The Danger of Change

The Kleinian Approach with Patients Who Experience Progress as Trauma

Robert Waska

• Publisher: Routledge
• Year: 2014
• eBook ISBN: 9781317724308
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Confusing clinical standoffs, loyalty to self-destruction and abrupt terminations are challenging and under-examined problems for the modern psychoanalytic practitioner. The Danger of Change is a timely book that addresses the so-called resistant patient so many clinicians are familiar with.

Robert Waska blends theory based on Melanie Klein's classical stance with the more contemporary Freudian/Kleinian school, to demonstrate how to understand patients that are resistant to progress. Divided into four sections, this book covers:

• reluctant patients and the fight against change: caught between the paranoid and depressive world
• greed and the dangers of change
• interruptions to the process of change: loss, envy, and the death instinct
• working toward change in the face of overwhelming odds

Extensive and detailed clinical material is used to bring clarity to subjects including symbolism, conflict resolution, projective identification, the depressive and paranoid positions, change and trust.

The Danger of Change brings hope and clarity to cases involving patients who experience progress as a threat to their emotional wellbeing. It will be of great interest to all practising psychoanalysts, as well as those studying psychoanalytic theory and practice.

Part I

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Reluctant patients and the fight against change: caught between the paranoid and depressive world

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Chapter 1

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I hear you knocking but you can't come in*

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There are patients I have treated with the analytic method¹ who, at some point in the process, refuse to explore, reflect, change, or even consider new ways of relating to themselves or others.

Sooner or later, change becomes the enemy. Taking in a new, more successful or hopeful object is avoided and they cling to the view of the self as bad. Change, growth, and the creation of a more friendly or enjoyable internal world are fought off. Of course, this manifests in various external difficulties and dysfunctional relationships. In the transference, the analytic relationship begins to feel like a debate, a duel, or a dead-end. At first, this anti-growth attitude may look like the patient is simply feeling unable or too frightened to change. However, I wish to emphasize the more active refusal against life and progress. Indeed, the successful analysis of these difficult patients seems to lie in the ongoing interpretation of their active participation in this psychic standoff.

In the psychoanalytic literature, these types of patients have been studied from several vantage points. Freud (1918) felt it had to do with rebellion and later conceptualized it as part of the death instinct (1923). K. Horney (1936) emphasized issues of competition, fear of success, and the ideas of progress leading to abandonment. Melanie Klein (1957) thought envy was involved. Others, such as Olinick (1964), Valenstein (1973), Asch (1976) and Loewald (1972) have attributed an important role to masochism. Rosenfeld (1971; 1975) wrote that narcissism played a significant role, along with envy. Kernberg (1984) investigated the destructive feelings that were directed toward the analyst.

Many of these authors have noted how their patients tended to get worse instead of better. I believe this is only one variant of the so-called negative therapeutic reaction. The patients I am exploring do not want to improve in one respect, but they usually do not get markedly worse either. They stay the same. They make it their job to remain internally frozen. They enter treatment with severe anxiety, depression, paranoia, or other fragmented states of mind and then do not improve. Eventually, they rebel at establishing any change, as it means something devastating and terrible.

Joan Riviere (1936), in her classic paper on the negative therapeutic reaction, has described a group of patients who exhibit these negative reactions as a result of overwhelming depressive anxieties. She notes that most patients have a combination of depressive and paranoid phantasies, but that the negative therapeutic reaction is part of a more debilitating depressive phantasy. By now, it is well established that in normal development and in psychopathology, the ego struggles with these two areas of conflict simultaneously, but with one usually weighing in more heavily.

I will use Riviere's paper as a starting point to show a clinically essential distinction in understanding internal states of mind. This distinction is important in helping patients who find themselves so fastened onto a world without growth.

I will show, through two case examples, the difference between the more depressive patient's negative therapeutic reaction as discussed by Riviere and the more paranoid patient's anti-growth attitude. The more paranoid patient develops an anti-growth transference with an intolerance for taking in a new, more positive version of the self or the object. This occurs within a markedly persecutory world where the idealized object turns into an attacking and abandoning foe. This restricts and freezes the analytic treatment process in place, due to the patient's desperate struggles to prevent these paranoid-schizoid catastrophes.

