Working With Difficult Patients

From Neurosis to Psychosis

Franco De Masi

• Publisher: Routledge
• Year: 2018
• Print ISBN:
  9780367102227
• eBook ISBN:
  9780429924262
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

In this book the author examines the series of connections that give rise to the intimate relationship between environment and individual in the construction of emotional suffering, emphasising both the undisputed pathogenic action of environmental stimuli and the active participation of whoever is obliged to suffer the negative situation. The author shows that the way in which one tries to escape suffering is what often seriously jeopardises growth. Working with Difficult Patients points out the intrinsic link between some forms of mental suffering and the distorted responses that the patient has received from his or her original environment. For this reason the author explores the concept of the emotional trauma in particular, since this trauma, which occurs in the primary relationship, often impels the child into relational withdrawal and towards constructing pathological structures that will accompany him or her for the rest of their life. The chapters are ordered according to a scale of increasing treatment difficulty, which is proportional to the potential pathogenicity of the underlying psychopathological structure.

PART I

CHAPTER ONE

What do we mean by difficult patients?

“I concealed carefully any need for people, cultivating an impression of independence. I turned tricks into real life, and real life into a sham. I found myself excluded from life on the inside as well as outside and was inevitably confounded by how or why people related to each other, seemingly so naturally”

(Williams, 2010, p. 37)

While infantile traumas are important as agents of suffering in adulthood, pathological developments are subjectively highly variable. The presence of psychopathological constructions, a disinclination for analytic dependence, and distortions of the superego can be counted among the factors that contribute to making some therapies especially arduous. We must also add that patients that are seriously ill do not approach analysis or any other type of therapy on their own account, perhaps because they are unaware of the level of their own suffering or because they fail to realise that treatment may work changes for the better. So, whoever decides to come into analysis has already achieved part of the journey.

With the analysis under way, what meaning does the adjective difficult hold, placed as it is before the noun patient and, thus, on the face of it negatively defining the analytic process? We could define as “difficult” all those patients showing reluctance to change during treatment or even those whose condition worsens. Traditionally, resistance to improvement, the analytic impasse, was thought to stem from the patient’s own difficulties. Freud (1937c) himself believed that the patient boycotted any chance of recovery for fear of losing the secondary advantages afforded by his illness.

This idea has been overturned to an extent in recent decades: while possibly deriving from a particularly complex issue in the analysand, the impasse in therapeutic progress is now held to be mainly of an iatrogenic nature, owing to the analyst’s partial inability to provide suitable responses to the patient’s requests to evolve. When the analyst successfully tunes in to the patient’s communications—which often pertain to the therapist’s inadequate listening skills—the analytic process takes off again and further develops.

However, as I shall discuss in this chapter, another negative factor, stemming from the particular structure of the patient’s psychopathology, often combines in many cases with the analyst’s shortcomings in comprehension.

Clinical severity

We cannot automatically label “difficult” those patients who come to preliminary consultations with marked psychopathological symptoms, since the analytic outcome cannot be predicted merely on this basis. In other words, the gravity of the clinical symptomatology does not exclude a priori the patient from analysis; neither does it necessarily forecast an analytic course that will be more difficult than others or that will conclude negatively.

* * *

By way of illustration, many years ago a young female drug addict came to me for an analysis. I remember feeling very worried when I first met her. She arrived late for her first appointment, unkempt and dressed in black. Her face was expressionless, her voice monotonous, and she made no attempt at all to participate. With her slatternly appearance and way of talking, she resembled those long-term patients it was so common to see in psychiatric hospitals at the time.

She told me she had taken hard drugs for a long time and that she had been imprisoned for dealing, which she had done with her boyfriend. Her court case still had to be heard. She became an addict at a very young age. After failing to pass the high-school final exams, she decided to go to India, which was pretty common then, where she could take drugs freely.

I have to say that the first year of analysis, at five sessions a week, was extremely difficult for me. I was always afraid that my young analysand might succumb at any moment. In the past, she had injected large doses of heroin with the explicit aim of killing herself and her assertions now that she wanted to end her life sounded most convincing. In vain, she made sporadic attempts to stop, but her circle of friends was limited to young addicts of her age, and her boyfriend also continued to take drugs.

She generally arrived in analysis very late, sometimes only in the last five minutes. During the session, she frantically tried to gather her ideas together and to put some order into the events of the previous day that ended, almost always, in shooting up (usually heroin), followed sometimes by promiscuous sexual encounters.

For a year I managed to withstand the anxiety that the patient cascaded into me at every session. I did not know if or when she might be able to give up drugs. I only knew that I constantly had to come to terms with my anxiety and that I had to continue my analytic work without invading her with my demands.

