PSYCHOANALYTIC CASE

FORMULATION
Nancy McWilliams

Objectives in psychotherapy:
- Disappearance or mitigation of symptoms of psychopathology
- Development of insight
- Increase in one’s sense of agency
- Securing or solidifying of a sense of identity
- Increase in realistically based self-esteem
- Improvement in the ability to recognize and handle feelings
- Enhancement of ego strength (adaptation to reality, reality testing and sense of reality) and
self-cohesion
- Expansion of the capacity to love, to work, (Chessick – love, work and play) and to depend
appropriately on others
- An increase in the one’s experience of pleasure and serenity (focus on mourning vs emphasis
on striving)
- (other specific improvements – such as better physical health and greater resistance to
stress)

Anything important enough to have become a major problem to a person is usually

overdetermined, not caused by a discrete variable.

Several areas…:
- temperament and fixed attributes
- maturational themes
- defensive patterns
- central affects
- identifications
- relational schemas
- self-esteem regulation
- pathogenic beliefs

…
First interview:
- After about 45 minutes, I ask how the person feels talking with me, and whether he or she
anticipates feeling comfortable working with me.
- During the last few minutes of the meeting, I want to accomplish several things: 1) to show
the person I have been listening and have a feel for his or her suffering; 2) to assess the
person’s reactions to whatever notions I have about how to make sense of the problems
described; 3) to convey hope; 4) to make a contract about regular appointement times,
length of meetings, payment, cancelation policy, insurance arrangements, and the diagnosis
to be submitted if a third party is involved. Finally, I invite any concerns that the person
 wants to have addressed before plunging into the therapy proper, and except when such
questions feel too intrusive, I answer them. Unless the patient has in the course of the hour
gone into most of the background areas I would ordinarily investigate, I then tell him or her
that during the next session I would like to take a complete history, so that I will have a
context in which to understand his or her problems.
- ...
- The reciprocity in psychotherapy is the exchange of financial support for emotional support
and expertise… The patient takes care of me by paying my fee… I expect no emotional
support in return…

WHAT CANNOT BE CHANGED

1. Temperament
2. Genetic and medical conditions
3. Unchangeable physical realities and life circumstances

- Adaptation to what cannot be changed and development of strategies that compensate for
unchangeable realities: the overcoming of denial, the
transformation of magical ideas into mourning and Psychoanalytic experience suggests that
coping, and the substitution of realistic explanations for we all harbour irrational desires to be
pathogenic beliefs. simultaneously child and adult, male and
- For exp. Not being free of depressive episodes but female, gay and straight, old and young,
reaction with self-acceptance rather than self-hatred, independent and dependent; we all want to
taking medication instead substance abuse or bravado, live forever.
sharing with important others instead withdrawal.
- … this communication begins a mourning process for the client.
- … encouraging patients to discuss the differences between them and their therapists – this is
psychoanalysis, not a tea party 
- Envy – producing “survivors guilt” in therapist – admitting that there are such areas and in
others where the client has the edge…
- Personal histories – the patient will profit in direct proportion to the degree to which the
therapist can facilitate mourning… the important “parent” to confront is the internalized
person, not the living relative… they cannot be glibly reassured, but they are deeply helped
by having a place to grieve and be understood.

DEVELOPMENTAL ISSUES1

In the clinical interview: “Why is this person coming for help now?” (person (fixed)
+stressors+developmental issues that s. activate = main outlines of good dynamic formulation).

1
Unfinished business - gt
 Why the person came for professional help at this particular time, and whether there have been
previous times when similar problems arose…. Earliest memory and family stories about him or her…
- Reactions to childhood separations, childhood illnesses and accidents, school and work
history, sexual history…
- Gertrude and Rubin Blanck – comprehensive review of pa developmental theory
- Greenspan – systematic integration of the newer discoveries…

Similar to Piaget’s accommodation and assimilation, person’s maturational stage determines

experience of a given stressor and template for interpreting the meaning and implications of future
stressors.

“Regression” to a point of “fixation”: when under stress people tend to revert to the methods
of coping that characterized an earlier developmental challenge that felt similar to their current
situation.

Freud: The earlier we experience “defeat”, the more severe pathology. But, others (Silvan
Tomkins) stress in adulthood can activate early issues even when these were reasonably mastered in
infancy in anyone! (Exp. separation, esp. in a public and potentially humiliating context is a great
stress.)

Assesment – conflict vs developmental arrest:

- Balint’s “basic faults”;
- Stolorow and Lachman “developmental prestages of defense”;
- Kohut: self-psychology – two lines of development: drives and their objects + self and its
wholeness, goodness and consistency.

