Therapeutic Implications of Transference Structures in Various Personality Pathologies

Neurotic Personality Organization: The Classic Psychoanalytic Treatment Situation

Classical psychoanalytic technique dealt primarily with patients presenting normal integration of identity, that is, an integrated concept of self, surrounded, we might say, by integrated concepts of significant others. This structure, within contemporary object relations theory, corresponds with the achievement of the depressive position, the integration of the persecutory and idealized segments of early experience into integrated concepts of self and others. It also involves full development of the tripartite structure of ego, superego, and id, a tolerance of ambivalence, and a capacity for deep and mature object relations (Kernberg and Caligor 2005). Most patients with hysterical, obsessive-compulsive, or depressive-masochistic personality structures fit this condition and, in the treatment, present typical development of regressive transferences involving the infantile self relating to the various dominant infantile transference objects (Figure 1) (Caligor, Kernberg, and Clarkin 2007). Within these regressive transferences the patient usually incorporates his infantile self in a defensive or impulsive relationship with a significant infantile object projected onto the analyst. The analysis of this transference proceeds by gradually exploring and resolving the corresponding unconscious conflicts, preoedipal and oedipal, involved in their defensive and impulsive relationships. The patient’s communication is mostly through verbal communication, although nonverbal communication, somatization, and acting out may at times prevail. Countertransference rarely acquires the role of a primary, overwhelming source of information regarding transference developments, though it is always present as important information.

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Figure 1.

Neurotic Transference

To illustrate clinically: a woman in her mid-forties with an hysterical personality structure and significant masochistic features initially developed a regressive transference as part of which the analyst was experienced as a rigid, demanding, controlling figure representing the patient’s mother. The patient experienced a sense of deep resentment for being oppressed, and rebellious competitive impulses toward the analyst-mother. After a period of gradual working through, that dominant transference was replaced by the patient’s activation of the relationship with a loving but weak and unreliable father, who was unable to protect the patient and take her side in what she had experienced as unfair treatment by her mother. Still later, the transference evolved into a resentful and derogatory attitude toward the analyst, now perceived as hypocritical in his friendly “fatherly” demeanor while being emotionally unavailable. In a later stage of her analysis, and after working through enormous fears of experiencing forbidden sexual impulses toward him, the early image of a powerful and sexually provocative father emerged, with both erotic impulses in the transference and the fear of being rejected and depreciated, deeply connected with a fantasied sense of inferiority as a woman incapable of competing with powerful, dominant women (“mother”). This rather simplified and condensed history of the development of the dominant transference patterns of this analysis reveals, however, the continuity of the patient’s self-concept throughout time, the projection of her temporarily corresponding object representations onto the analyst, and the relative stability of the self-concept in terms of the patient’s maintaining a certain capacity for self-reflection throughout the treatment. This integrated self permitted her to explore, within the psychoanalytic setting, the particular unconscious conflictual relationships activated in the treatment situation.

The intensity of countertransference reaction was relatively moderate throughout the treatment. A consistently present “observing ego” on the part of the patient, and the corresponding capacity in the analyst to maintain a consistent “split” between specific countertransference responses and the ongoing availability of his self-reflecting function signaled the availability of a relatively stable therapeutic alliance.

Structural Aspects of the Transference in Borderline Personality Organization

In the psychoanalytic treatment of borderline personality organization, the typical structure of the transference implies a sharp division between the idealized and the persecutory segments of early psychic experience and corresponding internalized object relations, with activation in the transference of split idealized and persecutory relationships (Kernberg 2004a). Here the lack of an integrated concept of self and the intensity of primitive affects facilitate the rapid activation of these split object relationships, reflected in the alternation of intensely positive and negative transference reactions, not only the corresponding unconscious conflicts but, at the same time, rapid role reversals in their expression. Self- and object representations are interchanged in the transference. Alternately, at times the patient experiences himself to be a victim of the therapist’s aggression, only then to make the therapist the victim of an aggressive transference. At other times, the therapist appears as an ideal, protective object and the patient experiences himself in blissful dependency on such an object. This relationship, too, tends to alternate, with times in which the patient appears in the role of a giving mother and the therapist is placed in that of a happy, satisfied child, only to revert rapidly to the earlier persecutory relationship (Figure 2).

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Figure 2.

Borderline Transference

In this emotionally intense, rapidly shifting activation of contradictory affective states and corresponding object relations, what may initially present as an apparent chaos that may only gradually be clarified, patients do not evince a basic, integrated self that would permit them to reflect on these activated states. These split object relations may be integrated only gradually, as the patient’s understanding of his double identification with self and object and of their relationship grows, with the corresponding understanding that the projection of these split-off, chaotic internal relationships onto relationships with others in present reality is the source of the chaos, regression, and failure the patient has experienced.

