In a prospective China-based study of early phase analysis, we report a case after two years' treatment to demonstrate As-If personality traits, which we suggest is a form of a False-Self. The countertransference enactments revealed the underlying diagnosis. As-If features escaped the initial assessment and manifested itself via projective identification in the analyst's dreams and personal life. This case adds countertransference to complement Deutsch's “As-If” and integrates this concept within the developmental framework of false self (Winnicott, 1965) Giovacchini, 2000). We contribute to 1) diagnosis using the countertransference, and 2) As-If's childhood developmental antecedents.
In 1942, Helena Deutsch described several patients who presented with an emotional relationship to “the outside world and to his own ego [which]2 appears impoverished or absent.” (Deutsch, 1942 p. 301). She called this character deficit in object relatedness, “As-If.” She continued publishing about this clinical presentation for decades, distinguishing this from impostership or hysterical defensive blocking of affect. The three component characteristics she identified include: 1. emptiness; 2. a passive/automaton quality of relatedness (suggestibility); 3. aggressiveness masked by passivity, a “mild amiability…convertible to evil.” Deutsch defined the qualities of the three cases she presents including being unaware of a “lack of emotional bonds and responses” that others notice or a “transitory sense of emotional defect.” The disturbance, we might say today, is projected. Of her three cases, the first is of a “girl… something is wrong with her” who readily orients to new professional
We present this disguised case with written permission of the analyst and analysand. They agreed that disguised material could be used for research purposes. (Gabbard, 1997).
Authors' addition.
techniques, but has a “real loss of cathexis,” and instead has a capacity for mimicry or imitativeness; the second, a woman with a “monkey-like imitation of her brother” in childhood, and others later; the third, a thirty-five year old woman with “many concurrent identifications,” who responded rapidly in treatment in the first six months, then plateaued when the patient decided to become an analyst, then after being rejected by an Institute, “disintegrated.” Deutsch called this a weakness of the ego.3 Paradoxically for a psychoanalytic paper, Deutsch presented minimal clinical material, often offering material from outside the analysis. She even described engaging in extra-analytic frame “parameters” (such as arranging for a job for a patient with an acquaintance) (Kris, 1956). Nor did she offered substantial developmental precursors nor countertransference responses.4 And, she admitted that treatment outcomes were at best modest.
Her as-if paper might have remained an account of a rare phenomenon. But, Winnicott, in a now well-regarded and later paper, described a similar clinical picture, but with far more analytic and developmental material: a patient analyzed by a colleague whom Winnicott knew and respected presented stating that she did not feel better, although she thought well of her previous analyst. Winnicott, listening carefully, found that the patient and her analyst unconsciously had analyzed a False Self, in part to protect her True Self. Giovacchinni developed and expanded this concept further, suggesting that there is a continuum of false/true self in any character structure and therefor the possibility of degrees of pathology (1965).5 Giovacchini suggested the phrase false
Deutsch titled the paper suggesting that As-If might involve some schizophrenic process. But, today and after seven decades of research, we would not use this term, schizophrenic, to describe these patients.
We are not criticizing Deutsch for not including countertransference responses: her paper was published almost fifteen years before Racker's seminal paper on using countertransference in treatment.
These cases share at least phenomenologically a chameleon-like quality with the Monica case described in the 1950's by Engel and Fleischman, later joined by Viederman (1979). Here, a young woman, who as a young child required gastric feeding because of esophageal atresia, developed an ability to get others to aid her (such as in removing her coat) without asking. She could position herself to get assistance. And those who did so (as demonstrated on film), did so without awareness and also without resentment.
social self to clarify that this is adaptation to the external world. That is, we all have (false) social selves—as teachers or analysts or citizens—that distance others (and ourselves) from our private selves. The mark of a pathological “false self” (and one specific manifestation of this, the as-if) is that there is a split, a lack of integration with a true self, a cutting off (Giovacchini, 2000).
Grinker and colleagues published the only book empirically comparing Borderline to As-If character disorders . For As-If, he cites the quality of “complementarity” as central, even pathognomonic: phenomenologically, patients appear driven to complement the interests or leanings of significant others (such as the analyst). In addition, this As-If group is affectless and defended (unlike the classically Borderline Personality). Psychiatrically, these patients are the emotional equivalent of Woody Allen's Zelig, that character who increasingly took on even the physical qualities of those to whom he was drawn(Zelig, 1983). Grinker was able to distinguish Borderline pathology with excellent interrater reliability from As-If.
But since the era of Grinker's more phenomenological approach, Deutsch's phenomenological and symptom-centered approach, analysts have increasingly relied on countertransference to aid diagnosis, particularly in character disorders.6 In this paper, we will emphasize the analytic diagnosis of the countertransference phenomenon: noting the analyst's responses to the As-If patient's relatively rapid adaptation to the analytic setting, followed by the patient's specific difficulty with free-association, and ultimately in a sense that there is no significant
We note here that “countertransference” has taken on multiple meanings not only very different than Freud's (1910. 1915), but also more varied than Heimann (1950) or Racker's . early use of the term. We use it here in terms of feelings and thoughts evoked in the analyst via the predominately nonverbal communication of the patient.(Giovacchini,). In any case, our paper underlines Heimann's statement and emphasizes its application to a diagnosis that can be elusive, like As-If: “…the analyst's emotional response to his patient within the analytic situation represents one of the most important tools for his work. The analyst's counter-transference is an instrument of research into the patient's unconscious.” (Heimann, 1950).
improvement that is not attributed to some sort of imitation or mimicry.7 The analyst expected something more, resulting in an unspoken impasse (Schlesinger, 2014, 2015).
