference states, F. had ongoing phantasies and conflicts about whether he needed me or not, manifested by how he would “draw the line,” which was cutting down how often we met. We met three times a week, twice a week, or once a week depending on how F. was able to tolerate feeling exposed and not in control. It was not my choice how the frequency changed; I had to go along with his anxiety and his way of controlling and making sure he was in charge.

F. was a 40-year-old accountant, working for a law firm, and self-identified as homosexual. When I first met with F., he engaged in rampant sexual activity, including real-time computer-camera masturbation with strangers, random sexual “hookups” at bathhouses, and online gay sex sites he used to meet random men several times a week. He would stay up until three in the morning and arrive at work exhausted; like an alcoholic, he would vow to not do that again, then when rested and he would go back to the same behavior.

Along with having this anonymous, random sex several times a week, F. was also prone to manic schedules of activity with friends and various social clubs. In any given week, he might be meeting friends for dinner and a show one night, going to a fundraiser the next night, and going out dancing another night. Between these outings, he would meet men either at his place or their apartments for sex. This was all done in a very mechanical, greedy, controlling manner, it was as if he simply pressed a button to get all his needs met, regardless of whom he was with. This was a symptom of how desperate and lonely F. had been for most of his life.

Over the nine years we met, F. would tell of how he often started to fall in love with one of these many men, and thus began a very complicated jungle of feelings in which he would be conflicted about if who he was with was “the right one” or “a big mistake due to … flaws.” He would become caught up in all the pros and cons of why he should or shouldn’t plan on spending the rest of his life with the potential partner, looking for signs of perfection or searching for fatal flaws.

Just as F. demanded so much from the world in these perverse ways, so he was in therapy. In the transference he often felt I could cure him magically overnight or complained bitterly that I disappointed him over and over. He wanted me to see him as my favorite, hardworking patient, but he worried I was sick of him and frustrated with his lack of progress. As a consequence, there were many periods on the couch analytic treatment, in which F. “didn’t want to feel judged anymore, didn’t want to feel pressured to change, and didn’t like feeling as though you were thinking I should be working harder at my job and in therapy.”

These persecutory (Klein 1946) transference feelings were part of a projective identification process in which F. put his lifelong adherence to what he called “the rulebook” onto me, and then felt obligated to come up to my expectations. He thought I would be as demanding as he.

It was not unusual for F. to spend many sessions telling me about how other drivers on the road were rude and not paying proper attention, how people at the grocery store were not correctly respecting the lines at the cashier, how people’s mode of dress was too informal, and how manners were not being adhered to pretty much everywhere. These unrelenting sets of standards were something F. collared others with, but by which he himself felt most collared. In the transference, he would put these standards on me by becoming impatient and irritated that we “hadn’t cured me yet” and that “you hadn’t told me the easy one-two-three way step to happiness yet.” But he also felt I was impatient and unhappy with his slow process and his constant complaining.

Also, F. felt stuck and helpless in life without all those things others seemed to have, such as relationships, money, importance, or attention. F. wanted them but felt unable, unwilling, and unsure how to go about achieving them. He would bring up these feelings of frustration, dissatisfaction, and envy with predictable phrases such as, “Why doesn’t a rich prince come along and take me away from all this? Other people seem to get lucky and have it so easy!” When I would bring up his obvious displeasure, sadness, or anger about this “lack of luck,” F. would not acknowledge it or own it. Instead, he felt I was “forcing my agenda” on him.

This persecutory guilt phantasy came up frequently in several situations. F. had worked as an accountant for years and often was bored. He spent hours playing online bingo games. As a result, he felt guilty that he was being lazy and irresponsible. His company essentially wanted him to do two jobs because of their budget problems so he was overworked and also hated his assignments. When he tried to “do his job like I should and take care of business like they pay me to,” F felt overwhelmed by the number of hours it took. When I would point out his displeasure, frustration, and resulting sense of helpless acceptance about it, F. would say he felt I was “wanting him to quit his job and do something better.” He would become upset with me for not being “okay” with him as is. In other words, when I voiced the projection of his wish for more and his displeasure with what he had, he felt guilty and anxious and immediately denied the projection belonged to him. Instead, he tried to see himself as “normal” and me as wanting too much.

F. said, “I don’t like my job and I am fed up with it. I have been for years. But, the only other jobs out there are exactly the same, so I should just accept what I have and realize I will be in this situation until I retire in 20 years.”

I replied, “You definitely don’t sound happy about it when you say that. In fact, you sound a bit resentful”.

F. would become even more anxious and angry with me and say, “You don’t seem to ever be okay with someone not liking aspects of their job and having regular ups and downs. You want me to walk away and find something perfect. Well, that isn’t out there!”