Transference-focused psychotherapy (TFP; Yeomans, Clarkin, and Kernberg 2015) has developed a specific technical approach that focuses on the dominant object relation in the transference at any point of the treatment, using the affectively dominant experience of the patient to diagnose the corresponding self- and object representations. The therapist pursues the activation of these relationships in the transference throughout time, diagnoses and interprets the sharp split between the idealized and the persecutory relation to the same infantile object, and thus attempts to integrate the self and the concepts of significant others, fostering the development of normal identity. Kleinian literature has stressed the fundamental function of projective identification in the attribution of internal object representations or internal self-experiences to significant others, particularly in the transference. But the Kleinian approach usually does not stress an activation of the total object relationship, with enactment of one aspect of this dyad by the patient, while the complementary object (or self) is projected onto the analyst (Spillius and O’Shaughnessy 2012).

The following case illustrates this transference structure in the psychoanalytic psychotherapy of a woman in her early twenties with borderline personality disorder and chronic, severe suicidal tendencies, sexual promiscuity, drug abuse, and failure in her studies. A central issue in her early childhood was the severe physical abuse to which she was chronically subjected by a maternal aunt, which her absent father passively tolerated. She initially displayed intense hostile reactions when her expectations and immediate wishes were not satisfied. Verbal attacks on the therapist escalated into attacks on objects in his office that required establishing rules limiting the patient’s destructive behavior in the sessions. At other times, the patient bitterly complained about the indifference and coldness of the therapist, his sadistic pleasure, as she saw it, in frustrating her needs, complaining to third parties about mistreatment by the analyst. Sometimes she presented rapid shifts between aggressive teasing, making fun of the therapist, provocatively sitting on his desk, and desperately crying when asked to leave at the end of the session; she would say she didn’t have enough time to express something really important to her. At other times, through desperate pleas for phone contact and requests to increase the number of sessions, she showed intense wishes to depend on the therapist. She expressed fantasies that if the therapist were a kangaroo she would be his kangaroo baby, sitting in his pouch and watching, in a reassured mood, the world pass by. At one point, learning about a sudden catastrophe in the life of the therapist, the patient became extremely concerned, arriving to her session with a huge bunch of flowers, showing a role of maternal empathy and consolation to what she thought was the suffering therapist. It was only in the advanced stages of this treatment that the patient was able to tolerate the emotional awareness of both idealized and persecutory reactions to the therapist, experienced guilt over her aggressive behavior toward him, and wished to repair the damage that, in her fantasy, she might have caused him.

This may be a typical case where the intensity of acting out induces a corresponding intensity of countertransference reactions, creates the threat of countertransference acting out, and poses the general question of how to deal with this development. This patient’s intense rage and frustration when I did not satisfy her demands for time, attention, or special privileges coincided with her perception of me as a sadistic, withholding, torturing object: I became the aunt, and the patient was totally convinced that I behaved like that aunt. The patient was my helpless, suffering, enraged victim. And while I attempted to maintain the therapeutic boundaries, I could experience the pleasurable refusal to give in to her demands. To the contrary, when the patient attacked me viciously, insulting me on one occasion in a public space, on another destroying objects in my office, I felt the helpless victim of undeserved savagery: now she became the aunt, and I became the patient as the young, abused girl.

My technical approach consisted in clarifying, at the same time, who I represented in her massive projective identification, and who she was identifying with in her response to that projected object. The enacted transference/countertransference relationship was that between a sadistic aunt and an enraged, helpless, desperate child. At times she experienced herself as a sadistic aunt in the transference, enacted this identification, and I became a helpless, enraged child in my countertransference. At other times, the relationship inverted to her experiencing herself as a helpless, mistreated child, while I became the vengeful, sadistic aunt. Through my interpreting this repeated reversal in our roles, the patient became able to understand her unconscious identification with both victim and perpetrator. The activation of this same object relation with role reversals between self and object in the transference made it possible, over time, to permit the patient to tolerate her unconscious identification with both self and object, and recognize in herself what previously could only be projected. Thus, countertransference analysis and utilization in the context of the analysis of rapidly shifting transferences permits the patient eventually to understand also what is going on in the analyst during such intense interactions, without having to communicate to the patient the countertransference reaction as it occurs. This technical approach, I believe, is different from the relational approach of communicating intense countertransference developments to the patient as they evolve, and it may add to the Kleinian interpretation of projective identification in focusing sharply on the patient’s experienced reaction to the analyst perceived under the effect of intense projective identification. “While you see me as sadistically commanding you around, you experience yourself as my helpless, impotent, enslaved victim.” The central focus is on helping the patient understand the activation of the self and object relationships.

There are cases in which the severity of acting out will require limit setting to protect the structure of the treatment, thus threatening technical neutrality. Technical neutrality may temporarily be relaxed or abandoned altogether, but must then be interpretively reinstated. These developments require the therapist to carry out very intense and ongoing internal work with powerful countertransference reactions typical in response to the activation of primitive transference developments in the treatment situation. While borderline patients may not tolerate a standard psychoanalytic setting, the flexibility of transference-focused psychotherapy permits systematic use of the four basic analytic techniques, so that these patients are provided a psychoanalytic treatment within a setting different from that of standard psychoanalysis.

