The Riddle of the Psychotic Transference
Lawrence E. Hedges PhD, PsyD, ABPP
Director, The Listening Perspectives Study Center
The Riddle of the Psychotic Transference
The riddle of the psychotic transference is, “how can we best formulate and analyze transferences emanating from life’s earliest relational experiences?” Sandor Ferenczi (1931, 1933) first understood the importance of the actual relationship between patient and therapist when studying early transference experiences. Harry Stack Sullivan (1954) and the Interpersonal and later the Relational schools of psychoanalysis followed Ferenczi in placing the therapeutic relationship, and the developmentally early transferences and countertransferences it spawned, at the center of the analytic process.
As early as 1911 Freud in his analysis of Judge Schreber was first to understand that the symbolic interpretation method that had proven useful in elucidating the “psychoneuroses” (i.e., the Oedipal-level neurotic transferences) was not viable when working with “narcissistic neuroses” (i.e., pre-Oedipal psychotic and borderline psychotic transferences). It remained for Heinz Kohut (1971) and others to elaborate the narcissistic relationship from the three-year-old period of self development and to specify how to formulate and frame the “selfobject” transferences. Donald Winnicott (1949, 1952, 1960), Otto Kernberg (1976,1980), and others developed techniques for eliciting and framing the merged self and other transferences from the four to twenty-four month symbiotic period of development (Mahler 1968). But the exact nature of the underlying psychotic transferences yet remained a riddle.
While many had worked with and thought about psychotic transferences–notably the followers of Melanie Klein (1957, 1975), Herbert Rosenfeld (1964), and Harold Searles (1965), Wilfred Bion (1993) was perhaps the first to intuit clearly the nature of the psychotic transference in his brief reference to “the obstructive object”. Following Bion, the Barangers (2009) conceptualize the “transference psychosis” as a process in the transference/countertransference of the bi-personal field of the psychoanalytic situation. Antonino Ferro, Roberto Basile and others (2009) further elaborate the concept of the psychoanalytic field. Grotstein (2007) speaks of the obstructive object as a “negative container”, an early step in Bion’s developing formulations of the “container-contained.”
Carl Jung (1964) had certainly understood that psychotic expressions were part of the archetypal collective unconscious. And Jacques Lacan (1977) had firmly grasped that psychotic transferences were embedded in speech and operated like a language. Following in his footsteps Francoise Devoine and Jean-Max Gaudillière have seen the psychotic transference arising from traumatic discontinuous forces in history that leave profound and enduring imprints of trauma down the generations. But the riddle of how to best formulate and frame the psychotic transference in viable clinical terms remained.
My intention in this paper is to review three quite different ways of systematically formulating and framing the psychotic transference that have emerged recently from writers from within three different psychoanalytic traditions and to point toward the striking commonalities of their therapeutic approaches—despite the differing theoretical orientations and vocabularies involved.
- Donald Kalsched’s Resistive “Self-Care System”
Jungian analyst Donald Kalsched in two remarkable books, The Inner World of Trauma: Archetypal Defenses of the Spirit (1994) and Trauma and the Soul: A Psycho-Spiritual Approach to Human Development and its Interruption (2013) addresses the psychotic transference in terms of Jungian archetypes. Stating that his work parallels the contributions of James Grotstein (1994, 2000) who writes from Kleinian, Bionian, and Object Relations perspectives, and that his work derives inspiration from Interpersonal/Relational analyst Phillip Bromberg (1998, 2006, 2011), Kalsched speaks of the psychotic transference as the resistive or defensive “self-care system.” Formulating processes of infantile trauma and dissociation, he writes:
Early relational trauma results from the fact that we are often given more to experience in this life than we can experience consciously. This problem has been around since the beginning of time, but it is especially acute in early childhood where, because of the immaturity of the psyche and/or the brain, we are ill equipped to metabolize our experience. An infant or young child who is abused, violated or seriously neglected by a caretaking adult is overwhelmed by intolerable affects that are impossible for it to metabolize, much less understand or even think about. A shock to the psychosomatic unity of the personality threatens to shatter the child to its very core–threatens to extinguish that ‘vital spark’ of the person so crucial for the experience of aliveness and so central to the later experience of “feeling real.” Such a shattering of the childhood psyche would be an unimaginable catastrophe–“soul murder” as one investigator called it (Shengold, 1989). (2013, pp 10-11)
Fortunately this shattering almost never happens–at least not completely. Instead, a life-saving split occurs that we call dissociation. Dissociation…prevents annihilation of the unit self, substituting multiplicity and an archetypal story that implicitly holds the parts together. The unbearable affect is distributed to different parts of the psyche that cease to ‘know’ about each other so that the personality does not have to suffer the unspeakable horror of trauma as a whole….These self-divisions have survival value because they save a part of the child’s innocence and aliveness by splitting it off from the rest of the personality, preserving it in the unconscious for possible future growth and surrounding it with an implicit narrative that is eventually made explicit in dreams. This allows life to go on, albeit at a terrible price–i.e., loss of the animation and vitality that have always been associated with en-souled living. (Ibid., p. 11)
Kalsched notes a predictable pattern to the dissociations
…[T]raumatic dissociation in the child leaves an inner world divided between regressed and progressed inner objects. Usually the regressed part of the personality is represented as a child or infant, often locked away in an “inner cocoon” … an “imprisoning sanctuary”…or a “psychic retreat”…whereas the progressed part might appear as a sadistic tyrannical figure, attacking or imprisoning the child…or as a “false god,” part of the narcissistic defensive system. (Ibid.)
