And One Patient’s Somatic Retreat from Unbearable Loss
by Robert Waska
There is an immediate transference process triggered the moment a treatment begins. With some patients, this appears to be hidden, with no noticeable counter-transference impression. It may take time for the more obvious aspects of the transference to emerge. With other patients, we can find and engage the various cords of unconscious phantasy being played out in the treatment setting from the very start.
This paper follows one patient who has been seen in psychoanalytic therapy from a Kleinian perspective for seven sessions so far. Details of the patient’s struggle with loss and the resulting loyalty to a somatic retreat are examined. Projective identification, counter-transference, containment, and issues of enactment are discussed.
This paper will focus on the application of the regular Kleinian technique to difficult and disturbed patients only able or willing to attend once or twice a week (Waska 2006, 2011b). I will demonstrate with clinical material how there is no real need to modify the technique. However, in low frequency cases, certain aspects of pathology, of transference, and of defense become highlighted and heightened so certain aspects of technique must also be highlighted.
The Modern Kleinian Therapy approach is a clinical model of here-and-now, moment-to-moment focus on transference, counter-transference, and unconscious phantasy to assist difficult patients in low frequency therapy to notice, accept, understand, and resolve their unconscious self and object conflict states. Projective identification is often the cornerstone of the more complex transference state (Waska 2004) and therefore is the central target of therapeutic intervention and interpretation.
A good deal of patients being seen in today’s private practice settings are mired in the primitive zone of paranoid and narcissistic functioning without access to the internal vision of a pleasurable object to merge with without catastrophe. These are patients who are using vigorous levels of defence against the more erotic, pleasurable, and connective elements of relationship just as they are massively defending against the fears of conflict, aggression, and growth. And, this is a state of psychic conflict so intense it may in some cases create psychic deficit.
While Modern Kleinian Therapy is fundamentally no different than the practice of Kleinian psychoanalysis, due to the limitations of reduced frequency, more severe pathology, and external blocks such as health insurance limitations and personal financial limitations, a greater flexibility is required in the overall treatment setting. Also, there is a greater need to notice the ongoing and immediate impact of unconscious phantasy, internal conflict, and transference that occurs in the analytic relationship. Careful monitoring of the counter-transference for the presence of projective identification-based communication is an important Modern Kleinian Therapy technique. The importance of combining interpretations of current here-and-now transference and phantasy with occasional genetic links as a therapeutic hybrid approach is also a modification of sorts unique to Modern Kleinian Therapy. This is more a question of emphasis, however, than a new or radical theoretical shift or unique technique.
Clinically, we see many patients who tend to quickly subsume us and whatever we do or say into their pathological organization (Spillius 1988) with its familiar cast of internal characters. Modern Kleinian Therapy focuses on the interpretation of this particular transference process by investigating the unconscious phantasy conflicts at play and highlighting the more direct moment-to-moment transference usually mobilized by projective identification dynamics. Bion’s (1962a) ideas regarding the interpersonal aspects of projective identification, the idea of projective identification as the foundation of most transference states (Waska 2010a, 2010b, 2010c), and the concept of projective identification as the first line of defense against psychic loss (Waska 2002, 2010d) difference, or separation all form the theoretical base of my clinical approach. Taking theory into the clinical realm, I find interpreting the how and the why of the patient’s phantasy conflicts in the here-and-now combined with linkage to original infantile experiences to be the best approach with such patients under these more limiting clinical situations.
In doing so, the main thrust of the analyst’s observations and interpretations remains focused on the patient’s efforts to disrupt the establishment of analytic contact (Waska 2007). We strive to move the patient into a new experience of clarity, vulnerability, reflection, independence, change, and choice. Analytic contact is defined as sustained periods of mutual existence between self and object not excessively colored by destructive aggression or destructive defense. These are moments between patient and analyst when the elements of love, hate, and knowledge as well as the life and death instincts are in ‘good enough’ balance as to not fuel, enhance, or validate the patient’s internal conflicts and phantasies in those very realms. These are new moments of contact between self and other, either in the mind of the patient or in the actual interpersonal realm between patient and analyst. Internal dynamics surrounding giving, taking, and learning as well as the parallel phantasies of being given to, having to relinquish, and being known are all elements that are usually severely out of psychic balance with these more challenging patients. Analytic contact is the moment in which analyst and patient achieve some degree of peace, stability, or integration in these areas.
