A Practical Casebook of Time-Limited Psychoanalytic Work

A Modern Kleinian approach

Robert Waska

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781134090303
• Edition: 1
• Topic: Psychology
• Subtopic: Psychoanalysis
• Index: Psychology

Modern Kleinian Therapy is a model of effective psychoanalytic work that offers relief to deep internal conflicts by establishing and maintaining analytic contact, and beginning to unravel, modify, and heal turbulent and torn minds. This book defines Modern Kleinian Therapy as a modality for treating severely affected patients in a fairly traditional psychoanalytic manner, even when the environment or frequency of sessions are compromised. Chapter by chapter the book provides detailed clinical material to illustrate the complex dynamics that unfold when working with more closed off patients, and each case report shows the often limited clinical situations that the contemporary analyst must contend with. The book's detailed material serves to emphasize the nature of psychoanalytic work with individuals and couples, who otherwise rarely find their way to healthy attachment or reciprocal whole object relational harmony.

Included in the book:

* Technical and theoretical methods of Modern Kleinian Therapy

* Psychoanalytic treatments to modify internal object relational conflicts

* The Modern Kleinian Therapy approach to couple's treatment

* The value of analytic contact.

A Practical Casebook of Time-Limited Psychoanalytic Work: A Modern Kleinian Approach introduces new aspects of Kleinian work and offers a contemporary view on Kleinian techniques and concepts. It will be valuable reading for psychotherapists, mental health workers, and psychoanalytic therapists.

1

Modern Kleinian Therapy and the Initial Psychoanalytic Interaction

Most of the patients receiving psychological treatment from practitioners trained in psychoanalysis are seen once or twice a week, have limited resources, and suffer significant emotional distress (Spivak 2011; Waska 2005, 2006, 2011a, 2011b). This chapter will follow the initial twelve visits with one such patient seen in a private practice setting. He was provided a psychoanalytic treatment process that is meant to be helpful to patients with severe paranoid-schizoid (Klein 1946) or depressive (Klein 1935, 1940) disturbances who are limited by choice or circumstance to only attending once or twice a week. Modern Kleinian Therapy is an effective therapeutic process for such situations and can provide important and lasting psychic change (Waska 2010a, 2010b, 2010c, 2010d).

Modern Kleinian Therapy is a therapeutic approach designed to establish analytic contact (Waska 2007) with patients who are struggling with ongoing internal conflicts of a more primitive nature and who equate change or growth with damage and danger to self and object (Waska 2006). Therefore, they live within a state of perpetual distress, anxiety, paranoia, guilt, or loss. Normally, the term therapy or psychotherapy indicates a diluted form of psychoanalysis, a supportive method, or a deliberate manipulation of the transference. The procedure outlined and illustrated in this chapter is not diluted, singularly supportive, or manipulative. Indeed, it is a psychoanalytic treatment that aims at working with the patient’s unconscious conflicts, their object relational phantasies, and their transference perspective.

As such, the technique of Modern Kleinian Therapy is no different whether practiced once a week or five times a week. The infrequent visits can and do create more difficult transference and counter-transference situations and the patient’s defensive system and pathological organizations (Steiner 1987) or retreats (Steiner 1990, 1993) as well as core issues of loss that are defended against with pathological levels of projective identification (Waska 2002, 2004) are more entrenched and difficult to unravel. However, it is still an effective, robust, and productive way of potentially transforming formally unreachable individuals and offering them a new and dramatically different way of living.

Modern Kleinian Therapy is a psychoanalytic method of treatment based on the work of the contemporary Kleinians of London (Schafer 1994). It is a therapeutic system that integrates the work of Kernberg’s TFP (Transference Focused Psychotherapy; Clarkin, Yeomans, and Kernberg 1999, 2006), the CCRT (Core Conflictual Relationship Theme) method of Luborsky (1984), earlier work of Waska (2005, 2006), some ideas from Sandler (1976), and a mixture of flexible technique principles from a wide variety of analytic thinkers such as Merton Gill (1994), Searles (1986), and others. The moment-to-moment focus on the total transference situation (Joseph 1985), and similar work by Segal (1962, 1974, 1975, 1977a, 1977b, 1993, 1997b, 1981), Britton (2004, 2008), Spillius (1983, 1992, 1993, 2007), Steiner (1979, 1984, 1987, 1992, 1994, 1996), and Feldman (1994, 2004, 2009), is adapted towards a continuous effort to establish analytic contact (Waska 2007) regardless of frequency or diagnosis.

