Treating Severe Depressive and Persecutory Anxiety States
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Treating Severe Depressive and Persecutory Anxiety States

To Transform the Unbearable

Robert Waska

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eBook - ePub

Treating Severe Depressive and Persecutory Anxiety States

To Transform the Unbearable

Robert Waska

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About This Book

This book serves two purposes. First, it provides the psychoanalyst or psychotherapist with a more flexible method of practicing psychoanalysis. This is the clinical approach of "analytic contact", a technical stance in which more patients can be reached in a deeper and more helpful manner. Analytic contact is an operationally robust Kleinian approach for the real world of private practice and targets the combination of internal and external factors there are consistently at play with all patients.The second aim of this book is to examine specific groups of patients that present unique challenges to the psychoanalyst. These populations are examined and new and creative ways of working with them are introduced. The author invites the reader to discover the clinical value and technical utility of analytic contact.

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Publisher
Routledge
Year
2018
ISBN
9780429923357

Part I
Combined Persecutory and Depressive Trauma

CHAPTER ONE
Psychoanalysis as defined by the clinical situation: Establishing analytic contact with acutely troubled patients

In psychoanalytic treatment, we strive to identify, understand, and work with the core unconscious phantasies that shape, distort, or constrict the patient's experience of themselves, others, and day-to-day existence. We seek to analyse the phantasies that create imbalance or anxiety in the patient's internal and external world. In order to perform this work, we strive to create the best conditions to learn about and change these psychological issues. This clinical situation is best described as the successful establishment of analytic contact (Waska, 2006; 2007).
This is a therapeutic process that holds the transference as the primary vehicle of change, but also considers the elements of containment, projective identification, counter-transference, and interpretation to be critical to therapeutic success. Dreamwork, genetic reconstruction, analysis of conflict and defence, and extra-transference work are all seen as valuable and essential. The concept of analytic contact is not so much tied to external factors such as use of couch or frequency of visits as it is to building a clinical forum for the understanding and modification of the patient's deepest phantasies. Analytic contact is about finding a foothold into the transference and as well as into the core phantasy states that are having the greatest impact on the patient's feelings, thoughts, and actions.
In working to establish analytic contact, I employ a combination of classical and contemporary Kleinian approaches to better reach the patient at his current internal experience of self and object. Again, this involves the consistent exploration and interpretation of all conflictual self↔object relational states and the struggle between love and hate within those states of mind. Counter-transference is vital to finding the often jumbled threads of transference and to understand the nature of projective identification communications or attacks that are so frequent in most treatments.
Working to achieve analytic contact involves utilizing the clinical perspective of contemporary Kleinian approach but without the constraints of frequency, couch, diagnosis, or duration of treatment as a primary element of working with the unconscious. In fact, the essential core focus is always on the internal conflicts, phantasies, and defences within the transference and extra-transference climate, regardless of how often the patient is attending or what the diagnostic profile might be.
Rather than wait for a "positive transference" to develop or a "therapeutic alliance" to form, the Kleinian-based concept of analytic contact technically moves on the premise that careful compassionate psychoanalytic work can and must be part of the treatment from the first moment of engagement. While some contemporary Freudians, Relationalists, or those influenced by Kohut or Winnocott would wait to cultivate some sort of reparative link with the patient and see the immediate and ongoing interpretive style of analytic contact as counterproductive or even aggressive, I advocate the more contemporary Kleinian trend towards moment-to-moment interpretive work on the total transference situation (Joseph, 1989). It has been my experience, illustrated by the case work in this Chapter, that this cornerstone of analytic contact helps alleviate the patient's more intense persecutory and depressive anxieties, thereby clearing the way for the integrative work of transference, defence, and phantasy analysis.
To summarize, analytic contact is a way to newly define the process of psychoanalysis from a purely clinical perspective, a process aimed at reaching the core phantasies and conflicts a patient unconsciously struggles with which they often demonstrate through projective identification acting out and other transference-related communications. Analytic contact holds as its goal to discover, investigate, and work through the repetitive, destructive archaic experiences of self↔object. Ideally, this takes place within the transference matrix and provides a new and healing experience of new, healthy, and creative self↔object experiences. This in turn leads to gradual integration of a less hostile, more hopeful internal view and the ability to function in the world in a more balanced and holistic manner. The patient can begin to feel more securely grounded in a more robust internal world of whole objects and fortified versions of self.