I replied, “If I bring up my observations that you sometimes feel trapped, unhappy, or frustrated and try and explore those feelings with you, you immediately think I am demanding immediate change, some immediate action, or I will be disappointed with you.”

F. would agree in a concrete manner, telling me that “I was being mean.” Sometimes he was able to reflect on what I said, “I think I see what you mean. If I look at my feelings I don’t necessarily have to do something with them right then and there, but I might feel better just talking about it”.

I replied, “Yes. And, you might figure out something you would like to do or not do as a result of talking about it. But, you get worried I see you as bad if you don’t do something with your feelings”.

F. agreed in the concrete way again and said he did, in fact, think I always push him to change and improve his life. I interpreted that this sense of demand and rush might be his own sense of expectation and his own desire for change (with which he struggles). Further, I interpreted the projective identification process in which he seemed so stuck. I advised that he might be dealing with feelings of having to put up with things he did not like or having to take a scary, rushed, and dangerous plunge into the unknown. He might have a hard time finding some middle area. F. calmed down when he heard this, agreeing, “… we might be on the same page after all.”

These transference feelings and phantasy conflicts would also emerge was in his other relationships. On one hand, F. craved a deep, committed relationship with someone who “could be his soul mate;” he felt lonely and empty and wished for “that special someone.” Yet, when I tried to explore (either externally or in the transference) his deep despair and his sense of hopelessness, F. would feel I “was pressuring me to date, pushing me to find a boyfriend, and expecting me to find a partner right away.”

F. would tell me he “didn’t see what was wrong with just accepting that “I would never find that special someone but that I could have a fine time anyway.” There was this quick retreat from need and unhappiness when he had to own and feel those conflicts. There was a rapid dive into justification, denial, and pseudo-acceptance of his plight. If I questioned this “normal level of frustration in life,” he would tell me I was being hypercritical and expecting too much of him. F. tried to be in control of the therapy and his life and not have to see himself as failing or lacking. Indeed, this was one interpretation I made that seemed to help. He defined himself either as reaching for the ultimate levels of love, money, and achievement or being trapped by shameful failure and loneliness. To recapture his sense of control and to avoid experiencing the envy he felt about those he pictured who had reached these pots of gold, F. would manically build his fortress of normality, and defend it with everything he had.

These cycles of emotional hunger and resentment followed by denial, justification, and defensive self-assurance were part of F’s struggle with the death instinct and chronic feelings of envy (Klein 1957). What others seemed to possess he was never allowed to have. Therefore, he had to deny ever needing it, and he clung to his phantasy of feeling fine with what he did have. Breaking “the rules” or wanting more in life was a constant conflict involving feeling angry and deprived versus feeling guilty, hopeless, and accepting what was rather than what might be.

Early Sessions

When I first met F., he was always trying to adhere to “the right way” of doing things, but he felt he often failed. He was guilty for having a promiscuous sex life but was quick to justify it and tell me he “was simply honoring my sexual nature.” While F. was prone to crippling bouts of depression as well as intense anxiety, he had never really seen these feelings as part of any unconscious conflict. He had been in the hospital and had numerous emergency room visits for depression, panic attacks, and thoughts of suicide. The few times during the last decade he had tried to stop taking his psychiatric medication; he experienced immediate and extreme relapses into depression. Therefore, he considered his depressive problems merely a “chemical imbalance” that was corrected with medication.

As we went along in the analytic treatment, F. revealed elements of his early childhood that seemed to have shaped his current psychological views of self and other and contributed to his depressive problems. When recalling growing up, F. reported his father was a “nice man” who worked all the time to support the family, traveled a lot for his job, and so, was never home. When he was home, he was always quiet and “went along with what Mother said.” This memory was often played out in the transference. I interpreted that F. was both himself as a child combined with his passive, dominated father and that I was the pushier, dominating, unsatisfied mother who left everyone feeling pressured and controlled. (This line of interpretation was possible only during the last few years of treatment when F. did no hold his mother up to an idealized standard in which she did no wrong.)

During the first few years of analytic work, F. described his mother as “perfect in every way. She was the most dedicated mother one could have and really matched the classic picture of a 1950s mom, baking cookies for all the kids and taking care of everything in the house”. Over the course of several years, I had the impression from F’s recollections that he remembered a mother who left him feeling a mixture of love and upset, gratitude and resentment. But any time I brought up my observation that he might have mixed feelings towards his mother, F. was steadfastly against it and felt “you are trying to make me think negatively about my childhood when everything was just fine”.