Whenever it was possible I described the power that the drug held over her mind and her idealisation of death. There were many occasions when I would have liked to telephone her family and tell them to do something, perhaps get her admitted to hospital, but I never did.

On returning from the first summer holidays, after a year of analysis, she surprised me when she came into the session and said that she had stopped taking drugs. She had left her boyfriend and had succeeded in staying away from heroin. She added that she had had to do this during the holidays when she was far from me because only then could she be certain that it was her decision and that she had not done it just to please me.

From that moment, this young woman’s life blossomed and flourished. She had only two relapses, for very short periods; both occurred subsequent to cancellation of the session—the first time I cancelled, the second she did. After much deliberation, she had decided to miss two sessions and go to visit a girlfriend who lived some distance away. On both occasions, she said, she had had to fall back on drugs to wipe out the intensely painful longing she felt for me in my absence.

* * *

If I had had to predict the outcome at the start of this analysis, bearing in mind the gravity of the situation, I would never have said it would be positive.

Thinking back over the patient’s story as it emerged during the analytic treatment, I was able to pinpoint a number of elements that, with hindsight, threw light on the gap between the initial psychopathological picture and the positive outcome.

My young patient came from a family of well-off intellectuals. She had been considered somewhat retarded as a child as she did not excel at school, and so her parents had channelled all their expectations on to her younger brother. He had been sent to a child therapist for a time when experiencing a period of anxiety, but no one had noticed that my patient was a depressed little girl who withdrew into a fantasy world, which made it difficult for her to get on well at school.

Hence, my patient’s sufferings clearly seemed linked to a disavowal of the self and to a very early relational trauma, while her recourse to drugs was a defence against the anxiety triggered by her feelings of non-existence, which had become unbearable as she approached her teenage years.

An emotionally sensitive type of listening on my part had given her the chance to emerge from her depression and stimulate her vital part. I had always sensed how important and profound her relationship with me was for her, right from the very start, and how useful and powerful the transference bond was for the good of the therapy.

In fact, as a baby, my young analysand must have enjoyed a certain amount of maternal warmth, as this type of affective receptiveness was soon reawakened in her in the transference. Although she was drug dependent, she was not destructive or cynical in her attitude to the world, or, in analysis, to me. Instead, she was deeply disappointed by her love objects and this had pushed her far from her affective relationships.

One of her first dreams clearly illustrated that she was aware that idealising drugs imprisoned her in a state close to death.

In the dream, she was imprisoned in a Nazi concentration camp. She was going towards a building located in the centre of the camp in which a fantastically coloured and powerfully attractive insect lived, in a protected state. It was intensely seductive, and she fell prey to it. The dream clearly showed how her healthy part was aware of the danger stemming from her attraction to drugs (the beautiful insect) and so was asking for help to get out of its clutches.

Bearing in mind the therapeutic response, the case was not difficult. The analysis did not last long and concluded satisfactorily for both parties. Despite the presence of worrying symptoms, I believe that this patient was able to benefit from analytic treatment because her suffering stemmed from an infantile emotional trauma.

Although her parents had been mainly positive, they had not been capable of giving her an emotional place in their minds or of supporting her adequately as she grew older. This contributed to creating in her a feeling of futility and constant anxiety about falling into an existential void. Her healthy part, though suffering, had not been seriously breached and the pathological structures against emotional dependence were not very deeply rooted within her. In other words, the substantial, initial symptomatology did not mean that she became a difficult patient.

Pathogenic effects

Some patients who have had emotionally less receptive parents, as in the case above, are undoubtedly complex but not particularly difficult in analysis because, on the basis of a relationship with a new object, it is possible to help them reactivate the elements of emotional development that have remained paralysed.

On the other hand, other patients might not only have been deprived of an adequate emotional exchange but might also have incorporated their parents’ mental states and anxieties. Particular emotional traumas—unusual even within the variation of mother–child relationships—can produce pathological distortions of considerable note.

While the intensity of the trauma can be equal, its effects can be different: much depends on the capacity of each individual to react and on the presence of a substitute figure (Modell, 1999).

In more complex situations, the child not only lacks a receptive object, but also suffers this same object intrusively projecting itself into his mind. Parents, at times, violate psychic boundaries and intrude with their anxieties or their delusional constructions, or they make their child a receptacle for their adult sexuality. In these cases, a link is generally created between the destabilising external situation and the mind that has to suffer it; early emotional traumas especially can inspire psychopathological structures that are destined to survive over time because they are perceived as supporting figures compared to the distressing experiences of dependence.

