The Struggle to Know What is Real

There has been long discussion of what is now commonly referred to as the regressed preoedipally organized patient. Such a patient is seen as having a more primitive level of psychic organization than the oedipal patient, with ego and self development, object relations, and drive organization reflecting the primacy of the dyadic maternal relationship in the transference. The countertransference reactions associated with such patients have many similarities, though the specific dynamics and diagnoses may vary widely within these common responses. Such patients may be called by many diagnoses and descriptions—to name a few: borderline personality, difficult-to-treat, regressed, psychotic, and infantile. Many analysts now see such patients; however, I believe that a way of understanding and utilizing the countertransference reactions associated with the analysis of these patients has yet to be fully integrated into our clinical theory, practices, and training procedures.

In the case that will be discussed in this article, the patient, who started analysis as a training control case, was severely regressed and acting out, and had considerable difficulty establishing a sense of reality. This could be thought of both in terms of her relying massively on omnipotent fantasies, and having insufficient affective maturation to sustain reliable and consistent reality testing. The patient used the dyadic transference organized around the denial of reality, commonly seen in the paranoid-schizoid position, to defend against the depression that would result should she progress in the analysis. Her tendency to enact rather than contain strong libidinal and aggressive affects in the transference eventually intensified to include regressive episodes of self-destructive acting out and continual sadomasochistic transference/countertransference