So, here was another way that my curiosity and inquiry was experienced as persecutory and damaging. I think a projective identification process was at work, in which F. deposited his dangerous feelings of unrest, unhappiness, and desire concerning his mother’s care into me, and he maintained a conflict-free zone of idealization. Over time, I also interpreted that F. strived to keep himself to that standard of perfection, always going by the rules, watching his manners, and trying to please others. However, this left him feeling alone, empty, and often resentful and envious of those who did not have to abide by these strict standards.

On one hand, F. would quickly debate me on this adherence to standards, saying “there is nothing wrong with being on time, holding the door for others, and saying ‘yes’ to any request for help from others.” On the other hand, F. was able to acknowledge his envy and sad helplessness when he watched others enjoy relationships while he faced the weekends without a date and lived alone. But soon after becoming vulnerable with me and sharing this unhappiness with me, F. quickly went back to using his intellectual defenses and denial to tell me that he was very busy most of the time, going to functions with friends and he “practically didn’t have time to be dating.”

F’s view of his mother was so hardened and one dimensional that it seemed to rule his internal life and constrict his ability to consider anything about his mother outside the realm of his idealized, always good-intentioned view of her. Any observation, speculation, or interpretation on my part of any type of irritation, anger, or general unhappiness inside of F. directed at mother was met with an immediate denial and a doubling of efforts to emphasize how he “understood” and “accepted whatever had happened with his mother without any sense of ill will.”

Breakthrough

In the fourth year of analytic treatment, we were talking about a memory F. had of his childhood. Suddenly F. jerked his body on the couch and froze in silence. After a bit, he said,

Over the next few years, F. began to think of his mother as someone more human, with both flaws and positive attributes. He began to remember numerous incidents in which his mother was obviously overworked, tired, and angry and then took it out on her kids. These memories revealed F.’s hurt and angry feelings about being subjected to his mother’s temper and mood swings. Now, in his mind, she was not just wonderful and loving, but also strict, controlling, and demanding of everyone around him. She had a “rulebook” that she felt very righteous about, and she expected others to follow. I pointed out that F. had followed mother’s footsteps in many of these traits with his own “rulebook” that he and others had to obey.

Over time, these rulebook ways of experiencing life emerged in the transference. F. was very diligent, loyal, and punctual in his appointments with me, his payments to me, and his overall way of relating to me. When I tried to explore this, he told me it was “simply polite to be on time and pay for services rendered.” However, he was also overwhelmed on occasion with phantasies and feelings of being chained to the treatment, obligated to have “something to talk about”, and pressured to “be changing his life and working on things even if I didn’t see anything wrong with my life.” F. would lapse into intense modes of feeling bullied by me or by his own guilt of “not wanting to be a bad patient and not wanting to look like he wasn’t motivated.”

F. thought I wanted him to be a certain way or to change certain things and then felt pushed to take action on those matters or to be talking about them even if he felt they were not a problem. Over time, I interpreted that there was a link between the way he tried so hard to be loyal, diligent, and punctual with me—always playing by the rulebook—and a sense of being chained down and obligated to please me at all times. I also noted that he grew up following mother’s rulebook and now had written his own rulebook, of which he seemed to be a prisoner. F. would relax a bit when I made these observations. My interpretations seemed to reduce his anxiety and guilt long enough for him to begin to reflect and think about these ideas instead of feeling a victim to them.

Depression and the Rulebook

Over the course of our nine years of analytic work together, F. made many changes in his life, both internal and external. As a result of our explorations, F. felt much less depressed and anxious. Because of his gradual analytic progress, when F. stopped treatment he was no longer on any medication and rarely felt depressed or anxious.

When I met F., he felt suicidal much of the time. He was on high doses of several antidepressant mediations and an anti-anxiety medication. There were many days when he would barely be able to get out of bed, frequently fail to go to work, and spend the day in bed. As part of this depressive cycle, F. would overeat and become quite overweight. In addition, he was out of shape and rarely worked out. Life was meaningless and hopeless for him.

After the first few years of treatment, F. would feel fine for the most part but quickly crumbled back into a black depression if certain disappointments occurred, such as a relationship not working out or a frustration at work. After nine years of treatment he was able to weather these choppy waters without falling apart. His remaining problem was a fundamental stance of denial and manic self-sufficiency that surfaces when he realizes he feels stuck, unwanted, or unhappy in some way. In other words, wanting more still brings about a sense of hurting mother and being punished for violating the rulebook by being greedy or envious. Of course, when he denies those desires, he only ends up with more envy, guilt, and persecutory anxiety.

