I was fortunate enough to be given a copy of this paper during my first year at the Cotswold Community. There were many times I felt completely useless and helpless in attempting to meet the needs of emotionally unintegrated boys. Reading this paper helped to find the courage to continue and during my career I have read it several times.
Helplessness in the Helpers
By Gerald Adler. [British Journal of Medical Psychology (1972) 45]
Traditionally, clinical descriptions of psychoanalytic work have elaborated a ‘one-person psychology’. The sparsity of material about the analyst’s feelings and comments has supported the fantasy of the classical image of the ‘analyst as a mirror’. We can certainly understand his reluctance to let others know that he can be very uncomfortable with specific feelings within himself during aspects of his work with a patient, not understand what is going on for long stretches, or even make mistakes. Many of us reserve a few close, trusted relationships with colleagues for the mutual sharing of distress in our work with problem patients. Yet the careful and honest reporting by such workers as Searles (1965), Little (1960, 1966) and Greenson (1967) has demonstrated the importance of the analyst’s personal attitudes and feelings towards his patient for the understanding of the analytic process and the limitations of the patient and / or the analyst in their work.
In this paper I want to describe problems analysts and therapists and their patients face when confronted with feelings of helplessness and hopelessness that both feel with conviction during the course of psychoanalysis and psychotherapy. I believe that such feelings in patients and their therapists are inevitable companions in the treatment of many patients, and especially manifest in work with certain difficult ones. And the inability of the therapist to understand and stand these feelings is an important limitation in the successful therapy with such patients. I also think it is particularly important to examine therapists’ feelings of helplessness at this time because of its relevance to the current state of training and service needs in the mental health professions. We are in the midst of a revolution of innovation as well as refinement of older treatment methods, in response to long-waited recognition of the effects of poverty and real deprivation on people’s lives. We also recognise that there is a paucity of mental health personnel available to implement the implications of this new awareness. One result of this revolution is that we have many more possibilities now in formulating a treatment plan for a patient or family. My concern today is that attractive new treatment modalities that promise more rapid results can at the same time turn our attention from some crucial tasks in the training of mental health professionals, i.e. the development and nurturance of the capacities in them to empathise with their patients, to be able to stand the discomforts of what they empathically hear, and to be able to use their own affective responses to the patient as part of their evaluation of the patient and the way to proceed therapeutically.
Not all people can or want to develop their empathic capacities as a major therapeutic tool, and they do not have to. The mental health field is broad enough for workers to make important contributions in many different areas. A student can determine the direction of his training through the choice of a specific graduate programme. However, it is more likely today than in the past that a person choosing a training programme to help him develop this empathic capacity may later find that he did not get what he signed up for.
Traditionally, many training centres have stressed helping trainees become aware of these issues in working with patients and families. Now, however, we have provided new ways out when things get tough in individual work, e.g. a treatment plan that quickly turns to drugs or couple, group or family work. Here I am referring to the defensive use of such treatment choices, not an appropriate choice of one or more of these modalities based on a careful empathic assessment of patient and family. To illustrate this further, I recall a psychiatric resident who could usually be counted on to see a couple in therapy when an individual patient had been referred to him. When his work was reviewed, it became clear that each time he reached a point with his patient in which he was moved by the patient’s despair, his response was, ‘Why don’t you bring your husband (or wife) in for the next session?”
My discussion of feelings of helplessness and hopelessness is an attempt to broaden our understanding of some obstacles in the empathic psychotherapeutic and psychoanalytic work with some difficult patients, some of whom are part of the group of people previously described as ‘unworkable’ by traditional psychotherapeutic methods. I hope it will also contribute to better work with neurotic patients who can arouse these feelings in therapists as elements of their pre-genital conflicts are relived in the therapeutic encounter.
