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Three Phases of Treatment with Borderline

and Psychotic PatientsRobert T. Waska

Published online: 06 Nov 2010.

To cite this article:Robert T. Waska (2002) Three Phases of Treatment with Borderline and Psychotic Patients,

International Forum of Psychoanalysis, 11:4, 286-295, DOI: 10.1080/080370602321124777

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Three Phases of Treatment with Borderline and Psychotic Patients

Robert T. Waska, San Anselmo, CA, USA

Waska RT. Three Phases of Treatment with Borderline and Psychotic Patients. Int Forum Psychoanal

2002;11:286295. Stockholm. ISSN 0803-706X.Three distinct, yet overlapping, phases of treatment emerge when working with some borderlineand psychotic patients. This are patients who test the ordinary limits of psychoanalysis, but canprot from its deep exploration. The rst phase is colored by acting out, interpersonally andintrapsychically. An analytic envelope of containment is necessary to sustain the treatment.Interpretive holding and containing help the patient nd a psychic receptacle capable ofdetoxifying violent projections. Many of these patients terminate prematurely. The second phase iscentered around the patients defensive use of the death instinct to extinguish or destroy certainparts of their mental functioning. This difcult standoff between parts of the patients mindbecomes replicated in the transference. The third phase reveals the more fundamental problem ofparanoidschizoid anxieties of loss and primitive experiences of guilt. These include fears ofpersecution and annihilation. Some patients abort treatment in the rst or second phase and neverwork through the phantasies and feelings of loss. Nevertheless, much intrapsychic and inter-

personal progress is possible. Given the instability and chaotic nature of these patients objectrelations, the analyst must be cautiously optimistic in their work and realize the potential to helpthe patient even when presented with less than optimal working conditions.

Key words: borderline, psychosis, acting out, death instinct, loss, guilt, working through

Robert T. Waska, Ph.D., P.O. Box 2769, San Anselmo, Ca 94979, USA

Introduction

I have noticed a pattern in the psychoanalytictreatment of certain paranoid-schizoid patients (1)and certain depressive patients (2, 3). These

patients have a fragile hold on reality and theiregos easily regressive into persecutory experiencesof primitive guilt (4). As a result, these difcultpatients frequently stop treatment early on. How-ever, some are able to remain and form rockyrelationships that can last years.

I have found three overlapping stages in theworking through of such cases. These borderlineand psychotic patients are in such intense states ofanxiety and paranoia that the rst stage oftreatment is primarily a period of limit-setting,

soothing, reassurance, and containment. I sustainand contain these patients through a combinationof interpersonal and interpretive interventions. Ind that ongoing attention to the here-and-nowtransference is critical and constant interpretationof anxieties, defenses, and extra-transferencephantasies is essential for reducing the patientsnear panic condition. Overwhelming feelings andthoughts reappear throughout the analysis, but aredened enough to conceptualize it as the rst stagein a particular type of analytic treatment.

Analysts are treating more patients who exhibitthese disorganized and frightening ways of think-ing and feelings. Ponsi states,

Proper psychoanalytic treatments are few and decreas-

ing in number, while treatments which for one reason oranother dont t with psychoanalytic criteria are themajority and, moreover, they are increasing in number.(5 p. 1)

Jean-Michel Quinodoz (6) adds,

My clinical experience as a psychoanalyst confronts memore and more with patients who display a mixture ofneurotic and primitive organizations in various propor-tions, according to each individual. During the initialinterviews it very often seems to me difcult to evaluate

the balance between the neurotic and the morepsychotic parts of the patients psychic reality. AsFreud himself has pointed out in 1938, psychoticfeatures are not restricted to the realm of psychosesproper but can also be detected within the neuroticand in the normal personality. (An acknowledgmentwhich even today seems to be too disturbing to bewidely accepted.) The presence of what we call nowa-days psychotic defense mechanisms like denial,splitting, and pathological projective identication doesnot necessarily mean that the patient is a psychotic inthe psychiatric sense... I have learned that both theselevels (the neurotic and psychotic) of the patients

2002 Taylor & Francis. ISSN 0803-706X

Int Forum Psychoanal 11:(286295), 2002


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organization can be worked through on the couch. (6 pp.12)

Many of these patients act out tremendously duringthe rst phase of treatment. In fact, many of themabort the analysis all together. However, somework with the analyst to reduce their discomfortenough to continue. As Quinodoz stated, these

cases, while involving difcult transferences andpsychotic or primitive defenses, can be approachedwith the psychoanalytic method.

While my technique during the rst phase ismore of a combination of support, education, andanalysis of transference and phantasy, the directionremains analytic. I follow the direction of Fenichelwhen he remarked,

Everything is permissible, if only one knows why. Notexternal measures, but the management of resistance

and transference is the criteria for estimating whetherthe procedure is analysis or not. (7 p. 24)

We strive toward many ideals for sound theoreticalreasons, but never obtain them in the actual clinicalwork. Adhering to the treatment frame is anideal, but rarely a reality. At times, to adhere to theframe, whatever that might mean, is to lose thepatient. With one entitled, anxious, borderlinewoman, bringing up the idea that she should payfor missed hours led her to scream at me and runout the door. When I spoke with her on the phone,she demanded that I stop trying to control her life. Iagreed to not charge her for missed meetings andwe continued the treatment. While she nowcontrolled me by not paying for missed sessionsand she did not allow us to ever discuss it, we werestill able to meet twice a week. After ve years, shetold me that she could see my point and wouldgive me twenty-four hour notice if she were tomiss. More important, we began to talk about howshe organized her life around phantasies of being

controlled and of controlling others. Now intreatment for seven years, she talks openly abouther struggles with letting me and others get closerto her and her fears of what that might mean.Again, I think of these types of parameters or non-traditional analytic work as all part of a warmingup phase that may or may not lead to a fullpsychoanalytic experience. It is the building up ofintrapsychic momentum in an otherwise closedmental system.

