About violent behavior and relational impasses during psychotherapy.

A reflexion on the use of the object through it's containing function.

by

Dianne Casoni, D.Ps.
psychologist
Professor, School of Criminology, Université de Montréal

Louis Brunet, D.Ps.
psychologist
Professor, Departement of psychology, Université du Québec à Montréal

 

Violent acting-in and acting-out behaviors occuring during psychoanalytic psychotherapy will serve as an extreme illustration in order to reflect on relational impasses occuring during treatment. Such violent manifestations can be seen as an ultimate means, most often of a desperate nature on the part of the patient, to obtain from the therapist some type of response which the patient could use as a psychic container for something felt to be unassimilable by the Ego. Overwhelmed with anxiety or with unrepresented bodily sensations, acting-out behavior in the course of treatment thus seems to correspond to something wich remains unthought by the Ego but nevertherless seems to be used as a delegate in order to try to communicate something of the enigmatic and unconscious contents which hopefully in the intersubjective context of psychoanalysis will make sense for the therapist to whom this communication is directed.

Bion's conceptualisations of projective identification and containing function will serve as theoretical references in an effort to seize the intersubjective play which can succeed or fail when one of the partners of the therapeutic dyad is overwhelmed with unrepresented somato-psychic contents which may or may not be contained and transformed by the therapist. Such a transferential scenario, where the subject uses projective identification as a means of communication, may help him take back into the Ego contents which were felt, until then, to be unassumable. However in case of failure of the communicative nature of projective identification and of the containing function of the therapist, such a scenario may give rise to violent acting-ins and acting-outs and ultimately to a relational deadlock within the therapeutic setting.

The present paper is limited to the theoretical framework which will help us understand some types of psychotherapeutical deadlokcs. Though the material from two case presentations will serve to illustrate this theoretical framework, it is omitted in this paper and will be presented only during the workshop.

For our purpose, we define therapeutical impasses as an incapacity on the part of the participants of the therapeutical adventure to resolve a transferential/counter-transferential conflict. Such conflicts are always present in varying degrees in all psychoanalytic processes, it may even be proposed that the absence of such conflicts results from failure within the process to permit fondamental unconscions conflicts to be dynamically lived in the transference. When fundamental transferential conflitcts do not arise and thus do not trouble the therapeutic relationship, it could signify that the apparent transferential/countertransferential harmony is obtained through an unconscious endeavour on the part of both partners to stay clear of the turmoil which such conflict would cause in each partner. In this sense,though the presence of transferential/countertransferential conflict might take both partners by surprise and appear suddenly as a stumbling block, such conflicts appear as a crisis inherent to psychoanalytic treatment. However, when such a stumbling block cannot be resolved, a therapeutical deadlock arises and constitutes a failure within the process, an impossibility for the patient-therapist dyad to modify the script of the unconscious transferential/countertransferential conflict of which they become prisonners.

Projective identification

Freud's elaborations of the concepts of projection and identification can surely be viewed as exceptional contributions to the development of the psychoanalytic theory. Notably, his papers describing identification processes (Freud, 1900, 1917, 1923, 1924) in which he studied identification in relation to depression, to the formation of the ego and superego and also in relation to the Oedipus complex, progressively increased the importance of the concept of unconscious identification processes in the understanding of the psyche.

So much so that identification processes can now be seen as an important metapsychological element and referred to as playing a major role in the structuring of the personality. Identification thus now appears as the basis to internal object relations, giving birth to intrapsychic structures and later character formation.

However, Freud does not limit his comprehension of identification to the process of introjection within the ego or the superego. He also describes as identification a process in which a psychic structure is projected onto someone else. He describes such a situation when the subject's ego-ideal is projected onto a leader who thus becomes idealized and with whom the subject identifies (Freud, 1921). A similar phenomenon is detailed by Freud (1914) in the narcissistic object choice by some women who project their ego-ideal upon their love object. These subtle distinctions in the use of the concept of identification by Freud will bring Laplanche and Pontalis (1973) to justifiably speak of a centrifugal and a centripetal understanding of the processes of identification by Freud.

