Suffering and Sacrifice in the Clinical Encounter

Ashbach, Charles, Fraley, Karen, Koehler, Paul, Poulton, James L., Fraley, Karen, Koehler, Paul, Poulton, James L.

• Publisher: Phoenix Publishing House
• Year: 2020
• Print ISBN: 9781912691579
• eBook ISBN: 9781912691586
• Topic: Psychologie
• Subtopic: Psychoanalyse

In Suffering and Sacrifice in the Clinical Encounter, the authors identify the ways in which some patients seek to create what Freud termed a 'private religion' and unconsciously substitute sacrificial enactments of scapegoat surrogates to protect them against the pain of separation, mourning, and loss of primary figures of attachment. They investigate the function of sacrifice and its relationship to the breakdown of psychic structure and the development of manic defenses and pathological narcissism. Such treatments are complex, the 'reversed roles' of victim and perpetrator central to the sacrificial process when enacted in therapy can trigger feelings of shame, guilt and inadequacy in the therapist. Perverse, vengeful, and sadistic transference distortions are explored to enable the therapist to appreciate the true nature of the patient's hidden traumatic experience, with the necessity for the working-through of genuine separation and grieving highlighted. Useful methods are detailed to counter the tendency to become overly active and inappropriately involved when working with patients who have deadened their desire to improve.

This book is unique in utilising the dynamic concepts of the effects of trauma and sacrifice, the role of the scapegoat, and the distinctions between the experience of pain and the accomplishment of suffering in order to develop a foundational understanding of such patients. It is a must-read for all practising and trainee therapists.

CHAPTER ONE

Trauma, resistance, and sacrifice

Charles Ashbach

Statement of the problem

In the introduction to this book we profiled a particular type of patient who seeks psychotherapy or psychoanalysis and presents as motivated, intelligent, and eager for help but after a seemingly successful introductory phase, where work seems to get done and the treatment and alliance seem to unfold in a positive way, we come to recognise this individual is decidedly constrained by some inner force or experience causing him difficulty in the access to his emotions, memories, and associations. His associations are anything but free and the material soon reveals a limited range, and though he is pleasant and appears cooperative the sessions do not bring forth a feeling of alive engagement. His description of his problem or the statement of his goals for the treatment is vague. He moves carefully within the sessions, revealing a generally defensive attitude protecting some element of his experience, especially his pride, and treating the therapy as a danger that needs to be managed and controlled.

The treatment continues but the work does not deepen and we feel held at bay. It is clear that he wants something, something important, but he reacts as if he does not possess the skill to communicate the emotional experience that is his reason for being in the treatment in the first place. Though intelligent, his emotional language is by and large flat or mechanical and his difficulties or hesitations increase our hunger to find the means to help release him from his shell. As our frustration grows we often become more active or impatient to help him find the right word or a helpful association. Of course the countertransference becomes increasingly problematic as we become agitated that our skills and intuition aren't enough to set the experience going.

The person does not seem obviously ill, broken, or depressed but the inhibitions blocking his speech and the communication of his emotions suggest he is operating under a burden that stops him from telling us his story. In some cases he might become more obviously defiant, arrogant, or condescending and be more interested in observing us as we wrestle with our problems rather than finding a way to understand his. Thus, the patient announces in either a benign or aggressive form the burden of encountering this overwhelming problem. Or is it an intentional choice? Whatever the answer he seems unable to free himself from the self-defeating ambivalence that leaves him chronically miserable and filled with despair.

A critical advance in the understanding of the problem of intense resistance was provided by Freud with his study of “Mourning and melancholia” (1917e), where he showed that in the condition of the loss of a primary object the subject regresses to a deep unconscious dimension where he is able to recreate, in an imaginary and delusional form, the lost figure of attachment. The subject uses aspects of his own narcissism to both identify with the lost object and from it to fashion the replacement figure of the ideal (Steiner, 2005). This replacement figure enables him to both “be” and “have” the object and in this way he is protected against (denies) the loss and uses the magic of his omnipotence to fend off feelings of helplessness and collapse. The narcissistic element of this transformed object provides the delusion that he is one with it, fused and inseparable and therefore does not have to contend with the horrifying demands of loss, grief, regret, and mourning. His identification with the ideal figure fuels his feelings of power and enables him to decrease his contact with the actual, external object world, leads to omnipotent thinking, decreases his encounter with reality testing, and, most importantly, increases the conflict between wishing to be alive in one's object relationships or to be “at one with one's dead internal objects” (Ogden, 2002, p. 767), thus increasing the danger of suicide.