Structural Organization of the Transference in Narcissistic Personality Disorders

Another type of typically structured transference developments is encountered with narcissistic personality disorder. Narcissistic personalities function at a broad level of pathology, with indication for standard psychoanalysis for those who evince a relatively normal capacity for work, and/or a stable, if superficial, love relationship in the context of an ordinary social life (Kernberg 2004a, 2014). At the pathological extreme, severely regressed narcissistic personalities present with a total breakdown of their capacity to work or to maintain any intimate love relationship. They show a typical combination of absence of tenderness or emotional involvement in the context of intense sexual urges and promiscuity, with a concomitant breakdown in their social life. The most severely regressed narcissistic personalities are often diagnostically confused, at least initially, with regressed patients presenting a borderline personality disorder. Careful mental status examination usually reveals the presence of a pathological grandiose self, the essential clinical characteristic of this personality disorder.

The transference structure of narcissistic personality disorder presents a very typical development that persists stubbornly throughout months of psychoanalysis or psychoanalytic psychotherapy. It reflects the typical relation between the enactment of a pathological grandiose self and a projected condensation of the devalued, worthless aspects of the self and the devalued, worthless aspects of significant others (Figure 3). Here the transference development appears as a relation between an omnipotent, omniscient grandiose self and the devalued self-representation, usually projected onto the therapist, but with an ever threatening role reversal. The feared transference reversal then projects the grandiose self onto the therapist, while the patient enacts the devalued self-concept. The grandiose self does not relate to internalized valued object representations, but exists in a strange isolation. Its only requirement, which is essential, is the admiration of significant others, needed to reconfirm its grandiosity and ensure its survival. Admiring objects, including the therapist in the transference, may be briefly idealized in an effort to incorporate what is admirable in them and potentially envied by others, but are devalued and depreciated once they are not needed to implicitly confirm the pathological grandiose self. These developments dominate the transference for extended periods. Occasionally the patient’s objective failure in reality or in fantasy he cannot deny brings about a sudden reversal of the relationship, so that the patient projects his grandiose self onto the therapist while identifying himself with the devalued self-representation usually projected onto others. By now it is well known how these grandiose, self-centered individuals suddenly become extremely insecure and dependent on reassurance from others in their social environment, only to rapidly revert to their original position of grandiosity.

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Figure 3.

Narcissistic Transference

In the transference this pattern is enacted in a controlling and devaluing attitude toward the therapist, while attempts are made to maintain the therapist in a condition of sufficient appreciation to avoid considering the treatment totally useless. An authentic respect, interest, and appreciation for the therapist, to the contrary, would be dangerous, putting the patient immediately in a position of intolerable inferiority. At the origin of the structure of the grandiose self lies an internalization of what these patients experienced in early childhood as powerful and admired aspects of significant others, and their identification with aspects of themselves fostered in a parental environment in which admiration for a strikingly positive feature of the child replaced authentic love and concern from the parents.

These component features that have activated the pathological grandiose self will gradually emerge, and in positive therapeutic developments this will allow that self to gradually decompose into its component idealized self- and object representations. This development will in turn activate the corresponding primitive object relations in the transference, idealized and persecutory split off from each other, and transform the narcissistic structure into a generally borderline one, a fundamental step toward improvement. When, as the pathological grandiose self is dismantled, component object representations are activated that reflect identification with unethical aspects of parental images, these patients may evince antisocial features and dishonesty in the transference, which may complicate the development of normal superego functions in advanced stages of treatment. These are cases that present psychopathic transferences, which must be gradually transformed into predominantly paranoid transferences by analyzing the paranoid fears lying behind patients’ dishonesty. Paranoid transferences may then be interpretively transformed into predominantly depressive transferences, in the context of identity integration.

But even when such complicating antisocial conditions are not present, the systematic analysis and decomposition of the pathological grandiose self usually takes months of “microanalysis” of the subtle ways in which the corresponding transference developments evolve. Subtle yet intense enactments of regressive part object relations occur as the pathological grandiose self is dismantled and carry a risk that the analyst will attribute the enactments of his countertransference reactions to “here-and-now” interactional processes, neglecting the profound early object relations being replayed in the transference.

To illustrate I offer the case of a successful biological researcher, a man in his early fifties, effective, dominant, and controlling in complex business affairs but with no close friendships, a rather isolated social life, and a loveless marriage characterized by total sexual indifference. Chronic promiscuity evincing little tenderness was his dominant source of sexual pleasure. This patient treated his wife like a slave who looked after his daily needs. In recent years she had gradually rebelled against this situation, expressed growing unhappiness with the empty nature of their marriage, and finally had told her husband she was considering divorce. At that point an anxious collapse of the patient’s grandiosity brought him to treatment, initially to deal with the marital conflict, which rapidly turned out to reflect deep problems in his sexual life and social interactions. The patient was diagnosed with narcissistic personality disorder, with psychoanalysis the treatment of choice.

