A Casebook of Psychotherapy Practice with Challenging Patients

A modern Kleinian approach

Robert Waska

• Editore: Routledge
• Anno: 2015
• ISBN:
  9781317590811
• Edizione: 1
• Argomento: Psychology
• Categoria: History & Theory in Psychology

Most contemporary psychoanalysts and psychotherapists see each patient once or twice a week at most. As many patients have reached a marked state of distress before seeking treatment, this gives the analyst a difficult task to accomplish in what is a limited amount of time. A Casebook of Psychotherapy Practice with Challenging Patients: A modern Kleinian approach sets out a model for working with quite significantly disturbed, distressed, or resistant patients in a very limited time, which Robert Waska has termed "Modern Kleinian Therapy."

Each chapter provides a vivid look into the moment-to-moment workings of a contemporary Kleinian focus on understanding projective identification, enactment, and acting out as well as the careful and thoughtful interpretive work necessary in these complex clinical situations. Individual psychotherapeutic work is represented throughout the book alongside instructive reports of psychoanalytic work with disturbed couples, and the more challenging patient is illustrated with several comprehensive reviews of films that follow such hard-to-reach individuals.

A Casebook of Psychotherapy Practice with Challenging Patients: A modern Kleinian approach is filled with a combination of contemporary theory building, a wealth of clinical vignettes, and practical advice. It is a hands-on guide for psychoanalysts and therapists who need to get to grips with complex psychoanalytic concepts in a short time and shows the therapeutic power the Modern Kleinian Therapy approach can have and how it can enable them to work most effectively with difficult patients.

Robert Waska LPCC, MFT, PhD is an analytic member at the San Francisco Center for Psychoanalysis and conducts a full-time private psychoanalytic practice for individuals and couples in San Francisco and Marin County, California. He is the author of thirteen published textbooks on Kleinian psychoanalytic theory and technique, is a contributing author for three psychology texts, and has published over a hundred articles in professional journals.

Part I
Clinical aspects of loss and disconnection

Chapter 1
Low-frequency Modern Kleinian Therapy and one patient's somatic retreat from unbearable loss

This chapter will focus on the application of the regular Kleinian technique to difficult and disturbed patients who are only able or willing to attend once or twice a week (Waska 2006, 2011b). I will demonstrate with clinical material how there is no real need to modify the technique. However, in low frequency cases, certain aspects of pathology, of transference, and of defense become highlighted and heightened, so certain aspects of technique must also be highlighted.

The Modern Kleinian Therapy approach is a clinical model of here-and-now, moment-to-moment focus on transference, counter-transference, and unconscious phantasy to assist difficult patients in low frequency therapy to notice, accept, understand, and resolve their unconscious self- and object-conflict states. Projective identification is often the cornerstone of the more complex transference state (Waska 2004) and therefore is the central target of therapeutic intervention and interpretation.

A great deal of patients being seen in today’s private practice settings are mired in the primitive zone of paranoid and narcissistic functioning without access to the internal vision of a pleasurable object with which to merge without catastrophe. These are patients who are using vigorous levels of defense against the more erotic, pleasurable, and connective elements of relationship just as they are massively defending against the fears of conflict, aggression, and growth. In addition, this is a state of psychic conflict so intense that it may in some cases create psychic deficit.

Clinically, we see many patients who tend to quickly subsume us and whatever we do or say into their pathological organization (Spillius 1988) with its familiar cast of internal characters. Modern Kleinian Therapy focuses on the interpretation of this particular transference process by investigating the unconscious phantasy conflicts at play and highlighting the more direct moment-to-moment transference usually mobilized by projective identification dynamics. Bion’s (1962a) ideas regarding the interpersonal aspects of projective identification, the idea of projective identification as the foundation of most transference states (Waska 2010a, 2010b, 2010c), and the concept of projective identification as the first line of defense against psychic loss (Waska 2002, 2010d) difference, or separation all form the theoretical base of my clinical approach. Taking theory into the clinical realm, I find interpreting the how and the why of the patient’s phantasy conflicts in the here-and-now combined with linkage to original infantile experiences to be the best approach with such patients under these more limiting clinical situations.