One guiding principle is to use the healing aspects of new knowledge about self and other gained from analytic observations (Waska 2012) and interpretations to bring about insight and foster psychic change and growth. This is similar in practice to work by Clarkin, Yeomans, and Kernberg (1999, 2006), Luborsky (1984), and others who focus on the here-and-now transference and core phantasy conflicts of the patient’s dynamic unconscious world. Modern Kleinian Therapy helps neurotic, borderline, narcissistic, and psychotic patients to engage in a restorative therapeutic process geared towards examining and shifting fundamental object relational conflicts.

Again, I deliberately do not call this approach a psychoanalytic psychotherapy but rather a psychoanalytic method and a psychoanalytic treatment because the vast majority of authors who write about and advocate psychoanalytic psychotherapy describe a deliberate watering down of traditional psychoanalytic technique, a reduction of interpretation regarding the transference and defense systems, and an increase in supportive and behavioral interventions that utilize manipulation of the transference instead of interpretation. I think this is a mistake with all patients if we are really trying to offer them the greatest degree of change and psychological growth. But, to not utilize the primary tools and potential of the analytic method with the more disturbed patient can be even more of a clinical failure in not offering what might be most needed.

Case of Y

The Initial Session #1

Y struck me as a very intelligent young man with great curiosity about himself as well as the genuine desire to change and to find satisfaction in his life. At the same time, I felt cautious and suspicious when he talked about his issues in a fuzzy, grandiose manner with excessive remarks about “spirituality and the essence of inner meaning, fulfillment of the heart, and true emotional resolution”. It sounded like something he had read in a self-help book and a way to avoid sharing his real self and his actual feelings with me. I made that interpretation and Y seemed interested. Indeed, he had attended many such workshops and programs over the years but never had been involved in any psychotherapy or psychoanalysis.

The more we talked, the more I felt he was both articulate and insightful yet out of touch with reality. In other words, I thought that Y’s grandiose, paranoid, and possibly delusional way of relating to me was buffered by a partial anchoring into a more intellectual, sincere, and eloquent manner of relating. As a result, I felt uneasy about whom he was, what he was really all about, and how he was really going to utilize me, depend on me, or possibly discard me. It appeared we would have a rocky ride in and out of grounded reality and possibly a relationship that would contract and expand in tricky or unexpected ways.

Y talked at great length about the “dynamic involvement” he found in the human potential workshops he had attended and the “interesting historical lineage” of the New Age church he had recently converted to. According to Y, this church advocated strict or fundamentalist rules of behavior about routine confession, no sex before marriage, and regular prayer combined with a Buddhist mentality. Y seemed to be very drawn to the punitive aspects as well as the rigid structure. He talked at length about how he felt spiritually drawn to the church, how he had a spiritual awakening recently when he heard the choir singing. He fell to the ground crying and thought he could see the image of his dead mother at the altar. He told me he had met a member who had his mother’s name and who introduced him to the head priest who also had a sister with his mother’s name. Y felt it “was destiny” and how it must be “a special spiritual path that had brought him closer to being able to finally find his mother again”. This sounded similar to his description of the time at a Zen retreat he “knew he was Jesus and obviously had special mystical powers”.

When I noted that he seemed to like the rules and structure of the church but that organized way of living was quite opposed to the way he had been in the last three years, Y told me, “I love the structure. I need structure. When I picture the ultimate way of feeling at peace, I have the vision of being in my mother’s arms”. I said, “So, you feel the structure of the church is much like the security and structure of being loved and back in your mother’s arms”. He said, “Yes. Even better would be to be back in her womb. That would be the ultimate structure!” In the counter-transference, my mental image was of something so wonderful and cozy but then suddenly too tight, confining, and restrictive. Y’s psychotic desire to reenter his mother gave me some ideas about how he might want to possess me, abort me, and establish an “ultimate fusion” state with me, to avoid differentiation and loss. These were provisional ideas based in my counter-transference feelings at this early point in the treatment.

Over the last three years, Y had traveled around the world in an aimless and desperate attempt to escape from his inner demons. At the same time, he felt it was a “wonderful quest in many ways, finding a spiritual path and many deep spiritual revelations along the way”. Over the course of our first two sessions, I learned how Y had grown up in a family of four brothers, two younger than him. Y’s mother died of cancer when he was three years old and his father remarried a few years later. Y told me he realized a few years ago that his lifelong unhappiness and sense of fragmentation comes from the loss of his mother at this sensitive young age. He believes this early loss has brought about his mental breakdown he says he had three years ago.