The case we present is unique in at least two dimensions, beyond its being a cross-cultural study. First, prospectively, we have attachment assessments on both patient and analyst at the beginning of treatment, along with anamneses. Second, we have chronic and acute crises (or impasses) in treatment (Schlesinger, 2014, 2015), with the analyst feeling out of sorts with herself later in the treatment, experiencing dreams that seemed unconnected with her inner life (but in retrospect, very connected to the patient) and ultimately acting-out in her intimate life in such a manner that the analyst herself, her supervisor, her own analyst, and her boyfriend felt that she was “not herself.” (Giovacchini, 1990). Ted Jacobs (1973) has written about how his own psychomotor reactions (touching his wedding ring; fingering his ear) were countertransference reactions to the patient's material. Giovacchini has written about how a patient invades the analyst's dreams as part of the treatment (1990). Searles (1979) was a pioneer in recognizing both how the analyst may feel the patient's symptoms impinging and how the patient may have non-human transferences towards the analyst, such as treating the analyst as if she were a tree, or rock, immovable, indestructible. While these phenomena can be understood as manifestations of projective identification (KIein, 1946; Schafer, 2009), our research and life-history material gives additional information on how this manifests in treatment.
Ms. O. is a 27-year-old single, Chinese eternal graduate student at a prestigious Chinese University, in an esoteric field of the humanities. One of her remarkable talents is to learn foreign languages, parroting her teachers, but unable to initiate independent conversations in that language. This served her well in reading texts, translating professionally and taking tests. This treatment took place in China and in
The latter may be considered a form of Sandler's role-responsiveness, a rather specific analytic reaction (not identical with countertransference per Sandler) that is “a compromise between his own tendencies or propensities and the role-relationship which the patient is unconsciously seeking to establish” (Sandler, J. 1976).
Mandarin. The analyst, Dr. X., was in analytic training. Because Ms. O. came to the University clinic, she was initially evaluated by the clinic director, who was analytically-oriented and knew that Dr. X was in analytic training. Therefore, the director assigned Ms. O. to Dr. X. as a case after initial evaluation. Dr. X. also discussed the patient's suitability as a control case with her supervisor, a training analyst, who was trained in the West. Both the director and the analytic supervisor agreed: this patient was a straight-forward success neurosis with some Oedipal issues around mother's affair and father's involvement. Because this was at the University clinic, it was very low fee.
Ms. O. came to treatment initially complaining that her mother had been having an affair. Ms. O. felt oppressed and embarrassed by this. The supervisor and therapist felt that Ms. O. was analyzable given her apparent ego strengths, including completing her bachelor's degree at a competitive University, her multilingual talents and her acceptance into a prestigious, demanding, graduate program. The initial evaluation raised concerns about Ms. O.'s lack of interest in intimacy (including apparent disinterest in sex) and as was learned later, her difficulty completing academic tasks. But, her initial presentation of apparent competence later became a central characteristic of how she could present herself to the world: as others expected or hoped her to be.
The analyst had agreed to participate in a research study of the development of the analytic relationship (organized by the two authors). She was interviewed and she agreed to ask one of her early cases to be interviewed also. The patients were not told that the analysts were also interviewed. The analyst interview included the Adult Attachment Pictures (AAP)8 and an anamnesis; the patient interview included the AAP, an anamnesis, the SCL-90 and after several months, the analyst completed the Shedler-Weston assessment of character of the patient.9 As with any
The AAP was chosen in lieu of the AAI at the suggestion of Carol George, who helped design both measures. The AAP has the same validity and reliability as the AAI, yet takes less time, is based more on projective (rather than question/answer as in the AAI) and is more easily used in cross-cultural, cross-linguistic settings (George and West, 2012)
Since this patient was in the pilot study, she completed only the AAP, an anamnesis, but the analyst completed the Shedler-Weston.
such research, both analyst and patient gave informed consent, and were told only that this was a study of what features facilitate or inhibit analysis. The participants were not told that the AAP assessed attachment.
Ms. O initially explained that mother asked the father to take a business trip for a few months. When the father tried to call his wife in the evening, and nobody answered the phone, he phoned the patient was who lived living in a different city, asking her to phone her mother and to find out if she knew where her mother was. Of course, the patient couldn't reach the mother either. So the father returned home and found mother in flagrante. Paradoxically, after the initial assessment, once treatment began, the patient never pursued this further, instead raising other concerns for treatment.
She now said that her chief concern was that she was unable to complete her Ph.D. thesis and wanted help to finish. She picked this therapist after an internet search, learning that the therapist had completed her graduate work and medical degree at the same university, spoke her native language and was fluent in several others. She also complained of a sense of emptiness, of not knowing who she was.
While clearly very knowledgeable, Ms. O. had been working on her thesis for several years with no end in sight and no sense that she can work productively. Yet, interestingly, in a demanding University and field, she had a thesis advisor and department chair who kept finding ways to keep her on as a student with various fellowships and excuses to the University that she was making progress. When her department pressed her to at least complete a Master's thesis, her supervisor called her daily to be sure she was writing this. When she presented the thesis to her supervisor, he read it in Ms. O.'s presence and angrily threw it into the trash stating that this was terrible, unoriginal, and imitative of his own work. Ms. O. silently agreed with him, but stated flatly in treatment, “Of course it was not original; he forced me to do this.”
The analyst tried to clarify whether there might be some masochistic submission to the supervisor (submitting to write the thesis so as not
to lose him). But the patient seemed untouched by this interpretation: she explained, as if the analyst were too dense to understand this, he wanted a paper, she wrote it and imitated what he had written before, rather than charting new territory, as one would expect in a thesis. She did what she did best, she explained: to conform to what another person needed so that he wouldn't perturb her.
Further, when the student presented and defended her Master's thesis orally, other members of the committee criticized it severely. Then, Ms. O's supervisor rose to her defense, as she sat quietly. When the committee passed her, the patient found it irritating. She complained to her analyst, “Why did they pass my degree thesis? I did a such bad job.” This became a repeated theme of her academic life: imitating previous work (without overt plagiarism), being protected by professors or academic administrators (without sexual favors); being kept on as a student and her sense of resentment, even as she didn't want to finish or leave. Also she admitted that she was unhappy when she overheard her supervisor describe her as a “potentially academic woman, if she were diligent.” She was afraid that she might become an “academic woman”; it was not her, she insisted. But she couldn't state what kind of “her” she thought herself to be. This became a recurrent theme in treatment also: the patient's overt objection to “changing,” becoming healthier. Over time, the patient stated with frustration that the analyst should help her stay the same, while simultaneously asking for help to finish her studies (Schlesinger, 2015).