My interest in problems of helplessness and hopelessness in psychotherapists arises from my attempts to make sense of some of my own experiences. As a first-year psychiatric resident I became aware of a reaction when I worked with some difficult patients and felt particularly lost and helpless. I would have the thought, ‘If only my supervisor were here; he’d tell me what to do’. Since he didn’t appear at that moment, I would try something I recalled him discussing or demonstrating with a patient. Sometimes it would work, to my relief and delight, but often it would not. I then might feel angry that his advice was not good anyhow, or probably, more often, depressed and hopeless that I wasn’t my supervisor and could not do what he could do. As my training proceeded, the syndrome I am describing continued; in fact, it got worse, for more names were added to it. But the essence of the syndrome was the same: my helplessness with a patient, the summoning of an image of the omnipotent teacher who in his own work with such a patient would have no trouble doing what I could not, and my gratified, depressed or angry responses after my attempts to carry out his fantasised intervention.
Years of struggling with these images have led me to put things in perspective, or at least some perspective. I began to see my omnipotent teachers more as people as I came to know them personally, found some almost as helpless as I was when confronted with a difficult patient, heard some disagree with each other on the treatment of a specific patient, and even disagree with what they themselves had said to me the week before, though I rarely had the courage to confront them with it. Also, as part of my evolution as a therapist, I discovered a few years ago that there was an occasional person in training who would summon up my image idealistically and ambivalently to rescue him – even while I was still having episodes of feeling helpless in my own work with patients.
I finally had to conclude that feelings of helplessness and hopelessness were part of the burden I had to bear as a therapist, and that I was not alone in experiencing them. I also began to see that these feelings tended to come up with greatest intensity in certain kinds of patients who had certain things in common. And, in spite of my best intentions, I found myself repeatedly hopeless, helpless, and furious with those patients and fantasising different ways to get back at them or get rid of them.
Let me now define the kinds of patients and their problems that I feel tend to elicit the most marked feelings of helplessness and hopelessness in their therapists.
These patients may present as insistently and urgently demanding, clinging, or empty on an intense or low-keyed level and yet find that any response of the therapist does not give them the answer or relief they seek (Giovacchini, 1970). If something the therapist does or says helps, it is usually for a short period of time, followed by an increasingly justified plea for further relief. When these patients begin therapy in a positive way, they usually maintain a view that their therapist is omnipotent (Kohut, 1968) and capable of gratifying and ‘curing’ them. After the inevitable disappointment of these wishes, they may regress to the described demanding unsatisfied position. When questioned about details of what they really want, they often become vague. But usually they can allude to a therapist who understands them fully and does not have to question them, since he intuitively knows what they feel and want. And of course their specific therapist is not that person. No matter how much he may try, the therapist hears that his responses are off the mark, not enough, or just plain stupid. And no matter how hard the therapist works, this kind of response from the patient seems to persist.
Helplessness and hopelessness begin to appear in the therapist as he finds that he can do nothing right (Giovacchini, 1970). In addition, the patient may repeatedly attack and devalue the therapist, supporting the therapist’s feeling of inadequacy and inability to give anything of worth. If the therapist gets increasingly angry, the patient uses it to confirm his initial conviction that the therapist was basically inadequate from the start. At the same time, if the therapist can stand back for a moment to look at it, he can sense a certain delight in his patient when he finally sees his therapist helpless and hopeless in fury and depression. The barrage of demands and attacks may subside for a while, the therapist finally convinced that he is forming a good relationship with his patient and that they are making progress at last. But then comes a disappointment in the patient’s life or in his relationship with the therapist, and the angry, demanding, clinging assaults return, as if the lull and positive relationship just before had never existed.
If we look at this group of patients in more detail we find that they are usually fixated at, or have retreated to a position involving a life and death battle with the important people in their lives (Adler, 1970; Kernberg, 1967; Little, 1960, 1966). Their concerns in this struggle are whether they will devour or be devoured, destroy or be destroyed. As part of this struggle they can alternate between swallowing and merging, or destroying the person completely through their biting, tearing anger, or by rejecting him. In therapy they can live out a constant expectation of abandonment and provoke the therapist to reject and hurt them. Helplessness and hopelessness, accompanied by severe depression and suicidal preoccupation are often seen in these patients. Inevitably, they can involve their therapist in their life and death, helpless and hopeless dilemma.