As reection and curiosity replace fear and

acting out, the second phase of treatment emerges.

Here, the patients reveal strong intrapsychicstruggles with the death instinct (DI). Due toexcessive envy and oral aggression (fueled bypathological projective identication, splitting,and idealization), often combined with environ-mental trauma, the patients ego is at war withitself. Through projective identication, the DI

compels one aspect of the mind to do away withother aspects of the mind. This defensive functionof the DI also becomes externalized via sadism andacting out in the transference.

This second treatment stage of the DI, is denedby dynamics quite different from the rst stage ofcontainment, yet equally challenging. Patient andanalyst often enter a standoff as they externallyplay out the patients internal battles. The analyst isburdened with countertransference feelings ofhopelessness, rage, and disinterest.

If patient and analyst can endure this secondphase without becoming hopelessly stuck inmutual acting out or without the patient prema-turely terminating as a way to gag certain parts oftheir ego, than a third phase of treatment unfolds.

The rst phase of acting out and intense anxietyis the result of and the defense against the workingsof the DI. Repetitious working through of the DIreveals its defensive function.

The third phase is a gradual working through ofthe more bedrock phantasies and feelings ofprimitive guilt, paranoidschizoid loss, and per-secution. The eventual goal is ego integration andthe achievement of the depressive position. How-ever, the patient must rst deal with overwhelmingphantasies of loss, which generate the experienceof annihilation. With this type of paranoidschi-zoid loss, the good, idealized object is replacedwith a bad, persecutory object wanting revenge.The ego is left without safety or control.

Not all patients are able to stay in the treatment

long enough to work through all three phases.However, I have seen enough borderline andpsychotic patients display these phases to thinkthat these patients intrapsychic struggles and theway their treatment unfolds all constitutes aparticular working through pattern. This includesincluding those fragile depressive patients whorely on pathological organizations (8) to copeinternally. My impression is that some of thesedifcult patients see many therapists over the yearsand may work out one phase with one analyst and

another phase with another analyst. However, it

Int Forum Psychoanal 11, 2002 Three phases of treatment with borderlin e and psychotic patients 287


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seems there is a clear pattern of structuralpathology and unconscious phantasy that unfoldsin this three-prong manner.

Case Material

After several years of analysis, P had improved a

great deal. She attended three times a week andused the analytic couch. Diagnostically, P enteredtreatment functioning at a primitive borderlinelevel. Her gradual internal growth and objectrelational shifts gave her a different internal andexternal life experience. P had stopped a lifelongpattern of binges and vomiting that had landed herin the hospital several times. She no longer bangedher head against the wall or yelled at herself whenfrustrated. P did not get drunk anymore and she hadnot burned herself with a cigarette for a long time.

She held a better job and now she got along withher roommates. This progress was the result of astormy but successful period of containment. Iserved as a container for Ps projective identica-tions and as the recipient of her split off feelingsand phantasies.

The way I analytically related to P was shapedby my assessment of her anxiety level, the natureof her phantasies, and her chronic feelings of rageand need.

Paula Heimann (9) pointed out this pairing of

technique with the patients intrapsychic structure:

The essential causes of the differences in psycho-analytic technique are in my view related to theanalysts appreciation of the role played by unconsciousphantasy in mental life and in the transference. (9 p.305)

In my opinion, the understanding of, workingthrough, and mastery of internal phantasies are thegoals of psychoanalytic treatment.

Bit by bit, P was able to function as a container

for herself and manage her own affects andthoughts. This phase of analytic containment ledto the next period in the treatment, the analysis ofthe death instinct and its manifestations in Psinternal and external experiences.

Despite her overall progress, P still felt quitedepressed and stuck in life. She couldnt gure outwhat to do for a career, even though she enjoyedher new job, and she wasnt able to nd a fulllingromantic relationship. P felt time was running out.She saw most of her friends married and secure. P

envied them and felt that kind of happiness wasbeyond her reach.

One day she was sobbing and told me howtrapped she felt. I dont know what direction totake and even if I knew which way to turn, I donthave the will to try. If I make a move, a part of meis on alert and ready to hunt me down. It feels so

hopeless. Over time, I addressed this as a fear ofme harshly judging her. She was so busy trying toappease me that she couldnt sort out what shereally wanted. I use the word appease because Pwasnt really trying to please me and win points.She was more trying to avoid a negative feelingbetween us and some type of revenge or punish-ment. Over time, she told me this was a lifelongfear of being abandoned, abused, or both. Aphantasy of being used until being useless andthen being discarded colored most of Ps close

relationships, including the transference.P experienced these mental and emotional

troubles as coming from others at times, but oftenshe felt it was as if a part of herself was afteranother part of herself. She would routinely hearmy observations, clarications, and interpreta-tions, as critical and accusatory. She would say,you dont have to tell me I am a fuck-up, I alreadyknow that! The more we explored her persecutorytransference phantasy, the more she was able tohighlight her internal persecutory experience. As

we understood the transference distortion, wecould see how a part of herself was indeed afteranother part of herself.