Case material

In day-to-day psychoanalytic practice, one encounters a number of patients who seem to share similar phantasies regarding the desperate longing for a loving object as well as the dread of being rejected by that same object. Hoping to please the object as a way to being loved factors large in their life, but equally important in their internal experience is the counter-phantasy of always disappointing the object, leading to combinations of primitive loss, abandonment, and persecution. These are complex conflicts involving paranoid and brittle depressive or pre-depressive phantasies that create tricky if not outright treacherous treatment situations.
Making analytic contact with such patients can be difficult and fraught with setbacks. In treating these individuals, the internal struggles with persecution, primitive loss, and fragmentation emerge quite quickly and need to be addressed as they unfold. The patients highlighted in this paper certainly have phantasies of injuring or destroying the needed and loved objected. But, they do not have the stable or enduring capacity for faith, hope, and trust in the recovery, reconstitution, and reunion with the lost or destroyed object.
The following case material illustrates very early presentation of such conflicts that necessitate immediate interpretation and exploration.

Case 1

Klein (1963) wrote about how the superego is actually made up of projected or split-off aspects of the ego. These cruel parts of the self deny forgiveness. Instead, they simply demand a lack of all things aggressive or destructive without any compromise or understanding (Klein, 1963). This separation from any human mix of good and bad creates unbearable loneliness and a sense of emptiness that this first case illustrates.
Bill was a man in his early twenties who had dropped out of college after feeling "depressed all the time and overwhelmed at never fitting in or finding a way to connect with people." He worked at a fast food restaurant and "felt like an alien, with his coworkers." He had broken up with his girlfriend several months before treatment when "things just fizzled out and faded away." Bill told me he felt "clueless to know how to socialize and wanted to sort out his feelings because he felt he was going no where and was very depressed."
Bill appeared extremely anxious when meeting with me and I interpreted that he might not be sure how to relate to me and was trying hard to fit in with me but didn't know how to connect. He replied, "That is pretty much on target. I am dreading these moments of silence after I say something and you respond. I am sure I am supposed to say something next but I don't know what that is so I feel terrible and on the spot. I am sure you are just waiting for me to respond so I feel like I am freaking out." I interpreted that he was trying to appease me and dreaded disappointing me. Bill said "that was so" and that he felt he was always "one inch away from looking like a fool."
He had been raised in an extremely religious family where sin and punishment were preached in the home and at church services. Bill told me he "has turned away from that way of thinking and is seeking something more spiritual in life." I interpreted that he may still be operating at that sin-sinner-banishment level that leaves him afraid of how others judge him, including his analyst. Bill associated to being a teenager and masturbating. He said he felt very guilt about being such a sinner but he did it anyway and thought he could pray for forgiveness later. But, then he became frightened that he would forget to ask God for forgiveness and end up going to hell. Or, more commonly, he imagined a giant meteor would fall from the sky and kill him before he had time to pray. During his teenage years, he "constantly worried about the meteor."
I interpreted that Bill felt something would always get in the way of forgiveness. I said he may still feel that he is blocked from the compassion and understanding of the object, left to suffer as a sinner in the object's eyes. He said he "totally agreed" and added that he "always feels without a soul, empty and hollow, like there is just wind blowing through a huge abandoned warehouse." I interpreted that he hopes I will help him find forgiveness and acceptance from others, so he feels less like a sinner. I said he must feel very anxious being so hollow and he must hope we can find a way to feel make him feel more solid, stable, and safe. Bill associated to "wild purik rock shows where I feel solid and alive when I dive into the crowd when fights are going on. I throw myself into the middle of the violence and am surrounded by angry people kicking and punching. I get hit and bloody all over and suddenly feel alive and connected. I look in the mirror the next day and see myself bloody and bruised and feel happy I was a part of something." I interpreted that he was in a real conflict because he felt connected to others and solid inside himself if he voluntarily chose to be beaten and attacked. But, I interpreted, that same aggressive bliss was what left him scared of others in situations where he felt he was not in control. In other words, I was starting to interpret the projective identification process with me and others in which he felt he would be emotionally beat with judgement and rejection without warning. I said perhaps this related to the guilt he felt. The beatings at the show were a form of penance that left him solid and forgiven. Otherwise, he felt guilty and unworthy, soon to be sent to hell without hope of forgiveness or understanding. Bill said my comments "make a great deal of sense and he wanted to figure it out so he could feel better."
This analytic contact was established in the span of the first three sessions of Bill's treatment. It remains to be seen how things will unfold in the future, but a difficult patient with profound anxiety and persecutory conflicts has begun to work with his analyst in the realm of transference and phantasy.