Depending upon complex constitutional factors and environmental experiences, these patients may exhibit varying capacities to test reality, to relate on higher levels with another person, to work productively, and to maintain control of their impulses. Diagnostically, these patients include psychotics, borderlines, and severe character disorders. In addition, relatively healthy psychoneurotic patients with a well walled-over and unresolved oral ambivalent conflict can show some of the manifestations outlined as patient and therapist reopen it, though rarely with the intensity that I am describing. In these neurotic patients the therapist is often faced with a choice of opening these areas based on his assessment that this is necessary for the patient to achieve mutually agreed-upon goals.
How can we understand the helplessness and hopelessness of these patients? And why does it have such an impact on us? Let me first summarise what I believe are some major factors in this understanding, and then amplify and illustrate them.
I feel that on the deepest level these patients have a firm conviction that they will ultimately find themselves alone and empty, having been abandoned and disappointed by the person they turn to, or because they drove away or destroyed that person upon whom they depend (Adler, 1970). The experience is akin to that of annihilation and nothingness (Little, 1960, 1966). This conviction is also based on the state of their internal objects: these patients cannot maintain an internal image of a basically helpful person without it being overwhelmed or lost because of negative introjects or feelings. In addition, I believe that these patients re-experience in the transference a situation of early, overwhelming abandonment, loss, and fury with a repetition of very early helplessness and hopelessness, either felt alone and/or perceived as really present in an important early figure. Ultimately, these feelings of helplessness and hopelessness have to become part of the psychotherapy as similar feelings are experienced with the therapist as object.
The intensity of the feeling of loss and abandonment experienced by this group of patients has been described and illustrated by Bowlby et al. (1952) and Robertson (1956) in their observations of very small children separated from or losing a mother, and by Winnicott (1960) in his writing about the early mother-child relationship. The very small child depends upon the ‘good enough mother’ to respond to his needs often enough, and to sense the limits of his capacity to stand frustration at a specific time and age. The ‘good enough mothers’ are not particularly afraid of their own, or their child’s, anger and can be firm when they have to frustrate. They can do this because they have confidence in their basic goodness and capacity to care and give without having to hurt and retaliate for old hurts. These mothers have clearly been able to internalise relationships with the good objects in their lives and make them a solid part of their identity. Children raised by such mothers are ultimately certain they can depend on them and trust them; as they grow they can carry away within themselves this basic solid relationship. When such a relationship with a ‘good enough mother’ has not occurred or been adequate enough, the frightening helplessness of the very small child remains, or reappears when a loss is threatened. Repeated experiences of lack of sensitivity to his needs can lead to the child’s or adult’s rage of abandonment turning into helplessness, a state of feeling annihilated, and then hopelessness and despair. The global rage of such a small child is never significantly modified, and can reappear after disappointments as a primitive, frightening, rejecting hate. The overwhelmed mother, in addition to her lack of sensitivity and relative or actual abandonment of her child, also presents the model of helplessness and inability to cope with her own emptiness and anger.
I have mentioned these patients’ difficulties with internalisation of objects. I have stressed it because of my experience that this is a major factor in their long-standing helplessness and hopelessness, and in their difficulties in psychotherapy. Kernberg (1967) has described the problem of ‘splitting’ in the borderline. I feel that splitting is an important defence mechanism in this entire group of patients and also present in neurotic patients as pregenital conflicts emerge in psychotherapy and psychoanalysis. In Kleinian terms, people who use splitting as a major defence are still in the paranoid position, and have not achieved the capacity to tolerate loving and hating toward the same person at the same time. In splitting, the loving and hating may alternative over time, i.e. the patient may love the same person one minute, and immediately thereafter relate to him with hatred as if the loving relationship never existed. Such a person may intellectually be aware that he is splitting, but affectively the alternations are a vivid and dominant force in his life.
