The Misuse of Persons

Analysing Pathological Dependency

Stanley J. Coen

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781317758051
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

In this major contribution to contemporary psychoanalysis, Stanley Coen illuminates a heretofore undescribed character structure especially resistant to analytic process. Pathologically dependent patients, for Coen, are identified not by surface character traits, but by their response to the intrapsychic demands of analysis. Such patients remain in treatment, sometimes contentedly, sometimes amid rebukes and complaints, but they do not profit from it. Their inability to use insight, especially in the transference, is matched by a proclivity for sadomasochistic enmeshment. In analysis, this tendency translates into a continuing dependent attachment to the analyst.

In exploring the genetic roots of pathological dependency, Coen ranges beyond extant trauma theories in describing a pattern of parent-child interaction in which repetitive behavioral enactments substitute for the acceptance and resolution of conflicts, both intrapsychic and interpersonal. In analysis, pathologically dependent patients use the analyst as they have come to use significant others throughout their lives: as part of a defensive structure characterized by repetitive enactments and a refusal to face what is wrong with them. This "misuse of others" is infused with destructiveness, hostility, and rage, and the analyst necessarily becomes the object of these powerful emotions. With such patients, then, the road to therapeutic progress invariably passes through the analysis of mutual transferential and countertransferential hate, the patient's tempting invitations to collusion and avoidance notwithstanding.

Part I

Background for the Study of Pathological Dependency

1

Introduction

In the course of writing a number of clinical psychoanalytic papers, I realized that there was a relatively coherent focus to the problems I had been addressing. A group of analytic patients had relative difficulty with using the analytic process productively so as to face their internal conflicts, resolve them, change, and terminate their analyses or intensive psychotherapies. They tended to protect themselves from responsibility for their own internal conflicts through the use of stable relationships with others. These pathological object relationships were highly resistant to change since they served as a predominant mode of defense against the patient’s own internal conflicts. I came to view these defensive, pathological relationships as varieties of pathological dependency, as a feared inability and avoidance of assuming emotional responsibility for themselves. Much of this difficulty centered on the dread of confronting rage and destructiveness in themselves and in their vitally needed objects. This difficulty led to terror of separateness and of the loss of the vitally needed relationship and to an exaggerated sense of the danger of rage and destructiveness, which could obliterate the needed other. Various defensive illusions (sometimes quasi-delusions) about the protective functions of the object relationship led the patient to idealize and cling to it. This behavior separated him further from his hostile aggression, his own autonomous abilities, and his perceptions of how crippling and unsatisfying this pathological relationship really was.

A central contention of this work is that the defensive uses of others could be understood within a traditional psychoanalytic perspective on intrapsychic conflict. I find no difficulty with integrating such interpersonal defensive operations (“the misuse of others”) with an emphasis on understanding the analysand’s attempts to manage and to avoid his own intrapsychic conflicts. A major purpose of this book is to describe the workings of such interpersonal defensive operations in relation to management and avoidance of intrapsychic conflict.

Pathological dependency is analyzable only insofar as these important defensive needs can be acknowledged and engaged within the treatment. This book focuses on dependent patients who tend not to change in psychoanalysis or psychoanalytic psychotherapy and on how to help them to move forward. Such patients may feel good within the treatment, want very much to continue it, or may chronically complain that they are not being helped, that they should see another analyst, or that they should be out of treatment. But, of course, they do nothing of the sort. An endless, supportive, or complaining treatment relationship may be what certain patients, consciously or unconsciously, feel they need. Is this relationship really the most such patients can obtain from treatment? If not, what prevents them from going further and how can we help them change?

We need to differentiate between analyzable and unanalyzable patients with pathological dependency; that is, we must decide whom we can and cannot help. This distinction may not be clear until there has been a trial of analytic treatment. The first step is for the analyst to face the impasse clearly in his own mind and then with the patient as well. Close attention to the protective illusions derived from the dependent relationship and to the dangers feared on one’s own assists the patient’s attempts at growth and individuation. These dangers largely refer to loss of the illusion of being cared for and protected, with the accompanying helpless, powerless, dependent submission that screens the patient’s terror of his own rage and destructiveness. Although much of the patient’s rage is focused at the parents he feels have not cared for him adequately, have encouraged his dependent adaptation and psychological disability, or both, this background need not be the whole story; that is, murderous rage is easier to tolerate if it can be justified. Much of it cannot be so easily attributed to others; invariably that fact is what is most painful to bear. For dependent patients, it is, indeed, dangerous to feel like murdering the vitally needed parental object. If analyst and patient can strip away the seductive appeal of regressive dependency so that the patient can face his rage and destructiveness on his own, then he can move forward.