P told me, I have this feeling. Actually, itsmore like a fact. I have been sentenced forsomething, a crime or something else very bad.But, I dont know what it is. All I know is that I haveto be very careful to avoid a terrible attack onmyself. My sentence is to be very still. This is alsothe way I stay safe. I can avoid being attacked bymaintaining a zero level of growth, always keeping

everything at a zero balance. If I try and gainsomething or rise up and achieve something beyondmisery, that is when I will denitely be attacked.

Throughout her analysis, P struggled with thesefeelings and thoughts. The more we explored them,the more it was evident they were mostly issues ofannihilation, loss, and persecution. At rst, thewords she used to describe the phantasies soundedlike oedipal conicts regarding competition andfears of retribution for besting the parental gure.However, the more we analyzed her feelings and

288 R. T. Waska Int Forum Psychoanal 11, 2002


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how they manifested within the transference, it wasevident that this was a much more primitiveexperience. Rather than avoidance of phallicsuccess, P was coping with pre-oedipal fears offatal rejection. Her ego was faced with permanentloss of self and object. Likewise, she appeared torelate in masochistic ways to me and other

important gures. However, it was not a strategyto gain masochistic gratication. Zero growth wasa survival strategy to avoid persecution. Thisfeeling of being hunted down came from a sadistic,destructive, and intolerant part of herself that keptclose watch for any level of deance. This was anintrapsychic projective identication process thatwas anti-life and anti-growth. Here were theworkings of the death instinct emerging in thetreatment. The strength of the death instinct (DI) inthis patient led to its appearance in the interperso-

nal and transferencial aspects of our relationship.Over time, I felt like P needed to maintain this

vigilant stance for her safety and also as the onlyway to connect to me. It became clear that shedeliberately hid any growth or life-afrmingthoughts from me and from this destructive partof herself. To always see things as grey and grimassured her that her relationship to the objectwould remain predictable and constant. Whensome evidence of life and success leaked out, Pfeared the end of our relationship. She told me,why would you let me come in if I only had goodthings to report? We would be different together,things would change. Indeed, she feared positivefeelings and achievements would bring on aban-donment and criticism. P said, we are not here todiscuss any positive crap. That is useless for ourpurposes. Obviously, we are here to focus on howbad I am and to nd out why I am such a fuck-up.It was only after I asked lots of questions andpulled for details that I learned P was promoted at

her job and the hospital staff had presented herwith an award for good service. She ltered the lifeout of things, so I was given a very stark andnegative picture of her daily existence.

As this dynamic went on, I noticed it took twoforms. I became the voice of life, pointing out Psprogress and her various accomplishments in andoutside the analysis. She took on the voice of theneutralizer, the naysayer, and the voice of death.She would point out how each victory was hollowor tell me we werent paying enough attention to

the important stuff, her failures. So, through

splitting and projective identication, she had mehold the desire for life while she held on to thedestructive aspects of her ego. This split wouldroutinely shift, again through projective identica-tion, to the reverse. I noticed I was at times beingoverly positive and invasive with my interpreta-tions. I realized I was being dominating and pushy

with my supportive comments. Indeed, some-times I felt like saying look, you are doing ne!You need to enjoy life! I think this type oftransference/countertransference dynamic is set inmotion because of internal projective identicationmechanisms and because these types of patientsare often both defending against the DI and using itto attack parts of themselves. One part of the ego isattacking another part of the ego, which tries todefend itself. Via projective maneuvers, thisintrapsychic battle begins to rage interpersonally.

Patients like P make the analytic situation into abattleground with progress, growth, and knowl-edge pitted against immobility, ignorance, self-criticism, and denial of object-relatedness. Narcis-sism is a common expression of this urge to destroythe link to the other. P seemed on a mission todestroy any evidence of uncertainty, need, desire,or vulnerability. She felt no compassion for herselfand thought that was a disgusting attribute to havein the rst place. Therefore, any link to me basedon empathy or compassion was considered ridicu-lous. P said, you just say what you do because youhave to. I dont want your pity! She would getvery agitated and yell at me if I commented on hertender feelings for her boyfriend or her lonelyfeelings for her family. And, if I brought up hertransference feelings, she would become outragedand tell me in no uncertain terms how I was grosslymistaken. Technically, I always operated as I dowith other patients. I interpreted the transference,the extratranference, her desires, her anxieties, and

her defenses. However, I also paid close attentionto the way she was so focused on destroying partsof herself and her link to the object. At this point inthe treatment, I made most of my interpretationsgeared toward the clinical manifestations of the DI.