Many years later, Melanie Klein (1946) develops Freud's intuition on the relationship between projection and identification. In so doing, Klein redefines the concept of projection by postulating that it is necessarily accompanied by an identification process, she refers to this new concept as being: "projective identification". Projective identification occurs when persecutive internal objects, often part-self objects, are projected into the external object as though, on a fantasy level, these projected parts are imagined as taking possession and controlling the external object. The identificatory dimension of the process is theorized by Klein as resulting from the relationship that is maintained between self and external object in the intraspychic on a fantasy level. Klein first begins the study of these identification phenomena from the viewpoint of their anal and sadistic dimensions, pointing out the confusing effects this mechanism has on the subject. She further explores the close relationship between projective identification and splitting and it becomes clear to her that projective identification cannot be dissociated from underlying splitting mechanisms.

But projection is not necessarily linked to sadistic impulses and Klein also describes a type of projective identification in which good parts of the self are projected into the object, giving way to feelings of love and empathy (Brunet, Casoni, 1991b; Sandler, 1991). Joseph (1991) suggests that this latter type of projective identification, by enabling the child to develop good object relations, contributes to ego and personality integration. To that effect, although Klein mostly describes the process as an expulsion of hated parts of the personality into the object, in a footnote, she insists on the importance of the mother's love and understanding for her child in order for him to overcome the states of disintegration linked to the use of splitting and projective identification.

It can be said that, in fact, two processes are combined by Klein under the name of projective identification. These two processes, whether they are based on sadistic, anal projections or on good and integrating elements, appear to be constantly at work in alternation in the duality of the schizoparanoïd and depressive positions (Casoni, 1985; Bégoin-Guignard, 1984, 1985a, 1985b).

Using these two forms of projective identification formulated by Klein , Bion (1962b) proposes a theory concerning a normal utilization of this mechanism. Thus, a child overwhelmed with intolerable anxiety, might feel the need to project this anxiety into his mother in order to find relief. When the mother is able to identify with her child's anxiety and tolerate it within herself, she plays the role of a psychic container for her child's anxiety. Thanks to her ability to think about this anxiety and to her desire to help her child restore some inner peace in himself, she then tries to offer him a satisfying response in the hope of relieving him of his anxiety. When such a communication process between mother and child is successful, the child can then take back into himself the part of his personality, now transformed into a bearable, thinkable form, which he had previously projected into his mother. By identifying with his mother and her "thought" product, the child is able to take back into himself a mended, decontaminated self, while identifying with the maternal ability to repair or restore (Brunet, Casoni, 1991a).

Meltzer (1984), further elaborates the associations Bion proposes between projective identification and psychic container. In describing the mother-child interaction, for example, Meltzer observes that a comparison can be made between what is experienced within the maternal relationship, within the therapist-patient relationship and within the transferential-type relationships which are seen in all helping or intimate relationships (Bégoin-Guignard, 1989c). Furthermore, Meltzer and al. (1984) propose that the term projective identification be reserved to describe phenomena of a communicative nature. They further suggest the use of the name "intrusive identification" for the more pathological defensive phenomena when the control of the object's psyche, or of a part of his psyche, is unconsciously sought by the subject.

A distinctive characteristic of the theories of Bion and Meltzer concerning projective identification is the addition of a complementary function assigned to the real object: be it mother, psychotherapist or educator. For example, projective identification is the mechanism used by the child to expel psychic contents not only out of himself but into his mother when he feels overwhelmed and unable to transform it into integrable thoughts. The unconscious goal may be twofold : first of all, the child may be driven by rage and anger, trying to make his mother suffer, as he is suffering, deeming her responsible for his distress. Secondly, the child may be trying, through projective identification, to communicate his distress to her in the hope that she be able to transform these agonizing psychic contents for him. In both cases, the ability of the external object to identify with, think about and symbolize such projected material will enable the child to reintegrate the previously projected elements and help him to assimilate them while identifying himself with the object's containing function.