Rather than face the initial feelings of helplessness, difference, or anger, he was quick to tell himself and to tell me, “I am fine with it. Life is full of ups and downs and I am just accepting that I can’t have everything.” While this sounds fine, it is a thin veneer that hides his anxious discomfort underneath—the unhappiness that would be against the rulebook of being a good citizen, a good Christian, and a good son. Now, this global bubble of manic denial is certainly an improvement over the debilitating depression that used to result from his denial. But, it still impairs F’s full enjoyment of life and his ability to rely on himself and others for security rather than feeling despair and envy, followed by a defense of false optimism and manic undoing. For F, the grief, mourning, and the ownership of healthy desire that are part of the depressive position (Klein 1935; 1940) remain an uncomfortable and unreached area of development.

Internal Emptiness

Over the course of treatment, F. changed much about his approach to coping with his internal emptiness. When I first met him, he was having random sex with several men each week, searching the internet for new sex partners staying up until the wee hours and staying up until the wee hours of the morning. He would be exhausted the next day but would manage to wake up enough to go at it again the next day. When I tried to investigate this destructive behavior he would try and pass it off as “just an ordinary gay lifestyle.” But over time, we were able to see how it was a desperate effort at finding control over his internal hopelessness, loneliness, and lack of contentment. He was constantly searching for “the one” and hoped to find the “perfect soul mate to spend my life with.”.

For the most part, F. engaged in safe sex, but on occasion, when he felt he had met “Mr. Right,” he desired to be in an instant merger or bond and “forgot” to take appropriate precautions. Our exploration of his demand and despair to find “the one” resulted in less anxiety, less desperate searching, and a greater sense of self he could rely on. Therefore, he was less prone to this type of acting out.

In the process of exploring this acting out, we examined his life long search for an ideal maternal object to merge with and to give himself over to completely. However due to very complicated core sadomasochistic feelings, this often resulted in F.’s feeling victimized, ignored, or unloved by that object or him devaluing and rejecting that object. In his acting out, this meant that he frequently exposed himself to a deadly and punishing internal object, and externally it mean that he put himself at risk in his sexual relationships. Unfortunately, in the last year of treatment, one of these times of acting out resulted in F. being diagnosed with HIV.

Parallel to this compulsive, desperate sexual acting out, during the first four years of treatment F. compulsively shopped and went into great debt. He bought all kinds of things including furniture, art, trips, and beauty supplies. But mostly, F. spent a great deal of time and money buying clothes. He often would buy ten shirts at a time and afterward feel guilty and stupid. He would return most of them, keeping a few items. As we began to understand this pattern as a way to hide loneliness and anxiety, and as a way to fill an internal void, he stopped the manic, compulsive shopping and started to consider each purchase more. For a while, he would tell me “it was excruciating to see something on sale and tell myself ‘no’ to buying it.” Part (as mentioned previously) had to do with his intense envy of “all that everyone else has … money to spend as they please and … able to retire while I will still have to work and save.” Eventually, F. was able to remind himself that he “already had a similar pair of pants and even if it was on sale I would be going into debt to buy it.”

I interpreted this to mean that for F. not freely feeding at the breast of excess was (at first) painful, and it felt like a cruel punishment. He couldn’t have the wonderful fusion with perfection and the bliss of having what he wanted. But gradually F. came to realize he was still secure and full from his last feed and didn’t need anything more.

Bit by bit, F. became more accepting of his current station in life without feeling frozen in failure. He realized he could work towards gaining a promotion at his job (without spiraling into depression if he did not receive it) or avoid increasing his debt by not overspending, but still buy things when he really needed them. In these ways, he was, in fact, more in line with the others he envied so much. This was a more genuine acceptance and contentment than the state of false contentment or bravado he usually showed about his job or his being single.

Continuing Treatment

In the last few years of treatment, when I inquired about the details of his feelings, it was much easier for F. simply share them with me. This was because he felt much more stable and genuine internally, and he trusted that I would not see him as a sinner, a lazy patient not doing my bidding, or a greedy bad boy breaking the rules. However, there were still many moments when he became defensive, guilty, and anxious and resorted to his more fragile, thin, manic conviction that “everything is fine.” During those moments, F. would say,

F. would be very worked up and irritated by the end of this proclamation. He would be quite agitated, as he felt I was interrogating him about why he was not going to do something to change his problems. This debate could go on for weeks until we worked through these phantasies and he was able to see that I wasn’t forcing him “to reach for perfection,” but that he was projecting his unhappiness or frustrations onto me and then claiming everything was just fine.