P considered the desire for knowledge, feelingsof curiosity, and any degree of uncertainty allpoison and something to eliminate from her mind.She avoided people who seemed to have thesetoxic qualities and she hated the quest for knowl-edge our relationship represented. P didnt want to

be contaminated. Her violent reactions to my



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interpretations also revealed a breakdown ofsymbolic function. She felt my questions andcomments were equal to a sexual assault. Sharingher thoughts and feelings was the same as beingrobbed, owned, or invaded. Through projectiveidentication, she put the destructive parts of herego into me and experienced me as a persecutory

inquisitor. During these more psychotic moments,I found it best to ask P to explain, in detail, what itwas I said that made her feel so defensive. Wecould then slowly take a second look at it and seehow she had started to distort me and ourrelationship with her own feelings and phantasies.This period of reection was often bumpy andstormy and took several sessions.

After several years, Ps grim and grey approachto herself, our relationship, and to herself began tosoften. She was less cruel and less destructive. She

started to play little sadomasochistic games withme. She would start a session by saying, ok, goahead and see if you can pry something out of me.Over time, we understood this as a complexmixture of wanting me to care for her by askingquestions and her defense against this caring incase it turned sour. Prying was soothing, sexual,and scary all at once.

Gradually, the workings of the DI diminished aswe explored and analyzed it from countless angles.For patients like P, I nd it important to interpret

the intrapsychic projective identication processthat goes on between different aspects of the ego aswell as the way it manifests within the transfer-ence. Extra-transference situations are also valu-able to explore, as they often are easily traced backto intrapsychic struggles. As the layers of defensesand anxiety fell off, P and I were confronted withher bedrock fear of loss. I think that when the DI isoperating as a defense, it is often a defense againsta primitive, primal form of loss and persecution.Upon analysis, this turns out to be a para-

noidschizoid experience of loss in which theego faces annihilation of both self and object.

Now, the nature of Ps analysis took on adifferent avor. The ongoing self-destructiveaspects of the DI still made a jungle out of thetreatment, but more and more we dealt with Psphantasies of being attacked and rejected. This fearof abandonment was of an all-or-nothing nature, inthat she felt either I would truly understand andlove her or that I was uninterested and ready to getrid of her. I was either for her or against her. This

was the result of excessive reliance on projection.P put her oral aggression and desires into the objectand then felt hunted down and overwhelmed.

The more we worked through the clinicalmanifestations of the DI and Ps self-destructiveways, the more her internal experience of loss andpersecution came to light. She was afraid that the

objects she craved for could easily turn on her. Thecombined phantasies of being persecuted andbeing left alone was very difcult for P to workwith. She had avoided talking about these feelingsand avoided exploring her thoughts about them.However, bit by bit she was able to deal with theseanxieties in this phase of treatment.

P told me the following dream. She realized,with shock, that she hadnt ever graduated high-school. P didnt remember anything else about thedream and felt blank about it. She had no

associations and she didnt know what it mightmean. I rst commented on how she was able togive me the dream and look to me for guidance onwhat it might mean. This dependance was differentfrom her usual stance.

Listening to the dream, I thought of the recentsessions/classes P had missed with me and how shemight have feelings about graduating from analy-sis. For some months, we had been exploring theways she hid her achievements from me and deniedany evidence of success. I commented on how the

dream might infer her fears of success just as sheseemed to fear succeeding in our relationship.

Here, I was using my own countertransferenceassociations to organize the dream. I believe myideas were inuenced by her projections ofintolerable thoughts and feelings. Rather thanbeing a violent projective identication process,this was more an effort at communication andsafety. P was using me as a maternal envelope totake in and translate the contents of her mind.

P said she was frightened to get better and

graduate. She said she was scared about being onher own and how lonely and hopeless that felt. Ptold me a phantasy of waking up in handcuffs on aoating iceberg in the middle of the sea. It was anincredibly stark and lonely feeling and there wasno hope of ever being found. Interestingly, after Ioffered my association, she was able to take in myfunction as a container and begin to reect onherself.

Her dream and her associations to it show theoedipalpre-oedipal, paranoidschizoidde-



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pressive position nature of her internal world.While she felt oedipal competition, guilt, andpower, the underlying threat was a pre-oedipalloss and violent persecution. P was not afraid ofpunishment, she was afraid of being banished toutter and total isolation. When P missed sessions atthis point in the treatment, it usually meant she felt

I was going to force her to act independently. So,she tried to leave me before I left her. She picturedme taking away my support and leaving her on thelonely iceberg. P thought I was trying to makeher grow up and in the process abandoning her.Then, she would revolt and refuse by regressingand demanding to be parented.

Another dream during this third phase of Psanalysis illuminated the ongoing struggle betweendestructive parts of her ego and other parts that feltthreatened and lost. P was standing in her home

next to a litter of puppies trying to nurse. Suddenly,a vicious pit-bull attacked the puppies. P tried torescue them but could only grab one puppy andrun. As she was running, she dropped the puppyand it broke, like glass, into hundreds of fragments.

P was able to explore this dream and engage mein understanding it. She wanted more of a teameffort than the other dream where she wanted me totake care of her. With this second dream, P felt wecould work together. Exercising her own intellectdidnt have to mean she was all alone. Weunderstood the dream to represent remnants ofthe DI, in which part of her mind was vicious andout to destroy needy and vulnerable parts ofherself. The hungry puppies were her needinessand her desire for my love and knowledge. The pit-bull side of her tore this bond apart. P tried to act asa container for the puppies but was only able toaccommodate one puppy and she dropped it. Itbroke into hundreds of pieces, much like Ps mindturned on itself and shattered the more needy parts

of P. We discussed the parallel of her not beingable to contain and save the puppy and her earlyexperience with a mother who clearly was toopreoccupied to properly tend to P. Historically, Pfelt her mother had dropped her over and over, justwhen she needed to be saved and protected.