The psychoanalytic literature on difficult patients tends to focus on two areas: problems of suitability for analysis and the “unanalyzable” patient and problems of severe psychopathology, such as serious narcissistic or impulsive acting out, infantile character disorders, the borderline, and the psychotic. The people described in this book cannot easily be classified under these diagnostic categories. In certain respects they do not seem to be very sick. Most of them would be regarded not as borderline but as neurotic character disorders. Their daily functioning can be quite good, even superior and successful. It is on the couch that they seem “sick,” in their difficulty with the analytic process, with concentrating in an ongoing, integrative way on what is wrong within themselves, and with working seriously to change that. They easily become stuck or seem stuck right from the beginning of treatment. This book describes such psychopathology, explains it, and describes techniques of working with such patients toward change and away from stasis.

Surprisingly little has been written about such inability to change in analysis; the exceptions are noted later. Psychoanalytic authors have been too hesitant to discuss their difficult cases or their failures. We need to clarify why we have had difficulty helping certain people, and who both we and they expect will benefit from psychoanalysis. My claim is that close attention to such problems will enable the analyst to help such patients better. We discuss conflicts in the analyst and in the patient that contribute to the dependent stalemate. To a degree, each partner has been willing or has needed to become enmeshed in a pathological relationship, which has subverted the analytic task. Careful consideration of the transference-countertransference interplay between patient and analyst usually allows both parties to move out of this impasse. That goal is the task of this book.

Equally surprising is how little has been written in the psychoanalytic literature about pathological dependency. It certainly has not been subjected to extensive psychoanalytic investigation. My view is that systematic analysis of pathological dependency in the patients described here is the only way to end the therapeutic stalemate. To do so, the analyst needs a clear understanding of the almost irresistible pull of such dependent attachment for his patient, as well as potentially for himself. If the analyst cannot tolerate his own reverberating with the patient’s wishes for dependent enmeshment, just as if such wishes are so strong that they lead to mutual enactment, he will be unable to analyze this dependency successfully in his patient. This book is intended to help the analyst to bear and then to reject such regressive wishes a little more comfortably.

Patients with pathological dependency fear being left alone with themselves and with what is inside themselves. They thus cling to others, even if this clinging is denied, reversed, or transformed into something erotic, perverse, or sadistic. The presence of others is felt to be necessary to regulate, contain, and manage oneself. Such pathological dependency may appear as just that, or as sexualization, sadomasochistic object relations, or perversion. To analyze sexualization, sadomasochism, and perversion successfully, the analyst must resolve the underlying pathological dependency.

Certain types of interactive defenses, which involve another person, tend further to tie the patient in with that person. Such interactive defensive modes and these forms of pathological dependency are interconnected. Their maintenance is felt to be essential by such patients; change is to be avoided. This book describes various genetic contributions to the adoption of such defenses, as well as the dynamic operation of such interactive defensive modes within pathological object relations. Emphasis is on how to engage patients about the stalemate in the treatment, how to motivate them to face, more fully, what terrifies them, and how to help them to integrate and manage such frightening affects and wishes. Most crucial is helping the patient to develop the motivation consistently to face what is wrong and to take pride in this difficult, new task. For such patients, this becomes a new, more mature ideal, very different from their prior ego and superego identifications. These internal parental imagoes have encouraged avoidance of responsibility for internal conflict, as if this were too much to bear. The patient has come to believe his inner voices, which have largely told him that he lacks the strength and ability to tolerate facing his conflicts. He must become capable of destroying/relinquishing these undermining parental imagoes and bearing his own rage and destructiveness. He needs to consolidate an identification with healthier aspects of the parents and with the analyst’s work ego, which emphasizes that facing and tolerating what is most painful within are necessary to become fully separate. The patient will need to value such responsible psychic management, so that he can become convinced that he can regulate himself on his own, without parent or analyst. Such analytic change is to be accomplished primarily by systematic analysis of the patient’s avoidance of responsibility for what is wrong within, rather than by identification with the analyst.