F. also shifted his formerly rigid and strict way of wanting others to do things his way. When driving, he used to feel that everyone on the road was “inconsiderate, rude, and impatient.” He would become very frustrated and “think bad things about all the other drivers, who obviously don’t pay attention to the street signs and the stop signs.” F. was more tolerant of others and gradually realized with our exploration that it was he who was often the impatient driver, demanding everyone else move out of his way and drive at his speed. However, this more accepting stance still broke down as he felt the anxiety of owning these more outright aggressive and demanding aspects of himself. F. would end up telling me that people “should pay more attention to the road and spend less time on their phone. There are rules to follow and those rules are there for a reason”. But overall, he was able to maintain a less rigorous and less strict view of others, and this made his world a bit more enjoyable and less constricting.

Another area that improved over time with F. was his intense quest for “a soul mate.” For the first five or six years, he was able to fend this desire off when I inquired about it by telling me he was only after sex and a good time. However, every once in a while, one of his random sex partners showed F some tenderness or kind words, F. would start to imagine how wonderful it would be to date this person, move in with him, and live with him for the rest of his life. F. would become excited and enchanted with every last detail of what that person said and did and how his wonderful life would be in the future. The more this intense fusion and relational emersion took place in F.’s mind, the more claustrophobic he became. In other words, as he mentally drew the person inside of himself, F. initially felt whole, safe, and satisfied, but very soon F. became so consuming and controlling of that person he became a casualty of his own excessive projective identification mechanism. He felt taken over and intruded upon.

In the countertransference, I noticed myself having a variety of reactions and feelings to F’s transference states. There were predicable and familiar transference cycles in which F. would alternate in seeing me as ideal and then as failing. He would see me as a magical chance at radical positive change, and later he would feel I was an obligation by which he was burdened. F. felt pressured to please me by continuing to see me even when he thought our work was useless or “something that forced him to look at things he would rather not have to deal with.” These states of mind created intrapsychic and interpersonal patterns that invited me or pulled me to be or feel a certain way (Joseph 1985). F. would see me as “a real help and a new way of looking at things,” “a guiding light,” and “a very important friend who helped him grow and change, someone who cares and listens.” He told me he really looked forward to seeing me and that he was “very grateful for my help and patience.”

I noticed I felt secure and content in how F. seemed to be attached to me, but I also felt there was a sort of static, false, concrete, and deadened quality to those same moments, as if no life were present in the room. He talked a great deal and told me many details of work and activities, but something felt dead or missing. I believe this was a countertransference experience engendered by his projective identification process, in which he put his own lifeless state into me. It was a state of mind in which he controlled his objects by staying distant and perhaps repeating what he felt was his mother’s controlling and emotionally restricting ways with him in childhood.

F. also had a pattern of telling me how he dreaded our meetings and felt trapped by them. He said he felt “obligated without any real sense of interest or reward.” I interpreted this as part of his narcissistic demand for instant gratification and immediate answers without having to feel or do anything. With this aspect of his transference, I often felt my own sense of dread, anger, and defiance, a reaction to feeling trapped by his demands and complaints. I felt a dread of how, in any given session, he might fill the entire time with his comments and questions about “what am I really getting out of it,” “never getting any input on what to do,” and his constant wondering why he should continue, if he was really just wasting his time, and how it would be so much nicer to go home and relax than that have to drive all the way to my office and dwell on all this stuff without any real outcome. F. would sometimes add that he resented feeling “he had to come to please me and do my duty.” Much of the time, he would pester me with questions about “what should I do,” “how can we fix this right away,” and “I want you to tell me what to do so I don’t feel this anymore.” When I would say, “you want me to hand over the magic cure without you having to do anything. I am your magic pill”, he would say, “Yes. Are you going to fix me today?”

As a result of all this sandpaper-like transference, I often felt irritated or fed up and wanted to tell F. off by saying, “Fine. If you don’t like it then stop complaining and get out. Either participate or leave. If I am so worthless than find someone else but stop bothering me”. This countertransference frustration and desire to retaliate alerted me to the way F. acted very passively with me and his other objects but was actually constantly demanding they give him more and more. When he felt they didn’t deliver, he wanted to throw them away. But, he often also felt scared and guilty about those strong feelings, so that he adopted a more masochistic profile to tolerate and deny his narcissistic hunger. However, he still stewed in his envious juices for the ideal object that would provide more, better, and quicker. F. would then try and either intellectualize, neutralize, or eliminate those feelings by projecting them into the object. His objects then carried out his dirty work, filled with these unacceptable states of mind, which he could deny and feel above having.