This fear of loss and the breakdown of acontainer into more of a harmful agent coloredthe transference. There were times when P thoughtI was masturbating in my chair as she lay on thecouch. Ps fears were twofold. She thought I was

abusing her by thinking of her sexually and

trapping her in a dirty, dangerous, and immoralrelationship. At the same time, she feared I wasignoring her and phantasizing about someone else.Here, I think she is demonstrating pre-oedipal andoedipal struggles with loss and persecution. Stilllater in the analysis, she feared I would die andleave her forever. This made her very anxious and

overwhelmed. With both phantasies, I interpretedher projective identication of oral aggression anddesire as well as genital wishes that were put intome and felt as belonging to me. These werefeelings she thought were wrong or dangerousand she tried to expel them via projection.

After ve years of analysis, P had progressed agreat deal. Externally, she lived a full life. She haddecided to change careers and focus on her creativeurges. Shewent back to school to become a designer.P now had a steady boyfriend whom she trusted and

who treated her well. Her day-to-day life was morerelaxed and grounded rather than a ght for survival.These changes were the result of internal shifts inher object relations. P no longer lived within anintrapsychic battle-zone. Now that her mind hadplentiful good objects and her aggressive oral drivesand phantasies had been worked through, she nolonger had to attack herself internally.

At the time of this writing, P still struggles withsome paranoidschizoid feelings of loss and guilt,but has a much better ability to deal with them.Most of the time, she experiences life from a moreintegrated, whole object perspective. In otherwords, she may feel overwhelmed or guilt-riddenat times, but she feels able to forgive herself,restore her object, and nd sustaining, safe contactwith her internal object relations.

Case Material

Randy, a young doctor, is an example of a higher

functioning patient, more oedipally secured than P,but still very much struggling with the deathinstinct and issues of primitive loss and persecu-tion. He was a high functioning borderline patient,who was prone to occasional psychotic regres-sions. He used the analytic couch and attended fourtimes a week. Randy, and many patients like him,have a tenuous and uctuating hold in thedepressive position and frequently experienceparanoidschizoid phantasies of persecution andprimitive loss. The idealized object fades and is

replaced by an attacking, revengeful bad object.



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I contained Randy in the beginning by verysupportive interpretations closely matching hismoment-to-moment affect state and not venturingout of that immediacy too much. Interpersonally, Icontained him by letting him pay an extremely lowfee and let him owe me for several months. I usedlogic, reassurance, and interpersonal support to help

him deal with overwhelming feelings of anxiety andoverpowering phantasies of persecution. After therst year or two, he took over this role and managedhimself most of the time. Of course, we explored themany meanings of his wanting me to be in that roleand the difculties of giving that up.

Randy had entered analysis because he feltdepressed. He was sleeping on a friends livingroom oor and couldnt decide what to do with hislife. The indecision and anxiety prevented himfrom working so he was almost homeless. For

several months, he was unable to work due tofeeling depressed and paranoid. At one point, heslept in a homeless shelter. Sometimes, he thoughtI worked with a secret team of colleagues whofound subtle ways of testing his sanity andevaluating his commitment to therapy. When hishome phone rang and no one was on the other line,he was sure it was a test from me and my team.When he went out to nightclubs, he thought that Ihad planted spies to watch him and report back tome. Randy also feared I was slowly brainwashing

him and would eventually hypnotize him intohaving sex with me. All these delusions andpsychotic phantasies slowed down when I used acontaining and supportive approach.

At the same time, I maintained the analytic focusby always bringing us back to the transference andhis phantasies as they played out in the extra-transference.

Randy now works in a hospital. This is his thirdjob after completing his schooling. His residencyand the last two jobs were marked by great turmoil.

He felt unable to count on his superiors andultimately made them anger by passively ignoringtheir various requests. He had a who, me? way ofrelating that eventually enraged his supervisors. Atthe same time, Randy felt powerless and weak inhis professional and personal life.

Randy hasnt had a steady relationship in tenyears and is still very attached to his mother. Hismother, a devout Catholic, always wanted him tobe a priest. She also felt he should stay at home andtake care of her. As an adult, he feels very guilty

about dating and following his interest in medicineand medical research.

In the transference, I have often been theauthoritative mother he censors his dirty thoughtsfrom. He secretly has fun on the side. He feels veryguilty about this but also enjoys rebellingagainst meand playing out a power struggle with me internally.

These sessions were from the middle of the thirdyear of analysis. He had just started his new job atthe hospital. His parents had moved out of state toretire a month prior and the Christmas holidayswere just around the corner.

P: I feel so tired. I have so much trouble sleeping. Mystomach is also very upset. (He talks about his physicalproblems for awhile.) Yesterday was my rst day atwork. It was really difcult. They didnt issue me a deskyet and most of my supplies werent delivered. I donteven have a computer yet! It is a big hospital so there is

so much red tape, its hard to get much done. One of mysupervisors asked me for some feedback on a projectthey have had in place for several months. It was strangeto be looked at like someone who knows what they aredoing. I felt intimidated.