Kalsched sees that these “regressed” and “progressed” dissociations are regularly expressed in archetypal images.
In certain patients’ dreams, the image of the regressed part of the personality would appear not just as a child, but as an extraordinary child–one that appeared to be supremely wise, or ‘divine’ in some way, perhaps surrounded by an unearthly light, or speaking in parables or showing miraculous physical powers. Sometimes the regressed self would be a magical animal–a talking bird, a dolphin, or a pony, representing a kind of soul-animal for the patient. On the other hand, the progressed self might also become mythologized, appearing, for example as a frightening vampire–a sadistic demon who tortured the patient from within. Sometimes this diabolical figure would turn into its opposite, suddenly becoming a guardian angel who protected the inner child. (., p. 12)
Kalsched came to understand that these archetypal images spontaneously emerged at certain critical relational moments of an analysis.
…I began to realize that I was observing an archaic and typical (archetypal) dyadic structure in my patients’ dream material that was devoted to defense….I referred to this typical dyadic structure as the “self-care system”….[I further discovered] that this “system” often made its appearance in dreams at critical moments in the psychotherapy process when new life of some kind was emerging for the patient–often in relation to myself in the transference. These moments of emergent hope and potential transformation seemed to trigger the defensive activity of diabolical [or angelic] inner figures who then attacked [or protected] the patient’s vulnerable [or innocent child-self] in nightmarish dreams, rendering the inner world as traumatized as the outer one (emphasis added). (Ibid.)
Regarding therapy with the dissociated selves, Kalsched declares:
Because psychotherapy is an attachment relationship, many of the early injuries in our patients’ lives can be re-lived. Because of the plasticity of the brain, the rigid neural nets can be re-wired and repaired. Psychoanalysts (including myself) have begun to realize that what has been broken relationally must be repaired relationally. Early injuries to the infant/mother rapport and empathic resonance must be repaired in a new relationship. This calls for affectively focused treatment–what Schore (2003) calls right-brain-to-right brain communication. The analyst “tunes in” on an affect level to those dissociative “gaps” or places of derailment where the intimate feeling-connection with the patient threatens to come apart. As Bromberg (2006) demonstrates, the analyst must become a full partner in the “dyadic regulation” of affect and co-creation of an entirely new inter-subjective reality. Fortunately, in this process, what the analyst says or does will be less important than “how openly what does happen is processed with the analysand” (Mitchell 1988, p. x). (Ibid., p. 13)
Kalsched richly illustrates the nature of the therapeutic relationship with passages and metaphors from Dante’s Inferno.
Dante and Virgil descend into Dante’s own personal version of Hell to confront the dark Lord of Dissociation otherwise known in Latin as “Dis.” Having found the courage (and the affect-tolerance) to remember his dissociated pain, Dante finally finds his way out of his depression and into a more creative and conscious form of suffering that leads (through Purgatory) to indwelling, and ultimately to the renewal of his life. But not before he has faced the pain he does and doesn’t want to face. (Ibid., p. 20)
Kalsched takes a strong position on the importance of the psychotherapeutic relationship itself.