A deficiency of emotional containing, combined with the impossibility of projecting oneself into the other, results in these patients suffering psychophysical pain, confusion, and chronic anxiety. They often identify with the aggressor and their sense of self is constantly threatened with disintegration. Anger, due to frustration at parents particularly lacking in empathy, turns against the living part of the self, felt as a source of pain. A confused blend of expectations and disappointment is thus created that prompts feelings of emptiness and passivity.

In such cases, the crisis is accentuated when the patient begins to feel more alive and looks for an object capable of satisfying his needs but, never having had experience of one, he finds himself again full of anxiety and disoriented.

* * *

Thirty-seven-year-old Teresa¹ has been married for fifteen years and has a ten-year-old daughter.

A state of depression lasting several years with a concomitant abuse of alcohol—for which she was being treated by a psychiatrist who had prescribed a course of antidepressants—spurred her to come to analysis. She judged emblematic of the inadequacy of her mother the fact that, when she was small, she risked dying because her mother, who was breast-feeding her, did not realise that her milk was not nutritious enough. Instead, from infancy, she enjoyed a privileged, reciprocally idealising relationship with her father. This alliance was brusquely broken in adolescence.

Her first years at high school were marked by an increasing sense of inadequacy, constraint, and anger towards her parents, and isolation from her schoolmates. So, she became a heroin addict, which lasted for some years until she successfully detoxed after a period in rehabilitation.

During the early part of her analysis, Teresa continued to keep herself going with drink and with a singular inclination for pleasurable fantasies that detached her from the real world.

Towards her third year of analysis, when she had begun to feel better, Teresa became even more anxious. She felt very exposed and helpless; her nights were disturbed and she used to wake up full of anxiety. She was, in fact, afraid that without alcohol she would no longer be able to control her mind. Her only relief was provided by the fantasy of a uterus in which she found refuge. She felt like an invertebrate, spineless, exposed to any “mutation”.

During this difficult stage of improvement, Teresa distanced herself from the analytic relationship and even missed a few sessions. Some weeks later, a dream helped her clarify the situation:

“My husband and I, with our daughter, were in our house in the mountains, where we have a dog and a small cat. With the weekend over, we had to close up the house and leave food for the two animals that we couldn’t take with us. We prepare bowls of food but realise that we cannot leave them there. So my husband and I decide to stay. I am overwhelmed by tremendous anxiety about the dark and about being alone. I sense my husband is suffering the same anxiety …”

Teresa speaks of the anxiety that torments her to such a degree at night that she is relieved to wake up in the morning and shrug off the pain. The dream vividly recalls her childhood anxiety when she was a little girl in bed in the dark: she would lie awake asking herself when her mother would return, dreading that no one would come back any more, feeling as though she would die, or would be squashed flat, or be split in half.

The animals in the dream and the anxiety appear to be linked to feeling herself alive: if she feels alive, she is frightened because immediately the risk of being left all alone emerges; there is no one to help, no one to think about her or look after her. It seems easier for her not to exist, to disappear in the general indifference and not to have any contact with her innermost needs and desires. The young animals undoubtedly stand for her vital desires and her anxiety stems from the sensation of not being able to succeed by herself, while not knowing who is capable of responding to her needs.

* * *

An object on which she can trustingly depend does not yet exist in this patient’s mind; consequently, instead of heralding well-being, any improvement triggers fear and unbearable pain.

This situation recalls what Rosenfeld (1978) observes in the case of the baby who feels physical deprivation associated with a marked lack of maternal empathy. In this case, a confused blend of libido and destructive experiences lead to feelings of emptiness, weakness, and passivity that become a wish to die or to disappear into nothingness.

The solution adopted by Teresa was to kill her living parts. She probably adopted the same solution in early infancy when she found herself depending on a mother perceived as non-empathic and non-accepting. Paradoxically, her analytic improvement unleashes anxiety and entails the risk of a brusque step backwards.

Withdrawal

One of the most common outcomes of failed early emotional interaction sees the child withdrawing from human relationships to seek refuge in his own separate world. This dissociating from reality can occur either by way of full immersion in sensual and masturbatory self-stimulation or the creation of an imaginary world perceived as real. So the child becomes used to living in a secret other world that gives him pleasure. Steiner (1993) was the first to conceptualise the pathological structure of the psychic retreat.

I am convinced that this pathological structure can almost always be found in more complex, borderline, or psychotic patients. It is, in fact, a massive distortion in psychic functioning that hinders emotional development and growth and relationships.

In some cases, the child has to defend himself against being invaded by an adult (for example, a mo...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• ABOUT THE AUTHOR
• INTRODUCTION
• PART I
• PART II
• NOTES
• REFERENCES
• INDEX