The patient hides his aggression against his objects by unconsciously heaping upon himself the displaced attacks against the lost love object. His self-abuse is in part a camouflage protecting his ego against the attacks and condemnation of his conscience and he feels perfectly entitled to express his displeasure without the slightest sign of humility; he is comfortable presenting himself as the victim. As Ogden says, the subject expresses his sense of “injustice” incessantly, but eventually his superego causes him to be “crushed” and he accepts his fate as punishment for his crime of driving the object away (Ogden, 2002, p. 772). It is this experience of ambivalence that causes the subject to be caught in an oscillating emotional space that allows for no pleasure and no peace.

So we are confronted with the irony that Freud in “Mourning and melancholia” (1917e) presented an object relations understanding of resistance using the central event of object loss and in The Ego and the Id (1923b) presented his formal theory of resistance based upon the impact of drive conflict focused around the impact of the death drive (1920g). He attempted to explain the patient's problem, which he described as the subject's “negative therapeutic reaction” (NTR) as caused by the distortions in the subject's superego and his inability to bear up under the impact of unbearable guilt. In this model the drive, actually the impact of unconscious guilt, makes the subject withdraw from the treatment process and use sadomasochistic acting out as a means of punishment to pay the price for his sins. This approach led to no further development and was eventually surpassed by developments in object relations thinking.

Thesis

The purpose of this chapter is to demonstrate that we can achieve a radically improved understanding of a patient's chronic resistance if we apply Freud's model of mind (1917e), articulated in “Mourning and melancholia”, to understand the ways in which the subject's mind has been crushed, disturbed, and disorganised by the traumatic and catastrophic loss of his primal object. The following elements are central:

1.The “primitive agonies” (Winnicott, 1974) unleashed by this loss trigger a desperate process of magical, narcissistic restoration that culminates in the creation of an ideal figure of love and connection (Steiner, 2005) that is the delusional substitute (replacement) for the lost actual object. Ogden's observation frames the impact on the subject of such a phantasmic, manic, and self-generated inner world: “[A] fantasied unconscious object world replaces an actual external one; omnipotence replaces helplessness; immortality substitutes for the uncompromising realities of the passage of time and death; triumph replaces despair; contempt substitutes for love” (2002, pp. 777–778).

2.The patient's regression causes him to experience a register of narcissistic, unconscious experience that enables him to activate a primitive sadomasochistic fantasy that his suffering and pain are the means for him to acquire gratification, forgiveness, and omnipotent power.

3.The splitting of the self leads to a dissociated “double self” (Wurmser, 2007, p. 11) where self-idealisation, perfection, and purity are active in one sector and the subject's enormous feelings of hatred, envy, and revenge exist in another. The problem of “owning” or taking responsibility for one's desires and actions cannot be said to coalesce under such fragmented circumstances.

4.The subject's extensive injuries compel him to seek to construct the treatment as a “stage” (setting) for the portrayal of his earliest battles and losses and for the disposal of his unbearable burden of guilt and shame. The treatment in such a form is often reduced to a process of constant conflict, disagreement, and injury until the decoding of the aggression and misunderstanding is solved.

5.The patient is a depressed individual operating in a register of regressed, omnipotent, and narcissistic unconsciousness that seeks to transform the treatment from a psychological process of investigation, insight, and understanding into a “private religion” (Freud, 1907b) by co-opting the ritualistic and ceremonial aspects of the treatment. He seeks to bring about a process of suffering and sacrifice occurring in a “sacred” order of experience where he seeks to “offer up” the positive elements of his life—his talents, accomplishments, hopes, and relationships—on the altar of the treatment in order to receive, in return, the bounty of his imagined god-object. His ego remains in control, now operating within the shadow of his imagined, omnipotent god-object and this form of treatment is a perversion of the dynamism and generativity of the actual process of therapy as it cancels out the need for the acceptance of loss, grief, guilt, and mourning. The “new life” of the patient, the therapeutic child of the treatment (Chasseguet-Smirgel, 1985a) cannot be born because the subject's fusion with his “ideal” delusional object destroys the power of the primal couple. The patient's dependency remains centred on the idealised version of himself hidden within the god-object that he directs his sacrifices to. The acknowledgement of the loss of the prime object and his acceptance of a new “libidinal position” of his relationship with the therapist (Freud, 1917e, p. 244) is fought and the success of the treatment hangs in the balance.

The path to achieve this new perspective on resistance is by relating the connections between trauma, the breakdown of the self, and the construction of a new self inside the register of suffering and sacrifice.

Trauma, breakdown, and the “new” self

Trauma is the force that crushes the self, overturns the order of the internal realm, and transforms the subject's expectations of the external world into an ominous and dangerous place; it drives the subject back into a fantasy world of wish and magic and makes the possibility of belief in human beings a difficult and risky challenge. It is the starting point to understand chronic and intense resistance.