This ongoing pattern of manic bliss and magical merger with the ideal object followed by claustrophobic entrapment and disappointment occurred in the transference as well as his external life. Not so long after telling me how the latest person he had dated seemed so perfect and how they could “easily spend every waking moment together,” F. would start to tell me how he was worried they didn’t like the same music, lived too far apart, had different political views, and made different salaries. The list became so big that he would start to see the relationship as doomed. Meanwhile, it was unclear if the other man was actually even interested in dating F. In fact, what often happened was that the other man never returned F.’s calls or told him he just wanted a “sex buddy.”

At first, F. would feel emotionally jarred or terribly rejected. But, very quickly he tried to regain control by telling me, “It doesn’t matter really. I don’t think it would have worked out anyway. We didn’t have much in common.” Over time, F. became less “star struck” in imagining these potential mates, but he still had a very difficult time exploring the underlying loneliness and desperation that he felt for a “soul mate.” Using his manic and narcissistic defenses, F. instead withdrew and stopped looking for someone special. He gradually tried to convince me—and himself—that he didn’t really need anyone. When F. relied on this defensive retreat, he became less and less interested in sex, and essentially gave up on finding love.

When F. developed HIV, this intensified. He decided no one would ever want to be with him; he resigned himself to be single forever and “just accept that. Since I know I would never want to be with someone like me, I know no one else would want to be with me either.” F. decided he was, once again, unlovable according to his standards and his rulebook.

However, by my continuing to explore this psychological barbed wire stance, over time F. did go on several dates and did have sex with a few of the men he met. I interpreted that he was allowing himself to be lovable to the object, though the rulebook said otherwise. I interpreted that perhaps he wanted to rewrite the rulebook, even though he idealized it. F. said, “Maybe a couple of pages.”

However, F. took the position that overall the love and sex area of his life was closed and he tried to be content with doing activities with friends and occasionally having sex with random partners he found online. When I brought up this resignation, F. would become agitated, explaining that I was pushing him to change something “he already felt fine about.” Here I came up against the resistance of “I have changed to the point I want to and I don’t want to face anything else. I am fine as is!”

F. thought of himself as a “plague victim with AIDS that no one would want to touch.” He was amazed that others would want to have anything to do with him. I interpreted this to be a reflection of his anger and disgust with himself. This included his analyst in the transference. He told me he believed I must think he is “so ignorant and foolish to have done something like that.” So, we explored these feelings of having been “so stupid” and “not using common sense.” I interpreted it as meaning that he was sure we all agreed with his punitive view of himself and hence didn’t want anything to do with someone so “stupid” and “disgusting.” I interpreted that he had a hard time allowing me to be a compassionate person trying to understand him and he instead put his rulebook between us, making it hard to have contact.

F. sometimes was lost in his concrete, rigid, black-and-white thinking, and other times he was able to see past this cruel vision and consider a more loving and curious view of himself and of us. The concrete thinking was F.’s lack of “as-if” symbolism, broken by excessive projection, in which he was essentially saying, “Well, yes! I think you are right about my stupidity. I am sure you do see me as a total loser that way.” Steiner (1989) noted that borderline patients slip out of the symbolic ability to think or communicate rather easily, and when they make gains in this area it is fragile.

Therapy Terminates

F. ended analytic treatment with a much more balanced view of himself, of me, of others, and of his mother. He still was severe in his judgments and confined to his rulebook in many ways, but much has shifted in nine years. Now when thinking of his mother, he allows himself to see her in a more realistic and human way, with faults and flaws as wells as wonderful qualities. He ended analytic treatment seeing himself, myself, and others in less of a punitive, demanding, and exacting light. Since his phantasies of self and other were less cutthroat and persecutory, his projections onto his objects rendered them less persecutory.

After nine years of analytic work, F. still was sure I might be unhappy unless he “did it your way.” To F. I was “disapproving” unless he quit his job and found something better, started dating and working to find his soul mate, worked hard at feeling more confident, and came to see me several times a week “forever.” He could allow for some degree of reflection that these were rules remaining from mother’s rulebook, and that I might simply be curious about his feelings in these areas of continued conflict and discontent. He could accept that “you simply wanted to know more about my feelings.” But, his acceptance was thin and quickly crumbled as he talked about it. He assured me he “was fine and would contact me in the future if he needed it,” but “for now I am done and living a life I’m was happy with.” In the counter-transference, I had to accept this as it was. My struggle was to stay in the depressive position and grieve what I could not and did not have, without having to deny it or force it upon F. I could not make him want more, and I could not make him be more curious about his current state of acceptance. How much was genuine and how much was a false, defensive, and envious retreat remains an unfinished question for both of us.