Freud: 3 infantile (i. e. preschool) stages) resolved by about age six into permanent personality
structure:
o oral - connectedness and dependency,
o Anal - control and conflict with demands of the civilization – compliance and
rebellion, cleanliness and mess, giving and withholding, promptness and lateness,
autonomy and shame, s/m – first year and a half – dramas of agency, terrible twos,
o oedipal - about age of three – fascination with issues about power, relationship and
identity; 3-4 – reality of death, guilt and projected guilt – bedtime fears of attackers,
fears of retribution resolved by identification with primary caregivers esp. the parent
with whom the child feels most competitive.
 “Children at his age need to idealize their caregivers, who, as self
psychologists have noted, must be attuned enough to be idealized in the
first place and nondefensive enough to tolerate the child’s deidealization.
This normal, expectable dethroning of the parents starts around the end of
the oedipal phase (when the kindergarten teacher starts knowing more then
Mommy).” Cardinal achievement of this phase – mature supergego replaces
the primitive all-good and all-bad images of the previous stage (complex and
well-internalized sense of conscience that is the natural consequence of
complex identifications with childhood authorities.
 Latency (after age of six or so) – repression, relief from struggle with
powerful primal urges
 Adult genitality – person capacity to integrate love, aggression, dependency
and sexuality into a relationship with another person.
 Developmental levels

1. Oral – symbiotic (Mahler):

- Trust and distrust (Erikson), me vs not me (Sullivan), ontological insecurity (Laing)
- Struggling to define a sense of existence and personhood
- Problematic reality testing, difficult affect regulation, descriptions of main persons as
shadowy concepts
- Uncertainty of their basic nature (male-female, straight-gay, omnipotent-impotent, good-
evil).
- Ct – interviewer tends to feel overwhelmed in a vague and disturbing way.

2. Anal – separation-indiviuation:
- Autonomy vs shame and doubt (Erikson)
- Good me vs bad me (Mahler)
- Coming closer or darting away (Masterson)
- Engulfment vs abandonment depression (Kernberg)
- The existence of the self will not seem fragile, but strong ct reaction due to struggle between
infantile helplessness and aggressive empowerment – sense of dyadic struggle (hostility,
demoralization, rescue fantasies).
- People described stark and unnuanced, all-good or all-bad actors on the person’s subjective
stage.
- Adequate reality testing, but identity will seem tenuous and primitive defences such as
denial, splitting and projective identification will predominate.

3. Oedipal phase
- Susceptibility to conflicts about sexuality, aggression and/or dependency
- Overall capacity for object constancy, an appreciation of the complexity of self and others, a
tolerance for ambivalence, an ability to take an observing position toward his or her
affective life, capacity to feel remorse and a sense of responsibility, secure reality testing,
relationships with devotion, consideration, appreciation of the complexity of others.
- Descriptions of main people will bring them alive as three-dimensional human beings…
- Separate person with a strong sense of I-ness
- Suffering seems to be well demarcated into a particular area
- CT – tends to be benign
- Symbiotic-psychotic, borderline or neurotic level (we all have aspect of all of these, but
usually one predominates) – supportive2, expressive3 or uncovering4 therapy.

Anxiety and depression – developmental contributants

- Annihilation anxiety – acute sch states, but residual in fears of intimacy (threat to individual
existence)
- Separation anxiety – esp intense at borderline level, feeling empty and insubstantial
(battered spouse), astonishing regressions and inexplicable explosions of hostility.
- Oedipal or superego anxiety – fears of punishment for unacceptable sexual, aggressive or
dependent strivings. There is no threat to perception of reality or identity of the self, but

2
To je stvarno teško, kako možeš da izađeš na kraj sa tim osećanjima da bude konstruktivno…
3
U smislu da T izražava, prevodi konfliktne i projektiovane delove („mislim da je to osećanje damned if you
do damned if you dont koje ovo kreira u mene osećanje sa kojim se ti stalno boriš“).
4
„Na koga te tvoja šefica podseća?“ 
 one’s personal good-enough-ness may be seriously compromised. Intense since oedipal
fantasies typically involve ideas of death and retribution. Common trigger – experience of
personal success!

Anna Freud – anxiety from the id - “dread of the power of the instincts” (feeling of danger of
being completely overwhelmed), anxiety from the ego – “signal anxiety” (a fear reaction signalling
that smth dangerous had happened previously in similar circumstances), anxiety from the superego
– superego anxiety (fear of punishment for unacceptable strivings).

Depression:
- psychotic-level sense that one’s badness is so overwhelming as to render one unsalvageably
dangerously evil
- borderline-level sense of despair, emptiness and traumatic abandonment
- neurotic-level conviction that it is hazardous to pursue happiness.

