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The impossible encounter – therapist’s emotions during the session
From several years I have been working with some patients that would have been defined difficult by Malcom Pines. But what does difficult patient mean?
I will describe it using the words of a 27 years old patient with a Borderline Personality Disorder. After several years of treatment this patient react with discomfort and anger when I told him about the necessity of a farmacological therapy. I was using the drug to reject him, he felt. He couldn’t accept the idea of depending from the drug, and felt like I was refusing him because his condition was too difficult.
I have had to reflect upon it for a long time to analize my counterfranfert during that session. Patient comunications sounds paradoxical. The more I took care of him, the more furious he got, rejecting my attemp of offering a good maternal reverie. The more I tried to think the patient, the more he felt expose and in danger. I addressed the question in the next session. I asked him why he got so angry, considering my attempting of protect him. The patient stared me and sad: “the greater is the good, the greater is the danger.” Then he described me the vicissitudes of his objectual relations. More the caregiver care about him, the greater the menace is. He felt that way for two different reasons. Meeting another one, a good, supportive, not abusing one, allowing him to be a separated mind and not an object of the other, puts him in front of his miserable caretaking experience. More cures he received in therapy, the biggest the rage is for beeing deprivated during his youth.
Inside his family he could only exist as a container of other’s wills and projections. Just a storage of deregulated emotions, never been mentalized by his parents.
The second reason was that the “good care” that the patient had known since than have had such a high cost. His psychich survival had dipended from parent’s almighty will. A parent that could have been benevolent or distructive whitout any advice. this mechanism dind’t allow him to create a coherent model of the other inside him, and as an extention, of himself. For the therapist the encounter whit such borderline patient seems to be an impossible encounter. The action of taking care become the biggest menace and fear for patient’s psychic existence.
The therapist finds himself invested by the projective identification coming from the patient, who would like, and at the same time mortally fears, that the other will reveal his sadistic face and mistreat him, reassuring him of the consistency and inevitability of his previous relationship experiences. According to Pines, difficult patients are “self-centered and worried about their painful existence, to the point of excluding others”. All they wanted was the attention of the other, whom could contain their toxic emotions. "They did not appear to be open to meaningful communication and realized that the other is the target for the attack or a tool of persecution." (P.103). Pines considered these patients to be predominantly "borderline". He noted that such patients had a weak ego structure and used the defense mechanism of splitting and projective identification. "According to Kohut, he claimed that these patients constantly fought to maintain a coherent sense of self and lacked resources to maintain self narcissistic balance ".
The awareness of these ambivalent elements, present in this patient’s therapy is a fundamental part of the healing process for the therapist, who must be "good enough", paraphrasing what Winnicott said about mothers, to have the ability to take care of the baby by appropriately dosing the level of frustration they inflict on him.
The therapist in the session must be able to provide the necessary holding to the patient, managing to step aside within the therapeutic space, to allow the patient to experience the illusion of creating the clinical space and also to destroy it at will, including the object - therapist with whom he is related. The sufficiently good therapist will be able to tolerate the emotional ambivalence he feels towards his patient, managing to tolerate the hatred he feels countertransference, and to make the feeling of love prevail. Only by managing to bring these opposing feelings together can the encounter with the borderline patient become possible.
Dr Valeria Colasanti
Psychologist and Psychotherapist
The impossible encounter
therapist's emotions during the session
To know more
Funzione Gamma, rivista telematica scientifica dell'Università "Sapienza" di Roma, registrata presso il Tribunale Civile di Roma (n. 426 del 28/10/2004)– www.funzionegamma.it;
Winnicott D.W. (1954). Gli aspetti metapsicologici e clinici della regressione nel-l'ambito della situazione analitica. In Dalla pediatria alla psicoanalisi, Martinelli, Firenze, 1975.
Winnicott D.W. (1962). I fini del trattamento analitico. In Sviluppo affettivo ed ambiente. Armando, Roma, 1970.
Winnicott D.W. (1962). La teoria del rapporto infante genitore. In Sviluppo affettivo ed ambiente. Armando, Roma, 1970.
Adamo ed Eva trovano il corpo di Abele, 1826 - William Blake. Tate Britain, London