Moments of Uncertainty in Therapeutic Practice

Interpreting Within the Matrix of Projective Identification, Countertransference, and Enactment

Robert Waska

• Publisher: Columbia University Press
• Year: 2011
• eBook ISBN: 9780231525237
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

One of therapy's greatest challenges is the moment of transference, when a patient unconsciously transfers emotion or desire to a new and present object—in some cases the therapist. During the course of treatment, a patient's projections and the analyst's struggle to divert them can stress, distort, or contaminate the therapeutic relationship. It may lead to various forms of enactment, in which the therapist unconsciously colludes with the client in interpretation and treatment, or it can lead to projective identification, in which the client imposes negative feelings and behaviors onto the therapist, further interfering with analysis and intervention.

Drawing on decades of clinical case experience, Robert Waska leads practitioners through the steps of phantasy and transference mechanisms and their ability to increase, oppose, embrace, or neutralize analytic contact. Operating from a psychoanalytic perspective, he explains how to cope professionally with moments of transference and maintain an objective interpretive stance within the ongoing matrix of projective identification, countertransference, and enactment. Each chapter discusses a wide spectrum of cases and clinical situations, describing in detail the processes that invite a playing out of the patient's phantasies and the work required to reestablish balance. Refreshingly candid, Waska recognizes the imperfections of analysis yet reaffirms its potential for greater psychological integration and stability for the patient. He acknowledges the limits and frequent roadblocks of working with difficult patients, such as those who suffer from psychic retreat, paranoid phantasies, and depressive anxieties, yet he indicates an effective path for resetting the clinical moment and redirecting the course for treatment.

SECTION 1

Interpretive Acting Out

1

CONTAINING, TRANSLATING, AND INTERPRETIVE ACTING OUT

The Quest for Therapeutic Balance

WHEN DEALING WITH the task of correctly interpreting the patient’s anxiety and core phantasy at the point of greatest urgency, the analyst is often on slippery ground. Despite our best efforts, when interpreting, we are often both colluding with certain defensive or projective mechanisms and helping the patient toward internal growth, integration, and change. Rather than it being a dichotomy—either making correct, timely, and purely therapeutic interpretations or falling into pathological enactments and countertransference boundary violations—the actual clinical reality of interpretive work is more messy and layered.

This chapter uses extensive material from several psychoanalytic cases to illustrate the often flawed nature of our interpretive efforts. When we attempt to filter, contain, translate, and interpret a patient’s phantasies and feelings, we will always leave something out or overemphasize one aspect over another. Any given interpretation is hopefully more right than wrong, more on target than not, embracing most of the patient’s phantasy conflict that is active at that given moment. However, it is inevitable that we miss certain aspects, act out others, and prioritize one over another. This clinical climate is made all the more uncertain when the dynamics of projective identification are used in intensive ways by the patient to ward off, hide, or play out certain phantasies that in turn create overwhelming anxieties for the patient and sometimes for the analyst. Under the constant influence of splitting and projective defenses, the analyst is prone to fall into certain moments of interpretive imbalance or deviation. Acting out can make its presence known in the types of interpretations made or the general pattern or approach that emerges when interpreting (Steiner 2006).

Clinically, we are constantly deciding what side of the coin to move toward at a given moment, what aspect of the patient’s conflict or projection to grapple with, and what chapter of their transference struggle to untangle. The patient’s most immediate state of anxiety certainly provides a useful map, just as our countertransference does. But, in many clinical situations, the moment of urgency is not singular. We may think it is, but other equal or more urgent aspects of the patient’s struggle may be hidden, expelled, or isolated through projective-identification mechanisms. Even though it may seem that we are focused accurately on what is really causing the patient distress in the moment, we will always be slightly ahead, behind, or out of touch with other aspects of his or her current internal battle. Moment-to-moment clinical psychoanalysis is always a game of catch-up, revisiting, reassessing, and regrouping. Our job is to be the emotional translator, but, like when dealing with a complex foreign text, there is never just one interpretation, never just one translation that encompasses all of the threads of the inner drama unfolding before us.