So, analytic contact is the term for our constant quest or invitation to each patient for the found, allowed, and cultivated experiences that are new or less contaminated by the fossils of past internal drama, danger, and desire. These moments, in turn, provide for a chance of more lasting change, life, and difference or at least a consideration that these elements are possible and not poison. Paranoid (Klein 1946) and depressive (Klein 1935,1940) anxieties tend to be stirred up as the patient’s safe and controlled psychic equilibrium (Spillius and Feldman 1989) comes into question. Acting out, abrupt termination, intense resistance, and excessive reliance on projective identification are common and create easy blind spots and patterns of enactment for the analyst.
While Modern Kleinian Therapy is fundamentally no different than the practice of Kleinian psychoanalysis, due to the limitations of reduced frequency, more severe pathology, and external blocks such as health insurance limitations and personal financial limitations, a greater flexibility is required in the overall treatment setting. Also, there is a greater need to notice the on-going and immediate impact of unconscious phantasy, internal conflict, and transference that occurs in the analytic relationship. Careful monitoring of the counter-transference for the presence of projective identification based communication is an important Modern Kleinian Therapy technique. The importance of combining interpretations of current here-and-now transference and phantasy with occasional genetic links as a therapeutic hybrid approach is also a modification of sorts unique to Modern Kleinian Therapy. However, this is more a question of emphasis than a new or radical theoretical shift or unique technique.
Norm is a 35 year old man who came to me for help with feelings of depression and anxiety. I have seen him for seven sessions at this point. Norm told me his doctors suggested he seek help for the psychological aspects of his recent symptoms. He reported a wide array of troubling pains and soreness including back pain, leg weakness, dizziness, shoulder troubles, arm tingling, shortness of breath, chest pains, exhaustion, trouble sleeping, and balance problems. While he had a history of physical problems dating back many years, a great deal of these symptoms had started or intensified in the last year.
Norm’s parents divorced when he was six. Afterwards, his uncle became his father figure. Norm felt very close to him growing up and still does. He does not say much about the effects of this history, so I am the one left to wonder about it and give it value and pain. Norm’s mother developed breast cancer when he was 10 years. She went in and out of remission until she died when Norm was 30 years old. Last year, Norm’s uncle was diagnosed with a terminal brain tumor and was given a year to live.
Norm does not say much about his feelings in general and when he relayed these sad events with these important figures in his life, he didn’t really show much emotion. I commented on this and he said, “I think I just got used to it with my mother since it went on for so long”. What Norm does show emotion about is his physical status and the problems he thinks he might have. He says he “is really worried about what might be wrong and if it is serious. The doctors say they have done all the tests and found nothing wrong but I still have all these strange feelings and the weakness and pain. I think I should get more tests”.
I suggested that he might be having a somatic reaction to the ongoing grief and loss in his life. Norm said he thought it could be but he “still worries about what might be going on”. He told me the referring physician told him he was stressed and having anxiety reactions. Norm said he wasn’t sure if that was right but was willing to try therapy “if it would stoop all these terrible feelings in my body.”
Norm was very athletic as a teen and played on numerous teams. He won several awards competitively and “loved to play ball”. I asked him if his mother’s ongoing illness made it hard to concentrate on sports or school when he was growing up. He said he didn’t think about it too much except when she had to go back in to the hospital for treatments. I asked if his father, uncle, mother, or anyone else talked to him about this difficult situation. Norm said no one ever did. I asked if he tried to ever bring up his feelings or questions to his mother. Norm told me he “never did because I didn’t want to be a burden. I thought she had enough to think about and deal with without me adding to her troubles.”
I interpreted that he felt his needs and worries were selfish and were burdens on others so he kept them to himself. But, that way of coping and protecting others left him alone and overwhelmed with his anxiety and grief. He said “I can see what you mean but I just did my thing in sports and school. The only time I really felt concerned was when she had a relapse and had to go to the hospital. Most of the time, she seemed healthy and didn’t talk about the cancer so I felt ok. The only time I really felt badly about it was years later when she was told she only had six months to live. Then, it was final and real. I really felt sad then. It was awful. She had cancer for so long and I had grown up with her that way that I didn’t really think of her as sick until the end”.
Norm’s mother died when he was thirty. But, when he was twenty, his grandfather died after a battle with cancer. Norm was quite close to him. Norm was playing basketball a few weeks after finding out that his grandfather had cancer and he felt some leg pain. Norm played again the next day and felt some back pain. The third day he played another basketball game, got changed, and suddenly experienced an excruciating pain in his back and leg. He ended up at the hospital that night. For the next month, he was on painkillers and in and out of the hospital, unable to walk. Overall, they found some problems with his back but nothing serious. But, due to his symptoms he was told that they could perform exploratory surgery but because of how young he was, they recommended no surgery. He was told to avoid straining the back until it hopefully recovered on its own. So, Norm stopped playing sports and kept his activities confined to going to work and minor shopping or short walks.