So a traumatic event is one that, for a particular individual, breaks through or overrides the discriminatory, filtering process, and overrides any temporal denial or patch-up of the damage. The mind is flooded with a kind and degree of stimulation that is far more than it can make sense of or manage. Something very violent feels as though it has happened internally, and this mirrors the violence that is felt to have happened, or indeed has actually happened, in the external world. There is a massive disruption in functioning, amounting to a kind of breakdown…. It leaves the individual vulnerable to intense and overwhelming anxieties from internal sources as well as from the actual external events. (Garland, 1998, p. 10–11)

The concept of trauma—from the Greek for wound, hurt, or defeat—has become so ubiquitous, used so casually for so many events, that it is near-saturated. Trauma as I use it defines an emotional and psychic catastrophe that envelops the self, rattles the soul, rips something whole into tragic pieces, and, as Garland says, “breaks through” and “overrides” the filters protecting the self and leads to a “massive disruption…amounting to a kind of breakdown”. Here Winnicott's (1974) characterisation of the subject's “primitive agonies” bears repeating: a return to an unintegrated state; falling forever; depersonalisation and loss of capacity to relate to objects, with a regression into an autistic or primitive mental state (1974, p. 104). Winnicott says that where the repressed catastrophe is not addressed, the treatment is in the grip of a collusion, a belief in a neurotic enterprise, and this leads nowhere because the problem is located in a psychotic register of inner experience. Movement in the face of such resistance requires the engagement of the “main issue”, to be able to approach and “experience” the thing feared, in the transference, which is the breakdown (1974, p. 105). It is this catastrophe, waiting to be experienced, that is at the centre of the tragically resistant patient.

Trauma gives rise to a sense of total helplessness in the face of clashing emotions, triggers the fantasy of omnipotence, and entails the hope for a magical transformation of self and world. Efforts towards conflict resolution fail leading to the constant repetition of the problem. Emotions and fantasies are global and out of control and are irreconcilable with each other but the self is driven to impose some measure of control on them; frequently this “control” shows up as addictive, compulsive, and perverse sexuality and behaviours that remind the subject that he is not in control of his life.

The subject's splitting and fragmentation results in the confusing experience of a dissociated “doubleness” (Wurmser, 2007, p. 11) that enables him to protect himself against the experience of breakdown by occupying different registers of experience. Davoine and Gaudillière (2004, p. xxvii) observe that the impact of trauma as a “powerful blow that actually took place” (a real external event) has ejected the subject out of the space–time coordinates of his life into a “zone of nonexistence” where time has been immobilised; he seeks to find some means of finding his way back to the moment where his time and his experience of being as he knew it ceased to exist. The patient is being pushed by an invisible event possessing substantial emotional gravity that attempts to use conflict, difference, and disagreement to find memory or create recognition through a scene that might enable some element of the trauma to come into being. In this way transference “difficulties” can be understood as the only means available for the tragically resistant subject to inscribe his lost meanings into the fabric of the treatment.

Of course, there are many forms of trauma and each possesses the power to fracture and crush the self and hold the subject in a state of suspended animation. Wurmser's definition enables us to consider the types that can drive the subject into his psychic retreat of intractable resistance.

I do not mean “trauma” in a trivial, universalized way, but in the sense of events with life-altering severity, intensity and usually repetitiveness, like the killing of the mother by the father, repeated severe operations in early childhood, massive fighting between the parents, sexual abuse and other forms of physical mistreatment, but also some severe intersubjective harm, like chronic humiliation and systematic squashing of all individuality by “soul blindness” and “soul murder”. (2007, p. 6)

In my examination of the histories of my most resistant patients the one common element that stood out was the subject's deeply confusing and inordinately frustrating experience of being cared for by a mother “who remains alive but is, so to speak, psychically dead in the eyes of the young child in her care”, the figure that Green (1986, p. 142) termed the “dead mother”. While other, more dramatic types of trauma have occurred (accidents, surgery, family violence) it has been this less “visible” trauma that seems to have had the most impact on the regressed patient.

It is this figure of apparent “love, care and attention” trapped in a bereavement of her own having to do with the loss of a primary love figure (parent, spouse, sibling, or other child) that causes her to operate in the painfully confusing register of being both “dead and alive” that subjects her child to “severe intersubjective harm”, which I describe as traumatic. As Green describes her, this mother:

has been constituted in the child's mind, following maternal depression, brutally transforming a living object, which was a source of vitality for the child, into a distant figure, toneless, practically inanimate…Thus, the dead mother…is a mother who remains alive but who is, so to speak, psychically dead in the eyes of the young child in her care. (Green, 1986, p. 142)