However, Bion also describes situations where the mother is unable to identify with her child's projections, feeling forced, unconsciously, to deny or to expel such non-symbolized elements. The child is then left with the need to use projective identification with increasing force and frequency.

The interrelated processes of projective identification and containing function can thus fail or succeed. Though these processes use the mother-infant relationship as a model, they can be applied fruitfully to the patient-therapist relationship (Bégoin-Guignard, 1981; Casoni, 1987; Green, 1974, 1979, 1987, 1990; Joseph, 1991; Kernberg, 1991; McDougall, 1972, 1978, 1982; Meltzer, 1967; Ogden, 1979; Speziale-Bagliacca, 1990). Bégoin-Guignard (1989a), reflecting upon Bion's work, qualifies the therapeutic relationship as a "container-content" relationship in which the analyst must use his ability for normal projective identification to contain his patient's intrusive and pathological use of projective identification. The fact of containing and altering the projected content enables the analyst to formulate an interpretation which may help the patient take back into himself the expelled elements in a manner that would be useful for symbolization and mental activity.

Moreover, Winnicott's (1952, 1956, 1960) conceptions of "handling", "holding" and "good enough mothering" appear to stem from the observation of similar phenomena. Like Bion , Meltzer and Green, Winnicott (1954a, 1954b) also applies these ideas to the patient-analyst relationship. The silent presence of these phenomena in every significant relationship prompted Bégoin-Guignard (1985a) to write that projective identification constitutes the "daily bread" of the human experience: "... the very breath of our unconscious and pre-conscious daily communication with ourselves and others" (p. 295). To summarize, it may be said that for all of these authors, projective identification is viewed not only as a defense mechanism but also as a pre-conscious or unconscious process that permits communication and empathy.

However, compared to the defensive and pathological forms of projective identification, empathy does not rely on splitting of the self, or of internal objects, and thus retains a quality of flexibility, of nuance, that the use of splitting and denial forbid. Without violent splitting, denial and their associated mechanisms, idealization and devaluation of the object; empathic projective identification can become a means of exploring the exernal object's psyche, to experience it through identification without defensively resorting to fantasies concerning the object that mainly belong to the subject's own psyche. This implies that, in some social as well as in therapeutic relationships, one must accept the risk of feeling, through an empathic use of projective identification, unpleasant and sometimes violent affects. In the case of the therapeutic relationship, such affects can be overwhelming and consist of feelings of confusion, despair, death anxiety, or a feeling of idiocy (Bégoin-Guignard, 1985b), especially so when a primitive conflict is involved.

Many authors (Kernberg, 1988, 1991; Meltzer, 1972; Sandler, 1991) have discussed different classifications of the concept of projective identification. In view of these developments since 1946, we propose three different meanings of the term:

1. Intrusive projective identification, defined by Klein as an omnipotent fantasy of penetration into the object. It is mainly described as an anal-sadistic fantasy in which the self, a part of the self or an internal object is imagined as trying to dominate, destroy or control the object of projection. However, an unconscious identificatory relationship is maintained with the object towards whom projective identification is used. Intrusive projective identification is regarded as a defense mechanism based on splitting and associated to psychopathology.

2. Communicative projective identification, described by Bion as a process necessarily involving two individuals. The subject, overwhelmed by an intolerable anxiety and an incapacity to think about certain psychic contents, feels the need to project these agonizing psychic contents into an external object, not only to get rid of them but also in the hope that this object will be able to contain, think about and propose to the subject decontaminated versions of the expelled psychic contents. The unconscious aim of this process is to allow the patient to take back and integrate these contents now rid of the excess anxiety which was associated to them. The communicative aim of projective identification can fail because of the object's incapacity to be used as a psychic container. In such cases, the anxiety felt by the object makes him unable or unwilling to identify with the projected contents. Another reaction could be the development of a complementary identification which is acted out by the object. However, a succesful communicative projective identification promotes psychic growth.

