Key Papers on Borderline Disorders

With IJP Internet Discussion Reviews

Paul Williams

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780367325275
• eBook ISBN: 9780429915420
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

The International Journal of Psychoanalysis Key Papers Series brings together the most important psychoanalytic papers in the journal's eighty-year history in a series of accessible monographs. Approaching the IJP's intellectual resources from a variety of perspectives, the monographs highlight important domains of psychoanalytic enquiry.

1: Thick- and thin-skinned organisations and enactment in borderline and narcissistic disorders

ANTHONY W. BATEMAN, London

In this paper the author argues that enactment is any mutual action within the patient/analyst relationship that arises in the context of difficulties in countertransference work. Such enactment is common during the treatment of borderline and narcissistic disorders. In order to delineate different forms of enactment, which in his view may be either to the detriment or to the benefit of the analytic process, the author describes a patient who was identified primarily with a sadistic mother and who threatened the analyst with a knife during treatment. Three levels of enactment involving countertransference responses are described of which two, namely a collusive countertransference and a defensive countertransference, were detrimental to the analytic process. The third level of enactment was beneficial but only because the intervention by the analyst was independent of the analytic process and yet in response to it. The author uses Roserifeld's distinction between thin-skinned and thick-skinned narcissists to illustrate how enactment is most likely when a patient moves between thick-skinned and thin-skinned narcissistic positions. Nevertheless, the move between thin and thick-skinned positions presents an opportunity for effective interpretation, allowing progress in treatment.

Introduction

This paper is about enactment in borderline and narcissistic disorders and draws on the distinction proposed by Rosenfeld (1987) between two types of narcissism, namely thick- and thin-skinned narcissists. In essence thick-skinned narcissists are inaccessible and defensively aggressive while thin-skinned narcissists are fragile and vulnerable. I consider Rosenfeld's division helpful in clinical practice and yet too schematic since narcissistic and borderline patients mostly move between thick- and thin-skinned positions, giving an unstable clinical picture that is both a danger to and an opportunity for analytic treatment. On the one hand, the movement increases the likelihood of enactment either in the form of violence to others or in the form of self-destructive acts, depending on whether thick- or thin-skinned elements respectively are to the fore. Yet, on the other hand, it is only when a patient is moving between positions that interpretation becomes therapeutically effective, allowing progress in treatment.

Enactment

Enactment is a hybrid term incorporating ideas commonly subsumed under acting out, acting in, actualisation, repetition, transference and countertransference. As a result there is no universally agreed definition of the concept, which in turn leads to a danger that it is meaningless, adding little to our attempts to refine analytic theory and to understand our patients better. Nonetheless, there are two main themes running through the literature on enactment.

Firstly, enactment is considered to be an interpersonal phenomenon, involving action of variable severity between patient and analyst. At the benign end of the spectrum, enactment is equivalent to an 'actualisation' (Sandler, 1976a, b) between patient and analyst of a patient's wished-for transference relationship. At the more severe end of the spectrum, the analyst's objective capacities are compromised and both analyst and patient jointly overstep a boundary, McLaughlin (1991), Chused (1991) and Roughton (1993) follow this view, distinguishing enactment from acting out on the basis of the contribution from the analyst. Enactment involves the analyst as participant, vulnerable to his own transferences, susceptible to 'blind spots', and caught up in the relationship rather than alongside it, whereas acting out implicates the analyst solely as an observer.

Secondly, there is a theme of enactment as a positive force in treatment, even to the extent of suggesting it may form part of a corrective experience (Roughton, 1993). Following enactment the analyst extricates himself, separates his own conflictual participation from that of his patient and guards against becoming self-punitive about his failure to maintain neutrality, thereby enabling the enactment to lead to understanding and progress. What is not clear is how this differs from a normal analytic process in which the analyst constantly tries to differentiate what is his and that which is his patient's, what is projected and what is not. If we are to call this process enactment then presumably the whole of the analytic dialogue is an enactment, rendering the term redundant. Despite these reservations, I continue to use the term. It is defined here as any mutual action within a patient/analyst relationship that arises in the context of difficulties in countertransference work on the part of the analyst. I consider this an inevitable occurrence in psychoanalytic work and it may be either to the detriment or to the benefit of analysis.

Countertransference

I argue here that there are three important clinical components of countertransference contributing to enactment. Firstly, the projective systems oscillating between patient and analyst (complementary countertransferences); secondly, the identificatory processes of the analyst (concordant countertransferences) (Racker, 1953, 1957, 1968); and thirdly, the 'blind spots' (McLaughlin, 1991) or defensive countertransferences (Reich, 1951) within the analyst. All three processes are involved in mutual analytic enactment. Action on the part of both patient and analyst results and this is particularly likely to occur with those patients dominated by a narcissistic or borderline structure within their personality.

Narcissistic/borderline organisation

As I have mentioned, Rosenfeld (1987) clarified two aspects of narcissism, identifying thick-skinned and thin-skinned narcissists. Both groups use their psychological structure to maintain a feeling of safety (Joffe & Sandler, 1967). In 'thick-skinned' narcissists, the survival of an idealised self is paramount. The analyst is experienced as someone who wishes to dismantle the patient's self, to effect a cure and to engender dependence. As a result, analytic sessions become dominated by defensiveness, a devaluation of external relationships and a wish to destroy the analyst as an object who can be a source of goodness and personal growth. In effect the thick-skinned narcissist is 'object-destroying'.