Stresses for coming to therapy … anniversary reactions, client reaching the age the parent had
when s/he died, when children reach the age when client had traumatic experience, etc. Being
gaslighted brings early issues from psychotic-symbiotic phase, rejected or losing – issues of the
separation-individuation, sexual temptation or triangular competitive relationship – oedipal issues…

Attachment styles: secure, avoidant, ambivalent-resistant. + disorganized-disoriented (80%

maltreated infants and 40-50% children with depressed or alcoholic mothers)

DEFENSE

(A. Freud, Laughlin, Vaillant)…

- Habitual (“character armor”) and reactive (situationally provoked)

Observations about defense from the behaviour in the interview situation:

- Simultaneously striving to be nondefensive and being propelled by their anxieties into being
more defensive than usual. (they minimize their issues so that the therapist will not be as
negative toward them as they themselves tend to be.)

Questions:
- what do you tend to do when you’re anxious?
- How do you comfort yourself when you’re upset?
- Are there any favorite family stories about you that claim to capture your basic personality?
- What kinds of observations or criticisms or complaints do other people tend to make about
you?
- How do you find yourself reacting to me?

Vaillant – defenses can alter one’s perception of any or all of the following: self, other, idea or
feeling:
 - Cognition (e.g. rationalization)
- Emotion (e.g. reaction formation)
- Behaviour (e.g. action out)
- Combination of these (e.g. reversal)

Kernberg
- primitive or primary (splitting, primitive idealization, projective identification, denial
omnipotence, primitive devaluation)- protect the ego from conflicts by means of dissociation
or actively keeping apart contradictory experiences of the self and significant others.
- secondary or mature (reaction formation, isolation, undoing, intellectualization,
rationalization) – protect the ego from intrapsychic conflicts by rejection of a drive derivative
or its ideational representation or both from the conscious ego
- McW. more archaic defenses involve the boundary between the self and the outer world,
more high-order deal with internal boundaries.

Characterological tendencies Main defense

Psychopatic Omnipotent control
Borderline-level Splitting, projective identification and other
“primitive” defenses
Narcissism Idealization and devaluation
Schizoid Withdrawal into fantasy
Paranoid Reaction formation and projection
Psychosomatic vulnerability and alexithymia Regression, conversion, somatization
Depressive and masochistic Introjection and turning against the self (and
reversal)
Mania Denial
Phobic attitudes Displacement and symbolization
Obsessional Isolation of affect, rationalization, moralization,
compartmentalization, intelectualization
Compulsivity Undoing
Hysterical Repression and sexualization
Dissociative Posttraumatic states of mind

- Characterological vs situational defenses – therapist’s ct is often guidance

Clinical implications:

Long-term vs short term implications:

- Situational: we can point it out and encourage to consider other ways…
- Characterological: One cannot remove a defense when it is the main structure by which a
person attempts to cope – there is no observing part of client to access, it is natural and
automatic… we spend the first months and even years of therapy making ego-alien what has
been ego-syntonic.
- How to work with defenses: hysterical (Mueller and Aniskiewitz), obsessional (Salzman),
habitual dissociation (Davies and Frawley)
- Frontal attacks on defenses leave only 2 choices: give up and become overwhelmed with
anxiety, shame or guilt or fight off the person who is assaulting one’s cherished method for
coping with life (people almost always choose the latter, or compensate via an idealization
of the therapist)…
 - Most therapists in short-term situations learn ways to sidestep and finesse clients’ defensive
patterns or to use their defenses in the service of their growth rather than their paralysis (e.
g. telling masochistic person that it isn’t good for him etc or to psychopathic associating
truthfulness with courage – “telling me fairy tales only wastes your money and my time”).

Systematically exposing vs “going under” defenses

- Systematically exposing (going from “surface to depth” – staying at the top of their personal
hierarchy of defenses) – “start where the patient is” and “don’t mess with a defense until
the person has something to replace it with” (hysterical, obsessive-compulsive,
- “Going under” – self-destructive clients, substance abuse - confrontation (“You’re in denial,
get real!” – anything less typically elicits more denial), with hypomanic – going directly to
depth, bypassing the surface and ignoring the layer of denial (“Your probably not conscious
of this, but I’m pretty convinced that you’re reacting to… based on some unconscious fears
that…), paranoid – similar

AFFECTS

Silvan Tomkins – 9 innate or “hard-wired” affects: interest-excitement, excitement-joy, surprise-

startle, fear-terror, distress-anguish, anger-rage, dissmell (contempt), disgust and shame-
humiliation.

- Affect integration (Socarides and Stolorow) – maturational accomplishment

- Moments of heightened affect (Stern) –
- The capacity to feel and to regulate affect…
- Kernberg - Therapists process client communications on at least three channels: verbal, body
language and affective transmission (mostly through facial expressions and tone of voice)
- Spezzano – character as “the container and regulator of a person’s affects… the balance a
person has achieved between what is and what might be in his affective life, an expression
of his belief about how the greatest sense of well-being can be maintained and how affective
pain can best be avoided.” – how people erect a personal shield of defenses against
upsetting affects

In transference/countertransference field:
- Racker (’68) – concordant (“I’m feeling what the patient was feeling as a child”) and
complementary (“I’m feeling what the patient’s childhood caregivers felt”)
- the less effectively a person can communicate emotional suffering in language, the more
powerful his or her nonverbal messages tend to be.
- E. g. with depressives more sympathy, for self-defeating – we feel a sadistic inclination to
criticize. With psychopathic – we feel duped or contemptuously bested. The appreciation of
a paranoid core under an ostensibly depressive presentation – anxiety-filled fantasy that the
patient will file a malpractice suit.

