by Robert Waska
The start of a psychoanalytic treatment can be quite varied depending of the nature of the patient’s phantasies, internal conflicts, their resulting transference and projective identification process, and the impact of these factors on the analyst’s counter-transference. The first twelve sessions of one Kleinian therapy treatment will be presented. This material will illustrate how the unfolding transference and counter-transference is understood and how important it is clinically to deal with the patient’s phantasies and anxieties as soon as possible through the mode of interpretation, analytic observation, and containment. The author uses this extensive case report to demonstrate the Modern Kleinian technique of working with difficult cases in various settings, frequencies, and situations.
Robert Waska PhD
P.O. Box 2769
San Anselmo, Ca 94979 USA
Most of the patients receiving psychological treatment from practitioners trained in psychoanalysis are seen once or twice a week, have limited resources, and suffer significant emotional distress (Spivak 2011; Waska 2005, 2006, 2011a, 2011b). This paper will follow the initial twelve visits with one such patient seen in a private practice setting. The approach described here is intended to be helpful to patients with severe paranoid-schizoid (Klein 1946) or depressive (Klein 1935; 1940) disturbances who are limited by choice or circumstance to only attending once or twice a week. Modern Kleinian therapy is an effective therapeutic process for such situations and can provide important and lasting psychic change (Waska 2010a, 2010b, 2010c, 2010d).
Modern Kleinian therapy is a therapeutic approach designed to establish analytic contact (Waska 2007) with patients who are struggling with ongoing internal conflicts of a more primitive nature in which change or growth is experienced as a danger to self and object (Waska 2006). Therefore, they live in a state of perpetual distress, anxiety, paranoia, guilt, or loss. Normally, the term therapy or psychotherapy indicates a diluted form of psychoanalysis, a supportive method, or a deliberate manipulation of the transference. The procedure outlined and illustrated in this paper is neither diluted, singularly supportive, or manipulative. Indeed, it is a psychoanalytic treatment that aims at working with the patient’s unconscious conflicts, their object relational phantasies, and their transference perspective.
As such, the technique of Modern Kleinian Therapy is no different whether practiced once a week or five times a week in terms of technique. However, the infrequent visits can and do create significantly more difficult transference and counter-transference situations and the patient’s defensive system and pathological organizations (Steiner 1987) or retreats (Steiner 1990, 1993) as well as core issues of loss that are defended against with pathological levels of projective identification (Waska 2002, 2004) are all much more entrenched and difficult to unravel. However, it is still an effective, robust, and productive way of potentially transforming formally unreachable individuals and offering them a new and dramatically different way of living.
Modern Kleinian Therapy is a psychoanalytic method of treatment based on the work of the contemporary Kleinians of London (Schafer 1994). It is a therapeutic system that integrates the work of Kernberg’s TFP (1999, 2006), the CCRR method of Luborsky (1984), earlier work of Waska (2005, 2006), some ideas from Sandler (1976), and a mixture of flexible technique principals from a wide variety of analytic thinkers such as Merton Gill (1994), Searles (1986), and others. The moment to moment focus on the total transference situation (Joseph 1985) and similar work by Segal (1962,1974,1975,1977a,1977b,1993,1997,1981), Britton (2004,2008), Spillius (1983,1992,1993,2007), Steiner (1979,1984,1987,1992,1994,1996), and Feldman (1994,2004,2009) is adapted towards a continuous effort to establish analytic contact (Waska 2007) regardless of frequency or diagnosis.
One guiding principle is to use the healing aspects of new knowledge about self and other gained from analytic observations (Waska, unpublished) and interpretations to bring about insight and foster psychic change and growth. This is similar in practice to work by Clarkin, Yeoman, and Kernberg (1999, 2006), Luborsky (1984), and others who focus on the here and now transference and core phantasy conflicts of the patient’s dynamic unconscious world. Modern Kleinian Therapy helps neurotic, borderline, narcissistic, and psychotic patients to engage in a restorative therapeutic process geared towards examining and shifting fundamental object relational conflicts.
Again, I deliberately do not call these approaches psychoanalytic psychotherapy but rather a psychoanalytic method and a psychoanalytic treatment because the vast majority of authors who write about and advocate psychoanalytic psychotherapy describe a deliberate watering down of traditional psychoanalytic technique, a reduction of interpretation regarding the transference and defense systems, and a increase in supportive and behavioral interventions that utilize manipulation of the transference instead of interpretation. I think this is a mistake with all patients if we are really trying to offer them the greatest degree of change and psychological growth. But, to not utilize the primary tools and potential of the analytic method with the more disturbed patient can be even more of a clinical failure in not offering what might be most needed.