We select aspects of her history that give a sense of family dynamics.
She was the only child, born after a normal pregnancy. Both parents worked long hours fervently at menial jobs.
When she was 5 or 6 years old, her mother bought an immaculate white scale. Her mother forbade anybody step on it with shoes. One day while her parents were napping, Ms. O. secretly put her father's shoes on the scale. Her mother thought her father violated her rule, became very angry and harangued him for a month. When the analyst explored the element of sneakiness and the possibility of hostility to the father, the patient—as usual, matter-of-factly, with bland affect—intimated that
she knew that her mother didn't want the scale soiled and also that her mother had it in for the father: putting his shoes on the scale, in her mind, served the mother's need to rail at the father. This appears to be an early example of Deutsch's “aggressiveness masked by passivity.”
She recalls that as a young girl, her mother told her that she looked ugly and wasn't cheerful. The patient's response was to buy a mirror and practice changing her facial expressions so that she looked cheerful. She succeeded in deceiving her mother by changing her facial expressions. Several years later, in her adolescence, her mother commented that another boy looked ugly and not cheerful. The patient reminded her that mother had said that of patient when she was younger. Mother, shocked, claimed she had never said such a thing.
The patient described a comfortably intimate yet allegedly asexual relationship with her father. For instance, this women in her mid-twenties continues to sit on his lap, even at some meals, without a sense of sexualization and she denied a history of molestation. Her father in turn, still pays for her expenses and buys her clothes. She said that she couldn't buy clothes for herself, because she relied on her father's taste; specifically, she didn't want to offend him by picking her own style. In fact, she was at a loss of what was her own style. She said that she sensed that her father liked her to sit in his lap and that he enjoyed buying her clothes, so she complied with these.
Academically, from early childhood, the patient attracted attention of teachers and school principals, who believed she was very smart and treated her preferentially. One middle school teacher said, “I wish Ms. O were here, then I wouldn't have to do all the teaching.” Also her English teacher gave assignments to copy an English text ten times. Ms. O. copied it once and submitted it without signing her name; her teacher never mentioned that she did not finish. One day, the English teacher gave the same assignment to all the students in the class. The teacher came to her came to her secretly and whispered in her ear, “This is the assignment for other kids, you only have to copy once.” Her unspoken reaction was “You don't know that I have been doing this all the time?” along with a feeling of surprise and mild disdain for the teacher.
Little more came spontaneously of her childhood history; she showed little curiosity about this part of her life; saw no reason to bring that into treatment.10
Medically, her life history had areas of vagueness about medical complaints and multiple, complex assessments with inconclusive results. Yet, Ms. O. showed little concern about these medical symptoms. For instance, Ms. O. said that she had had fainting spells since early childhood to the present. When these spells increased in frequency during the treatment, and no doctor could diagnose these, the analyst offered to review her medical records with her, but the patient said that her father had all the records and she delayed for over a year to retrieve them (and refused permission for the analyst to correspond with the various medical centers nor her neurologists and cardiologists). Therefore, for a significant period of time, the analyst relied on the patient report. Ms. O. said that multiple exams—both cardiological, neurological and sleep studies—could not pinpoint the etiology of her fainting. By Ms. O's report, during these episodes, she at times remained aware of her surroundings, but could not respond (sounding like cataleptic episodes). In light of this, her analyst suggested a sleep study, which the patient never performed, saying, “I'm not in a hurry.” Her cardiac studies showed occasional respiratory atrial slowing (a normal variant). When the patient finally agreed to get the records from her father, these confirmed multiple assessments from age five with no definitive diagnosis. In supervision, the analyst and supervisor discussed the analyst's concern about her patient's physical well-being, the patient's apparent la belle indifference, and how this seemed also to derail the pair from intrapsychic and transference/countertransference inquiry. The supervisor initiated concerns about the patient's suitability for analysis, particularly as a first
André Green stated that he saw an interest in childhood origins of one's ailments, at least towards the middle or end of treatment, as a criterion for calling a process psychoanalysis (personal communication, 2008). While we do not agree that this is a necessary component, we mention his idea in light of this patients sense that she saw no reason to bother with this material, except insofar as it might pique the analyst's interest. She had read also that childhood material was a component of psychoanalysis, so she was willing to present that.
case for an analytic trainee, a case that may need many years for analytic process, progress and resolution.11
The analyst's supervisor raised the possibility of the analyst acting-out by becoming so involved in suggesting medical assessments, even as the analysand kept refusing permission to contact her doctors, yet kept reporting worrisome medical symptoms. When the patient refused to permit contact with other physicians, the patient insisted she wanted to protect her confidentiality.
The patient was puzzled about free association. She asked the analyst to “teach” her how to do this, to give some examples. When the analyst asked her to say whatever came to mind, the patient responded with a story from childhood exemplifying her inability to move beyond imitation.
As a child, her parents sent her to learn the strategy game, “Go.” Yet, her teacher found that Ms. O could not play after the first few steps: one needs to use one's initiative to continue. Also Ms. O found it uncomfortable to finish a teacher's assignment in which the teacher said, “You can write anything related to this article.” If told what to write, she could and can do so. As mentioned above, she enjoyed learning foreign languages, provided she could parrot them, and not be required to initiate conversation. She was a valued translator, as she did not have to say things spontaneously, only translate exactly what was said. Even trivial things in her daily life were hard to initiate without someone showing her how to do them, such as swiping her Metro card on a bus. Therefore, being asked to say whatever comes to mind was a particular challenge to her. She asked, “Can you give me an example of what a patient should do?”