He quickly developed a transference with the characteristics described above. He considered the analyst a mediocre, small-thinking “technician” who was trying to apply the book, knowledge the patient, on the basis of his readings, felt he had himself possessed all along. An ongoing complaint was that he had been “conned into” a useless treatment. It took many months of treatment to open up an awareness of his defenses against intense envy of his wife’s emotional richness and the gratification he felt the analyst must take in his work. The patient, by contrast, felt himself involved in constant professional and financial competition in his work, which gave him no rest or relaxation. Gradually, a very frustrating early childhood emerged, both parents being experienced by him as insensitive and unavailable; the gradual development of a sense of successful competition and triumphant superiority over schoolmates was the only source of gratification in his childhood. Eventually, components of his grandiose self could be isolated, and explored in the transference.

The following example illustrates this development. This patient lived in the same professional environment as his analyst, a mid-size Midwestern city. He would attentively listen to any gossip that he could catch regarding his analyst, eventually constructing a story about supposedly inappropriate and ridiculous behavior by his analyst that the patient then spread among acquaintances. This story made the rounds and finally came back to him: somebody told him the same story he had spread about me, the analyst. The patient, frightened by this, decided to “confess” to me that he was the source of this gossip. Despite intense negative countertransference, the analyst was able to maintain the analytic relationship and gradually, over a period of several weeks, analyzed what had motivated this intensely invested behavior by the patient.

It turned out that it replicated the behavior of his mother, who, coming from a socially disadvantaged environment, chronically felt insecure in the socially privileged environment of her husband, the patient’s father. The patient had a clear sense of his mother as frequently gossiping about her social acquaintances in order to diminish the importance of people she envied and felt insecure with. As an aspect of his pathological grandiose self, he had incorporated this image and source of power of his mother, now expressed in the transference relation with the analyst. By the same token, here the relationship between the patient’s pathological grandiose self and the projected devalued self became transformed into the specific relation between the mother-identified patient and the projection of his neglected and rejected self-representation in the transference. In other words, this specific transference relationship heralded the dismantling of his pathological grandiose self. The patient now experienced authentic feelings of shame and guilt over his behavior, and it was a first recognition of the origin of aggression within himself, in contrast to its usual projection onto others.

I was quite shocked when I first became aware of the patient’s spreading gossip about me. My first reaction was the wish to terminate his treatment. I felt disappointed and betrayed, consulted with a senior colleague, and was able to maintain the treatment, but only with an inhibition in my interpretive interventions. I clearly became aware that the patient was identifying himself with his gossipy, envious, and depreciative mother, but it took me some time to realize that I was not simply reacting as the betrayed and abandoned son. I also developed a devaluating, vengefully superior reaction in my countertransference. Exploring with the patient his experience of me as superior and devaluating, and his shameful sense of having to depend on such an object, clarified for me why having put me down outside the sessions was a relieving reversal of the situation. Again I was able to help him understand his identification with both self and object in this conflictual, highly traumatic experience, as well as the related defensive function of his grandiosity.

Structural Organization of the Transference in Schizoid Personality Disorders

The concept of schizoid transferences lends itself to confusion because of two different uses of this concept. The classical psychiatric definition of schizoid personality disorder clearly describes the characteristic symptoms that lend themselves to a diagnostic assessment, and that indeed are fundamental for assessing typical schizoid transference dispositions that have been relatively underappreciated in the psychiatric literature. At the same time, the Kleinian concept of the paranoid-schizoid position (Klein 1946), based in part on the description of the psychodynamics of the schizoid position elaborated by Fairbairn (1954), has dominated the psychoanalytic literature and proven itself essential in the analysis of the defensive organization of the entire field of borderline personality organization, that is, the defensive dissociation or split between idealized and persecutory internalized object relations. Paranoid-schizoid dynamics are found in the entire field of patients with severe personality disorders, but are to be differentiated from the very specific transferences that characterize the schizoid personality disorder, which require a specific technical approach originally suggested by Fairbairn (1954), Guntrip (1969), and Rey (1979). These specific transference dispositions described by Fairbairn correspond more closely to the classical psychiatric concept of the schizoid and schizotypal personality disorders.

Typical descriptive characteristics of the schizoid personality disorder include social withdrawal, social isolation, a lack of intimate relationships, hypersensitivity to criticism, feeling very easily hurt by others, and a particular, heightened sensitivity to the feelings and behavior of others, in contrast to these patient’s social isolation (Akhtar 1992). At the same time, these patients seem to withdraw into a private, secretive self-affirmation, and an internal world of fantasy that they control. This self-affirmation lacks the sense of superiority and depreciation of significant others that is characteristic of the pathological grandiose self of narcissistic personalities. The schizoid patients described by Fairbairn present, as a dominant dynamic, a desperate desire for close, dependent relationships but, at the same time, an extraordinary fear of overwhelming control by the other, of being swallowed by any close relationship. In contrast to their lack of capacity for empathic and tender relationships with others, they frequently present a dissociated “explosion,” the activation of sexualized and aggressive relationships in a dissociated mode.