…[It] is relationship that heals trauma. But not just any relationship. The kind of relationship that makes a difference is the kind of transformative relationship actualized in the best contemporary psychotherapy and psychoanalysis….Such a relationship will re-open both inter-subjective and mytho-poetic ‘space. It will “awaken the dreamer” in the patient, (Bromberg, 2006) inviting both partners in the psychoanalytic dyad to “stand in the spaces” (Bromberg, 1998) of dissociated self-states reflecting on the stormy affects that are generated as the soul re-enters the body–until re-connections are made between affects and images, between the present and the past, between the inner child and its caretakers in the self-care system. Such a relationship holds the hope that both inner and outer transitional space may open once again, that connections in the brain can be slowly re-wired, and that archetypal defenses will release us into human inter-subjectivity and ensouled living. (Ibid., pp 19-20)
Summing up, Kalsched’s formulations of the psychotic transference can be stated thus: Traumatic impingent in infancy creates dissociations that are later experienced in archetypal images of, on the one hand, an innocent and vulnerable child-self and, on the other hand, of attacking monsters and/or protecting guardians—formulated by Kalsched as the resistive “self-care system.” This system consists of implicit body-mind-soul memories of the early impinging trauma that serve to prevent the innocent child-self being held in a painful Purgatory from ever venturing into affective attunement with others. Kalsched observes that these devils and angels spontaneously appear in dreams to ward off the possibility of interpersonal affect engagement at the very moments in therapy when there is hope of personal growth and transformation through the relationship itself. Thus formulated, the psychotic transference is framed by the realization in the dyad of the operation of the resistive self-care system in the transference-countertransference matrix and the ongoing and systematic processing of the interpersonal affects being warded off by the primitive defensive system—as Virgil leads Dante through the phantoms of Purgatory toward living with renewed vitality in the real world of emotionally interacting people.
- Jeffrey Eaton’s Formulations of the “Obstructive Object”
Bionian analyst Jeffrey Eaton, picking up on Bion’s cue, has recently considerably elaborated the concept of the “obstructive object.”
According to W. R. Bion, some patients give evidence of living with an internal object that is ego-destructive and that operates as a projective identification rejecting object. Bion names this ego-destructive internal object an obstructive object….Bion’s writing can be profitably read as the evolution of twin psychologies: one about the conditions that sponsor learning and emotional development, and another about the myriad obstructive forces and conditions, both internal and environmental, that lead to psychological stalemate, breakdown, or malignant transformation (emphasis added). (p. 355)
Eaton speaks of the capacity for toleration and transformation of painful experiences:
According to Bion, the capacity to learn from experience is characterized, in particular, by an ability to tolerate and transform rather than to evade the inevitable turbulence and frustration of uncertain and painful situations. It also involves a faith that in states of distress, including even acute distress, one will not become totally trapped in an atmosphere of emotional catastrophe….[I]nstead, this faith, based on the accumulated memories of the mother’s repeated capacity to receive and transform distress into comfort, promotes a capacity for personal reverie, that is, a reverie for one’s own experience as it arises and is lived through. (pp 358-359)
Eaton elucidates Bion’s concept of the obstructive object:
Bion (1993) introduces the term “obstructive object” in his “schizophrenia” papers, particularly in “On Arrogance” and “Theory of Thinking.” These papers, along with “Attacks on Linking” form the background for several passages from Learning from Experience that describe the consequences not only of a failure of maternal reverie and absent or inadequate alpha function, but also of the important variables of an excess of envy as well as very low [perhaps constitutional] frustration tolerance in the infant. Such a constellation of factors can contribute to severe vulnerability in the mother-infant dyad. Such vulnerability may inhibit or obstruct the development of the container/contained relationship over time and make faith in the reliable transformation of distress to comfort impossible to realize. (p. 359)
Bion describes this process in “Attacks on Linking” (1993) :
Projective identification makes it possible for [the infant] to investigate his own feelings in a personality powerful enough to contain them. Denial of the use of this mechanism, either by the refusal of the mother to serve as a repository for the infant’s feelings, or by the hatred and envy of the [infant] who cannot allow the mother to exercise this function, leads to a destruction of the link between infant and breast and consequently to a severe disorder of the impulse to be curious on which all learning depends. The way is therefore prepared for a severe arrest of development. Furthermore, thanks to a denial of the main method open to the infant for dealing with his too powerful emotions, the conduct of emotional life, in any case a severe problem, becomes intolerable. Feelings of hatred are thereupon directed against all emotions including hate itself, and against external reality which stimulates them. It is a short step from hatred of the emotions to hatred of life itself. (pp. 106-107)
Eaton considerers what must happen in psychotherapy:
The practical task of psychoanalysis is to identify, describe, and over time to transform the unconscious modes of coping with pain that were learned very early in life and that can be observed in transferences into the present. Our task is to learn to describe (and in doing so, contain and bring awareness to) the shifting levels of pain and anxiety that the patient experiences, moment to moment and session to session. Over time, the mindfulness and reverie that we demonstrate for our patient is internalized and becomes part of the patient’s own projective identification welcoming object world. These more creative internal object relationships can be increasingly relied upon to sponsor learning from experience over the course of a lifetime (emphasis added). (p. 369)
By avoiding the trap of concretely enacting a projective identification rejecting object, the analyst, through actual reverie and presence with the patient, gives the patient an experience that stimulates his or her own alpha function and in the best situations allows mourning and the working through of depressive anxieties to take place. This sponsors the reclamation of attention and thwarted life instincts that may now revive and expand by relying upon the new experience of a projective identification welcoming object and a sense of relationship to one’s own internal world (emphasis added). (p. 371)
Summing up, Eaton in his remarkable elaboration of Bion’s concept of the obstructive object gives us a way to formulate and frame the psychotic transference. Early experiences of a projective identification rejecting object—whether due to maternal failures or to constitutional limitations of the infant—lead towards a reluctance to engage affectively with others–thus blocking the possibilities for future learning experiences. What is broken in relationship must be repaired in relationship so that the therapist’s task is to hold steady in emotionally active reverie, thus resisting the projective identification rejections brought in transference. Reverie on the part of the analyst that creates a projective identification welcoming atmosphere fosters gradually developing alpha functions in the client, thus clearing the obstructions to curiosity and imagination so crucial to learning and affective engagement with others (2013).