A: How?

P: Well, it all seems so new. I guess I feel out of place. Idont feel like I t in very well.

A: Like you dont have the right to what you think?

P: Yes. I guess what I said was ok. They seemed to likeit. I dont think they have been running the department

very efciently. One of the other department heads wasthere and I didnt feel comfortable. Its like I am betterone-on-one, but in groups I get nervous. He wanted toknow what I thought and I asked if I could have sometime to think it over. I felt put on the spot.

A: You sound worried about having your own opinion.

Pt: Yes, I do. I wasnt thrilled with some of the workthat had been done in that department but I can see whatthey are trying to do in general. I just felt uneasy.Maybe, I feel I can control one mind at a time, but not awhole group. But I need to be able to interact withgroups more, its important for my career.

A: You are being asked to be more of a leader. From theway you relate to me, we know you prefer to be afollower and get me to be the leader, at least on thesurface. Youre more comfortable being the little guyandcriticizing me or whoever is in authority. If you are incharge, you will be the judge, executioner, and victim.

Pt: Exactly. This new position means I will have tomake lots of decisions and there will be people leaningon me. But, I think I can count on x for support. I amworried how I will do. If I can do it. But, even though Itry and get myself worked up into a lather and feel likequitting, this time around I dont think I will actually do



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that. I am getting better with this stuff, not as reactive orfull of crisis. I am in the big leagues now, but I am not asfreaked out.

A: Having to be strong and showing your own identitymakes you anxious.

Pt: Yes. Instead of being the little boy who takes orders,I want to be more of my own man. When I try andexplain that to my family, especially my mother, theyhave no clue. They come from such a different place,everything should be about family and religion. If Idont devote my life to my family and to God, then I amdoing something bad. Its hard for me to believe in what Ido too. My mother called me this week, believe it or not.Usually, she makes me be the one who always calls. Shestarted to put me down for my life-style and said shewas very disappointed in me. She wants me to comehome and be sensible. She says she and my father aregetting old now and need help. Why is that my job? Shestarted crying and said she has lost her son. She said Ihave turned my back on her and the family. Of course,

God was brought up, which is always so hard too.

A: You feel like you are hurting your mother by havingyour life.

Pt: Yes. I am just starting my life and not ready to do allthe things she wants me to do. Part of me wants to cutoff all contact with her for good, just run away. Maybe ifI move to another state or country it would be better. Or,maybe I should give up my life and move back homeand take care of them. (He goes back and forth aboutthis for awhile.)

A: Somebody will end up hurt. Either you or them.

Pt: Yes. I feel I will have to give up everything to beloved and accepted, or at least not criticized.

A: I think your feelings are so strong that it colors allyour relationships. You feel you could step on toes atwork, that you will betray your mother, and that youwill get in trouble with me if you tell me everything.

Pt: Yes. But, do I have to give everything over to you toget insight? It is all about balance. I feel I either have togive everything up or I get into lots of trouble. So, I endup disguising what I feel and what I want. (Here, he isrevealing the all or nothing quality of his object

relations and his fear of losing contact with the objectshould he retain his identity. Either he gives up his senseof self and feels lost or he gives up his object and feelsannihilated. I think this demonstrates the mixture ofparanoid-schizoid and depressive conicts he struggleswith at this point in treatment.)

A: Like how you tried to tell me you needed to conductsome research in Europe when really you wanted to goon vacation. You thought I would try and own you ifyou started to have your own ideas. You worry there is apower struggle going on.

Pt: Exactly. I paint things a certain way. I try and look

innocent and not say anything that might make you

criticize me But underneath, I am thinking somethingelse. I was afraid to tell you because it would beconsidered bad and you would try and convince me todo it your way, whatever that is. Its so hard to make anydecisions.

A: Especially when you feel they impact me or yourmother.

Pt: Oh yes! I dont know if I am abandoning her or ifthey are abandoning me. I dont know. I am soconfused, I feel pulled in two. I have so many dreamsbut I tear them down and think about how I need todevote myself to therapy and my family instead. So,eventually I have to come up with secret plans to dowhat I want behind your back. All this makes itimpossible to get involved in a relationship. (Hediscusses a recent relationship where he felt the womanbegan to pressure him. Both the woman and then himfelt mistreated and abandoned. This is very much howhe sees his bond with his mother and with myself.)

A: Your feelings about your mother really affect allyour relationships. You are not sure if you are hurtingall of us or if we are picking on you and controlling you.

Pt: Wow! Yes. I hadnt ever thought of it like thatbefore.

Next session

Pt: (He discusses how expensive it is to maintain hislifestyle and how much he worries about money. Hetalks about his concerns as if he is almost pennyless,while in fact he has a great deal of money in savings.)

A: Since I know you actually have money in savings, Ithink you are really talking about how you dont want tospend your own money.

Pt: I told my concerns to my supervisor and theymanaged to get me a cash advance. It is a real relief.Today was really intense. I had to talk with thedepartment staff about how they are operating andrunning things. It turns out they really have no plan atall. There is a real lack of organization. I mentionedsome of my concerns, which felt really strange.