Case 2

As Klein (1948) has noted, many of our more troubled patients have experienced a great deal of external hardship, deprivation, and even abuse in their early family years. Klein (1948) explains how this painful external environment combines with the aggressive and fearful internal conflicts and phantasies to produce a more toxic experience of life. In some cases, this leads to an adult life punctuated by confusion between internal and external and generates many unresolved paranoid and depressive conflicts. I would add that, through projective identification, the most troubling internal struggles become predictably acted out interpersonally.
Betty was a nineteen-year-old woman who came to me with full knowledge she could only have three visits because she had no money or family support and her college had provided for several free visits to a mental health worker of her choice. Betty was overweight and rather plain, but she exuded such sexuality that she seemed like the prettiest of women. This seductive presentation was combined with an extremely deferring, apologetic manner that immediately made me feel she was my love slave.
I told her she seemed overly eager to be polite and thankful. She said she "only wanted to make sure I was willing to see her and not kick her out." I interpreted that she already saw us in a very specific relationship and understanding that might help us. She agreed and said she was like that with everyone because "she never knew who liked her and she needed people to like her." I said it seemed she felt very anxious about being rejected and left alone. Betty said, "I hate myself so I need others to love me enough to counterbalance that."
Betty went on to tell me she was a drug addict and frequently used a combination of opiates, cocaine, marijuana, alcohol, and various pills. The main reason she had elected to start treatment was that she had recently stolen money from her mother, whom she lived with, to buy drugs with. They got into a fight that became physical and her mother told her to "get help or get out." Betty had been to three other therapists in the last two years. She said that one "was useless," one was "so troubled by my situation that she kept crying every time we met," and the last one "just tried to tell me what to do and wanted me to stop using drugs right away and I couldn't do that." I commented, "I think you might want to stop for yourself some of the time, but having someone else tell you to might be a whole different thing." Betty said, "Yes, I need to want to do it."
Betty's family experiences were troubled. Her parents divorced when she was five years old and she was shuttled back and forth for years. Her father is an alcoholic and I immediately wondered if she had perhaps been sexually abused by him given her seductive transference stance. Now that she wasn't getting along with her mother, Betty was staying with her father but told me, "its hard since he hasn't worked in years, is drunk most of the time, and he is completely broke." Betty's only other sibling lived in another state and had been in jail for a year from several drunk-driving arrests. Betty's mother worked at a local clothing store and barely made enough to pay the monthly bills, let alone help Betty out. Betty had been working for about a year at a bar but she was fired for showing up under the influence. She had been attending college for almost two years, but the first year was a series of failed classes due to the drugs. Now she was trying to "hang in there but was unsure how to pay for it" since she had no money and would be asked to leave within weeks. What was striking about her school problems was that she seemed very interested in obtaining a degree in science and when she put her mind to it, she was able to make good grades and said she "enjoyed it and really felt like she was doing something that felt right to her."
This was one of several moments where I not only felt sorry for her but thought that this was someone who really deserved a break in life, as she seemed like a person with a good heart living a dark tragedy and wanted better. I made note of this feeling because I also considered it a counter-transference feeling that gave me some insight into how Betty seemed to want a fatherly figure that would be supportive and believe in her. I made such an interpretation and she said she had never had such an experience, but was eager "to find that." I interpreted that she wanted that from me but also wanted it to be in a very dependent way where I called the shots and told her what to do. So, it was a wish for a caring father but also it seemed like she felt she had to make a bargain with her ideal object that in exchange for that feeling of guidance and love, she would have to give up her identity and rely on the object in a more sadomasochistic manner.
I made this interpretation and Betty told me it "made her realize something about how she relates to men." She said she routinely had sex with random men in exchange for drugs and often would have sex with multiple partners even if they didn't give her any drugs but simply "acted nice and asked her to come home with them from a bar." She went on to tell me that she "feels good when they pay attention to me and like me, even though I know they only want sex and will forget about me later. I really like it when they seem to value me and show me they care by giving me drugs and telling me I am pretty. I feel like I finally have what I have been looking for, I feel content. But, I know it is bad and I am ruining myself, which is why I want to work with you to stop all this. I know it isn't really me but I have been doing it so long it has become me."