Ms. O. had read that one should report dreams in psychoanalysis. So, she did. She reported a recurrent nightmare from five years of age: she is sitting on a bicycle seat as her father is pedaling; then her father disappears and she is left alone on the moving bicycle. She could not give associations. When the analyst explored if she felt she needed direction,
The supervisor's thoughts are particularly remarkable in that he was renowned for his writings on severe character disorders. That is, he was not someone who would be expected to shrink from treating such cases.
or if she feared her own impulses when left alone, the analysand reacted blandly. Again, as with the lap-sitting, the analyst wondered about possible early trauma and the apparent incestuous quality of the bicycle dream. but the patient denied any such history. Ms. O. didn't know what to do with these interpretations. The analyst had a sense that the patient was trying to be compliant, but unable to say whatever came to her mind, except to respond to the analyst's expectations.
By the second year of treatment, the patient began quietly criticizing the analyst's incompetence, insensitivity, insufficiency. Yet, the patient persisted in treatment and in fact on multiple occasions stated that before session she felt bad, but after session, “felt nothing,” a feeling that gave her relief.12 She also said, without making a connection to the treatment, that she found that she would make other people angry or miserable and she felt better, unburdened when this happened, and also puzzled about why they had reacted so negatively.
On occasion, her latent aggression burst more overtly to the surface—one of Deutsch's observations. Early in treatment, after seeing a mother and infant while en route to her appointment, Ms. O. arrived, announcing, “When I see glass, I want to break it; when I see a baby, I want to kill it.” This was said with no affect. When asked about how this might be related to the work in the office, Ms. O. shrugged and said she saw no connection.
In a complementary manner to the patient's latent aggression, the analyst did note that she felt increasingly irritated by the patient and the lack of progress, even as she could see that the patient did feel better by the ends of sessions. Intellectually and in supervision, she could understand this process as a kind of emptying-out of toxic stuff (David Rosenfeld, 1992). Yet, the analyst felt a chronic sense of strain: that she did not look forward to the sessions, even as she felt obligated to the patient (Flarsheim, 1977). In her own analysis, she could clarify her style of being overly dedicated, persistent, very hard-working; all these were consistent with her culture and family style and were highly adaptive in her being able to succeed in getting advanced degrees.
This is the opposite of Giovachinni's patient who generated content-less anxiety to avoid feeling dead (2000).
Vicissitudes of the treatment arose in supervision, a form of parallel process (Ekstein and Wallerstein, 1959). The therapist and supervisor could not come to a clear sense of the patient's diagnosis, particularly about her character structure. They vacillated between some degree of severe character disorder,13 but, at moments, wondered to what degree there was a sociopathic quality to her behavior: something more in the realm of conscious use of and manipulation of others. This puzzled both the analyst and her supervisor, as the pathologies lie structurally in different areas of the psyche: sociopathy being primarily a pathology of superego (and consequently a deficit in object relatedness; severe personality disorders (in the borderline—narcissistic continuum (Giovacchini, 2000)) being character deficits involving the ego and object relatedness. But, the supervisor also noted that he generally was not preoccupied with phenomenological diagnoses with patients in analytic work: he explained that at this point, his concern was the patient's suitability for an analytic process, particularly with a young candidate analyst. The supervisor wondered whether it might take many years for this patient to engage in an analytic process, if ever.14
In the research interview for attachment, the analyst was found to be “secure.”15 The patient's initially rating (done by a trainee who interviewed the patient face-to-face and was still achieving reliability) was “secure.” Yet, when the patient's AAP narrative was later rated by someone fully trained in AAP rating (CG), but who had not met the patient, she was found to show a rare form of Insecure, Disorganized: these individuals can appear to be securely attached on initial presentation (as was found
While she did not fit the criteria listed by Kernberg (1995), her ego deficits suggested a severe character disorder.
We recognize that there are schools of thought in analysis that the question of “suitability” for analysis, might be better phrased as suitability with a particular analyst (Giovacchini, 2000). In this sense the supervisor's concern was not whether the patient was suitable for analysis per se; rather how long it would take for an acceptable analytic process, given the analyst's need to have a case that shows progress within an Institute's time-frame.
That is, someone who's working model suggests that when faced with anxiety or fear, the person has an ability to seek both safety and comfort from another. The secure individual also shows good exploration (from a secure base). (Ainsworth, Blehar, Waters, Wall, 1978)
to be the case with the a small number of earlier children rated as secure on the Strange Situation, who were later found to be insecure/disorganized).16 We will discuss below how this initial “misrating” is consistent with the as-ifness of the patient, specifically her unconscious capacity to “read” and accommodate to the interests of needs of those whom she meets, such as face-to-face contact with an research interviewer. That is, with a face-to-face interview, the interviewer was led by the patient's chameleon-like accommodation to believe that she had secure attachment: only when the interview was read “blindly” by a very experienced interviewer, did the insecure attachment come through.
Another indicator of a problematic treatment was the lack of movement in the treatment (and in the patient's life), a quality that Schlesinger describes as consistent with chronic impasses (2014). Furthermore, the analyst and supervisor both had the sense that the patient was comfortably uncomfortable in her life stasis; while complaining about parents or graduate work, she defended against any possible shifts in her life position; she dug in her heels to remain in place. At one such point, six months into treatment, the patient describes this as “pretending to be dead.”
“A: After six months here… tell me what you want to achieve here.
P: (Silent, but appearing blank, removed.)
A: What are your thoughts or feelings?
P: No thoughts, I am not thinking anything, I am just doing nothing, I call it pretending to be dead.
A: Tell me more about “pretending to be dead”
Crittenden has postulated a fourth version of insecure attachment with mixed dismissive and disorganized qualities that are manifest in a sociopathic-like picture: these individuals show an ability to read fairly accurately others' reactions, but then use this knowledge to the individual's benefit, often to the detriment of the other person (Szajnberg, Crittenden 1997). While this category needs further study, it does capture the puzzling relatedness of an as-if or possibly Deutsch's impostor but in attachment terms.