They miss the modulated activation of affect dispositions and present a highly specific fragmentation or dispersal of affects. Positive and negative affects seem equally unavailable, except in sudden dissociated outbursts, in contrast to a chronic, apparent unavailability of explicitly affective experiences. These patients evince, as a predominant structure, a fragmented sense of self—that is, a disturbing, confusing unawareness of their present affective self experience, which contrasts with the alternating activation of idealized and persecutory affective experiences of ordinary borderline patients. Schizoid patients’ experiences of significant others are equally fragmented. They find it difficult to divide the world into idealized and persecutory objects: because of a great sensitivity regarding individual behaviors and interactions that defy a clear differentiation between “positive” and “negative” objects, they experience others in confusing ways. In other words, they experience fragmentation of affects rather than splitting mechanisms. From the viewpoint of Fairbairn’s analysis, that includes both the descriptive, classical symptoms of the schizoid personality and their dominant dynamics, the assumption of a purely descriptive psychiatric approach that considers these patients as having no desire for intimate relationships clearly ignores their deeper psychological reality. Figure 4 presents the schizoid structural organization that manifests in the transference as an activation of these fragmented relationships, including the fragmentary self and the fragmentary experiences with others.

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Figure 4.

Schizoid Transference

Practically, these patients appear very distant, with no specific affect activation in the sessions, thus confusing the therapist as to the dominant object relationship being enacted in the transference at any particular point. The therapist may feel confused about his affective reaction to the patient, which seems to center in the feeling of nonunderstanding or confusion about the situation, matched by the patient’s indications of being similarly confused, having no clear sense of what it is all about and no clear sense of his own affective experiences. It is as if, in spite of, or due to, verbal communications with a trivial, impersonal, meaningless, or distracting quality, the affective relationship in the session remains strangely distant. The therapist’s effort to clarify what is in the patient’s mind may lead the patient to a sense of confusion, a feeling of being invaded, or, if the therapist tentatively suggests that a dominant present relationship seems to be activated, the patient may evince a frightened sense of being invaded, controlled, or brainwashed. The therapist may in turn easily feel that he has engaged in a theory-driven statement rather than doing justice to the dominant affective relationship. The solution to this situation of therapeutic uncertainty for the therapist lies in recognizing the relative failure of verbal communication regarding transference clarification, and accepting the central function, under these conditions, of the activation of countertransference reactions.

Countertransference may provide answers if the therapist can let himself be influenced by the total situation in which he is now engaged with the patient. It is an intersubjective situation that cannot be traced back to any particular experience of patient or therapist, but clearly reflects the nature of the atmosphere created by their actual interaction. This requires an openness by the therapist to the activation of whatever dominant affect state develops in him, an openness to the fantasies that may accompany such an affect state or that may seem the activators of a certain affect state, and the use of that dominant affect and the related fantasy material to reexamine the interaction with the patient, in the light of the patient’s dominant pathology and his external reality at this point. That gradual, difficult, but feasible analysis may lead to an understanding of what affective relation is presently dominant, while being dispersed and fragmented to an extent that initially made it impossible to gather.

Technically, here the same use of the four basic techniques applies, but with particular caution regarding interpretation and, even more so, transference interpretation. The therapist may venture interpretations that may be easily rejected by the schizoid patient, and the therapist must be prepared to accept such a rejection, with further exploration about what the patient thinks might be more applicable at the moment than what the therapist is saying. A willingness to retrace one’s own observation, to share with the patient that one understands the patient’s difficulty in clarifying what is going on in his mind, as a difficulty parallel to that of the therapist to clarify what is going on in the interaction, may be a helpful, reassuring assertion of uncertainty. It should not be difficult to differentiate this development from a narcissistic patient’s contemptuous rejection of interpretations by the analyst. The therapist must therefore be cautious in interpreting the thinking of the schizoid patient, and must stress his search for clarity in the patient’s thinking, as well as in the therapist’s own.

In this context, the patient’s rejecting behavior and mistrust needs to be tolerated, as well as the indications of his hypersensitive reaction to a perceived rejection by the therapist. The patient may give indications of wanting to be close, being afraid of it, withdrawing in a suspicious attitude, and even a preventive explicit rejection of the therapist as a protection against excessively desired and feared closeness. The nature of the affectively dominant object relationship defended against by the prevalent schizoid fragmentation mechanism may vary widely: patients may reveal erotic fantasies behind the apparent emptiness of the session, intense fusional longings, or aggressive, dependent, paranoid affective dispositions, with variable condensations between oedipal and preoedipal relationships. The following case illustrates a prevalent schizoid transference.

The patient presented a typical schizoid personality disorder. A woman in her early twenties, she chronically cut herself with razor blades to observe the bleeding. She had evinced serious social isolation from early childhood on, and a total social breakdown in college, where she could not relate to other students, and where her withdrawal into an intense world of fantasies prevented her from concentrating on her studies. Clinically, the extent of her social withdrawal, her cutting off relationship with family and friends, the failure at school, her rapid withdrawal from several early dating experiences that seemed to cause traumatic reactions in her, and her almost disorganized way of talking raised the question whether she suffered from a schizophrenic illness. After extended psychiatric evaluations it became clear that she presented a schizoid personality disorder, and the treatment recommended was TFP.