In listening to Norm describe this, I noted that he did not convey any sense of frustration, anger, or anxiety about having to curtail much of his active life at such a young age. He was without emotion and seemed to just adjust to it. I said it seemed like what he must have done with his mother, just trying to adjust and somehow have no feelings about something shocking and unwanted. Norm said he “knew there was nothing I could do about it and I didn’t want to make it worse so I had to go along with it”.
In the counter-transference, I noticed I was becoming the voice of life and the one who had feelings, wanting more than life was offering. I made this interpretation of the projective identification based transference and Norm said he knew what I meant but had felt helpless to expect more given what had happened to his back. I said I was surprised he gave up so easily given how important sports and activities were to him growing up.
I said “You seemed to have had this emotional reaction to your grandfather but you were showing the pain and the utter helplessness you felt through your body instead of being able to talk about it and feel it. A strong driving force in your life was gone and your spirit was broken. But, you tried to be neutral and accepting about it. Yet, the pain persisted in your body.” Norm listened in an interested way but didn’t say much to elaborate. I asked him if he ever considered the back incident to be related to his grandfather’s illness. Norm said he had not but now that I brought it up and drew the parallel to his mother and uncle, he could see how it might be a factor.
What he was referring to was a line of similar tragedy and resulting physical reactions throughout his life. When his mother was dying, he went to the emergency room with severe swallowing problems and stomach aches. He went to many specialists and was told he had irritable bowel syndrome and acid reflux. On one hand he felt relieved at finally “knowing what the problem is” but he still doesn’t quite believe the doctors were right and “perhaps they didn’t find something else that was really the cause”. But, he seemed to really respond to the concrete knowledge of an actual physical diagnosis. I said, “Maybe that is easier than so many intense feelings for your dying mother and her loss that you can’t totally understand or pin down. You feel more in control with a physical label”. Norm said “Yes. I like it when I know what it is and can move on.” I said, “You haven’t been able to move on from your mother’s death and your grandfather’s death. We can try and solve that”.
After his mother died of cancer, some six years ago, Norm told me he was sad, but not surprised and glad his mother was no longer in pain. He said he felt like a very long story was now over, the story of his mother’s twenty year battle with cancer. I added that he had been in that war every day for twenty years and it had taken its toll on him. But, all the feelings seemed to have become stored or hidden in his body and in his fear of illness. He spent the years focusing on his body and what might be wrong with it. At this point, when I said this, it came to me that he was also identifying with his mother as well as reliving his conflicted childhood focus. Just like his mother, he was always worried, wondering about his health and what was wrong, and scared that the doctors had missed anything. And, as a child, on some level, he was always focused on his mother’s body and now as an adult he was always focused on his body.
Shortly after his mother died, Norm developed a great variety of physical symptoms, mostly related to his back. He felt great pain in his lower back and weakness and pain in his legs. He also felt shortness of breath and dizziness, as well as other symptoms of panic attacks. As the back pain increased, he started to visit specialists. Eventually, he ended up having back surgery. During the preliminary tests, the doctors discovered a bulging disc. They told him they had never seen one so damaged and wondered if he had suffered a traumatic accident or had tried to lift some incredible weight over and over. He had neither. In fact, he lived a fairly sedentary life.
After the first surgery, he was still in some pain so after about a year, he had a second back surgery. Now, Norm feels better but is very careful to not exert any pressure or strain on his back. So, he does virtually no exercise, no sports, and makes sure to not lift anything. He feels he cannot ever interview for any job that would require him to sit for a length of time. I listened to him and noticed the degree of conviction with which he had given up so much in life and settled for a limited lifestyle. I was almost convinced of how this was necessary by the way he told me the story, the transference method he was relating (Steiner 2000). But, then I asked him if his doctors, surgeons, and specialists had all told him to never exercise and if they had told him his condition was still that dire, restricted, and fragile. Norm said no, but that he “just could feel that in my body and I don’t want to push myself to a point of doing something damaging”. I interpreted that he had given up on himself as an active person and labeled himself as dangerously closed to collapse, even though none of his specialists or surgeons had told him so.
Again, I was speaking for life, activity, and hope while Norm seemed to cling to decline, danger, and doom. This was an example of internal conflicts regarding the life and death instincts emerging clinically and the role need, desire, dependence, and hope seemed to play in his life in this destructive manner.