P: From time to time I will get into this state that I am doing nothing, not thinking. Usually when I am taking shower or staying in my bed, until somebody disturbs me.“
When the analyst followed by asking if the patient felt “disturbed” by the analyst's questions, the patient blithely said, “No.”
In the second year of treatment, there was a similar, but more detailed exchange: The patient complained that she still could not progress in writing an original work (required for her Ph.D.). The analyst raised this issue with the intent to raise the issue of a similar stasis in her analytic work.
A: Under what conditions do you think you can work?
P: The only way I could work is to trick myself: like I turn on my computer, and tell myself that I am not going to do any work now, I am only going to edit my format, maybe I then accidentally write two or three pages. But as it went on (sic), it became harder and harder to deceive myself.
A: You present yourself as a very smart person: I don't think you can deceive yourself for long.
P: That's the problem. Eventually it won't work. Then I cannot work.
…
A: Sometimes I find that you lead me into a labyrinth. And I feel what you tell me are like red herrings to lead me astray.
P: Until you told me I did not realize that. I thought I only did this to other people, not here. I did not intend to do it to you.
A: Why do you feel you do it?
P: Because it works better. I had a friend who was very nice to me. One day we went shopping together. I told her honestly that I did not like her very much. She burst into tears. So, I decided I just won't tell her in that way, honestly.
But I don't know how to solve this problem. I might just have gotten used to it, I cannot control it. Some thoughts just come into my head; I have not
idea how they came in. And you ask me to say whatever is in my mind, then what I am going to do about this?
…
A: I have a feeling that you want to stay the way you are, just as you object to your University and professor trying to help you graduate, become an academic. Yet, treatment is predicated on change. Do you like to try a different way to deal with your issues?
P: I agree with you: if I want to enhance my own defense against bad feelings I don't need you.
A: But my way of working may result in your experiencing more feeling and emotions. If so, do you want to continue trying?
P: I have no choice; I will do as you ask me to do.
Attempts to connect the patient's sense of stasis in her academic work (and her contradictory protests against finishing her thesis) to her analytic work were met with the patient's agreement in a matter-of-fact manner and her not wanting to pursue this further. She both complained about the analyst's lack of ability to “help her,” yet foreclosed possibilities of change in treatment and in herself. It became more evident in the analyst's discussion with her supervisor (discussed further below) that the patient wanted desperately to remain the same.
What Deutsch described as “aggressiveness masked by passivity,” is unmasked when two years into treatment, the analyst asks again what the analysand thinks and feels are necessary for her life to change.
A: Under what condition, you can imagine, that you can move on to your life?
P: There is one situation, all the people who know my past have died.
Of course, the analyst was now in the category of those who know her past. More worrisome, the patient too is someone who (to some degree) knows her past. Yet the patient had a blasé reaction to such attempts at interpretation.
Then, in the course of chronic stasis over two years, two acute crises
occurred: 1) a series of nightmares in the analyst; 2) an acting-out within the analyst's personal life over two days during which she felt out of sorts with herself (and was identified as inconsistent with her analysis and commented on by her boyfriend.) That is, while the patient's life presented as a continuum of tedious sameness and the patient experienced emptiness, the analyst felt acute disturbances associated with the patient and even spilling over into the session.
First, the analyst's dreams and associations (We report the associations after both dreams):
“There is a killer in the town, who kidnaped and killed many people. The police search for and rescue the victims. A woman is “guiding” traffic; she is kidnaped by the two guys, (the killer has transformed into two killers). She is dragged into a car, and brought back to their storage room with many other people they kept.
The two killers gave her a knife, and demanded, “Cut yourself, otherwise we will kill you.” She cut herself many times as they had instructed. Finally they said, “This will be the last cut: cut your arm in this direction, you might die if the cut is going left, but you might be released if you cut to the right. She cut herself, knowing she might be dead after this one, but the two killers tried to grab her knife and stab her heart. She struggled with them.
Dream Two:
There is a group of pupils on an air train. They can see everything outside. The killer has spread the viscera and flesh of his victims on the train track. It is too late to stop the train, all the pupils saw all the terrible scene—body parts over the track. They were scared. They tried to close their eyes, but they knew that the terrible scene was still there.
When the pupils were back to school, they are frightened to go out. So they were placed into a secure building, you have to enter the security code to get in. One boy went out, he is walking through a plaza to another building, which looks like a shopping mall. He saw two little kids (one 5 year old and one 3 year old) were outside the building, so he went back to the building door, and entered the code. then he went to another building. Just before he got in, those two kids dragged him out. They beat him noisily,
so people in the shopping mall went out to see what happened. Then they accused the boy of hitting them.
The boy was shocked; he did not know how to defend himself. When he returned to his own building, he thought everybody knew what's happened in the lobby, where he changed his shoes. He saw other boys sitting and chatting, and he worried that they might bully him.
We share the analyst's report of her associations as it is related to this case.17 She discussed these with both her analyst and her supervisor. First, they had a consensus that the primitivity and harshness of the dreams were inconsistent with her work in her personal analysis (and her sense of self). That is, a characteristic of both dreams was that they felt out of sorts with the analyst's sense of herself and her high level of functioning. Second, her associations began with talking about this particular patient, also an unusual course in her work: other patients were never brought into the analyst's dream life.
The associations were unique in that for both dreams, she found herself thinking of the patient as a virus and herself as a human cell. The virus association was initially to the second dream—letting two little boys into the lobby of the secure building, who then transform into murderous bullies—but also to the first dream—the killers kidnapping someone who was trying to keep traffic safe, then “forcing” her to mutilate herself under threat of death.