Affects as presenting problems:

- Abnormalities of: cognition (e.g. delusions, obsessions, posttraumatic intrusive thoughts),
behaviour (e.g. compulsions, paraphilias, explosivity), sensation and perception (psychogenic
pain, anaesthesia, hallucination, tunnel vision), affect (depression and mania, anxiety and
panic disorders, phobias).
Diagnostic meaning of affect:
- Obsessive client cannot feel anger unless it is packaged as moral indignation, the schizoid
client who is frightened of tender longings toward real people, the emotionally labile
histrionic client, the grim paranoid, the mercurial borderline…
- Standard psychiatric evaluation: are they appropriate or not? Flat? Superficial? Controlled?
Can the patient express them verbally or via bodily distress or acted out?

1. Can the patient distinguish between affect and action?

o Does they express anger through words or actions?
2. Can the patient represent affective experience in words?
o Instead of acting out or getting sick
o To somatising patients – first we stay long enough empathizing with the physical
pain and suffering that are the consequences of their mechanism.
o Obsessive-compulsive – they don’t only defend against emotions – they don’t
know what they feel, so therapist’s job is not to penetrate their defenses but to
teach them slowly how to represent unformulated experience into words.
o If our countertransference is irritation and impatience – they probably know
what they feel at some level; but if it is confusion and inarticulateness – they
probably don’t have the way to represent internal experience. In first case,
therapist feels an affect (e. g. hostility) that presses for discharge; in the second,
he or she feels the diffusivity of the unnamed.
3. How does the client use affects defensively?
o Which affect operate in a way that protects a person from feeling other
emotional states
o Therapists, due to their depressive cast to personalities – it is useful for them to
get access to the hostility and rage beneath their conscious feeling of
unhappiness.
o Stosney: “Anger management training” for abusive partners is misdirected –
problem in batterers is not management of anger but rather the use of anger to
defend against fears of abandonment associated with shame, humiliation and
guilt. He offers strategy emphasizing compassion. They seek relief form their
pain by projection and acting out, blaming their partners for intolerable
emotional states and then attacking them.
o Common mistaken belief that antisocial individuals are impulsive – there are
reptilian, predatory psychopaths with cold, calculating fury that is chronically
and frontally in consciousness.
4. Is the patient’s suffering related more to shame or to guilt?
o Guilt involves an internal sense of malevolent power, a feeling of deep personal
destructiveness and evil. Shame by contrast involves a sense of powerless
vulnerability, the chronic risk of exposure to the criticism and contempt of
others.
o Fossum and Mason (86) – “Guilt is the inner experience of breaking the moral
code. Shame is the inner experience of being looked down upon by the social
group.
 o Freud – more about guilt; middle of XX century – Helen Merrell Lynd, Helen
Block Lewis… ‘70s Kohut and Kernberg – shame… ‘80s (“me decade” – Tom
Wolfe – narcissism and shame compensating operations).
o Pathological perfectionism – Freudian obsessional patients (chronically afraid
their aggressive impulses will erupt, do damage, make a mess) vs Rothstein’s
“the narcissistic pursuit of perfection” – a driven determination to appear sinless
betty carterand flawless, so that one’s human limitations are not revealed and
others’ disdain is avoided (being exposed as inadequate, empty, a sham).

Therapeutic implication of getting it right about affect:

- Instead of treating feelings like client’s parents – neglecting, judging, punishing and making
inaccurate attributions, therapists – welcome and are interested in feelings, name them
nonjudgmentally, encourage safe emotional expression and – they name them accurately
(perhaps the most challenging).
- Suggesting an affect as a response (with alexithymic patients and all others) – actively
suggesting and educating!
- Affects as motivators – Jane O’Reilly (’72) – emotional “click” – (for uncomplaining
housewife – a previously absorbed insult reformulated as a cause for righteous anger)
- Affects accomplish developmental goals (grief – normal mourning process – we need to
accomplish a piece of mourning if we are to avoid regression or psychological rigidity (Judith
Viorst (’86) Necessary Losses; Freud “Mourning and Melancholia” – grief and depression are
in a sense opposites – When one reacts to a loss with grief, the world seems emptier for the
absence of the person mourned; when one reacts with depression, the self feels
diminished.)
- Stark (94) – understands much psychopathology in terms of unmourned experiences – first
months or years of pt – client’s gradual assimilation of the fact that their problems are not
their fault; then coming to terms that they are the only ones who can do something about
them (giving up and mourning all their fantasies that some omnipotent good object will fix
things).

