Attachment Theory and the Healing Psychotherapy Relationship

Joseph Burgoin
Points of Departure
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The Psychotherapy Relationship
270

In the first part of this series, I discussed Allan Schore's video about early neurological damage resulting from failures in the attachment relationship between mother and baby. In the second part, I used Schore's research to help explain why our defense mechanisms are so tenacious, and why authentic change is difficult and rare. I'd now like to conclude with my personal, somewhat idiosyncratic view on how real change occurs, how that early damage can to some degree be healed, and what conditions are necessary to do so. I don't have the science to back it up; all I can offer is my experience, both as a client on the couch for 14 years, and in working with my own clients for the last three decades.

My thesis is simple: if failures in early attachment damage the brain as it develops, the way to repair that damage (to the extent possible) is through another "attachment" relationship that somewhat resembles but also differs in major ways from that early bond: the psychotherapy relationship. I suppose I mean that in therapy, something like a "corrective emotional experience" occurs, as long as we don't idealize that experience and we understand that therapy doesn't fully correct for all those early emotional failures. The corrective emotional experience in therapy is not a replacement for a mother who truly loved and cared for you. It's the closest to such an experience that many people ever get but it's a distant "second best."

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Rage and Entitlement in Borderline Personality Disorder

Joseph Burgoin
Love and Hatred
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The Psychotherapy Relationship
63

A site visitor who signed with the name "Jay" recently left an interesting comment to my earlier post on borderline personality disorder. As this bears on the issue of rage and the sense of entitlement, I'll quote his remarks at length. He's a young mental health professional, working at an in-patient facility:

"I have one BPD patient. Just one and the stress is starting to get to me. It is becoming a nightmare. She cuts, threatens suicide, hits her peers, urinates on the floor and yells at the top of her lungs when she does not get her way. She pulled the fire alarm during her tour of the building because she wanted to be let in the music room. That room was under construction. I explained to her why she could not go in there, her answer was "how do you know?" I pointed to the "under construction keep out" sign. She replied "well you still don’t know that.” She then proceeded to yell at me for not taking her side.

Another example, she ordered cereal for breakfast the night before. She woke up and asked for oatmeal and bananas. We did not have any oatmeal. We offered cereal and bananas. She flipped a few chairs, threw her tray at the kitchen staff, threatened to kill herself and burn the place down. That lasted 3 hours. There was no talking with her, no pacifying her. Finally she was placed in restraints and medicated. She sleeps 10 hours.

Empathy does not work, group therapy, one on one, drawing, meditating, bribery, nothing . Yes, I bribed her with snacks, tried a few reward systems. She’s in her early 20s, as I am. I can not reach that girl. She hates me one day and can not live without me the next. My colleagues are all sick of her. Being the youngest of the staff, she’s is mine until she leaves. I am seriously considering switching to hospice care. She has no boundaries and does not respect mine. For example, I stated that I am uncomfortable with kissing on the cheeks, hugging, holding hands and such. However I do shake hands. She will try to hug me every time I see her, or touch my clothes, hair, to touch my papers. I’d say "please don’t", she'd say "but I want to see what it is" or "they are just papers”. Yes papers that are on my lap . That make my blood boil."

In this comment, Jay dramatically illustrates the emotional challenge of working with someone who suffers from borderline personality disorder. His reactions are not unusual; I have felt very similar ways during sessions with my own clients. His account also reminds me of other such stories I've heard, about the way bpd patients affect their ward staff. They are highly provocative and evocative; they inspire feelings of hostility and resentment. They make you want to quit the profession.

In order to help someone like this young woman, you first have to get clear on the difference between empathy vs sympathy. Jay states that "empathy does not work," but I doubt he or anyone else on the staff is truly empathizing with her ... at least they're not aware that they are. She fills them (via projection) with all her own unbearable emotions of rage and anger; the way she treats her caretakers evokes the same feelings within them that she is struggling with. Jay says her behaviors make his "blood boil" -- that's where the empathy comes in. The problem is that, for the most part, we mental health professionals believe it's inappropriate to have such feelings, and when we're forced to admit that we do have them, we want to blame the patient.

What I recommend instead is to use those feelings to connect with her. In my response to Jay, I suggested that he say something to his patient like this: "When you can't force me do what you want, it makes you so furious you hate my fucking guts and want to kill me." It's clear from what Jay writes that she's struggling with murderous rage and it's important to name it for her, to articulate the emotions and impulses she's feeling. It's easy to assume that she knows what she's feeling; the truth is, her mind is continually blown apart by the violence of her feelings; she doesn't really know what they are in any way you or I would recognize. It's the job of the therapist to help her bear with those feelings and learn to understand them -- very difficult work.