The analyst explained that in her mind, a virus has four characteristics: first, to “disguise” itself in order to use the eukaryotic cell for its own replication, then bursts its host cell's membrane in order to invade others, eventually destroying the organism. Second, the virus is encapsulated, armored, so that it can both invade the cell and also be invulnerable to antibodies and cytoplasmic protections: the invaded cell can't “identify” that there is an invader. Third, viruses multiply only in order to multiply; they never evolve into a more mature organism, yet are powerful in their simplicity. Fourth, the virus is “dead” inside; it has only the genetic material to replicate by taking over its host. That is, the virus comes truly alive only when it enters its host, then destroys it. These countertransference
For confidentiality, the analyst did not report the more personal associations connected with her life outside this patient's treatment.
thoughts relate to Searles' observation that primitive patients may have non-human transferences towards the analyst (Searles, 1960), to which this analyst reacts countertransferentially in a non-human manner.
The analyst reported feeling powerfully impressed with how she associated to this patient as both so primitive and yet also so nefarious; Ms. O. using her character “armor” to disguise herself in order to use the analyst's inner life to replicate, yet Ms. O. remains unchanged. These terms captured the analyst's sense of how she felt about the two years of work with this patient. The analyst was also distressed to find herself thinking of the patient as so primitive, so virulent—like a virus. This was unlike how the analyst thought of other patients. Paradoxically, the analyst felt that this patient was dormant in her daily life (literally secluded to her room, except to shop for food or come to session), yet became lively only in session, but with a sense of destroying the analyst's mind. We will discuss below how this countertransference response captures the third component of Deutsch's brief allusion to the hidden hostility in such patients, an allusion that she does not illustrate fully, but we believe we can with this analyst's reactions.
The analyst was able to recognize how she felt that this patient's destructive aspects had gotten under her skin, insinuated itself into the analyst. This happened incrementally, so that only after two years, did the analyst feel suddenly as if she were about to “burst,” as if the viral aspects of the patient had multiplied and were ready to destroy the analyst's “membrane.”
But, it was the enactment by the analyst after two unusual, sequential sessions that helped her recognize how she had incorporated the destructive aspects of the process of the treatment.
In one session, the patient arrived on time, then after a few minutes, excused herself to use the restroom, which was near the office. After some twenty minutes, the patient returned, saying, “I had to take time to use the restroom, take a shit.” Then, the patient quickly proceeded with other material related to complaints about her parents or her inability to finish her thesis. When the analyst asked about the twenty minute break in session, Ms. O. complained, “Why do you never get to the point? Your questions showed your ignorance. A baby wants a diaper, but you gave
her food.” Her supervisor speculated that the patient both shat on the session and wanted the analyst to clean up her shit.
What happened next in this session was out of the ordinary for this analyst. As the patient was immersed in intense emotions about her various life dilemmas, and the patient was the last person that day, the analyst ran over by twenty minutes, to “make up” (in her later rationalization) for the time the patient was in the toilet. The patient simply expected the analyst to do something like this, and did not find it out of the ordinary. In fact, the patient complained after the added twenty minutes that she hadn't finished what she was trying to tell the analyst and felt she couldn't wait two days until the next scheduled session. The analyst responded by offering an additional session the next day, a weekend, again at the end of the day.
The analyst returned home late for a planned dinner with her boyfriend, who was impatiently waiting to leave with her for their reservation. He noted and remarked as she entered that her facial expression was different: she appeared stone-faced, stunned, then she became annoyed, even angry. When he mentioned this to her, the analyst burst into tears, saying that she hadn't finished her work with her last patient and asked her boyfriend not to holler at her. (The analyst reports in retrospect that he had not in fact raised his voice). Both he and she were surprised at the outburst. She explained to him only that there were some exigencies of this particular treatment.
The next day, she mentioned that she would again return home late. When her boyfriend asked if it was because of this same patient, the analyst again did something very out of character for her—she felt she had to keep this “liaison” with this patient secret, so she told her boyfriend it was for another patient.
It was after these two episodes and when she sought further supervision (with one of the researchers/co-author, and after her supervisor's agreement) that she realized how much the patient had gotten under her skin, how little the patient had improved during the course of two years intensive work, and more specifically, how the analyst had taken in the toxic aspects of the patient, including a sense of secret collusion (with associated guilt) for not having helped Ms. O. sufficiently.
Her analytic supervisor insisted that the case be shifted into supportive psychotherapy, as it would not qualify as a control case. The analyst's reactions were complex and conflicted. On the one hand, she thought that perhaps her taking in what she presumed to be at least some components of the patient's psychopathology and to identify the characteristics in her mind that might be enactments of the patient's life, was a major movement forward in working with this patient. On the other hand, she felt relieved not to continue with this patient in analytic work, given that this would not be considered an appropriate case for this training program.
Deutsch first began writing about as-if in 1934, then published her definitive English version in 1942, later refining the distinction between as-if and imposter in 1954: while both share traits, the impostor feels something is wrong with himself; the as-if does not have this subjective ego dystonic sense, but evokes it in others. Finally, a major panel for Am Psa, discussed the broader application of As-If.
When Winnicott introduced the concept of False (and True) Self, he did not refer to Deutsch. Yet, False Self and As-if share qualities and may be on a continuum of pathology.18 Furthermore, Winnicott, unlike Deutsch, gives a sense of how one can adapt technique to successfully treat the False Self. What is missing overtly from Deutsch's account is evidence of a True Self; yet her description of As-If fits those of a False Self. Giovacchini then broadens Winnicott's idea by giving a continuum of character pathology, as well as developmental etiology and how one can use psychoanalytic technique to treat such patients.