Sandler (1976, 46) mirrored many contemporary Kleinians in his ideas about projection, countertransference, and acting out. He took up the value of understanding the nature of the patient’s unconscious intent when he or she tries to shape us into various objects from his or her phantasy world. He notes,

In the transference, in many subtle ways, the patient attempts to prod the analyst into behaving in a particular way and unconsciously scans and adapts to his perception of the analyst’s reaction. The analyst may be able to “hold” his response to this “prodding” in his consciousness as a reaction of his own which he perceives, and I would make the link between certain countertransference responses and transference via the behavioral (verbal and non-verbal) interaction between the patient and the analyst. Paula Heimann went as far as to point out that the analyst’s response to the patient can be used as a basis for understanding the patient’s material, often by something which he catches and holds in himself. I should like to try to take this a little further.

This chapter uses extensive case material to show how the patient can coerce the analyst to act out, via interpretation, various roles in the patient’s unconscious phantasy life. This interpretive acting out may be subtle and passive or more aggressive and active. If not monitored, contained, and understood, it can be destructive to the therapeutic situation. However, if properly handled, it can shed important light on otherwise hidden aspects of the patient’s internal struggles and conflicts that, up to that moment, could only arise through a projective-identification process. While these moments of interpretive acting out can coincide with uncorrupted interpretive work, the overall analytic contact (Waska 2007) can suffer. While such acting out is probably unavoidable, the quicker the analyst can notice, contain, and understand such deviations, the better the chance that analytic contact can be reestablished and maintained.

CASE MATERIAL

Sarah and her two sisters were raised by very strict and critical parents. Sarah’s father was particularly demanding: he constantly told Sarah what she should be doing with her life and noted how she was failing him. She loved her father and felt they had some degree of resolution in their relationship before he died five years ago, but she still views her parents as “never really understanding her and quick to find fault. It was hard for them to ever imagine what I might be going through, whether it is positive or negative.”

During her career as a hospital manager, Sarah was frequently told she was too slow and disorganized. Part of this was the result of her emotional struggle with authority, in particular with men, and her feeling the need to take on everything so she could please the authority she also resented. But taking everything on meant that she was always overwhelmed, and she did a sloppy job as a result, displeasing her supervisors. At the same time, she always felt very fatigued. During a routine physical examination, her doctor discovered she had a disease that would only get worse over time. She went on disability about the same time she began her psychoanalysis.

Now in her fourth year of analytic treatment, Sarah is doing much better in many ways. She is not as severely depressed or anxious, and she has reduced her self-sabotaging patterns. Her difficulty relating to men remains. She has not had a boyfriend or had sex for almost ten years.

One theme within Sarah’s transference was prominent from the beginning and remains a central thread. Sarah sees me as an intimidating male authority from whom she wants to receive fatherly guidance, but she imagines that this will always be given alongside of judgment, sternness, and anger. She relates to me in a way that pulls me into that role. I will make various interpretations that are fairly on the mark, regarding a wide variety of topics. Soon thereafter, she will start to tell me about something she did that makes her seem naïve, lazy, or forgetful. I will ask for details. Sarah will offer clarification that reinforces this impression of her as clueless, stupid, or immature. At that point, I will sometimes end up making a comment about how it seems obvious that she should have done it this way or that way instead of how she did it.

Sarah will respond by telling me that she didn’t think of it or that she forgot. This makes me feel hopeless about her intelligence and frustrated about her motivations. Indeed, sometimes she tells me she “just didn’t feel like it” or “I don’t care if it was my fault. I guess I’m just lazy.” Depending on how she says it, I might feel empathetic, want to hear more about it, and help her find the solution to whatever the problem was. Or I might feel like she is being a lazy little brat and want to lecture her on the correct way of proceeding. I am caught up in either being an attentive, gentle, guiding father or an irritated, lecturing one.

When we both began to understand better this complicated climate of acting out by discussing our mutual ways of relating in that moment, certain things came to light. It often turns out that she in fact knew exactly what to do in the situation she was describing or that she had already taken care of whatever it was—but had failed to include that detail in her story. We can then see how she successfully provoked or invited me to be like a nice teacher who is ready to help but is also easily turned into a scolding, impatient teacher. We have explored how this pattern is a repetition of her childhood experience and memory of her father, combined with her wish for a different experience or memory. In analyzing this, we have come to see that it is now she who can be judgmental, impatient, and disappointed with either herself or others and that in the transference she puts me in that role as well. At the same time, she wants to be with a new, more loving man, but she feels that she must be a helpless, naïve little girl to do so, which then shifts the object back to being a critical and scolding father, leaving her feeling like a disappointing daughter.