Case of Y: the Initial Session #1
Y struck me as a very intelligent young man with great curiosity about himself as well as the genuine desire to change and to find satisfaction in his life. At the same time, I felt cautious and suspicious when he talked about his issues in a fuzzy, grandiose manner with excessive remarks about “spirituality and the essence of inner meaning, fulfillment of the heart, and true emotional resolution”. It sounded like something he had read in a self-help book and a way to avoid sharing his real self and his actual feelings with me. I made that interpretation and Y seemed interested. Indeed, he had attended many such workshops and programs over the years but never had been involved in any psychotherapy or psychoanalysis.
The more we talked, the more I felt he was both articulate and insightful yet out of touch with reality. In other words, I thought that Y’s grandiose, paranoid, and possibly delusional way of relating to me was buffered by a partial anchoring into a more intellectual, sincere, and eloquent manner of relating. As a result, I felt uneasy about who he was, what he was really all about, and how he was really going to utilize me, depend on me, or possibly discard me. It appeared we would have a rocky ride in and out of grounded reality and possibly a relationship that would contract and expand in tricky or unexpected ways.
Y talked at great length about the “dynamic involvement” he found in the human potential workshops he had attended and the “interesting historical lineage” of the New Age church he had recently converted to. According to Y, this church advocated strict or fundamentalist rules of behavior about routine confession, no sex before marriage, and regular prayer combined with a Buddhist mentality. Y seemed to be very drawn to the punitive aspects as well as the rigid structure. He talked at length about how he felt spiritually drawn to the church, how he had a spiritual awakening recently when he heard the choir singing. He fell to the ground crying and thought he could see the image of his dead mother at the altar. He told me he had met a member who had his mother’s name and who introduced him to the head priest who also had a sister with his mother’s name. Y felt it “was destiny” and how it must be “a special spiritual path that had brought him closer to being able to finally find his mother again.” This sounded similar to his description of the time at a Zen retreat he “knew he was Jesus and obviously had special mystical powers.”
When I noted that he seemed to like the rules and structure of the church but that an organized way of living was quie opposed to the way he had been in the last three years, Y said, “I love the structure. I need structure. When I picture the ultimate way of feeling at peace, I have the vision of being in my mother’s arms.” I said, “So, you feel the structure of the church is much like the security and structure of being loved and back in your mother’s arms.” He said, “Yes. Even better would be to be back in her womb. That would be the ultimate structure!” In the counter-transference, my mental image was of something so wonderful and cozy but then suddenly too tight, confining, and restrictive. Y’s psychotic desire to reenter his mother gave me some ideas about how he might want to possess me, abort me, and establish an “ultimate fusion” state with me, to avoid differentiation and loss. These were provisional ideas based in my counter-transference feelings at this early point in the treatment.
Over the last three years, Y had traveled around the world in an aimless and desperate attempt to escape from his inner demons. At the same time, he felt it was a “wonderful quest in many ways, finding a spiritual path and many deep spiritual revelations along the way.” Over the course of our first two sessions, I learned how Y had grown up in a family of four brothers, two younger than he. Y’s mother died of cancer when he was three years old and his father remarried a few years later. Y told me he realized a few years ago that his lifelong unhappiness and sense of fragmentation comes from the loss of his mother at this sensitive young age. He believes this early loss has brought about his mental breakdown he says he had three years ago.
Y’s older brother has some type of psychotic condition and has been in and out of mental institutions. He has been given various anti-psychotic medications and mood stabilizers, which, Y says, he has tried himself in an effort to “find some calm and clarity during the rough times.”
I interpreted that perhaps he identified with his brother and sought out the same kind of help with the medications. Here, I introduced an idea about him somehow seeing himself as his sick brother and needing the same treatment. I wasn’t sure about anything else regarding his brother but I felt it important to comment on this sense of sameness. It was useful to see how concrete Y was in his reply. He said, “I just thought his meds would help me with my moods and depression because my brother suffers with them as well. But, they did not help and I think they screw up your brain anyway so I am glad I stopped taking them.”
So, I kept my idea of him wanting to be the same and losing his identity in the process as a question mark. I knew he could be correct in diagnosing himself as suffering the same illness as his brother, but the way he described it had a feeling of a more blurred attempt at fitting into his brother, a way he seemed to desire fusion or sameness. This was all in the tone and manner in which he conveyed the story to me. Y went on to elaborate how the “main and most devastating problem in my life is the death of my mother. She died of cancer when I was three and I finally realized a few years ago how much that has affected me. That is the central core of all my issues. I must find her and reconnect that spiritual bond and find that missing part in me”. He went on to tell me of his “mental breakdown” three or four years ago and his “voyage ever since to free myself.”