IDENTIFICATIONS

Suggested by transference reactions:

- Benign sense of connectedness with a person raised by loving parents (whose generosity of
spirit has been internalized and permeates the intake session).
- Vague sense of being devalued – identification with someone sceptical or distrusting.

Identification, incorporation, introjection and intersubjective influencing:

- Freud – two kinds of identificatory processes: anaclitic object love (Sears, 65, “modeling”)
and later “identification with the aggressor” (later - A. Freud; Weiss and Sampson 86 –
“passive-into-active transformation”).
- Roy Schafer (68) – stages from “swallowing whole” (unreflective mimicry) of greater
discrimination and reflection to identification in the oedipal years (when children can
comment engagingly about just which qualities of which parent they want to adopt).
- Now – most commonly used term is “introjection” for the kinds of internalization that
predate more mature identificatory processes and “introjects” for internalized images of
people important to the developing child.
- How primitive or mature are the client’s identificatory processes:
 o borderline or psychotic levels: describes others in global, holistic ways that
emphasize either their overall goodness or their irredeemable badness (interviewer
feels at loss for any sense of what the described person is really like – a saint or a
satan, not a struggling human being);
o in healthy and neurotic ranges – balanced and multidimensional accounts of
people, but they can still have areas of this simplification (hysterically –
impressionistic about people – defends against perceptions that stimulate fears of
being overwhelmed or injured; depressive – only bad about themselves, and good
about others – it protects the hope that by association with good objects the
badness in their own soul can be counteracted).

- Clinical implications - important part of diagnostic formulation  supportive, expressive or

uncovering model of treatment:
o Initial connection: exemplify how he or she differs from the patient’s pathogenic
internalized objects (although it will not prevent client experiencing him/her
eventually as such – Freud: one cannot fight the enemy in absentia)
o Date of the main transference that
“Finally, it is important for therapists to
will appear understand primitive and unidimensional
o Understanding the cast of characters internal presences because the appreciation of
that live inside the client’s mind and the complexity and contradiction in others and
their meaning – is critical for devising in the self is such a central aspect of
strategies to help (e. g. psychological maturity and personal serenity.
understanding identification with That appreciation remains an important overall
suicidal parent and all its unconscious goal in long-term psychotherapy. The clinician
meanings (idealization and thus tries to modulate a patient’s all-good and
unconscious anger) as a way to work all-bad images, to bring into awareness the
through that and prevent suicide) positive features of the hated object and the
o Abused clients need to find their negative aspects of a revered one, to find love
anger at having been damaged, to alongside hate and hate where the person has
grieve their tragic histories, and been conscious only of love.”
eventually to appreciate that the
perpetrators of their injuries were damaged human beings, usually with horrific
histories of their own.

Clinical possibilities where counteridentification predominates:

- It often saves from the worst possible consequences of a difficult history
- One problem is that it tends to be total and uncompromising – and therefore self-defeating
- From mild observations to direct interpretations and even transference (“You are getting to
sessions late and cheating yourself of the time you pay for – all because you’re experiencing
me as an orderly person like your cold stepmother, whom you have to defy at any cost.”)
- Potent antidote to maladaptive behaviour

Ethnic, religious, racial, cultural and subcultural identifications

- Irish families tend to socialize people to control affect, while Italian ones socialize them to
vent it… McGoldrick et al.
- Protestant guilt about acting on one’s inevitably selfish feelings and Catholic guilt about
having selfish feelings (Lovinger’s Working with Religious Issues in Therapy)
- Clients are pleased to be asked…
RELATIONAL PATTERNS

- Identifications – who and what qualities, and relational patterns – how are connections
expressed
- Recurrent relational patterns: In interview history: “How would you describe your most
important relationships?”, “What is your marriage like?”, “Are you close to anyone?” or
“What do you value in people?” or most importantly – transference.
- Concepts of the researchers: nuclear conflict – Malan, patient’s experience of the
relationship with therapist – Gill and Hoffman, referential set – Bucci, RIG – representations
of interactions that have been generalized – Stern, cyclical maladaptive pattern – Henry,
Schacht and Strupp, nuclear scene – Tomkins, higher mental functioning hypothesis – Weiss,
Sampson et al., frames – fundamental repetitive and maladaptive emotional structure –
Dahl, personal schema – Hororwitz, model scenes – Lachmann and Lichtenberg, core
conflictual relationship theme – Luborsky and Crits-Christoph, representations – Bretherton
+ Structural Analysis of Social Behaviour – Lorna Smith Benjamin (1993)
+ nonpsychoanalytic – interpersonal psychotherapy – Klerman et al.
- Repetitive scripts – metaphors: templates, story lines, cognitive maps, personal tapes,
subjective constructions 
- Contemporary psychodynamic clinical literature – internalized object relations (Kernberg;
Ogden; Bollas; Horner; Scharff & Scharff); individual’s subjective “representational world”
(Sandler and Rosenblatt); structures of subjectivity (Atwood and Stolorow); Bern’s games
and scripts – popularized and highly simplified approach 
- We all have them, many of which are adaptive and benign – in psychotherapy when they are
problematic because they embody a persistent and unremitting conflict.