Betty tried to use this sexualized way of finding a loving parental figure in several ways with me. One example was when she was explaining how she might have to move out of her father's house and her mother would not let her return to live with her either. Betty said, "If that happens, I will have to live with a butch of guys I know in their place. It would be me and four or five guys. They love to party so there would be gangbangs and heavy sex all the time. Can you imagine me involved in a gangbang with four or five different men?" While she was saying this in a desperate way, relating her anxiety about her living situation and lack of money, it was clearly a very seductive manoeuvre to turn me on. I said that to Betty and she replied, "Oh, you got me! I am sorry. You are right. But, it just comes right out. I can't help it. I am sorry. That is exactly what I need to learn not to do." So, this led us to discuss how she felt unable to reach me or see me as a helpful male figure in her life without giving herself over to me sexually and in the process controlling and manipulating me.
When she said she really wanted to "stop that stuff and find a way to change," I interpreted that I believed she wanted to change but it was a confusing situation for her because it was unclear how much she wanted to change for me to please me and how much she simply wanted to change for herself. I interpreted that she may be reluctant to change for herself because that means she is establishing her own identity, separate from the object and that may feel threatening or frightening. She replied, "I don't know if anyone will want me or see me as important if I just follow my own path." I interpreted that she wanted to be special to me because she imagined I would consider her own true self to be inadequate or useless. So, she had to imagine what I might want and adapt to that in order to be special. This left her only temporarily fulfilled as it was an attack on herself and a cloning of my desires to preserve our relationship, not a genuine pursuit or expression of her own wishes, needs, and desires. Betty replied that she "wanted to learn how to do what I said, but isn't sure how to stop being what others want." This psychological problem is similar to what Bass (2007) outlined in his exploration of the as-if character from a Kleinian perspective. Betty was unsure of her own self because she tried to be what others wanted. Indeed, she was frightened of the consequences of freeing herself from this emotional slavery. If I was able to continue working with Betty, I would pursue the exploration of her projected aggression, dependency, and envy because it seemed that this was at the root of her struggle. In other words, she projected her envy of the object's ability to have an identity and have needs and then she felt threatened by that object in a "if you dare to be yourself we will punish you or leave you" way. Her dependency was so aggressive she felt she would crush the object so she needed to deny any personal needs.
So, here we were facing her core anxiety and phantasy of becoming abandoned, alone, and without value if she was to be separate or different from the object. To please the self was to displease the object in a manner that left her with a primitive sense of loss, attack, and rejection. This persecutory phantasy had more to do with her fear of survival than her concern for the object. As Segal (1994) has noted, in order to deal with internal or external chaos, the ego projects its good aspects into the good object. With pathological reliance on projective identification, this led to the ego being stripped of its own resources and potential. Betty seemed to need to prop others up in the hopes they would be able to finally parent her and love her in the way she felt denied. However, this projection was bound up with her aggressive view of the object as a disappointing, abusive, and weak entity so she had to sacrifice herself to prop up the object in the hopes of it now being able to provide her with the aid she so desperately needed.
Of course, this was a vicious cycle in which she felt more and more empty and desperate and her objects became more and more unreliable and false. In the counter-transference, I immediately had these types of feelings and phantasies, which when developed into interpretations, were confirmed by Betty's associations. As Brenman (2006) points out, some patients, such as Betty, need to distort their view of themselves and of the object in order to avoid unbearable emotional pain and to prevent what they perceive to be a constantly imminent relational catastrophe in which the self suffers emotional desolation. This was the condition Betty was in when she sought help from me. Sadly, it was the condition she left in as well. I think she may have been able to take in some of our work as a new type of introject that may eventually bring her back for more help in the future or at least offer a feeling of security in her moments of pain.

Case 3

Frank was a plumber in his late twenties when he sought help for his "rocky relationship." He was a nervous looking man who was undereducated and talked in a rough manner that at first suggested he would not be able to relate psycho...

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