A: You dont feel properly taken care of by the hospital

and their way of running things. But, you also feeluncomfortable to take charge and make sure you do gettaken care of. (I decide to take up his response, ratherthan point out how he ignored my comment. From thepast , I know he will try and engage me in asadomasochistic power struggle if I reect on hisdismissal. So, I choose to contain that for the momentand see if we can use his statement as a vehicle.)

Pt: Good point. Yes, I can see that. It is like I dont wantto do something that would assure me security. That isweird. If I do, its in a secret, round-about way. I do itunder the table.

A: Why?



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Pt: Because I would have to depend on other people if Idid it above board. (He discusses how he would like tosave for a new car but it is hard to do. Yet, he says herefuses to ask for help from anyone because of the stringsthat come with depending on others, especially family.)

A: So, the new car that you get all by yourself is like amixture of spite, guilt, competition, and independence.

Pt: You have that right. But, it is hard to hear that out

loud: spite and competition. That is hard to take. Yet,you are absolutely right! God-damn it! I guess I feel likeI really need to prove a point, with my parents andeveryone else.

A: How so?

Pt: Well, I am not sure. Maybe it is that other peopledont see me as capable or that I have a legitimateopinion or a legitimate life for that matter. (Heelaborates.)

A: You are worried about being being judged, so youwant to be seen as legitimate and get approval from

myself, your parents, and work.Pt: Well, I think part of me wants to conform and part ofme wants to rebel. I wish I could have both and not feelso divided. But, I dont want to be boring and a part ofthe system, like my parents. But, I also do want to havesome security like they have. I go back and forth in mymind and judge all this stuff so much. I think that if Icould just live each day without picking it apart somuch, and just accept myself and my decisions, then Ithink I could enjoy each day. I want that so badly. (Here,he describes the obsessional dilemma he weaves aroundhimself to deect the more anxiety producing para-

noid

schizoid phantasies of loss and guilt.)

Next session

Pt: I am feeling more in charge of the department now,but it is frustrating. Nothing seems to be getting done. Idont even have all my equipment yet. In general, thestaff seems to be very laid back. Their commitment isntvery strong. No one is around to make any decisions.(He goes on for awhile.)

A: Sometimes you want others to take charge and takecare of things for you, but then you feel they do a lousy

job.

Pt: Yes, that is true. Ok. I have been thinking about thatlately. Should I take more control of things and make afew more decisions or not. But, the hospital is all splitup. (He discusses how he sees all the departmentsworking against each other.) I am also very upsetbecause I want to go and visit my parents for theholidays but I cant afford the ticket. I could ask myfather but I know he will say no. It upsets me because Iwould like to be with them. My father seems so tightwith his money.

A: I am interested in how you feel hurt that your fatherwont pay for your ticket, but you have more than

enough to buy it yourself. It is like you are denying yourown abilities and instead feeling like he should buy youa ticket. Maybe you think that is the least he can dogiven how angry you feel.

Pt: Wow! I never thought of that! Wow. Now, I feelreally pissed at myself for not thinking of that solution.It is so much simpler. Wow. That is sure something tothink about. (He takes my comment as concrete advise

on buying a ticket and ignores my confrontation on hisgreed and sense of entitlement.)

A: You feel others dont take proper care of you, so youoften refuse to take proper care of yourself. I wonder ifyou feel that would be giving in to me?

Pt: (He agrees with what I have said and then elaboratesa bit. Then, he starts to talk about how empty and boredhe is with life and how meaningless everything seems.He sounds genuinely depressed and alone. I think he isstarting to feel the pain that he hides behind hissadomasochism and obsessional judgement.)

A: I think you want me to take care of you and run yourlife sometimes, and you end up feeling powerless andaimless without me. By having no opinions anddecisions, you can keep us safe and conict-free, butthen you feel controlled and dominated too.

Pt: That is interesting. Yes. I think that is probably ontarget. Ouch. Yes. I do feel better when I take charge ofthings, but what often happens is I start to feeloverwhelmed by all the things I think I should do andaccomplish. (He elaborates. I think he is revealing howhe depends on my superego as a less harsh and lessdemanding object than his own superego. When he triesto parent himself, he becomes a tyrant. Therefore, I looklike a less cruel dictator. Eventually, however, he tiresof being bullied altogether. Then, he secretly rebels.)

A: So, it might feel better to let me order you around abit than to be really bullied by yourself.

Pt: There you go! Yes. Sometimes, I go back and forthso much with myself that I feel I really am going crazy. Ido notice that Ive started to try and talk with peoplemore and reach out a bit. Even though I feel I amdisturbing them, it feels good. (I notice the doublemessage of his closeness and his satisfaction indisturbing the object.)

Conclusion

Randys current progress is mixed. He continues toexcel at his job and is gaining respect from hispeers. He has dated a few women, but never followsthrough in ways to build the relationship. Overall,he is more within the depressive position and wholeobject functioning as a result of treatment. How-ever, he uses the depressive position, with itsobsessional defenses, as shield against the deeperphantasies and anxieties of paranoidschizoid



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guilt and loss. I think he is still very much workingthrough his fears of being abandoned by adisapproving mother object and being attackedand persecuted for being a bad son. His oralaggression leaves him with disabled and disapprov-ing objects and few good objects to balance out hisinternal experiences. Yet, given his history of

steady progress in analysis and his willingness toimprove, I feel he will gradually nd moreintrapsychic integration , inner fulllment, and asense of guilt-free self identity for which he craves.