Relational themes in transference:

- Freud – “Who am I to this person?” and “Is that figure mainly positive or mainly negative?”
- Two step process: 1) How can one describe the pattern that keeps being reenacted? 2) What
are the origins, meanings, motives and reinforcers of that pattern for this person?
- Falling in love with one’s analyst is neither inevitable nor easily comprehended:
o Sexualisation or erotization of a therapeutic relationship is never uncomplicated –
usually overdetermined
o But experience of coming to love a therapist is an expectable and therapeutically
essential aspect of the treatment process – the more emotionally important a
therapist is to a client, the more power he or she has to counteract the negative
effects of the passionately loved and tenaciously internalized early caregivers.
o Co-construction of transference – Orange (95)
o Perfect self-knowledge and self-control are unattainable and patients come to
resolve their own conflicts and not those of their therapists 

Respective implications of transference themes:

- Classical PA – transference neurosis – gradual recreation between the analyst and the
analysand of the core conflictual relationship. Use of the couch, free association, high
frequency of sessions, unlimited time – controlled but regressive experience (not for
borderline, psychotic, dissociative, paranoid)…
Relational patterns conspicuously absent from the transference:
Almost any experience can be rendered
- Deficit formulations (Kohut, Stolorow & Lachmann, Ornstein & Ornstein, Stolorow,
nontraumatic if someone spends sufficient
Brandshcaft, & Atwood, Wolf)
time with a child to help him or her
- During 50s and 60s it was less painful and more
understand and emotionally process what
concrete to lament a mother’s sins of happened. At least after the age of two,
commission than a father’s sins of omission. when children can verbalize, it is often not
so much the trauma itself that is
pathogenic, but rather the atmosphere of
minimization and denial with which a
family treats it.
 - Contemporary scholars in trauma and dissociation (McFarlane & van der Kolk 1996) – the
role of neglect  (not: listening, comforting, helping verbalize, modelling the way of
coping…)

Relational themes outside the therapy situation:

- Important also for keeping the client coming back  solidifying working alliance
- Important to attain the description of other therapies – useful for avoiding similar
enactment and also to predict to the client that the same thing may very well happen (so
could he or she manage not to flee treatment this time but instead verbalize the anger and
disappointment?)
- “I now explicitly take the position that I will make mistakes, that they will probably be similar
in some way to the mistakes that others have made, and that the client and I can use these
failures of mine to understand together something important and find a constructive way to
react.”… it conveys the message that when people disappoint, something other than despair
may come out of the experience.
- “…you can certainly con me if that’s what you insist on… but is that really how you want to
spend your time here?” (for psychopathic inclinations)
- Competition with other therapists or with imagined other practitioners who lack one’s
special skills is fine as an internal state, but it can be disastrous if acted out.
- Leaving relationships (friends, jobs or sexual partners) whenever they begin to seem
constricting, or when the person begins to feel exposed, or when he or she notices a feeling
of deep attachment or dependency – make immediate contract with the client not to act
that response out reflectively: if the person abruptly decides for whatever reason (money,
time) to terminate – the client will come back for a designated number of sessions to
process what has happened.
- Sexual patterns contain relational themes in a highly charged, condensed form (either
dominant pattern or dissociated theme that needs to be integrated into life…)…
o Some people sexualize their dependency (valuing the oral and cuddling aspects of
sex to the exclusion of other factors), others sexualize their aggression (prizing the
dominance and submission aspects); still others use sex mostly in the service of
narcissistic needs (valuing the exibitionistic and voyeuristic features of sexuality, or
the illusion of having one’s desires magically known and wordlessly satisfied, or the
fantasy or defeating and humiliating the other party). Sometimes, especially when
there is a childhood history of physical suffering connected with the genitals (form
sexual abuse, accidents, or medical procedure), the enduring or inflicting pain may
be a prerequisite to orgasm.

Implications of relational patterns for long-term versus short-term therapies

- In long term – one of the motives for change: boredom form hearing themselves  “After a
while it becomes easier to try something new than to go back to one’s therapist and confess
that one has once more acted out the same old pattern. 

