‘Thick-and Thin-Skinned Organisations and Enactment in Borderline and Narcissistic Disorders’ by Anthony W. Bateman

Bateman's paper appeared in the Journal (79: 13-25), and was placed on the journal web site some weeks in advance of publication. It was the ninth paper selected for discussion by the Discussion Group (see the IJPA Home Page for details) and achieved great interest and praise, particularly for its frankness and clarity. In the paper Bateman argued that enactment is ‘any mutual action within the patient/analyst relationship that arises in the context of difficulties in countertransference work’ (1998, p. 13). Such enactment is common during the treatment of borderline and narcissistic disorders. In order to delineate different forms of enactment the author described the analysis of a patient identified with a sadistic mother and who threatened the analyst with a knife during treatment. Three levels of enactment were delineated of which two (a collusive countertransference and a defensive countertransference) were detrimental to analytic work whilst the third was beneficial but only because the intervention made by the analyst was independent of the analytic process, and yet occurred in response to it.

The author stated that enactment was most likely to occur when a patient moved between thick-skinned and thin-skinned narcissistic positions, a conceptual distinction first made by Rosenfeld and which Bateman sought to develop. This movement between thin- and thick-skinned positions, which was a characteristic of borderline psychopathology, also presented an opportunity for interpretation, allowing progress. Bateman considered enactment to be a term embodying ideas related to acting out, acting in, actualisation, repetition, transference and countertransference. There exists no agreed definition of the concept, and this is theoretically and clinically problematical. Two themes regarding enactment tend to emerge in the literature: firstly, enactment is interpersonal, involving action between patient and analyst. This may be ‘actualisation’ of a patient's wished-