But, the first step is to recognize the character pathology as As-If/False Self. To miss this is to be caught up in webs of various shifting diagnoses which speak to how the patient adapts in order to fulfill the expectations of that analyst. In this case, the analyst and supervisor vacillated
For instance, when writing about the development of a False Self, Winnicott explains, “The mother…is not able to implement the infant's omnipotence… (the mother) substitutes her own gesture which is to be given a sense of compliance of the infant.” (DWW, 1960 in The Maturational Processes and the Facilitating Environment, p. 145). This infant “compliance” describes the as-if-ness described by Deutsch, also referred to as “complementarity” by Grinker et al. (1968)
between sociopathy and a kind of helpless Borderline (Kernberg, 1995).
This case is further instructive since it was part of a prospective study of attachment in both analyst and analysand. Yet, it also shows the vulnerability of in-person assessment when the pathology involves As-If qualities. The trainee who had administered the patient's AAP—that is, had face-to-face contact—scored it as “secure.” Only later, when the AAP was rated by a trained rater who was blind to the patient and her history, did we learn of the Insecure/Disorganized rating. That is, contact with the patient resulted in an inaccurate attachment rating; we suspect that the patient was able to “read” the facial expressions or vocal intonations (Ekman, 2007) of the AAP administrator and accommodate to that person's expectation of secure attachment.
But, this paper gives more specific evidence—focussing on countertransference—that was not present in Deutsch's paper, of how the patient's core pathology—having a self that, at some (unconscious) level, presents chameleon-like in response to the outside world's expectations—was taken in by the analyst and manifested itself in dreams and in more intimate behavior that was out-of-sorts with the analyst's fundamental being. We note in particular that Deutsch's remarks about a hidden hostility (without clinical data to portray this) is captured not only in the patient's actions (shitting in session; critiquing the analyst's abilities), but especially in the analyst's countertransference dreams. Deutsch presented her work before the neo-Kleinians, and others (like Giovacchini), fully articulated the phenomenon of projective identification. Giovacchini (2000) describes this in the analytic frame as follows: the analyst's mind is a playground to work out the patient's pathology, with the patient exploring how the analyst can handle aliquots of the patient's pathology. This is simply another specific version of transference (and the corresponding countertransference). But, when the patient's core pathology is to shift surface pathology to accommodate to the perceived interests of the analyst, diagnosis becomes more critical and challenging.
We are given several hints in the treatment about the undiagnosed, underlying as-ifness. First, the analyst and her supervisor kept vacillating through at least two almost contending diagnoses: borderline versus sociopathy (the latter diagnosis containing more conscious intent). Second, the prospective attachment assessment, when scored by the person who
administered the measure, resulted in an inaccurate rating corrected only when re-rated by someone who not only was an expert rater, but also had never met the patient. Third, the sense of chronic impasses in the work, specifically with the patient presenting different, shifting primary complaints (mother's affair, incomplete thesis, finding a mate), added to concern that something was being missed by supervisor and analyst. We recall that Schlesinger finds that in many chronic impasses there exists an unspoken argument between patient and analyst (Schlesinger, 2015). This again highlights Deutsch's remark about “aggressiveness masked by passivity,” a kind of hidden hostility, which however manifests more overtly in the transference. Overall, the patient demonstrated the three characteristic features of Deutsch's As-If: 1. a sense of emptiness; 2. a passive/automaton relatedness; 3. aggressiveness masked by passivity. Our contribution is to articulate with the analyst's material how the patient's projective identifications19 are manifested in the countertransference. For the analyst, however, incorporating the patient's pathology into the analyst's dream life, and ultimately family life, brought “alive” the nature of the As-If pathology. That is, for As-If, in relying on the patient alone without examining the interpersonal context, one may miss earlier diagnosis. Including countertransference as a component of diagnosis takes into account how the analyst's needs or wishes result in the patient's complementary adaptations.
The clinical material and the analyst's reactions raise questions about what in the “As-If” structure might affect another analyst's
Because there are so many varying definitions of “projective identification,” we are using the most recent, lengthy and complete definition from Auchincloss and Samberg's Psychoanalytic Terms and Concepts (p. 203-5). They begin by describing “a process whereby unwanted, split-off parts of the self are forced into the object so as to control the object from inside,” but they refine this with the lengthy debates, such as Klein and her followers not distinguishing between projection and projective identification, or Ogden's expansion of Bion's work or Rosenfeld's (, ) distinction between communicative versus evacuative projective identifications. But, as noted earlier, the term projective identification is itself a redundancy, as “a subjective factor is intrinsic to every perception…(and)ß involved in all significant object relations.” (Giovacchini, 2000, p. 44)
Including the “need” for a “proper” control case as we discuss below.
countertransference (We put aside the more encompassing diagnosis of False Self for the moment.). It is entirely possible that another analyst—with different personality structure, or with greater clinical expertise, or who is not working under the rubric of training and the demands of a control case—might have different reactions. But, this is an empirical question which can be answered by others with similar As-If cases. The intent of this paper, in part, is to pose these questions so that they may be considered by other practitioners. This also is a valid form of psychoanalytic research: encouraging colleagues to think on their own work after description of a relatively rarely reported diagnosis, and one with a long history of unsatisfactory outcomes, even by Deutsch's account. Is this analyst's overall reaction—generally a sense of feeling out-of-sorts with the ways she is dreaming and even acting—a form of enactment of how this patient might have felt as an infant or child—feeling out-of-sorts as she lived and dreamed-out the expectations of her parents? We argue that this may be the central pathognomonic feature of the analyst's reactions: the sense of feeling, thinking and behaving in a manner that seems inconsistent with her core (True) self.