As part of splitting, a person can sometimes be aware of emptiness, helplessness, hopelessness, and despair. He is empty when he has only badness within himself with all the good gone from him and perhaps only visible outside in someone else. He is helpless in the face of the storm of good and bad around and within him, but with goodness not permanently inside. If he acts at a moment when he is in touch with good loving interactions with earlier people in his life, he cannot count on their permanence. In a period of lack of gratification which may follow his positive action, and which arouses fury in him, all the good can be lost. He is then helplessly buffeted by the badness inside as well as his projections of it outside. His hopelessness, depression, and despair can occur with the feeling that he is in the midst of an insoluble dilemma that permits him no consistent core experience of self-esteem and of the constancy of good internal objects. He also cannot count on current people in his life because he has projected his destructive and aggressive feelings on to them or provoked them to treat him in such a way to justify his distrust of them. And he may either destroy, devalue, or reject anything they attempt to offer.
This is often the situation between therapist and patient in the heat of involvement. The therapist’s helplessness and hopelessness in seeing these alternating states in the patient or a persistence of anger and devaluation with little evidence that there is any internalisation of anything good from therapy mirrors the patient’s own similar but usually more intense experience. And the therapist’s helplessness is compounded by the patient’s need to reject or destroy anything the therapist tries to offer during much of this time. Inevitably the therapist’s rage is aroused, resulting in possible serious consequences: he may, for example, sadistically attack his patient, confront him angrily about his narcissistic entitlement, withdraw emotionally, terminate, switch therapists or kind of treatment, or find some way to get the patient to leave therapy.
Part of the therapist’s rage can be understood as follows: we are willing to give, understand, and be helpful, but we expect something back as a reward. What may be a major distinction between one therapist and another is what and how much he can give and what and how soon he expects something back from his patient. With the group of patients I am discussing, that part of all of us is stressed even those of us who feel we have achieved high levels of altruism. And there is no better way to bring it out in us than in our work with a patient who repeatedly tells us he is helpless and hopeless, and demonstrates repeatedly that or giving is not enough, or valueless, or non-existent, even minutes after it was previously acknowledged, and that ultimately all our giving attempts are rejected and destroyed.
In addition, the therapist’s feeling of helplessness and hopelessness may be his counter-transference empathic response to the patient’s experience of annihilation and wish for fusion in the presence of the therapist. The helpless rage of the patient that can lead to the experience of annihilation can empathically frighten and enrage his therapist. When not understood by the therapist it can lead to the described ways the therapist can use to turn off or get rid of the patient.
In examining and reconstructing these patients’ histories, it is striking how often the turmoil and helplessness that patient ant therapist experience was a part of the patient’s early life. Either their mother was emotionally unavailable, or alternately smothering and depriving. Frequently, the mothers themselves were severely depressed and feeling helpless during the child’s early years. Precipitants for this depression in the mother include death of a parent, loss of an earlier pregnancy, death of a child before the patient was born, or threatened or actual break-up of the marriage. These mothers sometimes had severe postpartum depressions or psychoses. The conflicts of this group of patients may remarkably parallel those of their mothers at that time. And the manifestations of helplessness that arise in the patient and therapist may be recreations of this early mother-child relationship. Occasionally the overwhelming helplessness experienced by the patient in childhood can be projected on to the mother and is experienced as coming from her. But I suspect that, more often than not, the helplessness was a real part of these mothers. The re-experiencing of this early mother-child helplessness may be an inevitable part of the psychotherapy with these patients, and can become an important part of the therapeutic work.
I have described this theoretical model before giving a detailed clinical example because I have found it important for me in my work with such patients. It provides me with the understanding and distance that make work with intense feelings of patients tolerable to me. I hope that it is also theoretically correct.
The patient I want to discuss presents another question that derives from my previous remarks: how important is it for a therapist to like such a patient from the beginning? The therapist may be able to anticipate the hard times ahead while still in the evaluation period. Should he agree to continue to work with a patient if he has serious or some doubts about his capacity to have a genuine liking and respect for the patient? And what happens if the therapist is not sure, but increasingly has doubts about his caring, and respect for, and interest in his patient as therapy proceeds? And is a similar feeling important in the patient, i.e. does he feel, early in his work with his therapist, that he has chosen the right therapist with qualities he feels are essential, and with a basic liking and respecting as an important early ingredient? And how can both patient and therapist exercise this choice in their early and later negotiations?