3. Empathic projective identification is explicitly illustrated by the popular sentence "to put oneself in someone's shoes". It concerns the capacity to explore what another person is thinking or feeling by attributing to this person certain thoughts and emotions while maintaining a strong identificatory relationship to him. Such a process is tinged with love and libidinal impulses as opposed to intrusive projective identification which is charged with hostile impulses. Empathic projective identification can be the external object's appropriate answer to a subject's use of a communicative type of projective identification.

Projective identification and containing function: successes and failures

Bion's model of projective identification is helpful in order to think about the successes and failures of certain psychothrerapies when intense transferential crises occur, particularly in those cases when violent acting-outs and acting-ins happen.

Some patients are overwhelmed with an anxiety they feel is unbearable when confronted with certain psychic contents and they experience a relative incapacity of linking these terrifying contents, of containing and transforming them through symbolization. While some patients appear capable of using the therapist as an object capable of a containing function; that is, as an object capable of linking and symbolizing unrepresented or overwhelming psychic material; other patients appear uncapable of such a use of the object. In the first case, the patient, through the use of a projective identification, seems to be able to put into his therapist unthought contents, not so much in order to rid himself of these unthought contents or to attack the therapist but because he has confidence in the containing capacity of the analyst and hopes the object will be able to symbolyze and to link for him such material and render it back in a form which feels less dangerous and more assumable for the ego.

In ideal cases, not withstanding the primitive nature of the projective material and despite the anxiety brought by such projection, the psychotherapist is able to identify himself with what Green (1990) has called the patient's «folie privée». In these cases, the analyst is capable of returning to the patient through an interprative mode, a psychic content which will be useful to him.

However it is much more frequent that this type of interaction gives rise in the therapist to a phase of confusion and an experience of emptyness, of anguish and an inconscient refusal of identificatying with the patient's projected material. Such a phase of confusion and heigthened anxiety can lead to a feeling of deadlock in both partners and bring each partner close to a narcissistic retreat and give way to a tendency to attribute to the other the source of his own anxiety. Often this search, on the part of the patient, for a psychic container for his projective identifications is felt as being too dangerous to the analyst as though he felt persecuted by these projective identifications and needed an important effort of auto-analysis to be able to accept such material. It should be said that even when the fit of projective identification and containing function is ideally met, the therapist and the patient feel their psychic integrity to be in danger. Though both feel the danger of losing his own psychic integrity; on the therapist 's part, it is the risk of identification, in itself, which seems dangerous; however, on the patient's part, it is the fear of losing one's identity in the hands of the other that is felt to be the most threathening.

The unconscious of communicating primitive material through projective identification and containing function is however ridden with difficulties and quite vulnerable to misinterpretation and unconscious resistance on the part of both partners. In an effort to describe such scenarios on the intrapsychic level, we propose four simplified scenarios. Two of which describe a certain unconscious refusal from the therapist to become the object of his patient's projective identification. And two others describing the difficulties which may arise within the patient after having resorted to an attempted communication through projective identification.

On the therapist's part

André Lussier (1994) has already described with subtility the difficulties on the part of the therapist in identifiyng with certain objects of the patient's inner world, noting that such identificatory difficulties can lead to therapeutic failures. Bion (1962b) has also given us profound thoughts on the difficulty of accepting to assume a containing fucntion when the therapist must identify with primitive contents since such identifications imply a necessary encounter with forgotten terrors and the fear of reunion with old demons. In fact, we could very well imagine that the normal reaction on the part of the therapist would be to actively seek distance from such identifications, however since he has explicitely offered himself as an object of transference,this choice is no longer possible. This identificatory «duty» is nevertherless met with some resistance for, as humans, we cannot help but prefer to protect ourselves from such turmoil.