The thick-skinned narcissist is difficult to keep in treatment, remains unmoved by breaks in the analytic process, sneers at interpretation directed towards need and dependency, rejects before being rejected, and maintains an impenetrable superiority. His whole self becomes identified with a destructive self whose sole purpose is to survive by triumphing over life and creativity. Losing an external object not only leaves this destructive self unmoved but also stimulates a feeling of excitement and triumph as the destructive self is further empowered. Similarly, personal achievement fuels feelings of supremacy and self-importance.

In contrast, the thin-skinned narcissist is more vulnerable. He is ashamed of himself, feels sensitive to rejection, and persistently judges himself as inferior to others. Achievements at home or at work are a stabilising element in his personality rather than a source of power, increasing self-regard rather than feeding a triumphant, arrogant self. As a consequence, Rosenfeld warns against interpreting destructive narcissistic elements in such a patient. Interpretation may both inhibit his ability to build up satisfactory object relationships and puncture his vulnerable sense of self. In essence the thin-skinned narcissist is 'object-denying', continually abasing himself, looking for agreement and denying difference.

Rosenfeld is, I think, too schematic and categorical, since in many patients a division between thick-skinned and thin-skinned elements is unclear. The psychological processes change even during a session, sometimes from moment to moment, as different narcissistic aspects ebb and flow. This leads to difficulties in knowing when interpretation during a session is appropriate and when it is ill-advised since interpretive analytic work is hampered in both aspecto of narcissism. However, in my view, such patients are especially available for analytic work as they move between thin- and thick-skinned positions. In essence, the fluidity of the positions is dependent on the stability of the patient's identifications. Further, I suggest that during a shift between thick- and thin-skinned states of mind the likelihood of enactments is increased. In their static and rigid form both narcissistic positions are stable but a shift between them exposes a dangerous instability during which both violence and self-destruction are possible. There is therefore an intrinsic opposition between the uncovering, interpretive work of the analyst, which in itself destabilises the patient's equilibrium, and the survival of the patient. The experience of terror in both patient and analyst is critical in this process. Fear of both suicide and violence, and later an unthinkable anxiety, prevents effective analytic work and, unwittingly, leads to collusion and to the development of 'blind spots' in treatment.

In the female patient that I am going to discuss, thin-skinned elements form part of a defensive self protecting a powerful thick-skinned self. Her thin-skinned self provided a stable state and she was not suicidal but when she began to shift between thick and thin-skinned positions she was in danger of either attacking me or committing suicide in order to avoid a mental collapse into what she called a 'black hole'.

Clinical material

Jane is a 37-year-old woman, formerly in a successful career. At the age of 34 she took time out from her work to do some research. On her return to work, her colleagues informed her they did not want her back. Bewildered, she accepted their decision and cleared her desk. She experienced their rejection as a crushing, personal blow. It substantiated her terror of never being able to do anything well and confirmed her pre-existing view of herself as someone who was a fake, someone who was always on the edge of being found out, and someone who struggled to cover over her inferiority. In a similar vein, she felt there was nothing attractive about her. She had never had sexual intercourse, believing her closest friend, a man, visited her only because she conned him with a false liveliness. Her life had been a question of surviving and of not getting caught out. Indeed, she likened it to walking across a battlefield littered with land mines that might explode at the slightest vibration.

Jane came from a middle-class background, the third child and only daughter of professional parents both of whom were successful. Her father was physically disabled and a powerful, dominating man, bombastic, incisively intelligent and critical. Hard on his children, he had little time for their problems or difficulties, which he believed should be ignored. 'Pull yourself together gal' was his phrase when faced with childhood emotional expression.

Her mother, a successful writer, was quiet and long-suffering, always complaining that her only support came from Jane. Jane reported at the beginning of her treatment that her relationship with her mother was close and intimate. However, as her first few sessions progressed it became clear that there was another side to their relationship. Mother persistently complained to Jane about her 'lost love', saying that it was only Jane that stopped her from ending her life. Indeed, Jane was her mother's only confidante and carer, used by her mother to fill her own emotional void. Gradually Jane became locked into looking after her mother, hardly able to go out and frightened to go away from home, even to children's parties, for fear that her mother would kill herself. By adolescence Jane rarely went out with school friends, spending most of her time at home working at her desk. By the time she gained a place at university she was able to leave home but she returned every weekend.

This historical material was related in a desperate, piteous manner during her initial sessions. Jane attributed her depression to the loss of her job and to rejection by colleagues rather than to her past life. There was no sense of bitterness or anger, rather a desolation, gloom and overwhelming sense of emptiness. My remarks were, on the whole, limited to empathic statements such as 'you certainly feel very let down', to which she eagerly but defensively agreed.

