I wish to compliment the authors on several counts. First, this must be one of the first serious research papers on the Chinese psychoanalytic/psychotherapy experience. Second, the authors tackle a very complex theme adding the possible cultural component as it may affect the analytic process. Third, the authors also suggest some additions to the main theme of the character pathology of the ‘As if’ character structure as described initially by Deutsch in 1942. Fourth, and most important, a relatively inexperienced analyst is willing to expose his technique for all to see and comment upon. This will allow me a rare opportunity to examine the material in detail and focus on very concrete issues, something rare in our literature
I will concentrate on two central points first some problems arising if one uses ‘As if’ structure as a diagnostic organizer and second the nature of the analytic process so candidly described by the author including the nature of the impasses and the supervisory process. As I do not have a complete record of what actually transpired it may well be that some or all the issues I will mention have in fact been tackled and I must apologize if I am repeating some well-known facts.
The problem with the ‘As if’ concept dating from 1942 is that judging from the authors it is purely descriptive in nature and does not include any dynamic or genetic components. As a result, we can see ‘as if’ characteristics in a neurotic, a borderline or even a psychotic organization. This then complicates the choice of a patient for analytic therapy unless one includes the above components to evaluate the fitness for analysis. This was done to some degree by noting her high intellectual functioning
In the case presented, the initial evaluation seemed to confirm the suitability for analytic treatment for this gifted student. Rather quickly some concerns arose. The patient casually mentioned discovering her
mother's affairs yet strangely seemed to have no emotional response to this troubling fact. To my mind this raised a question about the nature of her object relation to her mother or her anger at her or her identification with her behavior.
Very soon her real reason for seeking treatment emerged: her inability to finish her work because she could not allow herself any personal ideas. Instead the patient is bound to copy or follow the professors' own work. At one point she says she was ‘forced to do this’ almost against her will, indicating the need to externalize in a massive way her inner turmoil. This may even suggest a mildly paranoid stance. This also alerts us to the possibility of a major transference issue which would require very close attention in order to move forward. How to treat a patient who will only blindly follow the therapist's lead and avoid any personal involvement of her ‘real self’? The patient also complained of a sense of emptiness and not knowing whom she was. These two are different: emptiness is of potential concern as to the nature of her internal objects, not knowing who she is may be the result of massive repression or of more primitive defenses.
The patient's request that the analyst should help her finish her studies and at the same time allow her remain the same reveals a core conflict. This issue unfortunately was not sufficiently addressed in treatment. The therapist did not address the adaptive nature of her symptoms, i.e., what was the nature of the problems for which copying another person's ideas was a condition for her to survive? There are 2 options: either the ‘as if’ protected her against a frightening inner world or/and, it was the only viable alternative to avoid emptiness, nonbeing, or psychological death.
Even though the patient's childhood seemed relatively normal I suspect some traumas must have occurred early. The scale incident in which she put her father's shoes on top of the mother's brand-new white scales reveals a great deal which does not seem to have been given the importance it deserves : (1) her sneakiness (2) her anger at her mother and most important (3) her anger at her father. It was surprising to me that she was not caught by either parent and properly punished. Did the mother actually believe the father would have been able of such a brazen disregard of the mother's wishes? If so what does it tell us about the nature of their marriage? Also I would wonder at what age did the ‘as if’ personality
emerge? It certainly was not present at age 5 or 6.
The relationship to the father was marked by mutual denial. It seems to me most unusual that he allowed his daughter to sit on his lap and bought her clothes until adulthood. In general, this should have been mother's job suggesting the he replaced an absent mother for this patient. Again, we are not sure whether the apparently Oedipal conflict was a thin cover-up for the much more primitive need for a mother. Unfortunately, an overall view of the patient's psychic functioning is not sufficiently spelled out to allow some orienting guidelines in the analysis.
The transference begins to emerge more clearly when the patient refuses permission for the analyst to see her medical records describing the puzzling symptom of fainting, a psychosomatic event. Is this a profound lack of trust or a fear of being discovered? She is most likely trying to hide something. The patient's belle indifference here does not suggest a hysterical element but more the indifference to their bodies found by Marty in psychosomatic patients. The patient's emptiness comes to mind and I am beginning to suspect deeper pathology suggesting a lack of organizing identity themes and stable mental structure.