For these patients, the need for the object and the need for interactive defenses, to a degree, tend to become one and the same. Such defenses are both intrapsychic and interpersonal; they operate both within a person’s own mind and between him and another. They tend to be learned in childhood by identification with a parent(s) who uses such interactive defensive modes. This defensive mode tends to be built into a style of relatedness between parent and child. Parents who need to protect themselves by using others will, of course, do the same with their children. To the degree that a person is unable to take responsibility for what is troublesome within himself, he will need to find other ways to cope with this. What the parent cannot tolerate and manage within himself, he will, most likely, be unable to tolerate within the child. Then the parent will be unable to help the child gradually to learn to tolerate and manage within himself such troublesome feelings and wishes, so that the child cannot accomplish the essential maturational task of affect tolerance and management.

Of course, any feelings or wishes can be found troublesome by the parent and then by the child. What seems to cause the most trouble, however, are various shadings of angry, destructive feelings. By trouble, I mean difficulty with tolerating, managing, and integrating these feelings, so that one can become comfortable with their existence within oneself. Without some resolution of these problems, a person continues to struggle to get away from what is troublesome and frightening inside himself. For the mother to assist her child with affect tolerance and management of destructive feelings, she must be able to tolerate and manage her own destructiveness and her hatred of her child. The mother must rely on her own ability to integrate and manage hostile aggression so that she can gradually assist her young child with this task. If she cannot do this for herself, she will also be unable to withstand her child’s aggression toward her. Certainly, she will be unable to help her child to learn to integrate aggression. Of course, more than assistance with managing aggression is needed from the parent for the child to feel comforted, loved, valued, and understood. The young child needs the mother’s protection so that he feels neither overstimulated by libidinal wishes nor overwhelmed by aggressive urges.

Since parents do not simply mold their children, what is wrong in our patients cannot simply be blamed on the parents. But certain recurrent factors tend to set the stage in childhood for the development of interactive defensive modes and for the clinging to pathological ways of relating. Many other factors, as we shall see, contribute to their maintenance during childhood and adulthood.

Difficulty with handling angry feelings ordinarily involves aspects of id, ego, and superego functioning. These people are angry, whether or not they show or acknowledge this anger. Superego standards and enforcement are harsh, restraining, and inflexible. In part, they have been needed to manage the overload of anger, to keep it inside, away from the core of the feelings. In part, the superego harshness derives from identification with similar hostile, restrictive qualities in the parental superego and ego attitudes. Further, the child will identify with the parents’ attitudes toward themselves as well as toward the child; these identifications will also be built into the superego standards and regulatory functioning, as well as into the ego attitudes that interact with these. Typically, the child as a whole will be insecure about his acceptability and about his capacity to manage this burden of anger. As a result and through identification with parental modes of defense and adaptation (here in relation to angry feelings), the ego will seek to avoid, ignore, get rid of, or magically transform into their opposite such threatening angry feelings. As a result, the ego cannot gain a sense of confidence and mastery that it can tolerate, survive, live with, and integrate intense anger.

Infantile attitudes in the parents breed infantile attitudes in their offspring. Rarely do these infantile attitudes occur in isolated sectors of personality functioning; more often, this is widespread, to be found in multiple areas of the personality. Similarly, we cannot easily isolate the ego’s defensive mechanisms from the rest of the personality. Brenner (1982) has reminded us that there are no specialized defense mechanisms, that any ego function can be used for defense, as well as, and even simultaneously, for other purposes. I emphasize the interrelations between defense and the ways in which people use or, rather, misuse each other. Such misuse of persons differs from the ordinary use of others in relationships that tends to be both more reciprocal, considerate, and loving and less destructive, extractive, and entitled. Infantile parents who feel they cannot manage what is frightening within themselves will be unable to assist their children with learning to manage their dangerous affects and wishes. These parents will envy and resent the child’s new potential for managing his life better than the parents can do. They will tend to use the child to assist them with their own needs for defense and survival. Such parents tend to be afraid of being on their own, of managing themselves, as if such autonomy were unbearable. Fears of abandonment-separation, unacceptability, mutilation, and guilt tend to lead such parents into enmeshment with at least some of their children. Incomplete separation-individuation during development intersects with incomplete ego, superego, and id development and integration.

Furman (1985) points out dynamic factors in not remembering good aspects of a parent and the mental representation of the absent parent. I believe that we need to be careful not to ascribe undue metapsychological or developmental significance to our clinical findings. Thus Furman reports that her child patient’s primitive rage at the absent mother felt overwhelming and killed her love for her mother. Furman describes her patients’ defensive use of their difficulty with drive fusion. Not to love and not to remember being loved serve to justify aggression, to lessen restraint and guilt. Willick (1987) criticizes Adler (1985) similarly and notes that a patient’s difficulty with remembering the analyst need not mean (regressive) failure of evocative memory but can derive from the patient’s anger and needs to protect himself.