Summary

It is not unusual for turbulent patients like F. to terminate abruptly, after having many tense standoffs along the way. I think of treatment with such an individual as a series of small, ongoing negative therapeutic reactions in which the patient’s need to control and feel superior is played out through projective identification cycles (Rosenfeld 1975). These create a sense of persecution in the patient and a sense of frustration and anxiety in the analyst. To the extent that the analyst succeeds in modifying the patient’s narcissistic control, contact is made with a dependent part of the patient. After this there can be a gradual working through of the raw and unprotected feelings and the core phantasies of loss, abandonment, and neglect. However, once the patient is in touch with this current state of psychic breakdown, he quickly returns to the negative therapeutic state as protection against emerging feelings of dependent vulnerability and helplessness. The patient is slow to thaw and quickly return to a frozen emotional state if threatened.

In her work with young children, Daniel (1992) substantiates Klein’s theory of the rich, imaginative world of unconscious phantasy populated with internal objects. These internal objects were distinct from the actual parental objects, although in interaction with and influenced by them. Daniel (1992) reminds us that for Klein, this world of inner phantasy objects was alive, active, and determined the transference. This meant it could be modified by interpretation.

Klein (1975) found that the primitive superego is extremely harsh and cruel, but she also found that its strength could be decreased by interpretations, particularly of the underlying anxiety and guilt. This was the ongoing effort with F. that was sometimes successful and sometimes blocked by the harsh and cruel aspects of F’s superego. His superego was partly his internalization of some of mother’s attributes, which he distorted and shifted in parallel with his own love, hate, and quest for knowledge.

Etchegoyen (1991) notes that the Kleinian approach sees transference as the externalization of current internal phantasies regarding self and object, not just a recycling of past object relational conflicts. While Kleinian theory sees integration in the paranoid-schizoid mode as the gradual blending, tolerance, and accepting of the good, giving object, and the contented and satisfied self with the frustrating, withholding, or hurting object and the frustrated, anxious, or injured self, some of our patients, such as F., have not found their footing in this more stable emotional plane. This makes the transition into the depressive mode much harder and fragmented. Thus, for F, acceptance of himself as living in the full spectrum of being hurtful, giving, sadistic, and guilty towards an injured, grateful, betrayed, and repairable object was the developmental challenge.

F. is an example of how some patients attempt to take on this psychological advancement into the depressive position as a defensive stance of pseudo-maturity. They claim to themselves and to their analysts, through their actions and words, to have this broad view of self and other, but it is false and brittle, easily crumbling. This was the case with F, not only in the beginning of his analytic treatment but also somewhat at the end.

When these types of hard-to-reach patients operate within the proximity of the depressive position, their fear of disturbing the object with their own displeasure, hunger, or identity is so great that it must be denied in a desperate, manic method such as F. exhibited, and when their defensive idealization of the object breaks down, the despair of no object/no self is extreme. In F.’s case it fueled the overwhelming and crippling depression from which he suffered. In order to avoid that, F. had to engage in manic cycles of sex, shopping, and exaggerated optimism.

The classical Kleinian method of interpretation consists of the analyst attending to anxiety whenever it reaches a critical stage in the patient, overwhelming to the patient with either paranoid or depressive conflict. At that point, it is important for the therapist to offer interpretations of the phantasy and/or transference state that brought the anxiety into its critical level. Here, Melanie Klein is a true follower of Freud’s quest to make the unconscious processes conscious and understandable to the patient.

Contemporary Kleinians, particularly those who side with the technical direction of Hanna Segal (1981), see a complete interpretation as eventually linking the past, the present, and the here and now transference state. With F, I attempted to interpret the difficulties he had facing the lack of a nourishing, available mother figure in his early life and his avoidance of anger and deprivation by substituting an ideal and perfect, by the book, mother in his mind. He avoided being an angry, lonely, and desperate little boy by remembering his mother as a classically available “Leave-it-to-Beaver” mother. I interpreted how this paralleled his present life struggles and his often rule-bound, striving-for-ideal-perfection way of relating to himself and others as well as his way of relating to me and the treatment.

As Bion (1962) notes, when the infant or adult feels overwhelmed by deprivation and envy for the better, available breast but must cling to something less satisfying for security and nourishment, the fragile ego relies on enforced splitting. Bion explains this as a controlled, defensive process in which the patient allows for the contact, nourishment, or interpretive connection with the analyst, but denies the emotional experiences of it. Symbolism is crippled and a voracious, but always unsatisfied, experience emerges. As in F.’s manic patterns, the thing, the sex act, the shopping spree, or the quest for immediate “progress” in treatment all become sterile goals with no emotional value attached. There is never a sense of being filled up and content.