In this sense a most frequent occurence in the psychotherapy of psychotics (Brunet 1995, Brunet, Zaloum & Lamirande 1992, Casoni, 1987) consists for the psychotherapist of not feeling much emotional turmoil, even of feeling empty or absent. In such cases, the therapist is often uncounsciencly protecting himself from identiying with his patient by not permitting himself to be in "his patient's shoes".This resistance probably stems from a fear of an intense encounter within himself with what he is perceiving in a confused manner in the other's psyche. In these instances the therapeutic encounter does not occur. At best, a whole psychic territory will remain split, unknown and unthought; a collusion betweeen therapist and patient is thus consolidated making the therapeutic relationship an inert relationship. At worst, an important regression will take place in the patient who will break down, feeling he has lost the object in which he had placed his hopes.

Another form of identificatory refusal is found in a defensive utilization of the very concept of projective identification. The defensive nature of such an understanding of projective identification manifests itself through the great difficulty the therapist has of identifying with the psychic material presented by the patient. In such a scenario the therapist seems to feel a diffuse anxiety and may perceive in himself hostile fantasies or fear the pressure within himself of primitive material, to protect himself from such distress, the therapist resolves the anxiety awakened within himself in the therapeutic encounter by believing that such affects and their associated psychic material does not belong to himself, as if he was saying: "this was put in me by my patient, such affect and fantasies belong to him and he is depositing them in me through projective identification" . If the therapist feels «empty», for instance, he does not have to analyse for himself this feeling and can attribute it to «the desire of the patient to make him feel empty»; if he feels distrought, to the «desire of the patient to distraught him». Such a "returning to the sender" that is acted out by the therapist appears as a counter-projective identifiaction. Though it appears as of an identificatory nature, it is much more a triumph of an identificatory refusal which secretely permits the therapist to avoid what in himself is split and unthought. Under an apparent use of the concept of projective identification, we find a refusal to act as a containing function and the utilization of a massive projection in replacement. In these cases a therapeutical «non-lieu» must be feared or, even more tragically for the patient, a breakdown of the ego may occur. Racker's (1957) descriptions of concordant and complementary identifications resemble what we are describing here as counter-projective identifications. Winnicott's (1969) description of a transferential counter-transferential collusion could be seen as another such manifestation in which both patient and therapist completly pass by primitive, hostile or psychotic contents to preserve the unity of a false self.

Despite such a resistance on the part of the therapist, we must add that some patients exercice a very intense pressure to force the therapist to identify with a part of them. In some cases, this additionnal pressure may take the form of violent acts in which the aggression seems to be an attempt to force the therapist to invest in the relationship and not stay at the outskirts of the therapeutical encounter. (see the case presentation of Philippe in Brunet, 1995).

On the patient's part

The question of why certain patients seem to be less capable of using the therapist in his containing function must moreover also be adressed. Failure of the linkage between projective identification and containing function cannot always be attributed only to the therapist. There are cases where the patient is unable to use the trasnferential object and will even on the contrary seem to defend himself from such a utilization with stunning determination. Thus, it is necessary to recognise that when a patient tries to communicate a psychic content which he believes can be contained, such a patient seems to be working or thinking on the basis of a fantasy of an object which is both present and reparative. On the contrary, when an intrusive projective identification is in use, the patient seems to be in a position where the anxiety is such that after having expelled a psychic content into the transferential object he feels the need to deny the existence of that object, or as Klein would say to destroy the object, in order to prevent what has been projected from attacking the subject back in a persecutive way. Such fantasies constitute a typical viewpoint in psychosis and is caracteristic of Klein's schizo-paranoid position. What such a patient seems to be attempting uncounsciously is to evacuate his anxiety by projecting it into an object which, having disapeared or been destroyed will take with him his overwhelming anxiety.