In 1936, Joan Riviere wrote:

The content of the depressive position (as Melanie Klein has shown) is the situation in which all one's loved ones within are dead and destroyed, all goodness is dispersed, lost, in fragments, wasted and scattered to the winds; nothing is left within but utter desolation. Love brings sorrow, and sorrow brings guilt; the intolerable tension mounts, there is no escape, one is utterly alone, there is no one to share or help. Love must die because love is dead. Besides, there would be no one to feed one, and no one whom one could feed, and no food in the world. And more, there would still be magic power in the undying persecutors who can never be exterminated – the ghosts. Death would instantaneously ensue – and one would choose to die by one's own hand before such a position could be realized.

(p. 312)

Many authors after Riviere have described the depressive position in similar terms, combining the same psychological elements. I think these formulations need to be, for clinical reasons, refined. To understand and treat these difficult patients, who seem to not tolerate change or progress, the analyst must create a finer clinical distinction between the paranoid-schizoid position, the paranoid aspects of normal depressive concerns, and pathological depressive anxieties.

To my reading, and the way I approach these anti-growth situations in the consulting office, Riviere is at first describing the collapse of the depressive position into a paranoid, more psychotic landscape where, “all one's loved ones within are dead and destroyed … nothing is left within but utter desolation … one is utterly alone … Love must die because love is dead … [there is] no food in the world”. This is a far more ominous inner state than the developmentally expected depressive position generally seen in the clinical situation. Riviere does bring in the concept of guilt, as an outgrowth of sorrow, and this correlates with the clinically expectable depressive reaction. In the second case example, I will highlight a man who experiences the more destructive and hopeless feelings Riviere is folding in with depressive reactions.

Again, it is clinically valuable to make a distinction between true depressive remorse, guilt, and mourning and the more primitive paranoid-schizoid experiences of loss (Waska 2002). Paranoid-schizoid states of loss are those in which the ego faces a dual threat. First, the object, in particular the idealized good object, abandons the ego by not providing it with the craved-for nourishment, security, and support. This phantasized abandonment is experienced as permanent and deliberate. This is usually the result of a greedy projective identification process in which the ego finds the object useless and disappointing. After this betrayal, “the ghosts”, as Riviere puts it, or the “undying persecutors”, return to hunt down the ego and destroy it. In this fragmented world, there is no rescue, no forgiveness, no hope. Instead, there is only blackness, desolation, and the eventuality of being betrayed and crushed by what was the ideal and now is the alien, the enemy.

Riviere goes on to say that the depressive patient may try anything, including a negative therapeutic reaction in order to save the analyst from harm. This is a state where there is indeed hope, because one's objects are not dead and despair is never complete because there is always the chance, even if slim, of restoration and repair of love.

The patient living within the paranoid-schizoid position feels complete loss has occurred, with no rescue possible. Riviere seems to point to the place in one's mind where there is a crossover from the depressive to paranoid phantasy state when she states, “the anxiety is so great because life hangs by a hair and at any moment the situation of full horror may be realized” (p. 313). She then goes on to describe what I view as the shift from depressive to full paranoid-schizoid anxieties if the patient believes he is unable to make amends for his aggressive ways:

But struggle as he may and does under his unconscious guilt and anxiety to repair and restore, the patient has only a slenderest belief unconsciously in achieving anything of the kind; the slightest failure in reality, the faintest breath of criticism and his belief sinks to zero again – death or madness, his own and others', is ever before the eyes of his unconscious mind. He cannot possibly regenerate and recreate all the losses and destruction he has caused and if he cannot pay this price his own death is the only alternative.

I think the patient's fear of being forced to death himself by the analysis is one of the major underlying factors in this type of case and that is why I put it first. Unless it is appreciated many interpretations will miss their mark. All his efforts to put things right never succeed enough; he can only pacify his internal persecutors for a time, fob them off, feed them with sops, “keep them going”; and so he “keeps things going”, the status quo, keeps some belief that “one day” he will have done it all, and postpones the crash, the day of reckoning and judgement.