Here the analytic compliance becomes a real problem in the transference. The patient needs to follow orders in order to survive. It is useless in such a case to look for free associations—again either because they are too frightening or because the mental structure is missing or because the patient will copy her analyst.
By the second year the patient begins finally to criticize the analyst for her incompetence, insensitivity, and insufficiency. Here, again, this does not seem to have been analyzed. I would have first asked the patient, how was the analyst failing, what was the analyst missing? In addition, we are dealing with both a projective identification and a reversal of roles, i.e., the patient may be showing the analyst how she was treated—a primitive sort of object relations. Her statement that when she sees a baby, she wants to kill it raises questions. Did the mother have a miscarriage? Was the patient terrified of being replaced, or does the baby represent parts of herself she cannot stand. Her murderous aggression is peeking through. Her pathology is revealed. She does not say ‘I have a fantasy I want to hurt it’ or ‘I feel tempted to kill the baby.’ She expresses a murderous
wish with no regret, no guilt or shame. There is here a severe defect in ego ideal and superego. The absence of affect again raises the question of her mental organization. This seems to be part of a disowned psychotic core. The lack of connection and linking also suggest the psychosomatic personality. Bion mentions the lack of linking in borderline or psychotic patients.
The analyst's increasingly irritated attitude towards this patient is multiply determined: in part the patient wants to defeat her, but in part the structure of her personality organization has not been tackled properly. It does not look like the supervisor understood the nature of the pathology or the approach necessary to engage with her. First, one needs to focus on sensory phenomena, on body sensations, and remain at the psychic surface, avoiding deep verbal interpretations that would reveal to the patient what the analyst was thinking, thus fostering her defensive posture. Also not addressed was the desperate nature of the patient's clinging to her character; the choice was to remain empty and disconnected or to destroy the world, including herself.
The analyst's dreams suggest that like certain borderline patients described by the Kleinians, such patients cannot put into words their primitive mental states. They can only evacuate them by putting them in another person. The challenge for the analyst is to be able to contain these states and to convey to the patient something about them, including the massive projective identification.
A few of the actual exchanges between patient and analyst are very revealing. In one example after the analyst tries to explain and cajole the patient into accepting more problematic feelings than she is used to, the patient accedes.
‘I have no choice. I will do as you ask me to do.’ She did not say, ‘I will try,’ or ‘I accept the challenge.’ This leads to as many problems as it tries to resolve.
Again, the analyst did not address this defense. There are however occasional breakthroughs. In one instance the patient tells her analyst that on one occasion she told a friend who was nice to her that she did not like her very much. The latter bursts into tears. Here was an opportunity to point out the danger of being free, and the challenge it might pose for her
in the treatment. Would her analyst also burst into tears, if the patient revealed some negative feelings? As these occasional breakthroughs are rare, they must be exploited like gold. In another instance when the analyst correctly questioned the patient about a 20-minute break she took to go to the bathroom after the start of a session, the patient flew into a rage and said, “Why do you never get to the point? Your questions showed your ignorance. A baby wants a diaper but you gave her food.” The supervisor commented that the patient both shat on the session and wanted the analyst to clean up her shit! I would not go so fast. First I would inquire why the analyst's question about the 20-minute break seemed so out of order. Then I would explore the curious metaphor the patient used about diaper and food.
The choice to move to more supportive treatment in this case makes sense.
I have not addressed the cultural issue raised by the authors, since even if present there is no evidence it interfered with the analytic process. I would imagine that the protective stance adopted in order not to challenge an authoritarian state is a conscious phenomenon shared by many. It is not based particularly on unconscious fantasies, even though it may dovetail with some childhood anxieties concerning the danger of rebelling against one's parents.
I very much appreciate the candor of the presented material which allowed me to explore crucial diagnostic and therapeutic challenges in this very difficult patient.