Over time, by consistently examining and monitoring my countertransference and my occasional lapses into interpretive acting out, I have been better able to reduce my enactments. And, as we work to learn, understand, and change her father↔child phantasies, there is much less provocative and teasing transference from her to draw me in. In fact, she now exhibits much more maturity, confidence, and pride. Her stories about her week are much more likely to be about her successes and how she figured out how to solve various problems. This demonstrates her ability to see herself as a more independent and vibrant woman relating to me as more of a proud, understanding father who respects his daughter’s autonomy and personal choice. When I bring this up, I also have interpreted that she seems not yet ready to see us as equal adults, because in so doing she would have to give up some of the nice father/happy daughter gratification she has with me now. She responded by saying, “I am getting there, but even if I can see myself as stronger and more able, the fact is that I still need your help. Sometimes, that feels like a good thing, and I like depending on you. Other times, I resent it and feel bad, because it reminds me of how much I am still struggling with my life.” We are having more of these genuine, important exchanges, and there is less acting out on both sides of the equation.

CASE MATERIAL

Nancy came to see me for her first visit looking rushed and anxious. She had never been in any type of therapy before, but she told me she had been thinking about seeking help for many years and “now it was time.” She was feeling more and more depressed and “found herself sleeping a lot and crying a lot.” She said her drinking was “out of control” and that she had known that for a long time but now was “taking a hard look at it.” I asked for details. Nancy had been drinking four to eight drinks almost every day for “the past ten years, or maybe more.” She described blackouts and a high tolerance. She was “really ready to try and get the drinking under control” and wanted help so she could “finally lick that problem.” She said, in a desperate and demanding tone, “I’m willing to do anything to get your help. I’m ready to change. Just tell me what to do!”

Nancy was an attractive woman, so besides the demand for immediate and instant change, which I took as a transference stance and a diagnostic clue, I felt that she was setting up an erotic transference in which she was “willing to do anything” and in which I could “just tell her what to do.” My reply was an analysis of the transference and an attempt to gather more diagnostic information. I said, “The way you said that shows you are really motivated to make some important changes in your life. The way you say it also seems to be a way of giving yourself over to me, putting me in charge. Is that familiar in any way?” Nancy responded by associating to deeper material, replying, “Wow. That’s exactly how I would describe most of my relationships with guys. I throw myself on them and let them call the shots. I see them as kings who are the perfect fit with me, and I’m sure we’ll live happily ever after. And this is after meeting them for five minutes at a party. It usually doesn’t work out too well, but I keep trying and run after them until they sort of dump me, and then I’m depressed for a long time.” I suspected that I might end up being another “king” and that our “perfect fit” might end in some type of tragedy.

The striking aspect of her drinking problem was that “without it I don’t think I will be a part of my friends. Without drinking, who am I, and why would they care?” I took this as also being a transference remark and said, “You probably worry that if you stop drinking, we will not have that to focus on anymore, and then maybe more difficult matters will surface.” Here, I think I could have fallen into making interpretations and asking questions about her drinking. On the one hand, this might seem appropriate, given the severity of her problem. On the other, I think I would have been colluding with her, interpretively, by helping her avoid issues of greater difficulty. I chose to adopt a wait-and-see attitude.

I was glad I did, because Nancy then looked anxious and became silent. She gathered herself and said, “There are other things I need to talk about. I know they have affected me, and I have known for years I should do something to understand it, but I have put it off.” After more silence, she said, “I was raised by two very nice parents. They were good to me and my older brother. They did their best, and I don’t really have any bad childhood memories of them. But when I was nine years old, my brother told me it would be fun to ‘fool around.’ We started to have sex whenever we could. I would sneak into his room after my parents went to bed. Or if we were visiting someone and had to share a bed, we would have sex. It wasn’t every night or even every week, but it was pretty consistent from when I was about nine ’til I was twelve. He is four years older. After about a year or so, I didn’t want to do it anymore. But I never said anything. So I would just lie there pretending I was asleep. He would go ahead and do it anyway.” I said, “It sounds like you were uncomfortable asking him to stop. So you hoped he would notice your being passive and acting asleep and understand that you didn’t want to anymore.” She agreed. “I think that has impacted my life in ways I don’t know. It probably affects my relationships with men. I think it’s time to find out about it.”