In doing so, the main thrust of the analyst’s observations and interpretations remains focused on the patient’s efforts to disrupt the establishment of analytic contact (Waska 2007). We strive to move the patient into a new experience of clarity, vulnerability, reflection, independence, change, and choice. Analytic contact is defined as sustained periods of mutual existence between self and object not excessively colored by destructive aggression or destructive defense. These are moments between patient and analyst when the elements of love, hate, and knowledge as well as the life-and-death instincts are in “good-enough” balance as to not fuel, enhance, or validate the patient’s internal conflicts and phantasies in those very realms. These are new moments of contact between self and other, either in the mind of the patient or in the actual interpersonal realm between patient and analyst. Internal dynamics surrounding giving, taking, and learning as well as the parallel phantasies of being given to, having to relinquish, and being known are all elements that are usually severely out of psychic balance with these more challenging patients. Analytic contact is the moment in which analyst and patient achieve some degree of peace, stability, or integration in these areas.

So, analytic contact is the term for our constant quest or invitation to each patient for the found, allowed, and cultivated experiences that are new or less contaminated by the fossils of past internal drama, danger, and desire. These moments, in turn, provide for a chance of more lasting change, life, and difference or at least a consideration that these elements are possible and not poison. Paranoid (Klein 1946) and depressive (Klein 1935, 1940) anxieties tend to be stirred up as the patient’s safe and controlled psychic equilibrium (Spillius and Feldman 1989) comes into question. Acting out, abrupt termination, intense resistance, and excessive reliance on projective identification are common and create easy blind spots and patterns of enactment for the analyst.

While Modern Kleinian Therapy is fundamentally no different than the practice of Kleinian psychoanalysis, due to the limitations of reduced frequency, more severe pathology, and external blocks such as health insurance limitations and personal financial limitations, a greater flexibility is required in the overall treatment setting. In addition, there is a greater need to notice the ongoing and immediate impact of unconscious phantasy, internal conflict, and transference that occurs in the analytic relationship. Careful monitoring of countertransference for the presence of projective identification-based communication is an important Modern Kleinian Therapy technique. The importance of combining interpretations of current here- and-now transference and phantasy with occasional genetic links as a therapeutic hybrid approach is also a modification of sorts unique to Modern Kleinian Therapy. However, this is more a question of emphasis than a new or radical theoretical shift or unique technique.

Case material

Norm is a thirty- five-year-old man who came to me for help with feelings of depression and anxiety. I had seen him for seven sessions at this point, once a week without the analytic couch. Norm told me his doctors suggested he seek help for the psychological aspects of his recent symptoms. He reported a wide array of troubling pains and soreness, including back pain, leg weakness, dizziness, shoulder troubles, arm tingling, shortness of breath, chest pains, exhaustion, trouble sleeping, and balance problems. While he had a history of physical problems dating back many years, a great deal of these symptoms had started or intensified over the past year.

Norm’s parents divorced when he was six. Afterwards, his uncle became his father figure. Norm felt very close to him while growing up and still does. He does not say much about the effects of this history, so I am the one left to wonder about it and give it value and pain. Norm’s mother developed breast cancer when he was ten years old. She went in and out of remission until she died when Norm was thirty years old. Last year, Norm’s uncle was diagnosed with a terminal brain tumor and was given a year to live. Norm does not say much about his feelings in general and when he relayed these sad events with these important figures in his life he didn’t show much emotion. I commented on this and he said, “I think I just got used to it with my mother since it went on for so long.” What Norm does show emotion about is his physical status and the problems he thinks he may have. He says he “is really worried about what might be wrong and if it is serious. The doctors say they have done all the tests and found nothing wrong but I still have all these strange feelings and the weakness and pain. I think I should get more tests.”

I suggested that he might be having a somatic reaction to the ongoing grief and loss in his life. Norm said he thought it could be but he “still worries about what might be going on.” He told me that the referring physician told him he was stressed and having anxiety reactions. Norm said he wasn’t sure if that was right but was willing to try therapy “if it would stop all these terrible feelings in my body.”

Norm was very athletic as a teen and played on numerous teams. He won several awards competitively and “loved to play ball.” I asked him if his mother’s ongoing illness made it hard to concentrate on sports or school when he was growing up. He said he didn’t think about it too much except when she had to go back into the hospital for treatments. I asked if his father, uncle, mother, or anyone else talked to him about this difficult situation. Norm said no one ever did. I asked if he had ever tried to bring up his feelings or questions with his mother. Norm told me he “never did because I didn’t want to be a burden. I thought she had enough to think about and deal with without me adding to her troubles.”

I interpreted that he felt his needs and worries were selfish and were burdens on others so he kept them to himself, but that way of coping and protecting others left him alone and overwhelmed with his anxiety and grief. He said,

I can see what you mean but I just did my thing in sports and school. The only time I really felt concerned was when she had a relapse and had to go to the hospital. Most of the time, she seemed healthy and didn’t talk about the cancer so I felt okay. The only time I really felt badly about it was years later when she was told she only had six months to live. Then, it was final and real. I really felt sad then. It was awful. She had cancer for so long and I had grown up with her that way that I didn’t really think of her as sick until the end.