About six months ago, Norm’s uncle was suddenly diagnosed with a terminal brain tumor. Right afterwards, Norm started to feel dizzy and weak. He has been convinced there is something “fundamentally unsound” with him physically. In listening to him, it sounded like he started having a series of anxiety attacks followed by a conviction that he “has something drastically wrong physically”. I thought that he was in a way taking over mother’s identity, having the feelings and fears she must have had over the years Grinberg 1990). I made this interpretation and said that perhaps this was a desperate attempt to stay connected to her. He told me he understood what I meant and “it makes sense” but that “I still has a conviction that there is something wrong with my body and a breakdown of either my back or something else because of all the pain, numbness, tingling, and soreness I feel in all these different areas of my body”.
In the counter-transference, I sometimes feel like yelling at Norm and trying to force or convince him that all these somatic issues are really his hidden grief, anger, sorrow, and anxiety over not having these vital people in his life anymore (Joseph 1987; Grinberg 1962, 1968). I want to shout, “It’s about cancer, loss, and fear, not mysterious back pain and dizziness!” In noting these feelings and not acting out on them, over time I have come to think of this counter-transference as representing how Norm wanted to yell out as a teen to someone for help since no one was ever talking about the terrible situation with his grandfather, his mother, and now with his uncle as well.
In other words, I think that through projective identification (Steiner 2008), Norm was putting his unexpressed anxiety and anger into me because he felt scared and guilty to own these conflicts. I think he both wants to jettison these dangerous feelings into me so as to never have to deal with them but also is making an unconscious communication and a hopeful move to have me express them. Eventually, he may join me in the process and re-own them as his own. In the transference, he is also now the one ignoring the obvious, denying the painful reality of loss and trauma just as he felt everyone else was ignoring it when he was young. Finally, he is able to merge or stay with mother by having the same type of symptoms and worries that he may have imagined his mother to have, such as “this could be serious”, “this might be something fatal”, “I hope the doctors haven’t missed something”, “maybe I should get more tests”, and “I know they told me I am ok right now but I still feel like there could be something terribly wrong”.
Norm has also told me about his envy of other seemingly “normal families who don’t seem to have had to go through all these terrible health problems. Everyone was healthy when the kids grew up and everyone is still alive now. Sometimes, I find myself wondering why!” When I tell him he is talking about a great deal of anguish, anger, resentment, and sorrow, Norm is quick to backtrack and tell me he didn’t have it that bad and lots of other families have troubles too. He adds that it is wrong to feel jealous or angry because this is simply his life experience and he shouldn’t feel cheated. I interpret that he feels guilty about showing me the extent of his strong feelings and now wants to take them back and smooth things over. I add that he may have had those feelings for a long time and felt so guilty about burdening his mother that he tried to keep them to himself then too. When he still tells me he is “managing ok and doing alright”, I interpret that he resists my compassion and understanding because it might lead to him feeling overwhelmed by all these feeling and also thinking his is being a burden on me and overwhelming me. In response, Norm told me, “I always felt so bad for my mother. She was a single mom without much money, raising all of us and suffering with cancer every day. I thought I would be selfish if I ever complained about anything or asked her how she felt. She never said anything about her feelings so I thought I better not ask or I would be making her feel bad. I feel like she worked so hard and was such a good mother and then lost out on enjoying the rest of her life. It seems so unfair!” At that point, Norm broke down and cried. This was quite a different moment in the transference in that he was allowing himself to feel the loss and sorrow and allowing himself to share it with me. He shifted away from his pathological organization and somatic retreat and, for a moment, related to me openly about the terrible separation and he was challenging his conviction that speaking was hurtful.
My sense of Norm’s unconscious coping method, the structure of his psychic retreat (Steiner 1993), was that he wanted to know the answers to this somatic “thing” that was happening to him. This quest seemed to protect him from facing the knowledge of the person who had left him and the person that was dying, a psychological loss of unbearable magnitude (Steiner 1990).
Most sessions were taken up with Norm starting off talking about his physical symptoms. If he were silent and I asked him how he was feeling, Norm would tell me the degree of pain he felt in his legs, the soreness in his back, or the level of dizziness he had that day. I felt compelled to force him to face the reality of his life, that he had lost these important figures in his life and was in the middle of yet another loss that no doubt was triggering his original grief experience with his mother. I wanted to show him how angry, grief stricken, and upset he was. When I did so by saying he was probably having a hard time hearing about his uncle’s latest round of chemotherapy he would agree for a moment, but then tell me, “we just don’t talk about it. I don’t’ want to bring it up and make my uncle feel bad”.