In the first few weeks of treatment, after the usual history was taken, our interaction evolved into a superficial, almost mechanical repetitive communication of trivial aspects of her daily living. After the first two or three months of treatment, I started to find it almost impossible to concentrate on anything in the sessions with her, or to use whatever cues seemed available to direct our interaction into some meaningful communication. My efforts to inquire into what she was feeling, what her fantasies were, led to more of the same trivial communications, and I could sense her irritation with me when she felt I was forcefully attempting to find new meanings in what she was saying. At the same time, she would come punctually to all sessions and seemed not to object to the empty content of what evolved in them. She referred vaguely to her tendency to cut herself discreetly, and to watch drops of blood emerging. There was an occasional seductive quality about some of her expressive demeanor, so tentative and transitory that it was gone by the time I felt there was some significance in it.

I had occasional fantasies that she focused on the discreet cutting of her skin to observe blood drops as a way to exhibit herself to me or perhaps enacting a fantasy of me attacking her sexually, or that I was a father figure who failed in protecting her, but all efforts to explore her world of fantasy led nowhere. It was as if whatever I said confused and disorganized her thinking, and my own thinking seemed to get confused at such moments. I pointed out to her that she experienced my efforts to understand her as invasive, and that it was as if any attempt at clarification was dangerous.

In one session I had great difficulty maintaining my attention on what she was saying. I was following my own thoughts, and suddenly remembered a film I had seen six months earlier, Investigation of a Citizen beyond Suspicion, an Italian film about a district attorney in charge of finding a sexual murderer. The D.A., who was himself the murderer, would kill women in the process of having sex with them. One image from that film came to my mind. A woman reaching orgasm was sitting on top of that district attorney, when he suddenly pulled out a knife and cut her throat, blood running over her breasts. This scene came into my mind, with a combination of excitement and disgust, followed by a kind of frightened surprise on my part that I should develop such a fantasy, and in the middle of such a session. I attempted to dismiss the memory of that experience the next few days. But then I realized that her repetitive comments about her body, and bleeding openings, and the strangely seductive moments in the sessions with this extremely inhibited patient, and my sense of “shock” over my sadistic sexual fantasy, reflected an oscillating countertransference identification with both a self- and an object representation involved in a sadomasochistic interaction. And I understood that my frequent sense of confusion also represented the effect of the patient’s defensive fragmentation of all emotional experiences. I said there were threatening sexual thoughts “in the air” that could not be talked about.

Several weeks later, when the patient mentioned there were thoughts she had difficulty talking about, she referred to a powerful fantasy about me that she had had repeatedly. She wished I would shoot her, and in killing her become a murderer. I then would remain, for the rest of my life, feeling regretful. I would never be able to forget her, and she would remain with me the rest of my life. She would not mind dying, knowing she would be my permanent companion the rest of my life! This sexual fantasy, with regressive oedipal and severely aggressive preoedipal sadomasochistic and self-destructive implications, became a central focus of our exploration in the following months. What I want to stress here is the close relationship between what was developing in the transference and the nature of my countertransference fantasy in the middle of the apparently fragmented, dispersed activation of a specific object relationship. This example may seem unusual, but in fact it is a quite frequent type of experience in countertransference developments when the therapist tolerates the fragmented relationship of a schizoid transference. The opening up of a specific relationship gradually transforms the schizoid transference into the more usual transferences of borderline personality organization, and makes the treatment much easier to carry out within the general technical approach for patients with identity diffusion. The specific defensive problem presented by this fragmentation or dispersal of affect raises an open question. Is this a purely psychological development of the intrapsychic world of these patients, or does it reflect a more basic neurobiological disposition to dispersal of particular, excessively intense negative affects?

Structural Aspects of Symbiotic Transference Developments

The term symbiotic has been used in ambiguous ways in the literature. In one use it refers to relationships in which an intense enmeshment between self and other would not tolerate another relationship to coexist with this particular enmeshed one. The boundary between self and other is maintained, but the relationship has an exclusive quality, no other relationship with a “third party” is tolerated, and exchange between self and other by means of projective identification facilitates alternative identification with self and other. The term’s other use refers to actual merger between the concept of self and other, a relationship in which there evolves a lack of differentiation between self and other, so that self experience and experience of the other are confused, with an implicit loss of ordinary ego boundaries. In the second use of the term, an authentic psychotic process is present, and the loss of reality testing underlies the development of abnormal perceptions, hallucinations, and delusions. In contrast, in symbiotic relationships in which the differentiation between self and object always is maintained—although they are enmeshed, there may be a rapid interchange of roles between self and other. I am reserving the term symbiotic transference for an intense, entangled involvement between self and other, but with clear maintenance of boundaries between self and other, even when rapid exchange of the role relationship develops. I reserve the term psychotic transference for cases with loss of differentiation between self and other, a merger of self and other that implies the loss of ego boundaries and reality testing. Figure 5 outlines a symbiotic transference, in contrast to Figure 6, which depicts a psychotic transference.

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Figure 5.

Symbiotic Transference

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Figure 6.