Norm’s mother died when he was thirty. When Norm was twenty, his grandfather died after a battle with cancer. Norm was quite close to him. Norm was playing basketball a few weeks after finding out that his grandfather had cancer and he felt some leg pain. Norm played again the next day and felt some back pain. The third day he played another basketball game, got changed, and suddenly experienced an excoriating pain in his back and leg. He ended up at the hospital that night. For the next month he was on painkillers and in and out of the hospital, unable to walk. Overall, the doctors found some problems with his back but nothing serious. However, due to his symptoms he was told that they could perform exploratory surgery but because of how young he was they recommended no surgery. He was told to avoid straining his back until it hopefully recovered on its own. So, Norm stopped playing sports and confined his activities to going to work and minor shopping or short walks.

In listening to Norm describe this scenario, I noted that he did not convey any sense of frustration, anger, or anxiety about having to curtail much of his active life at such a young age. He was without emotion and seemed to just adjust to it. I said it seemed like what he must have done with his mother, just trying to adjust and somehow have no feelings about something shocking and unwanted. Norm said he “knew there was nothing I could do about it and I didn’t want to make it worse so I had to go along with it.”

In the counter- transference, I noticed I was becoming the voice of life and the one who had feelings, wanting more than life was offering. I made this interpretation of the projective identification-based transference and Norm said he knew what I meant but had felt helpless to expect more, given what had happened to his back. I said I was surprised he gave up so easily, given how important sports and activities were to him while growing up.

I said,

You seemed to have had this emotional reaction to your grandfather but you were showing the pain and the utter helplessness you felt through your body instead of being able to talk about it and feel it. A strong driving force in your life was gone and your spirit was broken. But, you tried to be neutral and accepting about it. Yet, the pain persisted in your body.

Norm listened in an interested way but didn’t say much to elaborate. I asked him if he ever considered the back incident to be related to his grandfather’s illness. Norm said he had not but, now that I had brought it up and drew the parallel to his mother and uncle, he could see how it might be a factor.

What he was referring to was a line of similar tragedy and resulting physical reactions throughout his life. When his mother was dying, he went to the emergency room with severe swallowing problems and stomach aches. He went to many specialists and was told he had irritable bowel syndrome and acid reflux. On the one hand he felt relieved at finally “knowing what the problem is” but he still doesn’t quite believe the doctors were right and “perhaps they didn’t find something else that was really the cause.” Yet he seemed to really respond to the concrete knowledge of an actual physical diagnosis. I said, “Maybe that is easier than so many intense feelings for your dying mother and her loss that you can’t totally understand or pin down. You feel more in control with a physical label.” Norm said, “Yes. I like it when I know what it is and can move on.” I said, “You haven’t been able to move on from your mother’s death and your grandfather’s death. We can try and solve that.”

After his mother died of cancer some six years ago, Norm told me he was sad but not surprised, and glad his mother was no longer in pain. He said he felt as if a very long story was now over, the story of his mother’s twenty-year battle with cancer. I added that he had been in that war every day for twenty years and it had taken its toll on him, but all the feelings seemed to have become stored or hidden in his body and in his fear of illness. He spent the years focusing on his body and what might be wrong with it. At this point, when I said this, it came to me that he was also identifying with his mother as well as reliving his conflicted childhood focus. Just like his mother, he was always worried, wondering about his health and what was wrong, and scared that the doctors had missed something. And, as a child, on some level, he was always focused on his mother’s body and now, as an adult, he was always focused on his body.

Shortly after his mother died, Norm developed a great variety of physical symptoms, mostly related to his back. He felt great pain in his lower back and weakness and pain in his legs. He also felt shortness of breath and dizziness, as well as other symptoms of panic attacks. As the back pain increased, he started to visit specialists. Eventually, he ended up having back surgery. During the preliminary tests, the doctors discovered a bulging disc. They told him they had never seen one so damaged and wondered if he had suffered a traumatic accident or had tried to lift some incredible weight again and again. He had done neither. In fact, he lived a fairly sedentary life.