Summary

Translation and containment of intense anxiety andparanoia reveal the destructive and defensiveworkings of the DI. Gradually, this turns out tobe a large-scale intrapsychic defense against fears

of loss, annihilation, and persecution. Projectionidentication of oral rage, splitting and idealiza-tion, and manic defenses permeate all three stagesof treatment. If both analyst and patient cantolerate these three lengthy and stressful parts oftreatment, the results are startling. Signicant

character change is possible and these patientsemerge with much greater ego capacity andinternal resources. Object relations become wholeand integrated and internal experiences begin tomore closely reect and match external reality.

References

1. Klein M. Some notes on schizoid mechanisms, Int J Psychoanal1946;27.

2. Klein M. A contribution to the psychogenesi s of manic-depressiv estates. In: The writings of Melanie Klein, volume III, Free Press,New York; 1935.

3. Klein M. Mourning and its relationship to manic depressive states.Int J Psychoanal 1940;21.

4. Grinberg L. Two kinds of guilt their relations with normal andpathological aspects of mourning. Int J Psychoanal 1964;45:366 371.

5. Ponsi M. IJPA Internet Discussion Group. Bulletin 2000. Feb. 8th.6. Quinodoz J. IJPA Internet Discussion Group. Bulletin 2000. Feb.

4th.7. Fenichel O. Problems of psychoanalyti c technique, Psychoanal Q

1941.8. Steiner J. Psychic retreats: pathological organization s of the

personality in psychotic, neurotic, and borderlin e patients. Londonand New York: Routledge; 1993.

9. Heimann P. Dynamics of transferenc e interpretations , Int JPsychoana l 1956;37:303 .

Summaries in German and Spanish

Waska R. Drei Phasen in der Behandlung von Borderline- undPsychotischen Patienten

Behandelt man psychotische oder Borderline-Patienten, solassen sich drei Phasen unterscheiden, die sich gleichwohluberlappen. Solche Patienten testen die Grenzen der Psycho-analyse, konnen aber von deren Untersuchungstiefe wohlprotieren. Die erste Phase vom acting out, interpersonell undintrapsychisch, bestimmt. Ein fester analytischer Rahmen desContainment ist e rforderlich, um die Behandlungsbedingun -gen aufrechtzuerhalten. Deutung ,,holding und Containmenthelfen dem Patienten, gewalttatige Projektionen zu entgiften.Viele dieser Patienten beenden die Behandlung freilichvorzeitig. Die zweite Phase zentriert auf den defensivenGebrauch, den der Patient von der Aggression macht, umbestimmte Teile seines m entalen Funktionieren s zu zerstoren.

Dieser schwierige Kampf zwischen verschiedenen seelischenTeilen des Patienten wird in der Ubertragung abgearbeitet.Die dritte Phase offnet den Zugang zu den fundamentalerenProblemen der paranoid-schizoiden Angste von Verlust undprimitiven Erfahrungen von Schuld. Trotz aller Schwierig-keiten sind erhebliche interpersonelle und intrapsychischeFortschritte moglich. Angesichts der Instabilitat und derchaotischen Objektbeziehungen solcher Patienten, muss derAnalytiker vorsichtig optimistisch in der gemeinsamen Arbeitsein und sein Hilfepotential realisieren, selbst wenn er sichweniger gunstigen Arbeitsbedingungen gegenuber sieht.

Waska RT. Tres fases de tratamiento con pacientes borderliney psicoticos

Tres distintitas, aunque solapadas, fases de tratamiento surgencon algunos pacientes psicoticos y borderline. Estos sonpacientes que prueban los limites normales del psicoanalisis yque pueden beneciarse de su exploracion profunda. Laprimera fase esta coloreada de acting out, interpersonal eintrapsiquicamente. Una envoltura psicoanalitica de conten-cion es necesaria para sostener el tratamiento. Un holdinginterpretativo y continente ayudan al paciente a encontrar unreceptaculo psiquico capaz de dexintocsicar proyeccionesviolentas. Muchos de estos pacientes terminan prematura-mente. La segunda fase esta centrada alrededor del usodefensivo por el paciente del instinto de muerte, paraextinguir o destruir ciertas partes de su funcionamiento

mental. Esta dicil separacion entre las partes de la mentedel paciente se reproduce en la transferencia. La tercera faserevela el problema mas fundamental de las ansiedadesparanoides-esquizoides de perdida y las experiencias primi-tivas de culpa. Estas incluyen miedos de persecucion yaniquilamiento. Algunos pacientes abandonan el tratamientoen la primera o segunda fase y nunca trabajan sobre lasfantasias y sentimientos de perdidas. No obstante es posibleun progreso intrapsiquico e interpersonal. Dada la naturalezainestable y c aotica de las relaciones de objeto del paciente, elanalista debe ser cautamente optimista en su trabajo y darsecuenta del potencial para ayudar al paciente incluso cuandoeste se presenta con menos condiciones favorables de trabajo.


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