This young woman also finds any kind of frustration unbearable; she's goes into a rage whenever she feels it. In part, this reflects the sense of entitlement you so often find with borderlines; it also betrays the limits of her capacity to bear any kind of pain. She demands to be treated as if she were an infant, really -- ministered to by a perfect mother who would tend to her every need and never let frustration become an issue. It would be important to address this with the patient: "I think you find any kind of frustration unbearably painful; when you feel it, you just want to kill somebody." With my own clients, I've also said things like: "You expect me to understand and gratify your every need without you having to say a single word."

Neither can she bear the experience of separateness; those boundary-crossing behaviors that understandably annoy Jay represent her attempt to take possession of him, to own him, and to deny the separation between them. When the experience of need, separateness and frustration is unbearable, fantasies of merger often come to the rescue. If she "owns" Jay by merging with him, then on some level, she believes she won't have to feel frustration, or become enraged when he doesn't instantly do what she wants him to do. When she feels "at one" with Jay, she "loves" him (it's not really love, of course); when she experiences him as separate and frustrating, she wants to kill him. To me, these are familiar borderline dynamics.

I feel for Jay. His comment is overflowing with all the unbearable emotion she inspires in him. Using those feelings as a guide to the patient's emotional experience (countertransference in the broad sense) is the only way to make the work bearable for the therapist, and the only way you can truly help someone this troubled. In my experience, it also helps you feel more compassionate toward their suffering. It is painful and often terrifying to feel murderous rage. If Jay, with his healthier mind and greater mental capacities, finds it so difficult, imagine how hard it must be for his patient to bear with her experience. By using your reactions as a guide to understanding your client (instead of feeling quietly guilty because you hate her), you'll truly empathize with her experience, and probably feel a lot more sympathy as well.

Countertransference Issues in Treating Depression

Joseph Burgoin
Depression and Bipolar Disorder
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The Psychotherapy Relationship
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Unbearable Emotion
25

Countertransference was a term originally used by Freud to describe a client's influence on the analyst's unconscious feelings. Freud believed that no psychoanalyst "goes further than his own complexes and internal resistances permit," and for this reason, having a personal analysis as part of training was considered essential. In other words, Freud viewed countertransference as arising from unresolved and unconscious issues within the analyst. Since then, our conception of the countertransference has grown to include all of the therapist's reactions to the client, including his or her conscious experience during the session. From this point of view, as a working therapist, your own feelings, thoughts and fantasies provide important information to further your understanding of your client. This latter view is exactly the way I think about countertransference; during sessions, I rely heavily on my internal process to help me understand the person I'm working with.

In my recent post on repression, I gave a simple example: a client who communicated a lot of pain to me during session (that is, I felt pain) but seemed not to be feeling it herself. I often have similar experiences in session, where I'm listening to someone talk; feelings will start to stir within me but my client doesn't seem to be conscious of any particular emotion. Working this way, you have to be cautious not to assume that everything you feel comes about because of the client's issues; you need to listen for other material that gives you a basis for believing that it's a projection or unconscious communication. After a while working this way, you begin to trust your reactions (your countertransference in the broad sense) and feel confident about when and how to use them.

Part of that trust depends upon your comfort level with certain emotions. Remember Freud's remarks about how unresolved complexes and resistances will limit a therapist's effectiveness. If you're the kind of person who has trouble bearing anger or grief, it may limit your ability to understand your client's experience. This is especially true when dealing with certain types of depression. I'm thinking in particular of one type I discussed a while back, where unconscious and destructive rage plays a major role. Therapists who have a hard time acknowledging their own anger and aggression will struggle with this particular client because they don't want to feel the emotions aroused by treatment. Therapists who believe they should only have kind and loving emotions toward those in their care will also have a hard time. Such therapists may often dislike the client without quite admitting it. Their interpretations may come across with an edge; or they may become much more directive and impatient because they want the client to "move on." They may secretly dread that particular session in their day.

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Defense Mechanisms VI: Repression (and Resistance)

Joseph Burgoin
Defense Mechanisms
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The Psychotherapy Relationship
12

Although this post comes late in my series on defense mechanisms, it really should have been the first one: in a way, all but the most primitive defense mechanisms are forms of repression. When you're in denial, you repress the awareness of unwelcome truth. When you idealize someone, you must repress those perceptions that would undermine the idealization. If you were to develop a reaction formation such as homophobia, you would repress your attraction and physical desire. It's worth noting that, in each of these cases, it's actually the awareness of some aspect of your psyche that is repressed.

