The psychiatric community has been working to establish clear boundaries between different disorders through the revision of diagnostic criteria, while at the same time there have always been clinical phenomena that are difficult to define by the existing clinical diagnostic criteria and thus present ambiguous, paradoxical and changeable characteristics. This paper focuses on this topic. And the theme unfolds through a case study.
The patient was a 27-year-old single, Chinese eternal graduate student. The two years of therapy presented three distinct phases: in the first, she appeared very cooperative, always wanting to respond to the therapist's expectations, but not knowing how to do this. Not only did she have difficulty in free association, but she also could not understand analysts' analytical questions and explanations. At the same time, she also presented difficulties on a series of spontaneous activities. In chess, for example, she doesn't know how to play after completing her initial routine. She can translate between different languages very accurately, but she cannot express herself in words. She can only imitate, not create, in the process of writing her thesis.
At this stage, the patient also showed a drift in treatment goals. Instead of exploring the issue of her mother's affair further in her subsequent therapy, she shifted to two other issues—her being unable to complete her Ph.D. thesis and wanting help to finish it, and her sense of emptiness, of not knowing who she was.
The second phase of treatment repeats the pattern of projective identification. She constantly accuses the analyst of incompetence, insensitivity, insufficiency, and she often finds herself feeling bad, but after the session, feeling nothing, a feeling that gave her relief. She could not understand why she often felt relieved when others were unhappy. At the same time,
the analysts, while aware of the patient's “emptying-out of toxic stuff ” process, are unimpressed by the treatment.
In the third stage, her aggression becomes more and more apparent, and at the same time, the treatment reaches an impasse. Although the analysts repeatedly mentioned in the treatment that there was no progress in the treatment and no breakthrough in the paper, the deadlock existed in parallel, but the deadlock was not broken, and the patient presented a state of “pretending to be dead.” At the same time, the analyst exhibited a characteristic countertransference.
The clinical characteristics of “as-ifness” were well presented through the development of treatment:
The core pathology of “as-ifness” is the patient's automatic “complementarity” to the often unspoken desires of the other, which is the character of the patient's high suggestibility. This is most directly reflected in the patient's unconscious “chameleon-like adaptation pattern.” For example, if different people use the same assessment tool (APP), the assessment results will be totally different depending on the form of assessment (face-to-face direct assessment or indirect assessment). The patient's awareness of the inner desires of her mother and teachers at different times makes for her always being an understanding “good” child and “good” student. That is a way the As-If is different from the narcissistic personality which seeks admiration of others. As-If is affectless, defended (unlike the classically Borderline Personality), and empty.
The patient is passive aggressive. The attacker is passive and submissive, but potentially aggressive. The “white scale incident,” the copycat essay writing and the progressive manifestation of aggression at different stages of treatment all showed this characteristic. This aggression is also reflected in the persistence of the therapeutic stalemate, in which the patient repeatedly accuses the therapist, but in a state of “pretending to be dead,” in which she persists in not changing as a form of her wish not to separate.
The analyst's countertransference has two distinct characteristics. First, the analyst's dreams repeatedly present deformation and violence. Second, the analyst's life is completely different from his habitual emotions and behaviors. In the analyst's dream association, the
patient-analyst relationship is symbolized as virus cell. The greatest feature of a virus is that it makes use of its host cells to replicate itself and, after a seemingly unchanging incubation period, it accumulates its own number and causes the cells to disintegrate. This association symbolizes not only deformation and passive aggression, but also the defects of the self and the primitive object relationship.
Some clinical phenomena suggest possible, latent “as-ifness.” These clinical phenomena include: the diagnosis is ambiguous, constantly changing and controversial; the same assessment tool presents obvious differences due to the different assessment methods adopted by different assessors; treatment often presents a chronic stalemate; the therapist presents a characteristic countertransference.
In addition, the paper also raises some enlightening questions: based on the “as-ifness,” it discusses the influence of settings and different characteristics of therapists on treatment. From the perspective of culture, this paper gives its own thoughts on the “overcompliance” that is common among Chinese adults.