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One patient felt that he was extremely lucky to have a psychotherapist who represented, according to the patient, the best synthesis of the "intellectual superiority" of one country where the therapist was born, and the "emotional freedom" of another country where the patient thought he had lived for many years. On the surface, the patient appeared to be reassured by a clinging relationship with such an "ideal" therapist, and protected against what he experienced as a cold, rejecting, hostile environment by a magical union with the therapist. It soon developed that the patient felt that only by a strenuous, ongoing effort of self-deception, and deception to the therapist about himself, could he keep his good relationship with the therapist. If the therapist really knew how the patient was feeling about himself, the therapist would never be able to accept him, and would hate and depreciate him. This, by the way, illustrates the damaging effects of overidealization for the possibility of utilizing the therapist as a good superego introjection, in contrast to an overidealized, demanding one. It later turned out that this idealization was developed as a defense against the devaluation and depreciation of the therapist, seen as an empty, pompous and hypocritically conventional parental image.
It is hard to convey in a few words the unrealistic quality of the idealization given the therapist by these patients, which gives quite a different quality to the transference from the other, less regressive idealization that may be seen in the usual neurotic patients. This peculiar form of idealization has been described as an important defense in narcissistic personality structures (20; 33). Psychotherapists who themselves present strong narcissistic traits in their character structure may at times be quite easily drawn into a kind of magical, mutual admiration with the patient, and may have to learn through bitter disappointment how this defensive operation may effectively undermine the establishment of any realistic therapeutic alliance. To firmly undo the idealization, to confront the patient again and again with the unrealistic aspects of his transference distortion, while still acknowledging the positive feelings that are also part of this idealization, is a very difficult task because underneath that idealization are often paranoid fears and quite direct, primitive aggressive feelings toward the transference object.
Forms of Projection, and Especially Projective Identification
One patient, who had already interrupted psychotherapy with two therapists in the middle of massive, almost delusional projections of her hostility, was finally able to settle down with a third therapist, but managed to keep him in a position of almost total immobility over a period of many months. The therapist had to be extremely careful even in asking questions; the patient would indicate by simply raising her eyebrow that a question was unwelcome and that therefore the therapist should change the subject. The patient felt that she had the right to be completely secretive and uncommunicative in regard to most issues of her life. She used the therapy situation on the surface as a kind of magical ritual and, apparently on a deeper level, as an acting out of her needs to exert sadistic control over a transference object onto which she had projected her aggression.
The acting out within the therapy hours of this patient's need to exert total, sadistic control over her transference object could not be modified. The therapist thought that any attempts to put limits on the patient's acting out, or to confront her with the implications of her behavior, would only result in angry outbursts on the patient's part and in interruption of the treatment.
This raises the question of how to cope with patients who begin psychotherapy with this kind of acting out, and who attempt to distort the therapeutic situation to such a gross extent that either their unrealistic demands are met by the therapist or the continuation of the treatment is threatened. Some therapists believe that it may be an advantage to permit the patient to start out in therapy without challenging his unrealistic demands, hoping that later on, as the therapeutic relationship is more established, the patient's acting out can be gradually brought under control. From the vantage point of long-term observation of a series of cases of this kind, it seems preferable not to attempt psychotherapy under conditions which are unrealistic. If the therapist fears that an attempt to control premature acting out would bring psychotherapy to an interruption, the necessity of hospitalization should be considered and this should be discussed with the patient. One indication for hospitalization is precisely that of protecting the beginning psychotherapeutic relationship with patients in whom regressive transference acting out cannot be handled by psychotherapeutic means alone, and where the confrontation of the patient with his pathological defensive operations threatens to induce excessive regression. Hospitalization under these circumstances may serve diagnostic as well as protective functions, and should be considered even with patients who, even without psychotherapy, would most likely continue to be able to function outside a hospital. If psychotherapy is indicated, and if the psychotherapy is unrealistically limited by premature acting out, hospitalization, even though stressful for the patient, is preferable to undertaking a psychotherapy within which the necessary structuring is interfered with by the same pathology for which definite structuring is indicated.
identification is a main culprit in creating unrealistic patient-therapist
relationships from the very beginning of the treatment. The direct consequences
of the patient's hostile onslaught in the transference, his unrelenting efforts
to push the therapist into a position in which he finally reacts with counteraggression
and the patient's sadistic efforts to control the therapist, can produce a paralyzing
effect on the therapy. It has already been suggested that these developments require
a firm structure within the therapeutic setting, consistent blocking of the transference
acting out, and in the most simple terms, a protection of the therapist from chronic
and insoluble situations. To combine this firm structure with consistent clarifications
and interpretations aimed at reducing projective mechanisms is an arduous task.
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