Y told me he smokes pot every day to calm down and to find some peace of mind. Y also drinks heavily when he can’t find enough pot. When we were discussing his long time addiction to pot and how he uses it or alcohol to “self medicate”, Y casually mentioned an incident from the prior week.
He told me that he had moved into the city about two months earlier and had quickly found a job in a small grocery store. His job was to stock the shelves. Y said he hated it because it was boring, and when he was done for the day, it was a long walk to the bus stop. But, he kept at it for about three weeks. Then, one day at work, he decided to consume a “pot brownie,” and when he started to feel really high, he went to his manager and told him that he was now too high to work and wanted to see if he could leave early. The manager promptly fired him.
I asked Y what he had expected would happen. Y said he wasn’t too surprised, but he always hopes “that people can maybe see the real truth and find a way to have a connection that transcends the weight of rules and convention.”
I said, “You seem to be hoping for a pure, honest, and all accepting connection, perhaps the sort of thing you feel you lost out with your mother dying.” Y said, “Exactly!” I added, “It also seems to be a way that you sabotaged yourself and got fired. You could have hung in there and not told your boss or you could have elected to not get high. But, you took away something you had created in your life.”
Y said, “I do that over and over and over. I tend to achieve something and then give up on it or screw it up somehow. I have done that with girlfriends and plenty of jobs.” So, we discussed the elements of this pattern and how he seemed to be happy and proud of himself but then turn away from himself and let go of that positive element to create a negative. Here, I was thinking about the clinical manifestations of the life and death instincts and the destructive conflicts that can occur in that phantasy realm (Steiner, 2004; Rosenfeld 1971; Grotstein 1985). I also wondered to myself how long it might be before he took what we will build together and try to kill it off as well.
I noticed Y had a pen and pad on which he was taking periodic notes. When I made an interpretation, he wrote it down. He asked if we would be working psychoanalytically. I said he probably knew I was an analyst. He said he did and wondered where I was trained. I paused and said I was trained in the city but wondered what exactly he wanted to know. He wrote something down again. I asked him what he was writing and what exactly he was trying to find out about me. Y said he had written down what I said about trying to search for the perfect bond and structure with his mother and how somehow it always collapsing without him being able to sustain it. He said he was also writing down where I was trained so he could look it up.
I said, “It seems you want to know me and own me in some way that also makes it hard for you to be here right now. By trying to pin down everything on paper, you are not getting to know me right now.” Y said, “I am just a curious person and I want to know what type of treatment I am having and a little about the person I am supposed to trust in that treatment.”
So, for now, Y kept us at that concrete distance but based on my counter-transference, it seemed that internally he was fishing around to know me, possess me, and get inside me. I thought this might be part of what I would term the extraction process of pathological projective identification in which the subject attempts to hijack or acquire certain aspects of the object to call their own. It becomes an emotional theft based in envy, intense anxiety over not knowing, and not having control of the internal environment. I thought he might feel so weak or vulnerable about wanting to know and having to find out through an ongoing relationship that he was trying to hijack it immediately.
When I went to the waiting room to find Y for his second session, I found him standing there with his bicycle. He said he didn’t want to leave it on the street and have it stolen so he wondered if he could leave it in the waiting room. I had several thoughts about this. While there was no one else out there, it is interesting that Y didn’t think of how his bicycle would impact the next patient or how he might be impacted by them. I think he felt it was his waiting room and it felt safe to leave the bicycle there.
I was worried that someone would come into the waiting room and steal the bike so I suggested he leave it in the hallway by my office door. But, either way, I felt he was moving in. This sensation was confirmed when he entered my office and took out his cell phone and a charger and said, “Can I plug this in somewhere?” I had two feelings about this. The first feeling was that I had no choice. I had to either say yes or I would be telling him no in a very rejecting way, telling him that there was no room for him in my home.
The second feeling was that Y was indeed moving in. So, I said, “Looks like you are moving in! I wonder if you have decided you can trust me. But, with such a fast move in, I wonder if you will be able to stay for awhile?” I said this based on the feeling that this was an impulsive move into me and could easily be followed by an impulsive retreat. Y confirmed my interpretation when he said, “I have always had a hard time with commitment. I have a pattern of really getting into something and then it all falls apart. I give up on it.”
I asked, “Do you give up or do you choose to retreat and pull out?” Here, I was seeing if Y was able to consider himself as an active player in his life or just a passive observer. I wondered if he was caught in a more persecutory vision of himself or knew he was participating in what happened around him. Y said, “It feels like I just give up. I go into the job or relationship with a lot of hope and excitement. It works out and I am happy for a while. I am very successful at most of the jobs I take on and I have been very connected with a number of women. But, at some point, I feel it is almost going too well and I give up and stop trying. I think I can’t handle it and so I sort of fade away.”