The patient was a 28 year old accountant who came for treatment because he felt he was not advancing in his work, but primarily because he could not form any lasting relationships with women. Though of average height, he was thin, awkward, and adolescent in his gestures and voice. His sitting position from the start was characteristic of how he related to me for years: he would slouch and practically lay on the chair, talking to the overhead lighting fixture, the picture to the left of my head, or the window to the right. He spoke with a soft Southern drawl in a way that was aloof and distant, yet at the same time could summon up articulate and bitingly humorous descriptions of his work, his past, and the few people in his current world. He could readily define the major disappointments in his life which determined his responses to people ever since: his mother, who had held, hugged, and hovered over him for the first five years of his life had abandoned him for his newborn sister. To him it felt like being an infant that was suddenly thrown off his mother’s lap. He tried to woo her back by adopting her loving, smiling fundamentalist religious position, which included a denial of jealousy or anger. He also tried turning to his brusque, busy father who scorned him for his awkwardness and weakness. He struggled to love, but at the same time found himself vomiting up the lunches his mother packed for him to eat in school in the first grade. Gradually the vomiting included food he ate at home. His friendships at school were jeopardised by his need to report to his mother the nasty things the other children said and did; he agreed with her that he would never think such naughty thoughts himself. During his adolescence he became increasingly preoccupied with thoughts of inadvertently hurting people, which culminated in marked anxiety in his early 20s when he became afraid that he would stab pregnant women in the abdomen. This anxiety led him to his college health service and his first experience with psychotherapy.
In spite of these difficulties he did well academically in high school, spent two years in the navy, where he felt liberated, and was able to complete college successfully. His relationships with women consisted of looking at them from afar, actively fantasising closeness and hugging, but actual contacts were awkward and brief. He could form more sustained but distant relationships with men, but was transiently concerned that he might be a homosexual at the time he was discharged from the navy.
His previous psychotherapy occurred during his last year at college. He had felt frightened and desperate, and quickly saw his therapist as a man who had rescued him. His therapist was a psychiatric resident whom the patient described as large, athletic ‘like a football player’, smoking big fat cigars, and who actively gave advice and was very real and direct with him. In looking back at this therapy, my patient felt that it helped him to diminish his preoccupations and anxieties, but had left him still unable to form lasting, satisfying relationships with people. It had stopped before he felt ready, because his therapist, after one year of work with the patient, had finished his training and left the area. When I first saw the patient six years later he defined his problem as a chronic one which he felt he could not solve alone. Yet he felt pessimistic that anything could be done to change things.
This patient was one of my first private patients and really puzzled me. I was impressed by his wish to work, his loneliness and isolation, and the frightening quality of his anger implied by his earlier symptoms. I was concerned about his aloofness and distance from me; I did not feel he or I were making contact with each other, but did not know what to do about it. At that point in my experience I could not even formulate the question of how much I liked him and whether that was important. However, I did recognise that he had a choice of whether he wished to see me regularly and offered him that opportunity at the end of our first meeting. He replied that he was willing to see me, and felt that one hour a week was what he had in mind.