We also, in the previous paragraph, raise questions about the impact being in supervision had on the treatment. The analyst was both employed by the University mental health clinic and in analytic supervision. Of course, the analyst will feel a sense of responsibility and responsiveness to both the clinic director and the supervisor. But this general state of affairs would not explain the specific As-If diagnosis: otherwise we would find a multitude of “As-If” cases in all supervised analyses. We give evidence that this patient's history is consistent with the three criteria that Deutsch articulated for As-If. Our contribution is to ask that the analyst's countertransference also be taken into account to aid in diagnosis not only of the patient, but also of problems in treatment course. One specific effect of supervision upon this particular case is the decision, by the analytic supervisor with the support of the University clinic director, that the treatment be shifted to supportive rather than analytic. One might argue that the analyst's dreams and enactments might have been “break-throughs” for the analytic treatment, which a practitioner in solo practice, and unconcerned about whether the treatment is accepted as a control case, might have chosen to pursue in an analytic treatment. In fact, the analytic countertransference may support Rosenfeld's view that
“the desire to get inside the object becomes very intense (when) the object is felt to be separate from the self and possessed of good and valuable qualities” (Rosenfeld in Auchincloss and Samberg . This patient may have begun to sense the analyst's despair that no progress seemed to take place after two years. We do not justify the decision by clinic director and analytic supervisor; we can only state the outcome.
Another complication is the nature of doing research. While we agree that any research can have some effect upon the analytic process, we do not find that this research resulted in a multitude of As-If diagnoses: this case is the only one of twenty such cases. A general discussion of the impact of empirical research upon analyses—a rare enterprise in our discipline (Wallerstein, 2014)—is beyond the scope and space of this case report, but should be pursued further.
There are at least two larger issues raised by this As-If case treated in China: the relationship between mind and society and the cross-cultural value of psychoanalysis; and the nature of psychoanalysis performed in totalitarian or authoritarian societies. These issues are too broad to be discussed fully here, but we refer to a larger body of work on both topics [Cooper and Lausada, RD Laing, Esterson, Ffytche and Pick , Wallerstein (2014), Adorno et al. , Arendt , Showalter , André Green (), Gillian Isaacs Russel (2015)], and make some preliminary remarks based on our experiences.
We suggest considering that there may be an inverse conceptual relationship between As-If and narcissism and related to cultural context. Someone with narcissistic pathology seeks admiration of others, thrives on this (Kohut, 1984; Kernberg, 1995; Giovacchini, 2000; Szajnberg, 2005). The As-If individual seeks a chameleon-like (unconsciously) adaptation to the often-unspoken desires of the other. It is not yet clear what motivates the As-If, although it may be related to our finding of Disorganized Attachment. That is, experiencing a chronic sense of separation anxiety and being without a clear working model of how to achieve safety and comfort, the As-If may have developed an adaptive mechanism of becoming like the other in order to keep that person present. This may explain this patient's disinterest (not just inability) in finishing her graduate program: her aim is to remain in the presence of her advisors, not to leave them or have them leave her. She also does not
want to be admired by them, nor is she particularly admiring of them. The core issue in As-If is preventing separation and individuation by a chameleon-like imitation.
The second author has been supervising Chinese analytic therapists practicing in China for some four years. There appears to be a prevalence of forme fruste character trait—a kind of overcompliance—in many of the adult cases presented. That is, while we have not heard of another case with precise As-If diagnosis, we hear elements in the transference of overcompliance with the therapist or analyst, attempts to “read” the expectations of others. Under the rubric of respect for elders (a Confucian concept that was subsumed by the regime under Mao), some patients try to fulfill what they think the therapist desires. If an aim of psychoanalysis is greater autonomy (“self-rule,” from the Greek), greater freedom, then these aims can be foreshortened by an attitude (cultural though it may be) of trying to read the expectations, desires of an authority figure and accommodate to these .
China remains a totalitarian/authoritarian society with increasingly restrictive access to the outside world. In China, “reading” the expectations of a person (or bureaucracy) in power and complying with these are “adaptive” traits.21 This accommodation to the other has at least two external motivators: first, the long-standing Chinese (and Asian) emphasis on dependence (rather than independence) (Paul, 2013) and saving
The first author, who is native Chinese, adds some historical evidence to the governmentally-supported adaptation of self for the sake of others. In the 1990's, the Communist regime permitted only one cartoon to be imported, Baba. In brief, this primitively-drawn cartoon from France has a character, Baba, who appears like a blob. It cannot talk with clarity. People first are frightened of Baba and finally jail it in a zoo. But, Baba hears people in distress because of a fire. Baba learns that he can transform his shape for the sake of others: for instance, becoming a staircase to save the people in the apartment, or becoming a jail to capture an escaped lion. After this, people value Baba. Not only was this cartoon sanctioned by the government, but also she and her peers enjoyed watching this movie. One parent commented that it was important to listen to what the government says to do and to not speak contrary. This vignette shows that in normal development (that is, not necessarily towards As-Ifness), it was encouraged in China to adapt to the needs of others, not to one's inner life (which is never alluded to in the cartoon, in any case).
face (Loewenberg, 2011); second, the more recent Communist emphasis on adapting to the needs of ideology, of the government. An extreme example of this was the era of the Cultural Revolution.
From a psychoanalytic perspective of increasing autonomy, “self-rule,” and independence by being able to integrate inner and outer worlds, feelings and thoughts, such compliance would be considered maladaptive. We suggest considering that extreme compliance/complementarity (or, both reading and bending to the expectations of someone in power) may be both a form of False Self development (including one's sense of alienation from one's True Self), and a state of mind and behavior that has conscious, preconscious (such as scanning for other's emotions) and possibly unconscious components. In this sense, the As-If lies on a continuum of this culture-specific compliance. This is an empirical question to be resolved with further study.22 Nevertheless, Fromm cautions us about drawing simple lines of causality between a society and personality traits: in Escape from Freedom, he argues persuasively, even after achieving external political freedom following the Enlightenment in many Western societies, that many people in these democratic societies “run” from the responsibilities that freedom entails. Bettelheim, in his book on the Concentration Camps, argues, from the other side, the importance of trying to maintain an autonomous mind in a mass age. This paper intends only to raise these questions for further study and discussion.
We present this paper as a cautionary note and to emphasize the importance of accurate diagnosis including countertransferences, particularly for this version of character pathology. We also present this as the first report in a prospective, China-based study of attachment and psychoanalysis.
Lasch, The Culture of Narcissism (1979).