I said, “I wonder if something about being successful, happy, or close makes you anxious and then you have to fail. Almost punishing yourself or running away from something positive.” Here, I was interpreting a possible fear of success, a dread of closeness, and a reaction to having dove too deep into the object or situation. Y said, “I think that could be. I tend to fail at commitment.”
So, after only seeing Y for two visits, it is unclear what his struggles are and how the treatment will unfold. However, by adhering to a Modern Kleinian Therapy approach, I was able to make a few interpretations and help Y open up in certain ways. This has started a therapeutic process in which we have already established a degree of analytic contact, exploring and examining his internal world and the various unconscious phantasies and conflicts he is suffering with.
In the counter-transference, I notice that my feelings and thoughts sometimes parallel his description of himself and his emotional patterns. Specifically, I notice myself liking him as a person, trusting him, and wanting to engage in a working relationship. However, at the same time, I have an uneasy feeling, a slight distrust, and see him as more disturbed than he appears and possibly ready to terminate at any moment. So, I am keeping this counter-transference impression in mind as we proceed. I think it may help me understand him more and find my way as we continue our analytic journey.
For Y, he was still splitting his objects into ideal, all good, but unobtainable pieces as well as into omnipotent, all bad and hateful pieces. Y seemed to be lost in the quest and search for this mythical perfect object as a way to avoid facing the grief and rage he felt over the aspects of his lost object he resented and pinned over. Thus, he lives in a fantastic and frightening world full of incredible possibilities and constant failure.
I had seen Y for six sessions when he cancelled the next two and went out of town. He left for several weeks on a “wonderful business opportunity to provide some professional consulting and to begin to put together a potentially vast corporate Investment.” When he returned from a rather disastrous financial experience of high expectations and low results, we continued to investigate what was fueling such internal and external instability.
When Y walked into my office after this disappointing trip, he said, “Hello Doctor. Did you forget me?” I let him settle in, thought about what he said, and listened a bit more. After hearing some details about his trip, I said, “I think you are not sure who is feeling what or who is doing what to whom sometimes. You took off and left our regular meetings. But, now, you are worried I have forgotten you. It seemed like you might have forgotten us the way you just sort of slipped out of town.” I wondered if he was feeling guilty for forgetting about me and now was trying to flip it around to feel better. Y replied, “No. I think I am afraid that you are angry with me for cancelling the two sessions and that you might not want to see me anymore.” I said, “You are anxious that our bond is very precarious and that you could ruin it very easily. It is hard to trust that I could care for you and not just abandon you if there is some friction or if you need to be somewhere besides here.” He said, “I was worried that you felt I blew you off so you closed the door and just gave away my time to someone else. I am glad to hear we are okay.”
I thought to myself that Y had indeed “blown me off” and that this was part of his entitled, challenging transference in which he did as he pleased but then dreaded the fallout.
In this seventh session, and into the eighth, we continued exploring his desire to find some sense of peace and understanding about the loss of his mother and to understand how that might still be driving the direction of his life and creating the aimless and empty feeling he was plagued with. However, much of how Y spoke to me and much of how he thought about himself was distorted and filtered through a very intellectualized, manic effort to feel in charge, in control, and forever hopeful.
Y tried to feel successful about how he was doing in life, whether it was about the emotional issues we were exploring, his housing situation, his finances, or his relationships. But, the sad truth was that Y was in the middle of a collapse in all these areas. He was trying to better himself but also was in denial about the more destructive ways he thought about and related to both himself and others. He felt entitled and spoke of “not caring about doing much because it didn’t hold enough meaning for me” and “not really wanting to work at something I don’t like because I don’t want to be bothered.” Y told me of a “wonderful, tight bond with my roommates and the million dollar deals they were putting together” while he was actually being told to move out because his roommates were sick of his pot smoking and lack of employment.
In reality, Y was now on food stamps and barely able to find money to take the bus to see me. I understood these psychotic distortions in a number of ways, but primarily interpreted his precocious mourning (Feldman and Paola 1994) in which his desire for his idealized mother and their wonderful union felt beyond the ordinary grip of everyday life and created a constant conflict with reality. This caused him intense envy and anxiety. As a result, he was constantly fleeing emotionally from the overwhelming loss that reality brought him face to face with. He was always juggling his fragile quest for unavailable entitlement with his reach for illusive grandiosity. All this was tempered in some respect by his use of intellect and his talents and skills that seemed to have gotten him by, just barely, until now. However, his envy for the unreachable ideal self and other/mother put him at a distance from reality and from building any creative or emotionally profitable support system that would anchor him into everyday life.