From my perception of the first few months of our meetings, nothing much seemed to happen. He gave me more history to fill out the outline of his life and told me more about the emptiness of his current existence; but all with a manner that shut me out and maintained an amused distance. He became a patient about whom I would sigh wearily before inviting him in. Because of my distress and increasing boredom, I began to point out as tactfully as I could the way he was avoiding contact with me and keeping me out of his world. His response was a quick glance, and then a slow unfolding over a number of months, with an insistent sameness, that he had made a mistake. He did not know how to tell it to me, but I was not the right therapist for him. In addition to my soft voice and mild manner, I probably had never been in a bar in my life, had never been in a fist fight, and did not smoke cigars. He would then speak with affection about his previous therapist, and again spell out the vast differences between us. When I could sometimes recover from what occasionally felt like a devastating personal attack. I would try to help him look at the meaning of what he was saying. I would relate it to his relationship with his mother, his fury at her abandoning him, and his wish to turn to the other parent, who also let him down; and often I could point to specific parallels. Usually he rejected these interpretations as incorrect, irrelevant, and worthless. He would also deny that he felt any anger at me when I would point out the obvious attacking quality of many of his statements. How could he be angry when he wasn’t even involved or cared, he would reply. Over a nine month period I went through stages of boredom, withdrawal, fury, depression, and helplessness. I gradually began to feel like a broken record, and had run out of any new ideas except the increasing acknowledgement that maybe he was right: I probably was not the therapist for him. With relief I suggested that he see a consultant who would help us make that determination. I also had to acknowledge to myself that my narcissism was on the line. To fail with one of my first private patients, and also because of so many alleged personal inadequacies, was more that I wished to face at that time. Also, I had chosen a consultant I greatly respected, adding to my concerns about revealing my inadequacies as a therapist. The consultant felt that therapy had certainly been stalemated, but largely because of the infrequency of the visits and the lack of confidence I had in the worth of my work with the patient. He minimised my insistence that the patient did not feel I was the right therapist. He stated that in his interview with the patient the patient had told about what he did not like, but also conveyed a respect for our work and some willingness to continue with me. After the consultation I ambivalently negotiated with this patient for psychoanalytic treatment involving the use of the couch and five meetings a week. With the reassurance that at least my consultant loved me, I arranged to have him continue as my supervisor.
Psychoanalysis with this patient lasted for four more years. The position he took in our earlier therapy was maintained, but this time amplified and understood by dreams and memories that verified previous hypotheses. Clarifications about his murderous rage that appeared in dreams made it somewhat safer to talk about his fury with me. Gradually he could speak intellectually about the possibility of an involvement with me, but it was something he never really felt. Only on two occasions did he feel real anger at me, both leading to near-disruption of the analysis. One followed my inflexibility when he wanted to change an appointment, and led to his calling the consultant in order to request a change of analyst. The other occurred toward the end of analysis, when I pointed out his need to maintain a paranoid position in relation to people. It resulted in his storming out of the hour and phoning that he was never returning – which lasted through one missed session. Gradually, I became personally more comfortable with this patient, though seeing him was always hard work. I felt much less helpless and hopeless as I say his attacks, isolation and distance in the context of a theoretical framework and part of the transference and defence against it. My supervisor’s support and clarifications helped me to maintain this distance. But my helplessness was still present when my interpretations were rejected for long periods of time and I was treated as some non-human appendage to my chair. I often felt hopeless that we would ever achieve the goals we set out for. I say ‘we’, but usually it felt like ‘I’ and ‘him’, with little sense of our working together. I frequently had to ask myself whether I liked him enough to suffer with him all those years, but had to grudgingly acknowledge that in spite of everything, I did. Somehow, the process of long-term work with him had made me feel like a parent with a difficult child who could finally come to accept any change at all in that child with happiness. And the changes that occurred were presented to me casually and minimised. They consisted of passing comments about his increasing ability to date women, and led ultimately to his marrying a woman with whom he could share mutual tenderness.
I feel that certain aspects of this patient’s defensive structure and transference that emerged in analysis made working with this patient particularly difficult for me. He was reliving a relationship of helplessness and hopelessness with his mother. Not only did he feel abandoned by her when his sister was born, but was allowed no direct way to express the anger and jealousy he experienced. He chose to comply on the surface, but maintained an aloof, disparaging distance with her that protected him against his fury, helplessness, and despair. Since he did this with his mother to stay alive, he understandably repeated the same pattern with me – complying on the surface, but vomiting up and rejecting what I attempted to give. In a sense, he never left that position with me; he was able to change the quality of relationships outside of analysis, but maintained his aloofness with me to the end. He would say that to show real change with me was to acknowledge that he had taken something from me and kept it as part of himself; he just did not want to do that openly, for he would have to admit the importance of our relationship and how grateful he was. His compromise was to remain very much the same with me: to change significantly outside, and then ascribe the changes to things he could take from the new important people in his life.