Psychotic Transference

In the ordinary activation of transferences typical of borderline personality organization, patients may tolerate intense differences of views with the therapist, and express their conflicts in sharply differentiated roles within a specific affect-centered relationship between self- and object representations. In symbiotic relations, patients tolerate no difference in their view of reality and that of the therapist. The therapist must agree totally with the patient. Any disagreement indicates either a violent invasion of the patient’s mind by a therapist who disagrees with him, or total abandonment by a therapist who ignores him and, by the same token, violently abandons him. Britton (2004) has described this situation as an intolerance of triangulation. We also see this development in some severely regressed borderline patients. The patient has no tolerance of the therapist’s involvement with anyone else, with any other person or entity, or other ways of thinking, from which the patient would be excluded. This may reflect an archaic defense against an early oedipal situation, in which mother must be totally identified with the baby, and the existence of mother’s relationship with father must be completely denied; or it may express intense envious resentment of the life, knowledge, and general existence of the therapist outside the realm of the patient’s mind. In any case, only a primitive coincidence of thinking, or total and exclusive availability of the therapist to the patient in his mind, is tolerable. This is an ideal situation, against which any “betrayal” by the therapist’s otherness triggers intolerable rage and resentment in the patient, who fears destructive invasion or total abandonment by this betrayal.

The clinical conditions under which such a development occurs are difficult to foresee, though usually this complication presents in patients with an extreme incapacity to adjust to ordinary social interactions, who evince an intense aggression rationalized by projective identification and omnipotent control that severely distorts their intimate relationships. Once such a symbiotic transference becomes dominant, it can be recognized by its threatening character, the extended duration of a patient’s incapacity to tolerate contrary ideas in the therapist, desperate efforts by the patient to maintain control of reality under such conditions, and his apparently total incapacity to recognize ordinary logic. At this point the treatment must focus almost exclusively on this very development, the patients’ incapacity to tolerate any difference of views, and the reasons why such difference would cause panic in the patient.

The following example illustrates a symbiotic transference in a patient with the diagnosis of severe narcissistic personality disorder with overt borderline functioning, that is, almost total breakdown in the capacity for work, intimate relations, and an ordinary social life. She was a woman in her early forties, treated in psychoanalytic psychotherapy by a skilled psychoanalyst. At one point one of her brothers died, which she experienced as a terrible blow. At the cemetery, while her brother was being buried, the patient broke out in intense crying and dramatic manifestations of intolerable psychic pain, approaching the grave and looking as if she would throw herself in after the coffin. Naturally, she created quite a commotion. People were holding her back, as she became enraged and angrily accused her family of being insensitive to her grief. She had to be escorted from the cemetery by family members.

In the psychotherapeutic session following this event, the patient was still enraged, complaining about the insensitivity and brutality of her family at the cemetery. The therapist first expressed his interest and understanding of the patient’s emotional reaction. He clarified her sense of rage over her family’s lack of understanding and real feelings. Then, when he asked how she understood the reactions to her at the cemetery, she declared their behavior to have been completely inappropriate and incomprehensible. The therapist tactfully tried to confront her with the fact that it seemed, from everything he was aware of, that her behavior had been rather inappropriate, disturbing the ceremony that was taking place. To this she reacted with even more rage, accusing the therapist of being in cahoots with her family, being totally insensitive, and having no understanding of her, In short, he was a total disappointment. She wondered whether she could stay in treatment with him under these conditions. The therapist, realizing she was unable to reflect on this experience, limited his intervention to expressing his understanding of her suffering, with no further effort to clarify the situation at the cemetery. It took a number of weeks, and many sessions, for the patient to consider the possibility that the therapist might have a different view of the situation at the cemetery, even if she disagreed with him. It took even longer for her to recognize or even consider that the therapist’s view might actually be valid. Just her acceptance of the fact that the therapist might think differently, without that signifying a total attack or rejection of the patient, became a major issue to be explored in the treatment. In more general terms, this case illustrates not only intolerance of triangulation—the therapist’s holding to another view—but the patient’s profound underlying incapacity to consider that she might be taken seriously, respected in her own views, and appreciated by an early maternal object.

The Structure in Psychotic Transferences

Psychotic transference dispositions are characterized by a lack of differentiation between self- and object representations or a lack of differentiation between self and other that is reflected in the loss of reality testing. This situation has been explored in the psychoanalytic literature, and described in the experience of intensive psychoanalytic psychotherapy with psychotic patients in the United States and the United Kingdom before the development of psychopharmacological medication, particularly in institutions dedicated to intense psychotherapeutic approaches to psychosis. Harold Searles (1965) described intensive psychotherapy with schizophrenic patients as undergoing typical stages: first, a stage of lack of contact or absence of a specific transference relationship; second, a stage of intense symbiotic development, evincing the lack of differentiation between self and other as the typical dynamic of intense psychotic transferences; third, a phase of differentiation, in which the patient gradually learns to differentiate himself from the therapist, with recovery of reality testing regarding his behavior and his contribution to the transference relationship. A fourth phase follows in which the patient becomes able to integrate the mutually dissociated aspects of his earlier transference experiences, and experiences a parallel integration of his sense of self and of the nature of the relationship with his therapist. This integration may then be generalized to other relationships of the patient. Herbert Rosenfeld (1954) applied a Kleinian perspective to the analysis of the confusional states and primitive (psychotic) mechanisms dominating clinical encounters with schizophrenic patients.