During the ninth session, Y told me that he had been to the psychiatrist as suggested by his social worker and was told he was probably bipolar with some psychotic or manic traits and had been given an antipsychotic medication and an anti-anxiety medication. Y told me he was planning on not taking them because he “preferred natural remedies and didn’t really think he needed them.” Y said, “The psychiatrist thought I was manic and said the medications would help with that. But, I think that how I am right now is just fine. And, if I am manic right now, then I think it is okay because I am not being destructive in any way. In fact, I am being extremely productive. I read a 600 page Russian novel in the last week. And, since I saw you last, I have stopped smoking pot altogether. Now, I work out everyday at the gym and I do yoga by myself. I am praying and singing at church and feel great about life. Things are alright with my life and I don’t think I have any real problems right now.”
I said, “You seem to want to convince me of how wonderful you are doing and how carefree your life is. Since you are telling me today that you are broke, barely have enough for bus fare, are on food stamps, and are soon to be homeless because your roommates are kicking you out, I think it must be very painful to be more in touch with yourself and the lost and scared feelings that are probably there. I am glad to hear that you are not smoking pot and that you are working out now. But, I think you are quick to try and hide from the difficulties that are inside of you which leave you feeling alone and searching for mother.”
Here, I was interpreting his manic stance in the way Rosenfeld (1971) has noted that narcissistic defenses guard against the threat of separateness and the resulting loss and mourning of what could have been and will never be. I was interpreting it both from a genetic perspective as well as a here and now transference comment. Steiner (2011) has noted that certain patients will utilize projective identification to prevent any sense of loss or separation from their hoped for ideal object. A manic, narcissistic stance is developed to ward off the recognition of both bad and good elements that reside in both self and object. Y would not allow for these aspects of himself or his internal world and demanded excellence and bliss with no limits or restrictions.
Y said, “I am trying to realize she is no longer around and that I can never find her. She is gone. But, I have her inside of me!” I said, “I agree. But, there is something a little too quick about all these progress. I am concerned you are trying hard to feel better by ignoring some of the hardships in your life and that could backfire.”
Here, I was interpreting his reluctance to face the ongoing experiences of loss in his internal and external life. He used a manic defense against the mourning of his ideal object as well as the ideal vision he had of himself. Finally, I was interpreting how Y wanted to appear a certain superior and controlled way with me, not ever wanting me to notice the tattered and torn painful little boy that embodied his current existence.
Y said, “I know what you mean. When I went out of town, I thought I was going to make some real money. I was asked by an old friend to come down and consult for his small company. My job was to set up the structure for the people he would hire next year. I did a whole lot of work over the week for him but in the process we ended up having some of the same old fights we have had in the past. I realized I had made a mistake in judgment and that he was still the same very disturbed person I wrote off last year. I woke up the next day and told him I was leaving and that he owed me $500. He said he wasn’t going to pay me anything. I didn’t have any money at that point so I asked him for bus fare back. He refused. I had to use the last money I had in the world for a bus ticket back to the city and when I got here two days ago, I had twenty-nine dollars to my name. I am glad I secured food stamps. Now, I am hoping to sleep at the church. But, if I end up on the streets, so be it. I always bounce back and that is what life is about, these golden opportunities!”
I said, “You are feeling very upset over the loss of your mother and in the process you have never found yourself. That conflict and struggle seems to keep getting played out in a lot of your relationships and in how you try and avoid any pain or unhappiness.” Y said, “I have felt left behind by my mother for so many years. It is a great sadness that has taken over my life and left me terribly lost and alone. I have lived a lifetime of emptiness. But, now I am trying to find a new way of being and a new way of feeling. I want to take care of myself and respect the talents that I have. Coming here, going to church, and working out are some of the ways I believe I can accept her loss and continue to live my life.”
I said, “I think you are right. We have to keep exploring the mixture of feelings that keeps you on this zigzag pattern of come and go, commitment and disengagement with yourself, with me, with relationships, and with life. That way of wanting to be engaged and then disengaging happens here between us and you have pointed out how it has happened many times over with girlfriends and jobs and friends. You must feel quite pulled at times to want to be with someone and then suddenly not so comfortable with that contact and have to pull away. It is a confusing way of being with others but also a jumbled way of being with yourself.” Y said, “That is a good word to describe how I feel some of the time, jumbled.”