Early sessions

Her early sessions were taken up by a constant replaying of her work life as she searched for a reason for her dismissal. As she talked, it became clear that her continual anxiety and personal uncertainty about the adequacy of her work may have caused difficulties with her colleagues. She continually looked for reassurance. Was she doing well, was she achieving her objectives, was she understanding her work? She was never reassured. Relentlessly, Jane pestered her colleagues. In the same vein she would ask me whether she was doing the right thing in her analysis, was there anything else she should do, was she talking about the right topics? Although I tried to understand her insecurities, her constant questions became irritating. Reflecting on my countertransference feeling, I recognised them as defensive attempts to avoid reflection about herself. When I talked of her eliciting this she apologised, saying she always did the wrong thing. She then tried to show me how much she suffered at the hands of others, constantly looking to me for sympathetic comments. I thought that there was a repetition in our transference relationship of her interaction with her mother. Just as Jane continually offered help, support and sympathy for her mother's plight and yet never made any palpable difference to her mother's state of mind, I, too, was to offer Jane endless, fruitless sympathy and care. Constant internal watchfulness on my part was needed in order not to fall into this role, for example by not spending much time talking to her between sessions following her frequent phone calls. I remained both alongside and within the role in which I was cast, able to think objectively about Jane and her dilemmas.

Two years

At the time of a break, two years into analysis, Jane talked about having left home to attend university and how she had felt it was cruel to leave her mother alone, unsupported. Interpreting this as her feeling that I was cruelly and selfishly abandoning her, leaving her struggling on her own, resulted in a barrage of questions about whether I cared for her or not. Jane portrayed me either as someone who should feel sorry about her harsh treatment or as someone who was cruel, heartless and cold, contributing to her misery. She felt betrayed. She told me that taking breaks was a selfish act as I did not consult her, expected her to take her holidays at the same time and took no account of her capacity to manage.

On return from my break, Jane seemed quite different. In place of a sorrowful, compliant and vulnerable patient, there was an arrogant, tense and disdainful woman. During the first session she told me that she had managed well and hadn't given her analysis much thought. I told her she seemed proud not to have been affected by the break. She responded by asking if she was supposed to have been bothered. My lack of response to her question made her anxious. She demanded an answer. There was no doubt that she was in a combative mood and so I said that she seemed to have come back from the break determined that her analysis should have no meaning and yet the break had left her feeling unwanted and uncared for, abandoned by me as I followed my own selfish requirements. Haughtily, she laughed, telling me that I was clearly deaf. She had already told me that no thought had been given to the analysis during my absence. On the contrary, it had shown her that her need for treatment was less than she had believed. She wanted to know if I had given her any thought. I said that the thought I was giving her now was that her response to our break had changed her feelings of sorrow and of betrayal into hostility and dismissiveness. Again she laughed derisively.

She talked of a literature search that she had done during the break and of reading prolifically about lone female pioneers who obtained personal satisfaction through world exploration rather than through marriage and children. She described a doctor who had worked in Africa at the tum of the century with victims of smallpox. The descriptions by the doctor of vesicular rashes and pustular eruptions had been used in medical textbooks in the hope that doctors would recognise smallpox earlier in its course, thereby alleviating suffering and preventing spread. I interpreted her wish for me to recognise that beneath her disdain (her vesicular rash) lay a feeling of rage, abandonment and terror about my absence. It would spread if not properly diagnosed and soothed. Her dismissive attitude warned of pustular deterioration if no treatment was given. Jane accepted this and talked about the infectivity of smallpox and how it had been eradicated, although a small sample of the virus had been kept for research purposes. Scientists were now discussing whether the residual samples themselves should be destroyed in case they were released inadvertently or stolen by terrorists. I took up her own attempts to eradicate a deadly disease within herself. She was a research scientist who believed that she had found a method of eliminating her need of others as a support for her identity. However, there was a small needy part left within her that could kill her and I had become a dangerous terrorist who could steal the remaining virus, releasing it dangerously within her world, causing overwhelming infection.

Although Jane seemed to think about my interpretation at first, her mood suddenly changed and it was quickly dismissed. Once again, she became full of self-pity, talking about her bleak future, her inability to achieve, her lack of support and her boredom during the day.

Jane's hurt about my break had led to a break-out of a haughty dismissal of her neediness (a thick-skinned position), followed by a rapid return to self-pitying rumination (a thin-skinned state). This quick oscillation in her psychological state led me to reflect on what I had been doing in her treatment before the break. It seemed that when Jane was on her own during the break she had dismissed from her mind any thoughts of me by introjectively identifying with me as an analyst without need of others whilst projecting her needy self into me—she demanded to know if I had thought about her. On her return from the break this state became fragile because she felt threatened that I would take my analytic self back forcefully. She rapidly returned to her desire for reassurance and to her need to make me feel sorry for her but not before material about death, disease and terror, all of which are indicators of underlying danger, had bee...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• SERIES PREFACE
• Introduction
• 1: Thick- and thin-skinned organisations and enactment in borderline and narcissistic disorders
• 2: The central phobic position: a new formulation of the free association method
• 3: The unconscious and psychosis: some considerations on the psychoanalytic theory of psychosis
• 4: Psychopathology and primitive mental states
• 5: Problems of female sexuality: the defensive function of certain phantasies about the body