Y’s older brother has some type of psychotic condition and has been in and out of mental institutions. He has been given various anti-psychotic medications and mood stabilizers that Y says he has tried himself in an effort to “find some calm and clarity during the rough times”.

I interpreted that perhaps he identified with his brother and sought out the same kind of help with the medications. Here, I introduced an idea about him somehow seeing himself as his sick brother and needing the same treatment. I was not sure about anything else regarding his brother but I felt it important to comment on this sense of sameness. It was useful to see how concrete Y was in his reply. He said, “I just thought his meds would help me with my moods and depression because my brother suffers with them as well. But, they did not help and I think they screw up your brain anyway so I am glad I stopped taking them”.

So, I kept my idea of him wanting to be the same and losing his identity in the process as a question mark. I knew he could be correct in diagnosing himself as suffering the same illness as his brother but the way he described it had a feeling of a more blurred attempt at fitting into his brother, a way he seemed to desire fusion or sameness. This was all in the tone and manner in which he conveyed the story to me. Y went on to elaborate how the “main and most devastating problem in my life is the death of my mother. She died of cancer when I was three and I finally realized a few years ago how much that has affected me. That is the central core of all my issues. I must find her and reconnect that spiritual bond and find that missing part in me”. He went on to tell me of his “mental breakdown” three or four years ago and his “voyage ever since to free myself”.

Y told me he smokes pot every day to calm down and to find some peace of mind. Y also drinks heavily when he cannot find enough pot. When we were discussing his long time addiction to pot and how he uses it or alcohol to “self medicate”, Y casually mentioned an incident the prior week.

He told me that he had moved into the city about two months ago and had quickly found a job in a small grocery store. His job was to stock the shelves. Y said he hated it because it was boring and when he was done for the day, it was a long walk to the bus stop. But, he kept at it for about three weeks. Then, one day at work he decided to consume a “pot brownie” and when he started to feel really high, he went to his manager and told him that he was now too high to work and wanted to see if he could leave early. The manager promptly fired him.

I asked Y what he had expected would happen. Y said he was not too surprised but he “always hopes that people can maybe see the real truth and find a way to have a connection that transcends the weight of rules and convention”. I said, “You seem to be hoping for a pure, honest, and all accepting connection, perhaps the sort of thing you feel you lost out with your mother dying”. Y said, “Exactly!” I added, “It also seems to be a way that you sabotaged yourself and got fired. You could have hung in there and not told your boss or you could have elected to not get high. But, you took away something you had created in your life”.

Y said, “I do that over and over and over. I tend to achieve something and then give up on it or screw it up somehow. I have done that with girlfriends and plenty of jobs”. So, we discussed the elements of this pattern and how he seemed to be happy and proud of himself but then turn away from himself and let go of that positive element to create a negative. Here, I was thinking about the clinical manifestations of the life and death instincts and the destructive conflicts that can occur in that phantasy realm (Steiner 2004; Rosenfeld 1971; Grotstein 1985). I also wondered to myself how long it might be before he took what we will build together and try to kill it off as well.

I noticed Y had a pen and pad on which he was taking periodic notes. When I made an interpretation, he wrote it down. He asked if we would be working psychoanalytically. I said he probably knew I was an analyst. He said he did and wondered where I was trained. I paused and said I was trained in the city but wondered what exactly he wanted to know. He wrote something down again. I asked him what he was writing and what exactly he was trying to find out about me. Y said he had written down what I said about trying to search for the perfect bond and structure with his mother and how somehow it always collapsing without him being able to sustain it. He said he was also writing down where I was trained so he could look it up.

I said, “It seems you want to know me and own me in some way that also makes it hard for you to be here right now. By trying to pin down everything on paper, you are not getting to know me right now”. Y said, “I am just a curious person and I want to know what type of treatment I am having and a little about the person I am supposed to trust in that treatment”.

So, for now, Y kept us at that concrete distance but based on my counter-transference, it seemed that internally he was fishing around to know me, possess me, and get inside me. I thought this might be part of what I would term the extraction process of pathological projective identification in which the subject attempts to hijack or acquire certain aspects of the object to call their own. It becomes an emotional theft based in envy, intense anxiety over not knowing, and not having control of the internal environment. I thought he might feel so weak or vulnerable about wanting to know and having to find out through an ongoing relationship that he was trying to hijack it immediately.

Session #2

When I went to the waiting room to find Y for his second session, I found him standing there with his bicycle. He said he did not want to leave it on the street and have it stolen so he wondered if he could leave it in the waiting room. I had several thoughts about this. While there was no one else out there, it is interesting that Y did not think of how his bicycle would impact the next patient or how he might be impacted by them. I think he felt it was his waiting room and it felt safe to leave the bicycle there.