I interpreted that Norm probably felt that way with his mother and grandfather too. Norm told me he had indeed felt that way and he tried his best to not “burden them”. I interpreted that he was in fact emotionally burdened and overwhelmed by these events and needed someone to be there for him, which is part of why he came to see me. But, he ends up trying to be nice and not take up emotional space with me or his uncle. I said his feelings and focus end up on his body where he feels something is wrong or falling apart instead of having to focus on how his heart is breaking and his emotional life is falling apart. Norm told me he understood what I meant but he “cannot stop thinking about what might be wrong” with him and “if the doctors missed something”.
Norm hasn’t had a job in some time and feels no one would hire him with his history of back problems. He sees himself as without value and essentially damaged beyond repair. I interpreted this as his way of seeing himself as defeated and without life, a way he could stay close with his dead and dying family. If he felt more alive, he would have to end up feeling like he was moving ahead and saying goodbye to them. Here, I was interpreting his conflicts with both his actual external family and his internal family.
Rubin (2004) notes that contemporary Kleinians, in comparison with more traditional Kleinians, place a much greater emphasis on real versus phantasy conflicts with others as well as according greater value to the effects of early family pathology. I think that this is true of a general trend in the Kleinian approach but also a continued misunderstanding of how Klein and her followers actually worked. Klein herself wrote of the actual effects of the infant’s external family experiences and how the infant might take that experience in and then project the combination of real life interaction with internal reaction back onto the object, creating a new and distorted object to once again react to. Klein and her followers spoke of how the healthy mother-child bond could mitigate this from becoming too dark or overwhelming and instead help install an internal sense of hope, confidence, and trust. This would be the foundation of normal projective identification and the creation of positive unconscious phantasies about self and other.
Unconscious phantasies are internal, unconscious object relationships between self and other that underlie all mental processes. These phantasies are the expression of conflicts and defenses surrounding love, hate, and knowledge and shape the balance of the life and death instincts. These elements of human struggle and desire are what psychoanalytic treatment hopes to bring into more conscious awareness followed by increased integration. In working with Norm, I noticed my analytic efforts to do so became colored by my counter-transference urge to force him to know and face the painful truth about his objects. I believe he was trying to preserve his internal objects by making them part of his somatic state.
Internal objects are unconscious images and versions of external people and situations that the subject has intense emotional reactions to, both positive and negative. Throughout life, the subject projects his/her various feelings and thoughts about self and other onto his/her valued or despised object and then internalizes the combination of reality and the distortion back inside. This starts another cycle of unconscious coping and reaction to that new internal object which is then projected again. Thus, there is a never ending recycling of one’s vision of self and other that one is continuously organizing, relating, and reacting to, both externally and internally, both intra-psychically and interpersonally. In the paranoid-schizoid position, these internal objects are often fragmented part objects rather than the more integrated whole objects experienced in the depressive position.
Norm developed fragmented non-symbolic states of mind that existed in his body instead of his mind. This allowed him to avoid the terrible sense of unbearable loss he would face in a more symbolic depressive position experience of his life. The paranoid-schizoid mode is usually found in more borderline, narcissistic, or psychotic patients but we all exist within this mode to some degree or can easily regress to it under trying circumstances. Klein believed the healthy transition from the paranoid-schizoid experience (Klein 1946) to more whole object depressive functioning (Klein 1935, 1940) had much to do with the constitutional balance of the life and death instincts and the external conditions of optimal mothering. The primary anxiety in this position has to do with survival of the self rather than concern for the object.
Norm seems to retreat to this fear of self-survival to avoid the overwhelming loss and anxiety of the depressive position, where he would need to experience, accept, and grieve the terrible loss of his internal and external family of loved ones.
Based on the transference and my resulting counter-transference, my clinical impression is that Norm is overly reliant on projective identification as a method of surviving these conflicts and fears (Steiner 1989, 2011). But, the type of projective identification he depends on leaves him in constant fear and without internal stability or security. Rigid, excessive, or perverse forms of projective identification create brief, illusionary moments of safety from persecutory or guilty phantasies but also create the very terror that one is trying to evade.