(p. 313)

Finally, Riviere (1936) makes her point about the different unconscious concerns a patient has. She makes clear how she believes the depressive anxieties are more powerful and detrimental to the analytic work. Therefore, she sees the depressive phantasies as those contributing to failed or stalled treatments and a priority in what to interpret first. Here, I wish to agree with her findings but extend them as well. Some patients are indeed so trapped in depressive anxieties that they engage the analyst in a very difficult relationship that seems to become immovable at times. However, I believe there are other patients who manifest the same stuck, anti-growth transference for very different reasons. These are the patients who are immobilized within intense paranoid-schizoid anxieties of primitive loss and persecution.

In fact, I would argue that the majority of patients in private practice tend to be these more fragmented indivduals. Most of the patients I see in analytic practice, who resist the invitation of life, of change, and of progress, are indeed suffering with phantasies of hurting their objects and guilt over aggressive desires. However, the more immediate, core force in these patients' psychology appears to be a paranoid vision of ultimate loss and persecutory annihilation. This is not a defense against depressive fears, but a rock bottom, core dynamic. The primary solution they see, as a temporary respite, is to avoid, spit out, and refuse any taste of the good object, the good analyst, the good mother. Instead, they demand an idealized, perfect object. At the same time, the ordinary, good, usually available object is given no entrance because it represents the shift of the ideal into the dreaded. Through projective identification, this cycle also involves a search for the ideal, perfect version of the self and a rejection of anything common, predictable, or human about the self.

Using clinical material, I will first show how Riviere's ideas are still very relevant in the clinical situation, when dealing with a patient's depressive phantasies. Then, I will present case material of a more paranoid individual to show how Riviere's ideas can be extended to understand a standoff in treatment due to very different internal experience of the paranoid-schizoid posture.

THE DEPRESSIVE PATIENT

O was an intelligent, articulate man who prided himself in dressing nicely. He made a point of being polite to everyone he met and went out of his way to avoid conflict. He came to me for help in his late forties because he was unable to find a girlfriend. He had been without a mate for several years. “Once they get to know me, they only want to be friends”, O told me. So, we began to meet twice weekly, using the analytic couch. Lack of funds and problems with scheduling prevented a more frequent contract.

Almost immediately, O developed a particular transference relationship with me. He would deliberate back and forth over why he wasn't instantly improving. He would blame himself for not working harder on his problems, then he would blame me for not curing him right away, and then he would see himself as not giving me enough to work with successfully. After only two or three months of treatment, O would say, “why am I still coming? Nothing has changed. I don't see any difference in my problems. Why haven't you fixed me yet?” This message would be repeated over and over in the course of his four-year treatment. This message of nagging hunger and discontentment was kept very split off from O's other feelings, so it was difficult to analyze how they were related to the same object relationship. This was part of a crossover between depressive and paranoid anxieties and demands that I will mention again, a bit later.

O was one of two children, with a sister two years older than he. Growing up, he had hardly any contact with his father, who was a traveling salesman and only home two days a week. From a fairly young age, O was home by himself or with his sister much of the time. His mother was a factory worker and worked the swing shift. After O came home from school, he was alone as his mother was working until the late evening and his father was away at work. Food would be ready in the refrigerator and a neighbor would look in on them occasionally.

O spent most of his days doing homework by himself or chores around the house. He ridiculed his sister for watching television or playing in the yard with friends. O tried his best to follow mother's orders, to be a good boy, and to not cause his mother any problems. When I suggested he might have been frustrated and lonely, and even angry with his parents for being so absent, O quickly denied it. He said it was no problem, he understood his parents had their own lives to lead, and it was “just the way things were”.

This neutral detachment and denial of his feelings, especially any aggressive feelings toward his mother, was a major block for much of the treatment process. But, we made headway in fits and starts. In a session about a year into seeing me, O was talking about his mother. He started to feel angry with her and froze. “My heart is racing. I can't stop thinking I should be dead!” he yelled in panic. This reaction to feeling angry with mother was hard to explore as O immediately forgot what he was talking about and then switched the subject. Clearly, he had to keep the peace with this internalized object.