Y began the tenth session by telling me about his favorite movie, a tale in which there is a poor, ignored man who is actually a genius and is able to show up the head of his company with his incredible intellectual powers but never “becomes a victim of the corporate mentality.” He does what he wants and lives his life the way he wants, never letting himself be “controlled or taken over by the edicts of society.’’ I interpreted, “You seem to be feeling like you are that genius, fighting and winning against all the controlling authorities around you. You maybe even feel proud and superior in some ways.”
Y said, “Well, I actually do. I have always felt that I know much more than most people and have an edge on others in many ways. I think I have a great deal of creativity and special ways of thinking about things that put me above the herd, not just a follower.” I said, “From what I remember of the movie, the person you are seeing as a hero is also a very sad character who sabotages himself over and over and ends up quite alone. Maybe you have the same sort of struggle with wanting to feel so strong and smart but always having to fight the system so in the end you end up feeling little and lost.”
Y said, “I do feel that way. But, I also have a hard time figuring out why it would do me any good to be a part of what looks like a broken system. Instead of doing God’s work, people are just out for themselves and racing after power and money. I don’t see the point.” I said, “With me and with yourself, you seem to get stuck between these two black or white choices, to join the devil or fight against him. Maybe, we can sort out some other options, some middle ground.” Y nodded and said, “I am up for that!”
Not surprisingly, this brief phase of curiosity and reduction in anxiety, manic rebellion, and resistance was short-lived. In the next session, Y came in and said he had spent the night in a homeless shelter and that “at first it was a frightening and humbling experience. I felt out of control. But, then it occurred to me that I don’t need a home. No one does. We are all part of God’s home and that in many ways being homeless would help to teach me what I need to learn.”
I said, “I think it is hard for you to be vulnerable with me and to face those frightening feelings of being out of control. It is easier to try and see it as a golden opportunity you are in charge of.” Y said, “No. I feel great. I don’t need to have to claim anything as mine. That is a big problem in the world. Everyone is too scared to see that they have nothing expect the love of God. We have to learn to be happy with that and not be chasing so much more all the time.”
I said, “You have been chasing something your whole life. You want to find peace of mind and a sense of being loved instead of feeling lost and forgotten. But, you don’t want to depend on me or anyone or anything, maybe for fear of being let down again.” Y said, “that goes right back to my mother. I felt completely torn away from her and I have been searching for her ever since. But, I know that already! I want to know what you are going to do to help me with all of this. What exactly are you thinking about regarding my diagnosis and how you will be treating me? And, how long do you think it will take? I am not sure this is even the right type of treatment for me or the most effective solution. I have heard of quite a few other treatments that might be better!”
In the counter-transference, I felt challenged, attacked, devalued, and ready to be discarded. I interpreted, “You are making me useless and pointless by demanding that I help you after barely just meeting you. If I can’t solve it and fix it right away, there is something better somewhere else. This is the way you have been living life and in the process never giving yourself a chance. You are always pulling the plug on yourself as well. You are so busy wanting the magical reunion with your mother instantly that you are not giving us a chance to see what is really bothering you and to build a solution together. You don’t like the idea of needing me, of having to take some time to invest in yourself, and of not knowing or having it all immediately. That must be very hard to tolerate. But, we must try so we can get to the other side”. .” Y didn’t say much. It was the end of the session and he left.
In this next session, Y seemed quite agitated and manic. He was irritated and spoke of many situations in which he was unhappy or angry. He talked about “being sick and tired of how people like to dominate each other and how he will never allow that into his life.” Y insisted he “will always choose the road of freedom and self expression over being dominated and categorized.” Y had many examples of how “culture encourages domination” and how the “class system has brainwashed people into accepting this power imbalance.” He told me that “having me be on this couch is an example of that. You just want to feel impressive, lording over me like some kind of fucking authority figure. I don’t accept that. I would rather find someone who understands me and realizes that under God, we are all equal and should always relate to each other as equals.”
I said, “It is interesting to notice how out of all the possible ways of experiencing being here with me, you end up feeling dominated. Some people might feel freed up or given a special opportunity to relax and simply express whatever they wish at whatever pace they choose. But, you quickly push us into the box of jailor and prisoner, dominated and dominating. Perhaps it is uncomfortable to allow for something else.”
Y said, “I do go there very quickly. I don’t know why. But, I see what you mean. I just don’t like being told what to do. I never have. I feel I have the right to do what I wish and no one should tell me otherwise. This is God’s earth and it doesn’t belong to anyone.” I said, “You want me to see you as this special person with special rights and who is above the rest. I wonder if you feel weak or like a failure in some way so you have to fight hard to look the opposite.”
Y replied, “I do feel incredibly weak and like someone who has never found the answers. I have spent my life looking but I have yet to find them.” I said, “That sounds sad and a bit scary. A small boy lost in the world with no mother, no answers, and no direction.” Y began to weep.