Formulated by Klein and first discussed in her 1946 paper, projective identification is an unconscious phantasy in which aspects of the self or internal object are attributed to another internal or external object. These phantasies can be positive or negative in nature and may or may not have interpersonal aspects to them that engage others in patterns of relating that confirm the core phantasy elements. Besides attributing aspects of the self to another, projective identification can also involve finding and owning aspects of the other. So, the motives of projective identification are many and can be part of healthy normal development and relating or be part of destructive, defensive pathology. In reflecting on Norm’s transference state, it seemed like he would shift rather rapidly between different roles and motives in the projective process, leaving me to either experience multiple unwanted aspects of himself or to react to multiple versions of his internal objects. In other words, at times in the projective identification based transference, Norm took on the role of his mother not wanting to talk about anything emotional, a recreation of his mother struggling with physical worries and assorted ailments but trying to seem like everything was ok. Other moments involved Norm relating like a child who wanted someone to speak for him, a child who didn’t want to face the terrible reality of his life. Still at other moments, he seemed to convey the conviction that any independent move, personal statement, or sign of growth would endanger others. So, it was better to stay quiet, passive, and without any significant opinion or difference.
In the counter-transference, I found myself on the other end of these various states, initially feeling like acting them out, feeling confused and dragged into it, but then slowly making sense of it (Racker 1957). With Klein’s discovery of projective identification, the transference is seen by Kleinians as an unconscious method of communicating to, retreating from, loving, or attacking the analyst. And, modern Kleinian theory includes the interpersonal pressures put upon the analyst during the more intense moments of transference. Thus, the analyst will constantly be affected in the counter-transference. Therefore, enactments of various degrees are unavoidable. In this regard, the counter-transference is now seen as a valuable and crucial tool with which to better understand the exact nature of the patient’s conflict and from which to better construct accurate interpretations. With Norm, I often felt like I was fighting for the life instincts, the chance to grieve, and the realization of love that was lost. But, I also noticed the almost aggressive manner in which I wanted him to realize it and accept it. This alerted me to the possible feelings of anger, envy, resentment, and desire that were all very much unwanted and pushed over into me.
Riesenberg-Malcolm (1990) has noted that if the mother’s alpha function breaks down or is censored or shut off like in Norm’s case, the infant, child, or teen is left without a healthy projective identification system to process anxiety. As a result, there is a sense of inner fragmentation and idealized false objects are created to depend on. Roth (1994) thinks these patients do so to avoid knowledge of the actual nature of their object. For Norm, I think he felt alone without his mother’s ability to process her own anxiety and share her ability to contain it. So, Norm was left without adequate containment and dreaded the knowledge of his mother’s true condition, an emotionally frail and physically compromised woman without a husband to depend on. So, to cope, Norm projected idealized false maternal objects into his body but they lacked any real qualities. He stripped them of any symbolic function in order to shield himself from the pain of a broken or dying mother and to shield his mother from his needs and aggression. But, this resulted in Norm feeling possessed by strange, dreadful, unknown entities in his body that he could not contain or control. Norm was left in a state of nameless dread (Bion 1962b) and this brought on organismic panic (Pao 1977) that left him overwhelmed, persecuted, and lost.
The maternal container must be open and receptive or the sender feels kept out and alone with unbearable internal anxiety. The basic function of the interpreting analyst is a model of receiving, containing, modifying, translating, and returning that provides the patient with this fundamental infant/mother experience. There are many ways this container/contained cycle can fail, be perverted, or put to test during the patient’s early family experiences as well as duplicated in the transference situation (Joseph 1985; Steiner 1996). This was part of the pushy counter-transference I felt and the desperate rush Norm felt and conveyed to me about what to do and how to get rid of his anxiety.
Without any real containment, Norm floated in this limbo of panic and uncertainty. Over time, however, this has become a pathological organization. Pathological organizations are rigid and intense systems of defense used to avoid unbearable persecutory and depressive anxieties and result in a distancing from others and from internal and external reality. Some more difficult to reach patients are involved in highly destructive narcissistic actions of certain parts of the self against other parts of the self, resulting in a variety of sadomasochistic, perverse, or addictive character profiles. Other patients exhibit a desperate attempt to create a fragile and precarious retreat from both paranoid and depressive fears but eliminating any hopeful object relational balance that comes from the normal experiences of both positions. Pathological organizations are destructive states of psychic equilibrium, providing a temporary sense of control and respite but ultimately removing the patient from the healing aspects of reality and the working through of both paranoid and depressive issues. The idea of psychic retreats is a parallel concept that explains how patients seek a protective shell, haven, or refuge from overwhelming phantasies of loss, annihilation, persecution, and guilt. In treatment, these patients are stuck and out of reach. The patient feels safely out of touch with reality and from threatening or threatened objects but also out of touch with the understanding and help of the analyst.