- Hedges’ “Organizing Experience” and” Organizing Transference”
My first formulations of the psychotic transference–which I termed “the Organizing transference” were published in my 1983 book Listening Perspectives in Psychotherapy. I envisioned an infant, in attempting to organize a safe and meaningful world, reaching towards a mother searching for empathic responsiveness but–for whatever reason–being unable to achieve satisfying contact or responsiveness. I formulated that if the sought-for and needed response from the human other could not be satisfactorily found, the reaching emotional tendril would simply wither or collapse. On the other hand, if the seeking and needful emotional tendril encountered a painful response, the reaching tendril would constrict and withdraw. In either case, the fearfully conditioned result or “lesson” would be “never reach that way again.” The ensuing internalized terror of being left alone to die or of being hurt, maimed, or killed would presumably be the infant’s body-mind-relationship experience of failure to achieve essential connectedness to the human environment. Others have spoken of “annihilation anxiety” and “predator anxiety.” With the help of numerous colleagues, I have later elaborated these theoretical formulations with extensive case illustrations in four subsequent books: In Search of the Lost Mother of Infancy, (1994) Working the Organizing Experience, (1994) Terrifying Transferences, (2000) and Relational Interventions (2013).
Thus, my own answer to the psychotic transference riddle has been to say that what is likely to be transferred into later relational experiences are the early-established terrors of connecting–either the terror of reaching for needed emotional responsiveness with no reciprocating response, or else the terror of reaching and being met with relational hurt and pain. I postulated that some sort of anticipatory “fear signal” or “fear reflex” would be conditioned which would serve to prevent future attempts to connect emotionally in certain ways, not unlike Freud’s concept of signal anxiety. That is, whatever forms of terror were once experienced as a result of failed emotional connections with others would be expected to be a part of implicit memory and would work to prevent other similar connections from being attempted in the future.
With crucial emotional channels for connecting to others for nurturance and growth shut down as a result of failed or hurtful responsiveness, future personal development would be expected to be functionally limited in certain specific, idiosyncratic, and perhaps even major ways – depending upon the early experiences of the individual child. I came to see that most—if not all—so-called “psychotic symptoms” serve this disconnecting and alienating interpersonal function–that is, that the interpersonally distressing effects of strange behaviors and symptoms such as delusional preoccupations, hallucinatory formations, obsessions, compulsions, and hypochondraisis serve mainly to stave off the threat of dreaded forms of interpersonal emotional engagement.
Framing the Organizing transference involves studying how two people approach to make connections and then turn away, veer off, rupture, or dissipate the intensity of the connections. Psychotherapists study all of the relationships in a person’s life for clues that will permit formulations about how the person regularly moves toward human contact and connection. And then how that person regularly accomplishes some—transference or resistance-based—form of interruption or breach, which prevents sustained mutual and reciprocal relatedness. When considered in this way the task of psychotherapy with Organizing experiences suddenly becomes clearer:
- The therapist must first spend considerable time and energy helping to establish an interpersonal atmosphere that the client can experience as safe.
- Next the therapist must encourage whatever forms of contact and connection the client can allow.
- Then the therapist must devise ways of holding the relating steady until the transferentially-determined resistance to relating appears.