I do not mean to dismiss problems of developmental arrest; however, before we assume developmental arrest, we need to consider how such psychological disability functions dynamically for the patient. I am very cautious about assuming actual psychological deficiency. I prefer to consider the multiple, dynamic uses served by the apparent disability. A major theme of this book is that regressive functioning is highly motivated, overly determined. Because of the protections it offers and the dangers it avoids, it is not at all easily relinquished.

Incomplete separation-individuation tends to be exploited defensively. Parent and child, afraid of loss and destruction, will tend to form object relationships that are narcissistic in one of their aspects. By a narcissistic object relationship, we mean that self and other are not clearly and separately perceived; nor are self and other acknowledged to have equally legitimate and separate needs. That is, self and other will be defensively confused, mixed up to lessen the fear of losing or destroying someone who is fully differentiated from oneself. Differences between self and other will be denied or blurred so as to capture the other within one’s own psychic orbit. Such blurring of differences involves magic, grandiosity, omnipotence, and playing at merger. One either becomes a god in a world of one’s own creation or else shares in the parental omnipotence by trading roles with the parent with regard to who is the god and who is the worshiper–or both. If one is a god or the parent is a god, one can undo destruction and maintain the illusion of safety, permanence, and protection. This protective play is not psychosis but a fantasy world of omnipotent illusions, that protect against loss and destruction. The appeal and excitement of mixing and merging are defensively heightened, as by sexualization or sadomasochism. The danger of destruction of a hated object is attenuated by the excited longing for special, forbidden, sexual, or sexualized merger with this object. This mixing and merging leads to an intense enmeshment between self and object, from which the patient has been unable (terrified) to extricate himself.

Such defensive narcissistic object relations in pathological dependency link with defensive analization. This defensive mixing and merging of self and object can be regarded as an anal defensive mode. As in one’s object relations, one attempts similarly to manage painful, frightening affects by mixing and merging feelings, destroying differences between feelings, so as to make them (everything) meaningless. These regressive anal defenses first, in object relations and second, in the management of affects are aimed especially against fears of destructiveness. The first alters the representation of the object, so that some aspect of the self is, in effect, pasted onto it or some aspect of the object is pasted onto the self. The second attempts to alter one’s affective experience, so that dangerous feelings (and wishes) need not be fully faced, because they are made meaningless.

Some important disclaimers are in order. First, I wish to point out that my aim here is not neo-Kleinian. It is a pragmatic issue that defense against destructiveness is a central task for the patients under consideration. In this sense, the Kleinians and neo-Kleinians have been helpful. Influential traditional psychoanalysts have also needed, from time to time, to remind us of the difficulty we all have tolerating the most intensely troublesome of our human feelings and wishes, which can be or are destructive. It is a relief for psychoanalysts, just as for our patients, to shift the emphasis away to less destructive issues such as narcissistic injury, fragility, depletion, deprivation, and needs of others to support self-esteem and self-cohesion. These issues are all important in their own right; they should not be minimized. On the other hand, they also need to be understood in connection with destructive affects and wishes. Of course, frustration and narcissistic injury can lead to rage, but once it has come into existence, the rage must nonetheless be managed; it is not of secondary importance. When I refer to rage and destructiveness, I mean by the former the affect and by the latter the linked wish or intention. Destructiveness refers not to behavior alone but to wishes and intentions. Sometimes the affect will be either more prominent or more obscured; sometimes, the wish. But they are invariably connected.

The second disclaimer is that the focus here on the use or misuse of people and on the connections between defense and object relationship is not intended to be an interpersonal one. That is, our psychoanalytic focus is on internal (intrapsychic) reality, rather than what we may assume transpires between two people. I am interested in how elements of ...

Table of contents

• Cover Page
• Half-Title Page
• Title Page
• Copyright Page
• Dedication
• Table Of Contents
• Preface
• Part I Background for the Study of Pathological Dependency
• Part II The Inability to Manage Oneself
• Part III The Need to Avoid Destructiveness
• Part IV The Pathological Need for the Other
• Part V Conclusion
• Appendix: A Guide to the Literature on Repetition, Sexualization, and Perversion: Central Issues in Pathological Dependency
• References
• Index