SELF-ESTEEM
- What analysts sometimes call “healthy narcissism” 
o How secure is it
o On what is it based
o What undermines it
o How is it restored when it is injured
o How realistic are the aspirations
- Its quintessentially internal phenomenon, its nature must be inferred from a client’s
behaviour and verbal reports
- The preservation and enhancement of self-esteem is at the center of all mature human
activity (plastic surgery instead of narcissistic suffering they associate with normal aging;
soldiers, heroes – when prevented from doing their good deeds, they got depressed –
therapists ; power…)
- We all tend to project – to assume that the things that make us feel good about ourselves
are the same ones that instil pride in our clients.
- “What do you admire in people?” most telling question, supplies the main ingredient in the
person’s self-evaluation
o “What kinds of things make you feel good about yourself?”
o “What kinds of things get you down on yourself?”
o “On balance, do you feel positive about yourself and your life, or are you
disappointed and self-critical?”
- Praising and rewarding for trivial accomplishments produces self-deception and feelings of
fraudulence. Analyst has not shrunk from loathed parts of the self, not reframe it as positive
or minimized or distorted it or provided superficial emotional support.

Psychoanalytic attention to self-esteem:

o First – harsh superego – depressive and obsessive-compulsive clients
 Identification with harsh caregivers (oedipal)
o Second – (un)integrated superego, inconsistent self-esteem - borderline clients
 Bouncing between all-good and all-bad ego states (Kernberg) that are
totalistic, that lack the sense of a tension between what one wants to do
and what one’s conscience decrees is permissible.
 They lack the sense that they are good-enough (as long as they conform to
reasonable moral standards)
 Caregivers not idealizable – oedipal phase not resolved by identification
o Third – uncohesive self (identity) – narcissistic clients (“First, preserve the client’s
self-esteem.” – support and praise, empathic attunement, occasional self-disclosure,
acceptance of small gifts…) (Kohut)

Clinical implications of assessing self-esteem

1. Do the requisites of this person’s self-esteem permit me to work effectively with him or
her
o E. g. clinicians who cannot find a power-related area in their own self-esteem
economy are better off not working with the antisocial (raw power and financial gain
vs authenticity and connection with others).
o Or therapist’s unconscious shame about his or her own unacknowledged narcissism
– avoiding narcissistic clients.
o Other examples – religious (un)sentimentality, sexual fidelity, offering low fees (for
the clients which self-worth is connected with monetary value - either charge a hefty
fee or refer )
 o Problem: not just the therapist’s difficulty to empathize, but client’s difficulty to
identify with so different therapist

2. How can I give patients useful information without injuring their self-esteem
o We want to learn, but it feels humiliating to be taught – every pt interpretation is
thus a narcissistic injury – we need tact, but sometimes it is not enough
o Classical PA - Wherever possible, it should be client who comes with insights, who
derives interpretations – the analyst only clears away the resistances; self
psychology – even more
o Diagnostic flag for borderline and narcissists – our empathic and supportive
comments experienced as sadistic criticism
o Shift to two-person metapsychology (Aron, Mitchell, Black) – co-construction of
transference – when we take responsibility and acknowledge our contribution, the
client carries less of the burden of shame
o Resources:
 supportive therapy (Pinsker), therapy with borderline and narcissistic clients
(Meissner, Kernberg…), substance-abuse (Levin, Richards)
 Lawrence Joseph (95) – Balancing Empathy and Interpretation
 Sue Elkind (92) - …
o For persons with marked narcissistic vulnerability – package an intervention in such
a way that the patient feels not just criticized but also admiringly accepted. It is
useful to know on what specific foundations the patient’s self-esteem is built.

3. How can I modify this person’s maladaptive self-esteem pattern

o Often reason for coming to therapy – inability to abandon an established reservoir of
self-esteem despite life circumstances that no longer feed it (ingenue, briliitant
young guy on the way up, athletic whiz, sexpot… - replaced with durable sense of
pride).
o Different diagnostic categories and self-esteem:
 Self-defeating (masochistic) – pride in self-sacrifice and care for others
 Psychopathic – excitement and power
 Narcissistic – validation and admiration
 Schizoid – creative authenticity
 Depressive – basic acceptance by, and closeness to, others
 Obsessive-compulsive – sense of control.
o we attempt to make the antisocial person capable in pride in honesty, the
narcissistic person responsive to an internal voice, the schizoid person pleased with
a tolerance for ordinary social hypocrisis, the depressive person proud of risking
anger, the masochistic person capable of relishing self-assertion, the obsessive-
compulsive gratified with a growing ability to go with the flow.
o Questioning a person’s internalized standards amounts to criticizing the early love
objects… (first we appreciate existing methods to feel pride and avoid shame…)
o Depressive – self-esteem based on having “nice” thoughts and feelings. 
aggressive education + challenging the superego in a teasing way + welcoming the
anger (=increased intimacy, genuineness and not rejection)

4. How can I help this patient create a reasonable basis for self-esteem
o Easier to soften an overzealous superego than to strengthen a weak one.
o Harsh – identifying with therapist’s nonjudgmental interest, realizing the infantile,
all-or-nothing nature of their severe judgements, mellowing out in one area while
becoming compensatorily more demanding elsewhere.
 o Narcissitic and impulsive – “if it feels good, do it”… our desires are both boundless
and conflictual – we will never have “enough” (of goods or experiences of fame), we
need to find ways to enjoy what we have. – the capacity to delay gratification has its
rewards.  “That must feel good. But what about your self-esteem? Wouldn’t you
feel better about yourself if you had stuck it out for a while?”