Other patients do not feel the defensive necessity of denying the existence of the object after having projected into him some psychic content which feels dangerous to him. Nevertherless these patients are not capable of imagining the object as beeing available to act in a containing function and transform for them these split and projected parts. Though projective identification is resorted to often quite actively, it's communicative aim seems either absent or, at most, not founded on the hope the object will respond to it's communicative aim. In such instances, since the subject cannot hope the transferential object will consent to contain his projections neither will he help him to transform them, he feels the need to deny the importance of the object for him. Clinically this gives rise to a transferential relationship where the patient feels a very great need to minimise and deny all feelings of dependency towards the therapist, a narcississtic retreat and a feeling of envy thus becomes preponderant. Though the need to deny all dependency upon the object assures the ego a sense of narcissistic survival it however contributes actively to boycotting the help potentially offered by the therapist.

In an ideal situation, the subject would be able to recognize not only the existence of the transferential object but he would be capable furthermore of recognizing the importance of his dependency upon the therapist which he would then be able to imagine as beeing available and capable of exercising a containing function with regards to what he has projected upon him. In the first tranferential scenario described, in additioin to an intrusive projective identification, the subject further feels the need to protect himself by denying the very existence of the object because he fears his projections will destroy the object. The use of the object in his containing function is the ground for much resistance on the part of the patient and this constant struggle brings him to feel a great deal of despair . However, in the second descriptive scenario, the subject has difficulty using the containing function of the psycotherapist because he denies the importance of his dependency upon the object; not only is dependency feared per se because of the dread of becoming the extension or the psychic propriety of the transferential object, thus fearing a loss of ego integrity through the ackowledgement of the dependency towards the therapist but dependency might also be feared because of a sense of being overpowered or belittled by recognising in the therapist a capability of helping the patient, the help offered felt to be a narcissistic attack meant to gain not so much control but thriumph over the patient. Thus in such cases, through the use of intrusive projective identification does not entail the need to deny the very existence of the object, it does not permit the patient to yet imagine that the transferential object would really accept helping him. Possibly moreover sometimes in this second scenario, an reversed repetition is played out by the patient who hopes to protect himself by becoming the one who frustrates or refuses to be available for the other's use in answer to an anticipated refusal on the part of the transferential object.

In brief, two defensive patterns regarding the containing fucntion are described on the psychotherapist's part as, in the first case, an identificatory refusal and in the second case, as the utilisation of counter-projective identifications. On the patient's part, the incapacity of using the object in it's containing function as described by Bion does not apear as a fundemental deficiency but rather as a defensive stragegy by which the subject feels he must either deny the very existence of the object, either deny the importance of the dependency relationship towards him.

Rarely, however, do such transferential scenarios present themselves in such a univoqual way for it would mean that not many psychotherapeutic treatments could take place, dynamically evolve or permit psychic growth. Therefore most often do we witness an oscillation betweeen a certain recognition of the existence of the object and of the need for his help, with denial, in some instances, of his very existence and, in other instances, of the patient's dependency upon the transferential object. A great deal of confusion is brought upon by this oscillation for when a patient permits himself to recognize the existence of the object and lets himself see in the therapist an object upon whom he could depend with confidence, he may feel overwhelmed with a terrifiying fear of becoming prisonner of the therapist's influence or even under his total control. Moreover when a defensive strategy based upon denial of the very existence of the transferential object is predominant, the patient is vulnerable to feeling very intense despair, an important feeling of solitude and is often overwhelmed with the terrifying fantasy of not only having lost the object but of having destroyed it. Often despair is also an important though hidden affect for patients who deny the importance of the dependency relationship upon the therapist since quite often such despair is protected against by envious attacks and the presence of a self-feeding rage in the unconscious hope of triumphantly overcoming the feeling of dependency upon the therapist.

The successful building in a therapeutic relationship of the link formed by projective identification and containing function necessitates on the part of the patient a certain capacity of not resorting too exclusively neither on the denial of the existence of the object neither on the denial of the importance of the dependency relationship on the transferential object. On the part of the psychotherapist, this linkage of projective identication and containing function necessitates the capacity to identify and contain what has been awakened within himself of his very own «folie privée» by the patient's projective identifications.

 

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