Though I feel satisfied with the results of my work with this patient, I still sometimes wonder whether I was the right analyst for him. Perhaps if he had seen someone who could remind him more of his father as his first therapist had, the intensity of the mother transference would have been less and he would have found it safe to feel more about his mother with the analyst.
How does a therapist avoid the difficulties I have described when feelings of helplessness and hopelessness arise in therapy? Since I believe that intense feelings of helplessness are inevitable in both patient and therapist in the treatment of this group of patients, we deny the human qualities of people to expect a therapist to maintain a therapeutic position throughout his work when he feels so much. What then can we say about the therapeutic position with these patients and how can we help a therapist remain useful as much as possible in his work with them?
In the heat of battle a tendency for counter-transference regression is certain. The ultimate ability of the therapist to recover some distance and an observing ego is a crucial ingredient in such stressful work (Adler, 1970). The therapist’s capacity to grow during his own analysis, and use his counter-transference responses diagnostically and empathically are crucial with these patients (Heimann, 1950, 1956).
The therapist has to accept, as part of his human frailties, that hatred within himself for these patients is expectable, and can be put to therapeutic use in assessing what the patient is experiencing. Though the hatred is obviously the therapist’s own, it is often experienced at that moment because of a projection or provocation on the part of the patient. This awareness can support the therapist in exploring what the patient feels and why.
The regressive counter-transference situation often places the therapist in a position of feeling he literally has to rescue and comfort the patient (Heimann, 1956, 1957). The patient demands and expects the rescue from the omnipotent parent, and the therapist, as that parent, feels he has to respond. The inability of the therapist to see this as an essential part of the transference experience with such patients leads to his tendency to respond with a rescuing, smothering, gratifying, yet frightening message. For many patients this provides temporary relief. But, ultimately, this therapist-response provokes increasing regression in the patient, who perceives that the therapist sees him as the helpless child who has to be held and saved from disaster. Inevitably, demands increase, the patient regresses more, and often ultimately rejects and devalues in his increasing fury. The therapist who began as the rescuer ends up feeling as helpless and furious as the patient. The capacity of the therapist to anticipate this transference-counter- transference situation is crucial. He also has to anticipate variations of this theme. But once he sees it, the therapist is more able to control his helpless and angry feelings so that he does not attack the patient sadistically in what he feels is a useful clarification, interpretation, or confrontation. It is at such times that the therapist may confront his patient with his narcissistic entitlement or infantile wishes rejectingly and sadistically, though the therapist may feel that he is trying to help his patient see something important. The mechanism is poorly defined by which a therapist transforms his sadistic hate into a useful, productive therapeutic tool. But those therapists who can do it use their counter-transference regressive tendencies as a signal to convert their helplessness and fury into a force to help a patient understand and stand what is happening and how therapist and patient can both master it. In effect the therapist is also providing the patient with a model for identification in the mastery of unbearable feelings and their constructive uses and a corrective emotional experience in contrast to the mutual helplessness of the original mother-child setting. And a major part of the corrective emotional experience very much follows Winnicott’s (1969) beautiful description of the patient finding that he cannot destroy the object. As part of this work, the therapist ultimately assists the patient to recognise that he has increasing choices as he masters and understands.
Yet for certain patients at certain times a concrete physical expression of concern and caring is necessary to provide the setting for a corrective emotional experience. Little (1966) and Balint (1968) describe such instances and at the same time discuss the dangers of poor timing and indiscriminate use.
It is obviously easier to talk about the issue of rescuing patients versus helping them see the choices they can have than to do it successfully with this group of patients. The art of being a good therapist consists in part of a sensitivity which can weigh how much a patient is genuinely overwhelmed and needs to be fed symbolically, and how much he can stand and examine at a specific moment. The ‘good enough mother’ aspect of the therapist ultimately determines whether the patient has a corrective emotional experience as part of therapy or a pathological experience similar to that of his early childhood. As many authors have described, limit-setting is an important ingredient in a group of patients whose wishes are enormous, and whose impulse control is often tenuous, and may become even more so in the heat of the transference. But the vicissitudes of the therapist’s helplessness and fury determine whether the limits are part of a firm, caring, facilitating operation, or a punitive, attacking, rejecting and envious assault.