Freud originally discussed repression as it related to trauma, leading to his famous formulation from the Studies on Hysteria (1893-95) that hysterical symptoms actually symbolize the repressed traumatic memory. In these early years, he used the words "defense" and "repression" almost interchangeably. He soon expanded his conception of repression as pertaining to instinctual drives of all kinds, not traumatic memories. (As I discussed in my piece about Freud's id ego superego theory, I have a problem with this kind of language. "Instinct" doesn't really capture what Freud what trying to describe in his native German). He also distinguished between a primal repression and repression proper, which I won't get into as it's theoretical and doesn't feel clinically relevant.

There are places, however, where Freud speaks very simply and elegantly about repression: "the essence of repression lies simply in turning something away, and keeping it at a distance, from the conscious." That "something" could be an unacceptable emotion, either about someone else or yourself; it might be a perception of reality you'd rather not acknowledge. While Freud largely thought of the motive for repression as evading conflict -- between id drives and superego prohibitions, for example -- I find it more immediate and clinically useful to remember Donald Meltzer's formulation, that all defenses (including repression) are essentially lies we tell ourselves to evade pain. When we repress something (i.e., keep it at a distance from consciousness), it's because we're trying to avoid pain of one kind or another. There's an idea everyone can understand.

Freud also made clear that repression isn't something that happens just once; it's a process that requires a continual expenditure of energy to keep the repressed from returning to consciousness. In other words, we tend to develop strategies that are designed to keep the repressed feelings from breaking free of their dungeon. I've seen a number of clients with eating disorders who used binge-eating in this fashion: whenever some repressed emotion threatened to come up, or they faced a new and threatening experience, they would overeat in order to ward it off (see my earlier post about unbearable emotion in bulimia). You could think of this defense in different ways: as an anesthetic, for example, or as "shoving" the feelings back down along with the food. (In my experience, binge-eating is one of those symptoms whose meaning is usually "over-determined", as they say -- it might also be a kind of self-soothing, or even a kind of punishment. It's not a simple issue.)

Anyone who has been in psychodynamic therapy or practices in that modality most likely regards repression as an accepted fact of life, but there are many scientists and mental health professionals in other disciplines who will dispute its existence. If you browse through books in the self-help section at Barnes & Noble, you'll rarely find a reference to repression and the unconscious. In my view, without an understanding of repression, real growth is nearly impossible since you're unlikely to come into contact with that pain you're trying to ward off. Even if you do manage to overcome some kind of maladaptive behavior or thought pattern, you're likely to develop another equally maladaptive strategy to keep the repressed at bay.

Freud came to understand repression through his clinical experience with resistance. In the very early days, when he thought it was enough for his patients to recover their lost traumatic memories, he found that they didn't want to recover those memories and fought him in his efforts to bring them to light. He decided that there must be some psychic force keeping the traumatic memory from entering consciousness. Likewise as a practitioner, your day-to-day encounters with resistance show you repression at work. Now and then you identify something clearly in a client -- some pain they're not facing, some level of shame they can't bear to face -- and when you try to help them to look at it, as empathically and sensitively as you can, they'll often deny they feel that way or appear to agree with you and then change the subject. Sometimes they'll just tell you that you're wrong (and of course, on occasion, you are!).

In more serious cases, they'll quit treatment if you get too close to the repressed material. I had a recent experience with a new client, a woman with a horrendous past, obviously in excruciating emotional pain. As she talked in session, she communicated that pain to me on a non-verbal level while she herself didn't seem aware of feeling it; when I tried on several occasions to draw her attention to that pain, reminding her of all the very good reasons she had for suffering, she halfheartedly agreed. She then began to have scheduling conflicts, telling me she couldn't make our next session because she had a conference the next day and didn't want to be "distracted". After three sessions, she decided not to come back.

There are other possible explanations, of course. For one, it could be that, as gently as I tried to put it, I was premature in addressing the issue. When someone terminates without an explanation, you never really know. But to me, the experience spoke powerfully to the enduring power of repression, and the resistance so often aroused in your clients when you try to address it.

The Development of Mind and Meaning (Part I)

Joseph Burgoin
Points of Departure
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The Psychotherapy Relationship
·
Unbearable Emotion
5

We've all heard people say things like, "I felt completely overwhelmed" or "I just couldn't take it"; they mean that the emotions arising for them in a given situation were more than they could tolerate at that time.  In psychodynamic psychotherapy, we often talk about the ability to "contain" feelings, where the mind is thought of as a kind of holder or container for experience. People have differing abilities to contain their emotions:  some can continue to think in the presence of powerful feelings while others explode under pressure and "lose their minds."  Some of us "over-contain" our feelings, flattening or deadening them, and others get carried away by an emotion and have no capacity for thought or self-reflection.  Wilfred Bion, a British psychoanalyst, originally put forward these ideas.  Based on his understanding of early mother-infant communications, he elaborated the relationship between the mental container and the contained experience, using it to explain what goes on between client and therapist in the consulting room.

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