Norm’s pathological organization centered around his body and his conviction of something being wrong that was not yet understood. This internal system of psychic equilibrium (Joseph 1989) in which he never felt like he knew what was going on with his body defended him from knowing what had happened to his mother and now his uncle and knowing how he felt about it. He would rather live with nameless dread than to face a named dread, the known loss of the depressive position and the psychological trauma of his dying family.
Knowledge, knowing, and learning are a central component to the Kleinian theory of what makes up the human psyche. Klein placed the desire to know the object alongside the life and death instincts as fundamental in understanding human motivation. The subject is curious, envious, and wanting to understand the workings of the object. This creates a desire to be inside the other to taste, test, share, own, and be the other. In healthy development, this involves a thirst for knowledge, a drive to find out, and a talent to solve problems by learning. The unknown becomes something that fuels growth and exploration. In unhealthy or pathological states, the unknown is unbearable, envy of the other takes over, and a desperate and aggressive attack is launched to find entry into the object and take what is inside. This can result in claustrophobic phantasies, fears of reprisal, revenge, and retribution, as well as a sense of self as inferior and without, that others know and one is clueless and left out. Anxieties about knowing can cause learning disorders and fuel an aggressive quest to know. This can lead to obsessive disorders that require knowing at all times with a resulting feeling of terrible guilt. Also, experiences of annihilation, fragmentation, and of being unfixed and uncontained can occur. In treatment, many patients display the resistance or fear of knowing themselves, feel trespassed by our wanting to know about them, and rely on a primitive system of withholding or of projecting what is inside out to protect themselves from others knowing more about them.
Grinberg (1977) has described how many borderline patients have experienced, either in phantasy and/or with actual external caregivers, traumatic separation and loss. This usually has been based in the infantile experience of a mother who has not been able or willing to receive, contain, or modify the infant’s unorganized inner conflicts. This idea of Grinberg’s is based on Bion’s container concept (Bion 1962), which has been elaborated upon by other Kleinians. The concept has been defined as a fundamental psychic state of mind in which the infant feels helpless in the face of loss, abandonment, or rejection by the object, leaving the infant in a blank emotional void and an internal sense of meaninglessness.
Grinberg (1968) notes how primitive patients are prone to acting out in search of and in reaction to the felt lack of a containing object that can sustain their separation anxiety, grief, guilt, and loss. I would add that this acting out is not just part of a searching out for the lost object but an angry retribution and revenge as well, for the perceived abandonment and betrayal. So, the containing object, the ideal good object, even if found, is never enough and always at fault. This creates a persecutory cycle of paranoid phantasies and unbearable guilt in which the lost object is now purposely neglectful and absent and the patient is always hungry and always has blood on his/her hands. This brings back the most fundamental and terrible infantile state of mind of when absence was intolerable and the missing object was no longer a good object temporarily absent, but a persecutory non-object cruelly missing and permanently gone, yet forever haunting the empty, hungry, and desperate child’s mind and heart.
Steiner (1992) and other Kleinians have noted the early, more immature stage of the depressive position in which the patient has great difficulty tolerating and accepting the loss of the needed object. Denial, manic, defenses, or narcissistic and pathological organizations that defend against paranoid collapse are all common. This is similar to Quinodoz’s (1996) concept of untamed solitude as well as Palacio Espasa’s (2002) idea of the more para-psychotic and para-depressive phantasies of catastrophic, irreparable, and life deadening or life draining states of loss. Only when the patient is able and willing to face, tolerate, and integrate the actual and/or imagined betrayal, traumatic loss, and perceived rejection, can they move towards the more mature stage of the depressive position where forgiveness, hope, and a livable future exist.
In erecting his somatic containment, a pathological organization in which Norm attempted to establish a grief free zone where he merely needed to know what was wrong with his body in order to quickly shut off his physical experiences of anxiety, he found himself lost without the true translating function of the mother container. I offered him the chance to talk about what was really going on, something he wanted as a child but also dreaded and avoided so as to not burden his mother and not have to feel the sorrow himself. This is now being repeated with his uncle and with myself. But, when faced with having the opportunity to finally face these feelings and experiences, he turned away to avoid the depressive pain that would emerge with it.