After the first surgery he was still in some pain, so after about a year he had a second back operation. Now, Norm feels better but is very careful to not exert any pressure or strain on his back. Thus he takes virtually no exercise, no sports, and makes sure to not lift anything. He feels he cannot ever interview for any job that would require him to sit for a length of time. I listened to him and noticed the degree of conviction with which he had given up so much in life and settled for a limited lifestyle. I was almost convinced of how this was necessary by the way he told me the story, the transference method he was relating (Steiner 2000). But then I asked him if his doctors, surgeons, and specialists had all told him to never exercise and if they had told him his condition was still that dire, restricted, and fragile. Norm said no, but that he “just could feel that in my body and I don’t want to push myself to a point of doing something damaging.” I interpreted that he had given up on himself as an active person and labeled himself as dangerously closed to collapse, even though none of his specialists or surgeons had told him so.

Again, I was speaking for life, activity, and hope while Norm seemed to cling to decline, danger, and doom. This was an example of internal conflicts regarding the life-and-death instincts emerging clinically and the role which need, desire, dependence, and hope seemed to play in his life in this destructive manner.

About six months ago, Norm’s uncle was unexpectedly diagnosed with a terminal brain tumor. Immediately afterwards, Norm started to feel dizzy and weak. He has been convinced that there is something “fundamentally unsound” with him physically. In listening to him, it sounded as if he started to have a series of anxiety attacks, followed by a conviction that he “has something drastically wrong physically.” I thought that he was in a way taking over his mother’s identity, experiencing the same feelings and fears she must have had over the years (Grinberg 1990). I made this interpretation and said that perhaps this was a desperate attempt to stay connected to her. He told me he understood what I meant and “it makes sense” but that “I still have a conviction that there is something wrong with my body and a breakdown of either my back or something else because of all the pain, numbness, tingling, and soreness I feel in all these different areas of my body.”

In the counter-transference, I sometimes feel like yelling at Norm and trying to force or convince him that all these somatic issues are really his hidden grief, anger, sorrow, and anxiety over not having these vital people in his life any more (Joseph 1987; Grinberg 1962, 1968). I want to shout, “It’s about cancer, loss, and fear, not mysterious back pain and dizziness!” In noting these feelings and not acting out on them, over time I have come to think of this countertransference as representing how Norm wanted to yell out as a teen to someone for help, since no one was ever talking about the terrible situation with his grandfather, his mother, and now with his uncle as well.

In other words, I think that, through projective identification (Steiner 2008), Norm was putting his unexpressed anxiety and anger into me because he felt scared and guilty to own these conflicts. I think he both wants to jettison these dangerous feelings into me so as to never have to deal with them but is also making an unconscious communication and a hopeful move to have me express them. Eventually, he may join me in the process and re-own them as his own. In the transference, he is also now the one ignoring the obvious, denying the painful reality of loss and trauma just as he felt everyone else was ignoring it when he was young. Finally, he is able to merge or stay with his mother by experiencing the same types of symptoms and worries that he may have imagined his mother to have, such as “this could be serious,” “this might be something fatal,” “I hope the doctors haven’t missed something,” “maybe I should get more tests,” and “I know they told me I am okay right now but I still feel like there could be something terribly wrong.”

Norm has also told me about his envy of other seemingly “normal families who don’t seem to have had to go through all these terrible health problems. Everyone was healthy when the kids grew up and everyone is still alive now. Sometimes, I find myself wondering why!” When I tell him he is talking about a great deal of anguish, anger, resentment, and sorrow, Norm is quick to backtrack and tell me he didn’t have it that bad and that lots of other families have troubles too. He adds that it is wrong to feel jealous or angry because this is simply his life experience and he shouldn’t feel cheated. I interpret that he feels guilty about showing me the extent of his strong feelings and now wants to take them back and smooth things over. I add that he may have had those feelings for a long time and felt so guilty about burdening his mother that he tried to keep them to himself then too. When he still tells me he is “managing okay and doing all right” I interpret that he resists my compassion and understanding because it may lead to him feeling overwhelmed by all these feelings and also thinking he is being a burden on me and overwhelming me. In response Norm told me,

I always felt so bad for my mother. She was a single mom without much money, raising all of us and suffering with cancer every day. I thought I would be selfish if I ever complained about anything or asked her how she felt. She nev...

Indice dei contenuti

• Cover
• Title
• Copyright
• Contents
• Acknowledgments
• Introduction
• PART I Clinical aspects of loss and disconnection
• PART II Counter-transference elements of modern Kleinian psychoanalytic work
• PART III Modern Kleinian Therapy and the treatment of turbulent couples
• PART IV Character structure as portrayed in film
• PART V Problems with psychic equilibrium
• Bibliography
• Index