- Finally, at the moment of interruption in the relationship a relational intervention is offered. The relational gesture is designed to communicate somehow:
“I see that you believe that you must pull away from our
emotional contact now….But that is not true. You have repeatedly established for yourself that I am a basically safe person to be with. The compelling sensation that you are in grave danger, that your body and mind may at any moment experience excruciating pain or fragmentation, that you are confused or lost, or that you must somehow compulsively pull away is essentially delusional no matter how real it feels. Try staying emotionally connected with me now so that we can see what further fears and demons lurk inside trying to pull you away, unnecessarily attempting to prevent your being hurt by our interaction….What do you feel in your body now? What shakiness, numbness, or terrors can you allow yourself to be aware of? Who am I to you at this moment? And how do you experience me and our relationship as a danger right now?”
The working through of the Organizing transference consists of countless instances of encouraging the person in therapy to come to the brink of her or his sense of safety in the therapeutic relationship. And then for the therapist to find some concrete way of holding the person in emotional relationship a moment longer—long enough for some unsettling or terrifying reaction to emerge so it can be known and processed within the relationship.
The key feature here is for the therapist to encourage connection while simultaneously recognizing and addressing the terror being created by the attempt to connect. I have written about the potential usefulness of token physical contact—such as touching fingers, holding hands, locking eye contact, demanding full voice contact or other concrete forms of contact—for the sole purpose of holding the connection so that the transferential terror can become known. Discussing with the client in advance what moments of interpersonal contact might look like and having a well-understood informed consent in place create safety nets for the otherwise risky process of elucidating primitive transference experiences through relational interventions.
The working through process consists of therapist and client learning together over time how to catch in the moment the transferentially-based resistance to sustained emotional contact and connection. And learning how to hold these contactful moments together through whatever body-mind-relationship reactions of terror, numbness, fragmentation, and/or confusion may occur in one or the other or both members of the therapeutic dyad. Studying together characteristic modes of resistance to contact enacted by both participants allows both to be watching for the special ways connection is being avoided.
Summary of Hedges’ Organizing Experience
The “Organizing experience” refers to the earliest human desire to organize channels for contact and connection—first with the maternal body and later with the maternal mind. And to re-living in later life experiences the primitive and painful terrors of being life-threateningly alone in the universe and/or of being injured as a result of interpersonal connections. The specific and idiosyncratic fears associated with reaching for contact and connection are transferred into later relationships and serve as resistance to certain or all kinds of interpersonal intimacy. Through projective identification as well as dissociation and mutual enactments both client and therapist become immersed in dissociated and not yet formulated experiences (Stern 1997, 2011, in press). The goal of relational interventions in psychotherapy with the Organizing experience is to demonstrate in word, deed, and action that the transferred terror of contact and connection is essentially delusional—that it is based on early developmental experiences and not on the current possibilities for rewarding intimate relating.
Summary and Conclusions
While many theoreticians and practitioners have studied psychosis in its diverse presentations over the years, few have specifically addressed the riddle of how best to formulate and systematically frame the psychotic transference in viable clinical terms. The three very different approaches considered here—the Jungian approach of Kalsched, the Bionian approach of Eaton, and the Interpersonal/Relational approach of Hedges—display remarkable commonalities in how to formulate and frame the psychotic transference–despite their springing from very different psychoanalytic traditions. I view these commonalities as:
- None of these theorists actually uses the term “psychotic transference,” presumably because this term is from a different discourse—one that focuses on symptoms and illness—whereas these contributors all speak to universal human experiences that have an opportunity to be usefully re-engaged and transformed in a robust therapeutic relationship.
- These psychoanalysts envision psychotherapy with early developmental trauma as involving the establishment of an intimate attachment relationship necessitating full affective engagement that is bound to breed disturbing experiences in both participants.
- Each of the three therapists anticipates fierce resistance to arise on one side of the relationship or the other in order to prevent the re-establishment of mutual affect regulation processes that were disrupted by early trauma.
- By extension, all three therapeutic approaches can be fruitfully applied to traumatic intrusions in later life that serve similarly to arrest affective development.
- None of these three practitioners shows particular interest in understanding or decoding whatever “psychotic symptoms” or “bizarre content” may emerge per se along the way. Rather, their focus is on establishing a fully affective attachment relationship while simultaneously tuning into the overwhelming forces of terror and resistance that arise—no matter how these experiences are expressed.
- Kalsched, Eaton, and Hedges—contrary to tradition—are essentially optimistic about the transformational possibilities with these difficult to reach people and with universal but difficult to reach pockets of traumatic experience.
The riddle of the psychotic transference has been successfully addressed.
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