Norm retreated to the non-symbolic pseudo-containment of his somatic phantasy and then expected me to quickly help him identify exactly what was wrong. I interpreted that I wanted him to know what was emotionally wrong and he wanted me to tell him what was physically wrong and find out what to do about it. He said that “even if it is psychological, I want to know what to do to make it go away as soon as possible”. I said, “You can’t make the loss of your mother and uncle go away. But, we can face it together and work on how to live with it”. He said, “I don’t want to. I just want to stop having all these problems with my body”. So, I noticed we both became impatient with each other about what we wanted and what we thought was the best goal. I seemed to stand for the life instinct and the quest for emotional knowledge and Norm seemed to stand for the death instinct, trying to always deny, destroy, or denude the emotional connection with his lost objects and annihilate any need, dependency, or feeling for them. He wanted to exchange that known lost love in his heart for an unknown dire enemy located in his body.
Regarding the life and death instincts, Modern Kleinian Therapy (Waska 2010a, 2011a, 2011b) clinically considers the distinct anti-life, anti-growth, or anti-change force that seems to have an upper hand in some patients. The death instinct seems to arise most violently in situations of envy, difference, separation, or challenge to enduring pathological organizations and pathological forms of psychic equilibrium.
Hanna Segal (1993) has defined it as the individual’s reactions to needs. Either one can seek satisfaction for the needs and accept and deal with the frustrations and problems that come with those efforts. This is life-affirming action or the actions of the life instinct. It is life promoting and object seeking. Eventually, this leads from concerns about the survival of the self to concerns about the well-being of the other.
The other reaction to needs is the drive to annihilate the self that has needs and to annihilate others and things that represent those needs. Kleinians see envy as a prime aspect of the death instinct and that early external experiences of deprivation and trauma play as big of a role as internal, constitutional factors in the ultimate balance between the life and death forces.
For Norm, he seems trapped in-between and reluctant to emerge as it looks to overwhelming and devastating (Steiner 2008). Yet, the few sessions we have had together show that he is cautiously willing to slowly consider facing that frightening new way of remembering his objects, mourning them, and finding a new way to bond with them.
Bion, W (1962a) A Theory of Thinking, International Journal of Psychoanalysis, 43: 306-10
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Steiner, J (2000). Containment, Enactment and Communication. International Journal of Psycho-Analysis 81: (2) 245-255
Steiner, J (2006) Interpretive Enactments and the Analytic Setting, International Journal of Psychoanalysis, 87:2, 315-320
Steiner, J (2008) The Repetition Compulsion, Envy, and the Death Instinct, in Envy and Gratitude Revisited, edited by Priscilla Roth and Alessandra Lemma, Karnac, London Pg. 137
Steiner, J (2011) Seeing and Being Seen: Emerging From a Psychic Retreat, Routledge, London
Waska, R. (2002) Primitive Experiences of Loss: Working with the Paranoid-Schizoid Patient, Karnac, London
Waska, R (2004) Projective Identification: the Kleinian Interpretation, Brunner/Rutledge, London
Waska, R (2006) The Danger of Change: The Kleinian Approach with Patients who Experience Progress as Trauma, Brunner/Rutledge, London
Waska, R (2007) The Concept of Analytic Contact: A Kleinian Approach to Reaching the Hard to Reach Patient, Brunner/Rutledge, London
Waska, R (2010a) Treating Severe Depressive and Persecutory Anxieties States: Using Analytic Contact to Transform the Unbearable, Karnac, London
Waska, R (2010b) Love, Hate, and Knowledge: The Kleinian Method of Analytic Contact and the Future of Psychoanalysis, Karnac, London
Waska, R (2010c) The Modern Kleinian Approach to Psychoanalysis: Clinical Illustrations, Jason Aronson, New York
Waska, R (2010d) Selected Theoretical and Clinical Issues in Psychoanalytic Psychotherapy: A Modern Kleinian Approach to Analytic Contact, Novoscience, New York
Waska, R (2011a) Moments of Uncertainty in Psychoanalytic Practice: Interpreting Within the Matrix of Projective Identification, Counter-Transference, and Enactment, Columbia University Press
Waska, R (2011b) The Total Transference and the Complete Counter-Transference: The Kleinian Psychoanalytic Approach With More Disturbed Patients, Jason Aronson
Dr. Waska’s clinical work, now thirty years in the making, focuses on contemporary Kleinian topics including projective identification, loss, borderline and psychotic states, 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.
Robert Waska LPCC, 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, presented papers, and provided consultation internationally.
Dr. Waska is the author of thirteen 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.
Robert Waska LPCC, MFT, PhD
Individual Psychotherapy, Couple’s Counseling, and Psychoanalysis
Licensed Professional Clinical Counselor LPCC #19
Certified Psychoanalyst and Marriage Family Therapist MFT #28161
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