After a few minutes, he went back to his more entitled, manic stance. He told me about how he had gone to church and started singing in the middle of the service, feeling “connected with God and in touch with the universe.” When the priest asked him to stop, Y asked why and the priest said it was just not something that they wanted because there was a service going on and that should be respected. Y became angry and told him that “this is God’s church and you can’t tell me to do anything!” The priest told Y that he needed to respect the rules of the church to which Y yelled at him, “I will never come here again! I will find a church that allows me to worship like I want to. You don’t have the right to prevent me from praying in the fashion I need to or want to!” I said, “You seem to not want to respect the church or the priest’s property and regulations. You are trying to impose your wants and ways on other people. It seems you are in fact the one doing the dominating. It seems like it makes you very angry to encounter limits or to be told no.” Y said, “I don’t want any limits. I will do what I want or go elsewhere if I can’t. No one is going to put limits on me.”
I said, “Maybe, you are furious and very hurt about the limits that you felt when your mother died. Now, you are taking that out on me, the church, the priest, and the world.” Y said, “I am very angry and hurt about my mother.” At this point, he pulled out a book that he had borrowed from the local library. It was about the effects of death on young children. He started to read passages to me about the devastating effects of a parent’s death on a young child. I said, “You really identify with that. You still feel completely lost, still very sad and angry. I think you feel very much entitled to do as you please now so as to maybe finally get to be special. You want to be special now because you feel you lost out on a mother who could treat you special.” Y said, “I think you are reading my mind, Doc!”
As he was reading the library book, I noticed how many of the passages were underlined. I asked, “Did you underline the passages?” Y said yes. I said, “Maybe that is another example of how you want to feel special and above all the ways of the world, over death and disappointment. The book is not your property, it belongs to the library. But, you ignored that and decided to treat it as if it is your book without regard to the library or the next person who wants to read it. And now, you have pulled me into being a lecturing or dominating authority telling you off. So, I think you really want the right to be special so you don’t have to feel so unspecial and unimportant.”
Y yelled, “That is bullshit! This book belongs to no one. This is God’s book! I don’t care and I will do what I want! I am trying to learn something from this book and if I want to underline it I should be able to!” I said, “I think you feel, deep inside, that either you are special and entitled or small and meaningless. You feel you have to grab what you want or you will have nothing.” Y said, “Well, that is true. I don’t want to miss the bus in life. I want to find out what is wrong with me and put me life together!” I said, “It is hard for you to find a peaceful place to fit into life when you are either feeling dominated or when you are dominating others like the church, the library book, or wanting me to fix you in a handful of sessions. You need to allow for some disappointment and delay in order to get what you want, but I can see how hard that is. You don’t want the pain of that limit.” Y said, “It is very hard.”
In the next session, Y seemed a bit more calm and less angry. However, he told me about how he was “now focused on finding the answers to his problems, moving ahead in life, and putting things in perspective and in the past,” He said this in a pressured and rushed way that felt like he was impatient and somewhat demanding. He went on to talk about how he “wants to know how I see him and what I think his problems really are.” He said, “What is your assessment of me, Doc? What do you think is going on and how can we change things so I can move into a more holistic way of living and find a more complete way of seeing life or reaching my goals.”
This struck me as not only rushed and demanding but also part of a globalized, generalized way he would sweep his hand over the world and come up with grand and entitled slogans that sounded great but were really so intellectualized and far reaching that they were out of touch with reality and certainly out of touch with us in the moment. So, I interpreted, “You seem to be jumping away from your feelings and the problems we are working on together and suddenly going to this more global vision of how you will find the answers and finally live your life. But, in the process, you are more and more out of touch with yourself. What we are doing here today in this room seems more and more useless and meaningless. I think your desire for something very special and big gets in the way of what you actually have now or what you are actually achieving right now.”
Here, I was interpreting his devaluation and attack on the contact we had achieved and how he was replacing this with a demanding search for the ideal. Y said, “I see what you mean. I gave a lot of thought to what we talked about last time and I think we are learning things. I just want to find my way and start to live life.” I said, “You have put your life on hold trying to find your mother or at least try to find the feeling of being with a perfect loving mother.”
Y said, “I have. I try and go after other things but I always get detoured back to trying to find what is missing in me.”
He paused and went on, “But, I just want to know what you will be doing for me and how we will be proceeding. I want to know that we are making progress.” I replied, “You do not want to have anyone say no to you or put limits on you. You want what you want when you want it. By not accepting that you can’t have it all or that it might take some time to get what you want, you are missing out on the good work we have done and the good direction we are headed in.”