Finally, Nancy repeated, with the same frantic wish for immediate results and gratification, some of what she had said earlier about wanting to stop drinking and start “a new life.” She also repeated her fear about what life could be like without drinking and “how empty and alone she would feel if no one wanted to be with her anymore.”

From a psychoanalytic perspective, Nancy displayed a transference that combined borderline pathology with an erotic, manic way of relating. I saw her as having to rely on drinking to prevent an inner collapse, abandonment anxiety, and primitive loss (Waska 2002). She had high hopes for the object, but these hopes rapidly caved into disappointment, which she internalized as rejection. The history of sexual relations with her brother seemed to have a great effect on her psychological well- being and shaped her current view of self and object, leading to a passive yearning and a helpless fear. It was still unclear what other early events or experiences in her life might also have left their mark. I noticed a pull to pigeonhole everything into her sexual-trauma theory, so I instead tried to maintain my analytic balance and kept that countertransference pull as a piece of data to refer to later if needed.

Toward the end of the session, I told her that I thought she didn’t see herself as having much value or identity unless it was defined by me or others. I said that if she gave herself over to me and did whatever I wanted her to, she might end up different, but it would be a change I had chosen instead of one she had. I added that we would have to see if being herself with me presented a danger. If so, we would need to learn about that.

Several themes unfolded over the next few months. At about the six-month mark of her psychoanalytic treatment, on the couch, Nancy was doing much better. However, her progress has been part of a manic goal of pleasing me and “doing whatever I should or that you tell me so I can finally get my life together.” Even though she had reduced her drinking, stopped sleeping around with men to “capture their love and attention,” and begun to see her pattern of idealizing and devaluing, which went back to early childhood, she was now engaging in a particular type of transference with me. This was a seductive, manipulative method of relating in which, to keep me attentive and interested, she provided me with what she thought I wanted.

Nancy thought I wanted her to work hard and fast to achieve insight and change. She was actually doing quite well in her treatment and was achieving genuine progress and insight. But the work she was doing in treatment was also part of this attempt to guarantee my approval. By making interpretations about her internal struggles, I was both helping her to change and grow and enabling her and colluding with her in this pseudotransformation and instant victory.

With Nancy, there is a delicate balance between interpreting her material and enacting her projective-identification process. One way this emerged in the treatment was in how I noticed obvious parallels in her material to her sexual experience with her brother. I saw these parallels in the transference and in her stories about her work and friends. I began making these types of interpretations but quickly noticed that I kept bringing them up in a way that felt perverse, voyeuristic, provocative, and rapid. These countertransference alarms made me realize that Nancy was subtly drawing me into making rather fast links to her brother in a slightly erotic, invasive, or authoritarian manner. This became a perverse acting out within the transference/countertransference. Therefore, I tried to refrain from this interpretive acting out and instead attempted a contain-and-interpret approach (Rosenfeld 1987; LaFarge 2000), in which I waited to gather and understand the various countertransference reactions I experienced before formulating an interpretation that put together the different aspects of her object- relational conflict.

In one particular session, I said, “I think you are trying to pull us along very quickly, so we don’t have to linger on anything too painful. It would be nice to come up with a one-two-three formula to solve everything, linking everything to your brother. But I think that would be a reaction to something else we don’t understand yet.” Nancy replied, “I tend to jump around and want things to happen right away. I want it simple and fast.” I said, “It sounds like that can lead to results you actually don’t want.” She said, “Well, that’s a big part of how I screw it up with boyfriends. I always speed it up and try to create a perfect instant relationship with them. I get so excited and happy in the beginning. Then, I think things are going great, but the guy doesn’t like me or doesn’t call or something. Then I feel completely rejected and depressed.”

Sometime...

Table of contents

• Cover
• Copyright
• Title Page
• Contents
• Preface
• Acknowledgments
• Introduction
• Section 1. Interpretive Acting Out
• Section 2. Difficult and Jagged: Imperfect Clinical Situations
• Section 3. The Emotional Foxhole
• Discussion
• Bibliography
• Index