Should the more difficult patients I have described be seen in more than once weekly therapy, and should the therapist ever make the transference manifestations an important part of their work? Zetzel (1971) has stressed the regressive potential of these patients in intensive treatment. In my experience such patients do not necessarily regress behaviourally when they are involved in intensive psychotherapy and psychoanalysis, i.e. two to five times a week. Whether they do or do not regress depends in part on whether their therapist can respond and give when the patient genuinely needs it, with clarifications and interpreting on the appropriate developmental level (Little, 1960, 1966), and withhold when the patient is capable of standing it. As I have described, the therapist who only gives, and then does not recognise the patient’s increasing strengths at a later time, communicates to his patient that he is only in touch with the patient’s infantile side. The result is often increasing behavioural regression and disorganisation. The difficult art in this work requires the therapist to be able to frustrate the patient maximally, but never more than the patient can stand.
Transference clarifications and interpretations do not necessarily lead to behavioural regressions in psychotherapy and psycho-analysis with these patients. These patients have varying capacities to look at elements of the transference and make use of it. It is important for sufficient material to be present for the therapist to be certain of his statements before the transference is discussed, and then in a tentative, supportive way as the transference, especially the negative transference, emerges. The therapist can be certain only in this way whether it facilitates or impedes therapy. Exceptions about waiting involve patients who develop massive regressive reactions practically in the first session. Then active work with transference material may be the only way to preserve the possibility of treating the patient.
Many of these patients can be treated in once weekly therapy with some success. I feel that more intensive work can help many of them achieve significant changes in the quality of their object relations as described by Balint (1968) and Little (1966) that less intense, more supportive work does not permit. Of course, the danger of opening issues that cannot always be shut off is a risk. The patient’s and therapist’s mutual decision to take these risks should be a factor in defining the frequency and intensity of the work.
How is the therapist to assess whether real changes are occurring in therapy as the patient attacks, rejects and devalues? Is the rejecting by the patient part of the therapeutic process occurring while assimilation is taking place on a deeper level, or is the patient genuinely rejecting the therapist and their work? I am not certain of the answer. But I do know that there is a real danger in agreeing with the patient that all is hopeless and that the therapy is essentially worthless. The patient I have discussed is one with whom I could easily have stopped with the feeling, even after two or three years, that he was correct. It was only in the last year of therapy that I was convinced that a genuine assimilation of our work was occurring. The therapist’s awareness that the patient can use his defensive structure and the transference repetition to present insistently the hopelessness of the task can alert the therapist that he may be missing genuine therapeutic growth which is occurring simultaneously. Little (1966) described a similar experience of initially not recognising the growth of her patient during long barrages of hopelessness and devaluation.
I have tried to stress that treatment of these patients is a task that requires an empathic understanding as well as a theoretical model to provide the structure and distance to make the work possible. And I have presented part of a theoretical model that has helped me intellectually and emotionally to pursue this work. I hope that a paper that focuses on treatment of difficult patients will be used to foster understanding of certain elements of all patients, and not to divide therapists into groups of those who work with borderline and psychotics, and those who work with neurotics, which involve our narcissistic defences, depending on which group we fall into, that split therapists into good guys and bad guys.
Feelings of helplessness in patients and their therapists can limit the possibility of successful psychotherapy and psychoanalysis. The kinds of patients most likely to elicit these feelings in therapists with greatest intensity are usually those who are reliving the helplessness of a very early unsuccessful relationship with a maternal figure. This helplessness is experienced by the patient and therapist as the defences, conflicts and feelings of that early period become manifest in the transference; the therapist’s helplessness probably repeats the helplessness the patient’s mother experienced during that time. In addition, problems of internalisation of new objects and experiences in these patients contribute to this helplessness as the therapist’s attempts are rejected, destroyed, or devalued. A detailed clinical example illustrates the difficulties of the therapist in his work with such patients.
Dan H Buie, Jr., M.D., Paul G Myerson, M.D., and Douglas F Welpton, M.D., assisted in the preparation of this manuscript
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