Due to pharmacological advances, intensive psychotherapy of psychosis has receded as an important treatment modality, but it may still be indicated for a subgroup of patients identified by Michael Stone (1983, 1986). These are schizophrenic patients who do not respond to psychopharmacological treatment with restoration of reality testing, have a high intellectual level, maintain a certain integration of the personality and significant differentiation of affect states, do not present antisocial features, and provide the possibility of intensive long-term treatment under the provision of a sufficiently structured environment to absorb unavoidable periods of acting out.

I once had the opportunity of treating an eighteen-year-old girl who suffered from paranoid schizophrenia, at a time when intensive psychotherapeutic treatment seemed an important aspect of the treatment of such conditions, when psychopharmacological treatment was still in its early experimental stages and had not yet become the treatment of choice. I saw the patient under supervision in a highly regarded hospital specializing in this kind of treatment. In the first few months of the treatment I had to see her in a padded cell under constant nursing observation. This patient would tear up all her clothing and could only with great difficulty be made to wear anything on her body. She was sitting naked in the cell, masturbating much of the time, and smelling the fingers she had used in masturbating. When I entered the cell to see her, she ignored me completely, and continued masturbating.

I need to stress that, in spite of her physical attractiveness, and this open sexual behavior, there was a total lack of erotic quality in her demeanor and in the atmosphere of that room. It is difficult to describe, but there was a totally impersonal quality about the contact she established with me, as if I were some strange object rather than a human being. I was myself totally surprised by the lack of any erotic quality of her behavior, or of the atmosphere she created in that cell. Her delusions were that the devil was forcing her to have sex, and invading the world to force everybody to have sex with him. She was attempting to assure herself that the devil had not destroyed her genitals, while believing that her parents were being held prisoners by the devil, who had divided humanity into those who were in prison, and those who would be sexually abused. It was a quite chaotic system of delusions, mixed with other fantasies and delusions involving nurses and teachers. I was trying to find the sense of all this delusional material, trying to formulate it to myself as clearly as I could, conveying an attitude of interest and effort to understand what was going on in her mind, and attempting to help her clarify whatever was confusing her. It was painful and laborious work, in the course of which I found her becoming more and more attentive to me, but giving no indication that what I was saying influenced her in any way.

Only gradually did I realize that she was evaluating whether I was in any way a secret representative or emissary of the devil, and hiding that from her. Eventually we could talk about her suspecting me of not being honest and straightforward, and that this seemed frightening to her. Then one day I entered her cell, and there was a clearly erotic atmosphere in the air. I couldn’t decide what brought this about, but the patient clearly showed a seductive attitude toward me, and looked at me provocatively while still masturbating. She told me with a sardonic smile, “I am the devil and you are the devil,” treating both of us as if we were the devil enjoying seducing her sexually. It was an intense and disturbing experience because she now really appeared sexually attractive to me, while at the same time I was afraid she would assault me. I was reassured by the fact that the windows of the room were constantly monitored by the nursing service.

My effort in the following sessions was to point out to the patient that the danger of being sexually assaulted by the devil had now taken the form of misdiagnosing “us” as the devil, rather than her simply being the victim, and I an emissary of the devil. In other words, my effort went into attempting to differentiate two people out of what at that moment was a clear condensation of her experience of herself and of me: we both were the devil and the frightened girl. I believe this vignette illustrates the shift from an early phase of a psychotic transference (“symbiotic” in Searles’s terminology) and my early efforts to help the patient move into the phase of differentiation between self- and object representation.

The Dead Mother Syndrome: Dismantling Transferences

A final type of specific transference disposition may be characterized as the dismantling of all internalized object relations, and the corresponding implication of a radical emotional unavailability in the treatment: namely, the “dead mother syndrome” described by André Green (1993; Kohon 1999). Here the tragedy is the patient’s lack of capacity for any investment in a significant relationship because of the unconscious protective dismantling of all internalized relationships. These patients usually present a very early traumatic background of an absent mother, often due to severe chronic depression in the mother during infancy or early childhood. In these cases the unconscious wish to become reunited with their mother in death is reflected in a sense that only the absence of all actual relationships will facilitate such a condition. These patients develop a dangerous lack of emotional investments despite otherwise normal intelligence, capacity to differentiate self from non-self, capacity for superficial yet adequate social and work relations, and surprisingly normal superego functions, so that the lack of emotional involvement becomes evident only in intimate contexts. Their extraordinary capacity to maintain an apparently friendly but insurmountable distance in the therapeutic relationship poses a major challenge over many months, even years, of treatment. These are, fortunately, very rare cases, with reserved prognosis, and are mentioned here only to contrast them with transference patterns determined by internalized object relations, patterns that require specific employment of the four basic psychoanalytic techniques. I will not explore these cases further here. The specific technical requirements and challenges of the “dead mother” syndrome have been explored elsewhere.