The two ways we were able to access these forbidden feelings were through his trouble with dating and through the nature of the transference. We could see how, when he dated, he kept this same type of mechanical distance from the other person until they felt alienated. Also, he tended to become involved with women who took advantage of him, but since he tried to keep his negative feelings at bay, these relationships would go on until he made some polite excuse to not meet anymore. By that time, he had been used. Later, he would ruminate back and forth as to whether it was his fault or the woman's. He would be furious, but unable to make sense out of the feeling or find a right place to put them.

In the transference, he was as nice and neutral as possible, except when he told me to hurry up and cure him. These more aggressive, demeaning comments were said in a way that was so detached he didn't have to take emotional responsibility for them.

An example of this occurred in the third year of treatment. O usually paid me in cash and he had recently spoken of his idea of paying me electronically, where a check would be automatically sent to me each month.

O asked me what I would prefer. I asked him for more details. O began to go back and forth about the pros and cons of each method of payment. He speculated how I might want cash on one hand, but that it might make my bookkeeping difficult and cumbersome. On the other hand, he thought the electronic checks might make my accounting easier but deprive me of the immediate cash. I said, “this is difficult because you picture hurting me one way or the other”. Here, I was interpreting the depressive anxieties of harming the object. O said, “Yes. I feel I will be causing you some kind of trouble and you know how I hate conflict.” O went on to discuss how he wanted to avoid any sort of ill-feeling with me or the specter of my being frustrated or angry with him. “I am starting to feel really anxious right now, my chest feels tight”, he said nervously. After a few minutes of silence, O said, “I have totally forgotten what we were talking about.” I interpreted that he wanted to do something for himself, making life easier via the electronic checks, and began to worry that this was selfish and hurtful. In response to my comment, he launched into another intellectual exercise about which method of payment was best, noting all the details in each camp. I commented on how he was now needing to use logic and forgetfulness to escape his anxiety about our relationship.

O replied, “I am angry with myself. This is a lifelong pattern and I haven't ever changed it. And, I am angry with you for not having gotten rid of it.” I interpreted that he wanted to get rid of his problems electronically, in a distancing way where he didn't have to feel it and didn't have to deal with the dirty money and dirty feelings. O replied, “I feel guilty about being angry with you. I feel uncomfortable. Wait a minute. Wow. I suddenly started thinking about my mother. That is weird. I have always wanted mom to see me as perfect. That way, I don't run the risk of losing her love or approval.” After O explored these thoughts and feelings for a while, I interpreted that he kept his mother on a pedestal to avoid facing the anger he has toward her for being imperfect and leaving him out in the cold when he needed her. O replied, “yes, I think you are right about that. But, I am quick to forgive. Even if she is imperfect, I can see why and I forgive her.” I commented on how instantly he forgives, out of both desperation and omnipotence. O replied, “I am the king! I guess you are right though. If I don't make everything smooth, there would be friction between her and me. And, that doesn't feel right.”

O's treatment seemed immovable for several years and this was primarily the result of the depressive anxieties Riviere spoke of. O feared exposing his mother and his analyst to the rage, disappointment, and anguish he felt. These feelings leaked out as a grandiose, biting sarcasm, as wanting to control me, and as demanding my cure. However, this would quickly be replaced with guilt, intellectualization, and repression. O believed there was a way to gain forgiveness, even though he felt this was rather magical and thin. Sometimes, it was more a facade of forgiveness in which he used pleasing, logic, or debate to wash away any conflict with his objects in order to achieve or maintain his blissful state of peace, approval, and love. While O constantly feared the loss of love, he felt it could be saved. Again, this was questionable at times and pointed to an internal teetering between the depressive and paranoid positions. However, in an overall sense, O represents the type of depressive patient Riviere wrote about.

The stalling out of O's treatment was gradually corrected as we, over and over again, explored his core fear of injuring, hurting, and disrespecting his mother and me. The more we analyzed his hidden neediness, greed, and oral deprivation the more these depressive anxieties arose. Th...

Table of contents

• Cover Page
• Half-Title Page
• Title Page
• Copyright Page
• Table Of Contents
• Personal statement
• Introduction
• Part I Reluctant patients and the fight against change: caught between the paranoid and depressive world
• Part II Greed and the dangers of change
• Part III Interruptions to the process of change: loss, envy, and the death instinct
• Part IV Working toward change in the face of overwhelming odds
• Summary
• Bibliography
• Index