Etchegoyen (1991) notes that we do not try to eliminate our patient’s anxiety and guilt, but, over time, through assisting them to understand, own, and learn from their internal experiences, the patient can come to reduce, face, and manage these experiences. F. demonstrated how some more difficult-to-reach patients feel this invitation to better know themselves and their objects is very dangerous. They feel as though the analyst is taking away something important, their control and sense of things, instead introducing something threatening, unknown, and out of their control.

Regardless of the turbulent and faltering nature of some of our more difficult analytic cases, I am advocating focusing on Freud and Melanie Klein’s clinical discoveries: the understanding and working through of unconscious phantasy and the warded off object relational conflict. In this view, consistent exploration of transference and phantasy defines the goal and the modality. Rather than frequency, use of couch, duration of treatment, or the type of termination, the working through of unconscious conflict and defenses, created by core object relational phantasies, becomes the bedrock of what constitutes helpful and successful psychoanalysis.

Many clinicians have extended Klein’s (1946) intrapsychic concept of projective identification to include the interpersonal and interactional aspects of the analytic situation. Joseph (1988) and many other contemporary Kleinians have noted the patient’s unconscious ability to stimulate and provoke the analyst to pair up with the specific object relational phantasy embedded in their projective identification process. I have provided examples of this with my work with F. My moments of countertransference enactment verified Spillius’s observations (Roth & Rusbridger, 2007) that the technical relationship between countertransference and projective identification is as important—if not more important—than the patient’s verbal associations. Careful examination of my countertransference feelings, thoughts, phantasies, desires, reactions, and acting out helped me to understand the motives (Rosenfeld, 1971) F. had in his use of projective identification, including communication, discharge, attack, plea for help, and invasion of the analyst’s body and mind.

The key Kleinian concepts (Waska 2010a, 2010b, 2011) include the total transference, projective identification, the importance of countertransference, psychic retreats, the container/contained function, enactment, splitting, the paranoid and depressive positions, unconscious phantasy, and the value of interpreting both anxiety and defense. In my work with F., most of these concepts came alive clinically. He retreated into manic optimism because of his sense of having no containment. But after allowing some more depressive feelings, such as anger, desire, and hunger, he felt a persecutory containment. Due to splitting and projection, he felt persecuted by my interest in his conflicts. Therefore, I tried to explore consistently and gently and to interpret his anxiety and defensive reaction to a set of intense core phantasies regarding envy, deprivation, and guilt.

Hinshelwood (2004) notes the three key elements of current Kleinian technique to be interpretive interventions aimed at modifying the source and nature of the patient’s anxiety, understanding of the inevitable enactments that emerge as projective identification based transference states infect and shape the analyst’s countertransference, and the working between patient and analyst to jointly discover and create new knowledge about the patient’s internal world and thus promote new ways of thinking and feeling. Of course, the more disturbed patient will react to knowledge and change as something dangerous to either self or other (Waska 2006) and show corresponding transference styles of perverse relating or destructive nonrelating.

The use of projective identification as a vehicle for the death instinct in evading or eliminating threatening knowledge and new ways of thinking or being can immobilize the treatment and erode effective analytic contact (Waska 2007, 2010a, 2010b). When a patient is addicted to such massive evacuative methods of projection, we see the patient ending up empty and robot-like, internally and interpersonally (Sweet, 2010; Williams, 2010)

For F., our focus on knowledge was extremely disturbing, whether it was prior knowledge, which he denied, or new knowledge about himself and his beloved objects. When he began to allow himself to know more about his mother, he was filled with guilt, anxiety, and fear. By our work together, and my specific interpretations, he started to know more about himself and how he came to feel so depressed as a result of his own demanding rulebook. F. came to know more about how he made others into critical and unloving bad objects through his projection of the rulebook. However, F. would only allow and tolerate a limited amount of new knowledge about himself and the world, and when it began to shift his psychic equilibrium (Spillius & Feldman, 1989), he pushed back and rebuilt his psychic retreat. Ending analytic treatment was another such retreat into comfortable, yet false, optimism. We gained a great deal of ground and learned quite a bit. F. decided not to allow any more learning or change at this point. Perhaps at a later point in time, he will tear another page out of the rulebook, but for now, we must allow for what is, what isn’t, and the unknown of what could be.

We always seek to find a mind of our own (Caper 1998) in which we can still share and experience the patient’s provoking and recruiting transference aspects of their internal phantasies. We may at any given time feel extra comfortable, unusually awkward, strangely excluded, lustfully pulled into, curiously greedy, carelessly uninterested, sadly unimportant, or outright angered by the different ways we are used or not used as a transference object.