I was worried that someone would come into the waiting room and steal the bike so I suggested he leave it in the hallway by my office door. But, either way, I felt he was moving in. This sensation was confirmed when he entered my office and took out his cell phone and a charger and said, “Can I plug this in somewhere?” I had two feelings about this. The first feeling was that I had no choice. I had to either say yes or I would be telling him no in a very rejecting way, telling him that there was no room for him in my home.

The second feeling was that Y was indeed moving in. So, I said, “Looks like you are moving in! I wonder if you have decided you can trust me. But, with such a fast move in, I wonder if you will be able to stay for a while?” I said this based on the feeling that this was an impulsive move into me and could easily be followed by an impulsive retreat. Y confirmed my interpretation when he said, “I have always had a hard time with commitment. I have a pattern of really getting into something and then it all falls apart. I give up on it”.

I asked, “Do you give up or do you choose to retreat and pull out?” Here, I was seeing if Y was able to consider himself as an active player in his life or just a passive observer. I wondered if he was caught in a more persecutory vision of himself or knew he was participating in what happened around him. Y said, “It feels like I just give up. I go into the job or relationship with a lot of hope and excitement. It works out and I am happy for a while. I am very successful at most of the jobs I take on and I have been very connected with a number of women. But, at some point, I feel it is almost going too well and I give up and stop trying. I think I can’t handle it and so I sort of fade away”.

I said, “I wonder if something about being successful, happy, or close makes you anxious and then you have to fail. Almost punishing yourself or running away from something positive”. Here, I was interpreting a possible fear of success, a dread of closeness, and a reaction to having dove too deep into the object or situation. Y said, “I think that could be. I tend to fail at commitment”.

So, after only seeing Y for two visits, it is unclear what his struggles are and how the treatment will unfold. However, by adhering to a Modern Kleinian Therapy approach, I was able to make a few interpretations and help Y open up in certain ways. This has started a therapeutic process in which we have already established a degree of analytic contact, exploring and examining his internal world and the various unconscious phantasies and conflicts he is suffering with.

In the counter-transference, I notice that my feelings and thoughts sometimes parallel his description of himself and his emotional patterns. Specifically, I notice myself liking him as a person, trusting him, and wanting to engage in a working relationship. However, at the same time, I have an uneasy feeling, a slight distrust, and see him as more disturbed than he appears and possibly ready to terminate at any moment. So, I am keeping this counter-transference impression in mind as we proceed. I think it may help me understand him more and find my way as we continue our analytic journey.

For Y, he was still splitting his objects into ideal, all good, but unobtainable pieces as well as into omnipotent, all bad and hateful pieces. Y seemed to be lost in the quest and search for this mythical perfect object as a way to avoid facing the grief and rage he felt over the aspects of his lost object he resented and pined over. Thus, he lives in a psychotic world full of incredible possibilities and constant failure.

Session #7

I had seen Y for six sessions when he canceled the next two and went out of town. He left for several weeks on a “wonderful business opportunity to provide some professional consulting and to begin to put together a potentially vast corporate investment”. When he returned from a rather disastrous financial experience of high expectations and low results, we continued to investigate what was fueling such internal and external instability.

When Y walked into my office after this disappointing trip, he said, “Hello Doctor. Did you forget me?” I let him settle in, thought about what he said, and listened a bit more. After hearing some details about his trip, I said, “I think you are not sure who is feeling what or who is doing what to whom sometimes. You took off and left our regular meetings. But, now, you are worried I have forgotten you. It seemed like you might have forgotten us the way you just sort of slipped out of town”. I wondered if he was feeling guilty for forgetting about me and now was trying to flip it around to feel better. Y replied, “No. I think I am afraid that you are angry with me for canceling the two sessions and that you might not want to see me anymore”. ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Preface
• Acknowledgements
• Introduction
• 1. Modern Kleinian Therapy and the initial psychoanalytic interaction
• 2. Once a week frequency with Modern Kleinian Therapy
• 3. Paranoia and the object of dread
• 4. Couples treatment and the quest for analytic contact
• 5. Stumbling in the counter-transference
• 6. Catching my balance in the counter-transference
• 7. Combative and reactive patients
• 8. Embedded enactments and emotional truth
• 9. The limits of our value and the value of our limits
• 10. Keeping the faith when working with turbulent patients
• 11. Phantasies of dread, demand, and desire
• 12. Captured and absorbed into the familiar
• 13. The give and take in projective identification
• Summary
• Bibliography
• Index