There is a group of patients who are overtly functional but who are chronically limited in certain specific aspects of their functioning due to characterological rigidities that cover an underlying propensity to experience psychotic thinking and/or decompensation of varying duration. Many of these patients find their way to our analytic practices where their initial presentations suggest that their difficulties are in the neurotic range. Such a patient presents the analyst with a daunting challenge and an exceptional opportunity for her own growth as well as the patient's.
If the patient is not immediately responsive in some expectable way to the analyst's initial interventions, the analyst begins to sense that the ground beneath the patient's presenting symptoms is less solid and more treacherous than anticipated. As the analyst begins, often gradually, to sense (consciously and/or unconsciously) the extent, seriousness, and pervasiveness of the problem, she has to come to terms with her willingness and capacity to form an attachment to the patient, which will determine whether she can accompany the patient where the patient needs to go emotionally. The analyst's openness to seeking and discovering meaning in the patient's experiences is predicated upon this attachment.
This attachment allows the analyst to develop, maintain, and modify the holding environment (as described by Winnicott) that is crucial for the treatment to proceed. The traditional aspects of the holding environment, i.e., frequency of meetings, tolerance of regression in the content and form of the patient's communications, provision of safety, dependent gratifications, and the attendant development of trust, are necessary. While the provision of interpretations is a typical part of classical psychoanalysis, in analyses of these patients it is equally important what the analyst does not interpret. Some of what the analyst comes to understand about the patient is not interpreted, but is utilized by the analyst in dealing with the patient. Responding to a patient's needs without interpretation is “holding” the patient and his needs. This often helps the patient to maintain some self-cohesion in the face of disruptive affects, especially shame, and distressing life experiences.
Responding to a patient's needs without interpretation is “holding” the patient and his needs.
With some seriously disturbed patients a portion of the content will never be interpreted but will simply form the shape and the nature of the holding environment. As such, it will provide a sense of what the patient comes to count on from the analyst, his expectable analytic environment that “holds” him by its very predictability. Another way to think about this is that it may constitute a parameter in Kurt Eissler's sense; it may or may not eventually be understood and addressed by the patient in the analysis. Analysts make these choices unconsciously, preconsciously, and consciously at different times and in a variety of ways. They fall under the rubric of issues of tact, dosage, and timing, about which analysts make implicit judgments all the time.
These patients often have irrational and/or unrealistic wishes and hopes for rescue, succor, and resolution of problems. For these patients the need for a powerful “other” who can save and protect them is strong, especially during the early phase of the analysis. Often the view of the analyst is excessively idealized and, as Kohut cautioned, the analyst may feel uncomfortable with such idealization. The idealization is often a defense against a fear of abandonment or the expectation of the intentional infliction of pain by the analyst. Such idealizations must be allowed to persist without being endorsed by the analyst until the patient has a sufficiently strengthened ego and self-structure that will allow him to tolerate acknowledging the analyst's failures to meet his needs. The structure of psychoanalysis is ideal for allowing the patient the time and psychological space to develop the capacity to deal with these disappointments.
My understanding of the development of psychotic adjustment started with Winnicott and has been enriched and elaborated by attachment theory. I understand these patients as having experienced neglect, trauma, or multiple traumata during the first years of life to such an extent that their psychic structure has been seriously compromised.
Because the nidus of development of the self is in the first year of life, when these patients have experienced trauma, their difficulties are best understood as occurring in their self-structure. The core difficulty is with their compromised ability to maintain and sustain a cohesive self-structure in the face of the ordinary buffeting of life. This difficulty may manifest itself as problems with affect regulation including self-esteem regulation,
Marlene Kocan, Ph.D., is a clinical psychologist and psychoanalyst in Columbus, Ohio. A graduate of the Post-doctoral Fellowship at The Menninger Foundation and the Cincinnati Psychoanalytic Institute, she was director of psychology at a private psychiatric hospital for 19 years.
intentionality, identity, and relationships with self and others. Affect regulation problems may give rise to psychosomatic symptoms; an approach that focuses on the emotional aspects of these symptoms helps the patient begin to acknowledge his emotional self.
Development during the first year of life is marked by a mixture of hallucination, memory, sensation, perception, and fantasy in the mind of the infant. If the infant is lucky enough to experience optimal frustration, he is able to begin to discriminate between wish- fulfilling hallucination and reality. These patients have to be able to regress in psychoanalysis to a state in which reality and fantasy can coexist unchallenged before they begin to be sorted out. In order to do this, the distinction between memory, fantasy, and hallucination must be left unmade during the prolonged process of the analysis, when they are held in the transitional space of the analytic relationship. During the time these distinctions are not being made, the analyst focuses on clarifying the emotional aspects of these “experiences” rather than on their truth value. An elaboration of these aspects allows the patient to deepen his sense of his own experiencing self and of his continuity in time and space. The growing ability to make the necessary distinctions must and will be made on the patient's timetable.
Because my practice is completely outpatient, the issue of maintaining the occupational role for these patients must be addressed. In my experience, for these patients their occupational role is a central factor in the maintenance of self-cohesion. Some of these patients function adequately or even well in their occupational roles and ensuring their capacity to continue to do so is crucial for their psychological well-being as well as (often) for their ability to continue the treatment. Frequently, issues about occupational functioning consume a large portion of the time in analytic hours. To view this time as spent in the service of maintenance of self-cohesion leads to a very different approach from what one might choose if such a preoccupation were viewed as a neurotic obsessional manifestation. The more useful approach with these patients is to focus on the affects that arise, particularly the wounds to self-esteem and self-cohesion (the approach here is very much in concert with Kohut). The analyst's attachment to the patient with its attendant understanding of the source of the occupational preoccupation is necessary in maintaining the analyst's capacity to attend to the details of the patient's occupational functioning.
This brings to the fore the issue of countertransference, which must be managed throughout the treatment. An understanding of the nature and consequences of trauma during early development can allow the analyst to tolerate and understand the patient's difficult-to-tolerate responses, including the defenses of omnipotence and grandiosity that the patient brings to the analytic setting.
The development of our capacity to engage and hold these patients may allow for an expansion of the range of efficacy for psychoanalysis.