Green observes (1986, p. 146) that this loss for the child is not bloody, as in castration anxiety, but bears the “colours” of mourning—black or white—and is the consequence of a “blank” anxiety which expresses a loss that has been experienced on a narcissistic level. Here we discover Freud's earlier observation in describing the melancholic patient (1917e) that his link to the object was limited and secondary, a “shadow”. Thus the loss of the mother in such a paradoxical and confusing situation evokes a series of reactions that Green describes as blank anxiety, blank mourning, negative hallucination, and blank psychosis and leads to the problem of emptiness or the emergence of the negative (1986, p. 146) as a central dynamic feature of the patient's problem. Here the patient's deadening and lifeless withdrawal points to the tragedy of why he would choose to exclude himself from the treatment process and, more poignantly, from life itself so as not to re-experience the catastrophe of his barely recognised but continually felt loss. The patient's tragic resistance understood through the lens of the “dead mother” matrix offers the therapist a greater capacity for empathy and containment and helps protect against joining him in his hopelessness and deadness.

This “dead mother” situation presents a complex and paradoxical scene that enfolds the patient in its turbulence. The mother has been “lost”, captured in the psychic–emotional circumstances of her bereavement but continues to be bodily present to her child as she attends to his outside and the job of managing his material comforts is retained. She is both present and absent, though a more emotional way to consider it, following Bion (1965, p. 107), is to describe her as an “active no-thing”. She is the “shadow” cast by the mother she might have been and continues to act on the subject as a type of ghost figure. Here we might think of her as a kind of “zombie” mother who is both dead and alive in an emotionally bizarre and terrifying form.

As McDougall (1980, p. 252) points out, psychic suffering at this early phase is “indistinguishable” from physical suffering and thus these painful and crushing experiences are often taken up in a physiological form (unrepresented beta elements, Bion, 1962) and determine many patients’ psychosomatic and addictive difficulties. As Davoine and Gaudillière (2004, p. 12) point out, where the patient experiences such a powerful experience there is often no conscious memory or representation of the actual events he received from that blank, empty, or dead mother and accordingly he cannot communicate his experience through words. In such cases the patient makes use of an “inscription”, a type of emotionally powerful, projective identification to “communicate” his experience to, or more correctly into, the being of the therapist in the hope of establishing a connection that might lead to the development of a meaning.

And as importantly, the “dead mother” projectively exudes a constant signal of distress, pain, and tragedy that binds her child to her. Though she is generally elsewhere she nonetheless desperately needs her child to contain the unbearable, split-off realities that make her experience so saturated with grief and bereavement, and thus a constant circuit of projected internal objects from the mother are used to gain ever deeper access to the privacy of the child's self. Though it may not be expressed with the drama of “soul murder” (Shengold, 1989), it is nonetheless a ruthlessly powerful form of trauma and personality invasion. Thus, from a split-off aspect of his unconscious the child is forced to become a witness to the tragedy of her life. The patient's subsequent attempt to communicate his plight involves the elements of “her plight” that leads to confusion and inarticulateness. A double-bind response emerges in him: on the one side to flee or destroy her; and on the other to become the heroic figure of rescue and salvation that seeks to repair the grave damage affecting her. This feeling, experienced as a compulsion to repair the mother, is at the centre of Klein's (1935) “depressive position” and adds an additional dimension to the problem of dealing with the lost object. The patient not only is tasked with replacing her in his psyche but now the job of repairing her to an impossible position of wellbeing complicates the patient's experience further and adds to motivation of wanting relief without having to understand his challenges.

Where the subject has been subjected to the intense and sadistic forces of his mother's or of the family's frustrated and overwhelming pathology, there is born in him the experience of being a prisoner in a “totalitarian family ambience” that Jarrell (1962, p. 146) calls “one of God's concentration camps”. This experience often leads to a deep feeling that the subject has been exposed to “the deliberate attempt to eradicate or compromise the separate identity of another person” (Shengold, 1989, p. 4), and in response there grows in him an absolute intention of retaliating against this monstrous and overwhelming figure that is supposed to be a figure of love. Thus subject and object become fused, forced together through the mad extremes of love and hate, and the subject is now “possessed” by the Other with his soul in “bondage to someone else” (Shengold, 1989, p. 2). In this way the patient's resistance seems to be a last, desperate opportunity to rework the psychotic, psychopathic moment when his subjectivity was taken from him and often such a hope is greater than his desire for freedom and liberation. In this way the patient (child) is tied to the object within ...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Acknowledgements
• About the authors
• Note to the reader
• Foreword
• Introduction
• Chapter One: Trauma, Resistance, and Sacrifice
• Chapter Two: The Scapegoat Sacrifice: Repeat or Reprieve?
• Chapter Three: Documenting Parricide: Abraham, Isaac, and Hans
• Chapter Four: Into the Arms of the God-Object: The Seductive Allure of Timelessness
• Chapter Five: Clinical Factors in the Treatment of the Traumatised, Resistant Patient
• References
• Index