5. How can I reorient this person’s self-esteem to reduce destructiveness to others

o More severe narcissistic pathology, most psychopathic people, most addicts (of
various kinds)
o Psychopathic – form pure power to more benign narcissistic one, from feeling
powerful at any cost to looking good to community.
o Slowly, conveying a rigorous honesty, not sentimentalizing good behaviour, the
focus has to stay on concrete matters (whether the person is in control, whether he
or she has risked looking weak or foolish, whether the behaviour under discussion
will come back to haunt the client).

PATHOGENIC BELIEFS

o Freud – „primary process thought – prerational, prelogical, egocentric and wish-driven,

governed by the pleasure principle
o Weiss and Sampson – “control-mastery theory“ – organizing beliefs – often unconscious
and as self-fullfiling prophecies; benign and adaptive or pathogenic (badness of self,
futility of effort, danger of closeness, inevitability of betrayal)
o CBT (but not unconscious, except Barlow)
o Family systems approaches – family myths (esp. against differentiation-individuation
from the family)
o Most are ego-syntonic! What remains unconscious is the interpersonal scenario that
created them in the first place – N. M. it cannot be changed until we understand where
they come from. “At some level” they still believe, “in my gut and not in my head”
(usually discovered in the regression of PA or shock of falling in or out of love, watching
play, drugs etc.)
o Intermittent reinforcement inevitable – self-fullfiling prophecies or projective
identification (people who expect certain kinds of results tend to provoke what they
expect).
o Often conflicting – esp. in borderlines (also polarizing staff, if only one side is dealt with –
therapist will provoke regression or stubborn opposition).
o Developing hypothesis based on:
a. General comments about life
- Listening carefully (in intake interview and later)
b. Descriptions of individual histories
 - Demographics: socioeconomic status, ethnic composition, religious
upbringing, political attitudes
c. Repetitive behaviour
d. Transference reactions
- Traumatized people – conviction that the T will abuse them.
- Depressive – periods of torment in T during which they are sure that
T is about to reject them.
- At the beginning: questions, eye contact, schedule, fee, cancellation
policy…
e. Clinical implications
- For anxieties and fear (often fears conceal wishes – therefore need
for desensitization to lack of attention and not to negative
attention).
- Enactment vs interpretation of transference – both!
- Necessary the knowledge of the conditions that gave rise to them.
f. Passing tests
- Weiss and Sampson
1. Transference test
o The client checks whether the therapist will act like the
early object
2. Passive-into-active transformation
o The client treats the therapist as s/he was treated as a
child (and then observes closely whether the therapist
can handle the situation without recourse to the
convictions the client developed to cope).
- (Racker 68, concordant and complementary countertransference)
- Interpretive intervention (quietly inquiring vs judging for exp.) and
enactement (react differently to their parents – exp. not reactive
defensively or with too much guilt)
- Traditional style (nonjudgmental listening, caring, remembering),
but for some necessary deviations (exp. letting client have a small
debt, invoking personal questions – and analysing their feelings and
catastrophic fantasies)
g. Exposing and understanding the beliefs that produced the tests:
- Jennifer Freyd (cognitive) – “betrayal trauma” (memory loss etc.)
- Severe maltreatment in childhood - it is not enough to pass
transference tests (T
being nonabusive) and Interpretation is passing the test – every
time a therapist feels in this kind of helpless
dilemma (“OMG, whatever I do is wrong”
phenomenon), it makes sense to look for an
underlying pathogenic belief system in which
two sides of a conflict are expressing
themselves and needing the therapist’s
 to pass passive-into-active tests (refusing to be demoralized by the
patient’s abuse) – we must unearth and deconstruct the powerful
cognitions…

CONCLUDING COMMENTS

o Trying to understand how it is to live life in that person’s skin.

o One needs to tolerate some disorganization and ambiguity in the process of letting the
patient’s psychology make an impact on one’s own.
o First subjective reactions to the client (set aside a little time after a intake interview): a
metaphor that comes to mind, what feelings and how strong, how and where our body
is tense, where are we similar/different, reminds us of anyone, which song goes through
our head, anxieties about working with them, intuition…
o Overidentification is a much less serious failing than underidentification.
o Keep letting your patients know that your curiosity about their actual feelings, fantasies,
beliefs, and actions is greater than your need to get validation for your own
formulations… The commitment to discern and acknowledge unpleasant truths about
human nature…