Y nodded and smiled. The session was over. When I went out through the waiting room some ten minutes later to get something from my car, Y was sitting in the waiting room. He was reading one of the magazines there and said, “Doc, can I borrow this magazine and bring it back next time?” I replied, “No. It is the office’s magazine and needs to stay here on the premises. But, I think you are testing out what we talked about today.” He laughed and said, “Oh no! You are right. Sorry.” This unconscious way of seeing the world as a place where he can receive everything he wants when he wants it with any push back is experienced as a gross rejection and outrageous restriction continues to be a major factor in his internal life but one we are working on.
The following week, I came out to the waiting room to find that Y had unplugged the lamp in order to plug in his mobile phone. I said, “Did you unplug the lamp?” He said yes. I said, “Plug it back in”. .” I was aware of the irritation and the forceful authority he engendered in me as part of the projective identification process that is so much a part of his object relational conflicts and his transference struggle. He was able to tolerate me being a roadblock to his maternal utopia and said, “Okay.”
Another example of this was when Y came into a recent session, the 20th visit, and said, “I hope you brought your cell phone charger today. I want to use it to plug in my IPod.” I responded to his entitled and bullying way of being by interpreting, “No. I will not give you the charger. There are limits. You are often testing the limits with me and others and never want to be denied. But, we must look at what it means to feel disappointed and not have everything or everyone care for you right away.” Y was angry and told me I was a “shitty person”. He was upset and agitated but we were able to go on to a discussion about how difficult it is for Y to feel special and loved without having to constantly grab for what he wants and feel entitled to it.
No doubt, we will continue to navigate and explore those moments of friction, demand, and disappointment and gradually explore a way to replace them with some hope, acceptance, and healthy mourning.
To briefly summarize the Modern Kleinian Therapy approach, it is a style most characterized by Betty Joseph’s (1985, 1987, 1988, 1989) way of working in the moment, examining the here-and-now interaction between patient and analyst, both intra-psychically and interpersonally. I apply this focused intrapsychic and interpersonal style of working to individual patients or couples who are suffering with significant psychological disturbance often seen only once or twice a week.
This reduction in frequency reflects the current state of practice in most analysts’ offices in which patients are unable either financially or practically to attend more often or are unwilling emotionally. However, they still are looking for psychological assistance and we can still offer them significant help. The reduction in frequency naturally brings about some degree of difficulty in the overall treatment process. The transference will be harder to find, engage, and interpret and the patient’s pathological defensive systems and psychic retreats will be harder to work with. Acting out is often more severe and difficult to contain and analyze. Counter-transference can also be more tricky and enactments more probable. However, we must work with what we have and the Modern Kleinian method uses the containing and reparative aspects of both analytic observation (Waska, unpublished) and analytic interpretation to help the patient restore and renew his or her internal knowledge of self and object, free from their more destructive phantasy view of the past. This enables them to better cope with reality and to begin to unravel and untangle their unconscious conflicts with love and hate, life and death, knowledge and the unknown.
This process is what I term the establishment and maintenance of analytic contact (Waska 2007), a therapeutic process that is at the foundation of any true and lasting working through procedure. The case of Y, a very difficult to reach and hard to thaw patient, allows the reader to really see the in the moment, step by step way the Modern Kleinian Therapy approach actually works right from the beginning of the treatment process. The working through of the total transference and complete counter-transference (Waska 2010a, 2010b, 2010c), in which therapeutic success and insight and psychological transformation can take place, is still the cornerstone of the treatment, along with the inevitable failure, resistance, and acting out (Rosenfeld 1979,1987) that takes place in all therapeutic endeavors.
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Robert Waska MFT, PhD is a 1999 graduate of the Institute for Psychoanalytic Studies, an International Psychoanalytical Association affiliate organization. He conducts a fulltime private psychoanalytic practice for individuals and couples in San Francisco and Marin County, California. In addition, he has taught classes and supervised therapists in the Bay Area as well as presented papers in the U.S. and internationally. Dr. Waska is the author of eleven published textbooks on Kleinian psychoanalytic theory and technique, is a contributing author for two psychology texts, and has published over ninety articles in professional journals. He also serves on the review committee for several journals and book publishers. In addition, Dr. Waska is an artist who creates unique combinations of photography, poetry, and digital design. His clinical work focuses on contemporary Kleinian topics, the practical realities of psychoanalytic practice in the modern world, and the establishment of analytic contact with difficult, hard to reach patients. He emphasizes the moment-to-moment understanding of transference and phantasy as the vehicle for gradual integration and mastery of unconscious conflict between self and other.
P.O. Box 2769
San Anselmo, Ca 94979 USA