Transference Regression and Psychoanalytic Technique with Infantile Personalities
Otto F. Kernberg
Kernberg, O.F. (1991). Transference Regression and Psychoanalytic Technique with Infantile Personalities.(1991). International Journal of Psycho-Analysis, 72:189-200
Presented at the 36th International Psychoanalytical Congress, Rome, August 1989.
(MS. received July 1990)
Copyright . Institute of Psycho-Analysis, London, 1991
THE INFANTILE PERSONALITY AS AN 'HEROIC' INDICATION FOR PSYCHOANALYSIS
Some years ago Ernst Ticho (1966) described undertaking the psychoanalytic treatment of narcissistic personalities as an 'heroic' measure. In what follows, I am adding the infantile personality to this category. Until about twenty years ago, these patients were usually considered to be hysterical personalities. Easser & Lesser (1965), Zetzel (1968) and I (1975) saw them as regressive forms of the hysterical personality and have referred to them as infantile, histrionic, hysteroid, or Zetzel Types 3 and 4. I have dealt with the differential diagnosis of these personalities in earlier work (1975), (1985) and shall only summarize their salient characteristics before examining some typical developments they present in the course of psychoanalytic treatment.
Patients with an infantile personality present the three characteristics dominant in all borderline patients: identity diffusion, primitive defence mechanisms, and good reality testing. Because of identity diffusion—a lack of integration of the concepts of self and of significant others, their capacity for empathy with others and for a realistic evaluation and prediction of their own and other people's behaviour is reduced. In consequence, they present highly conflictual object relations, although they can engage in depth in the sense of lasting—though chaotic and clinging—relations with significant others. This capacity for deep involvement with others, even if highly neurotic in nature, differentiates these patients from other patients with borderline personality organization, such as the narcissistic personality, the schizoid personality and the paranoid personality.
Because these patients present a predominance of defensive operations centring around splitting, they evince fewer repressive mechanisms than would be typical of the hysterical personality proper. Thus, the sexual inhibition of the hysterical personality may be replaced by conscious persistence of polymorphous perverse infantile trends, even in patients who definitely do not present evidence of sexual perversion. Splitting operations underly these patients' contradictory, discontinuous, chaotic interpersonal behaviour.
These patients present the emotional lability and histrionic quality characteristic of hysterical patients, but it is present in all their object relations rather than specifically linked to their sexual relationships. They also show the extraverted, exhibitionistic behaviour of the hysterical personality, except that this behaviour has a childlike, clinging quality rather than an erotic one. Infantile patients convey the impression that erotic seductiveness is a means to gratify clinging and dependent rather than sexual needs.
From a psychodynamic viewpoint, infantile patients present the typical condensation of oedipal and pre-oedipal conflicts characteristic of borderline personality organization, but with an accentuation of later or advanced types of oedipal conflicts, which bring them much closer to the hysterical personality than would be true for all other borderline patients.
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As I suggested in earlier work (1985), one might indeed describe a continuum from the hysterical personality proper to the infantile personality proper, a point of view already implicit in Zetzel's (1968) classification of this syndrome into four types. In the light of my more recent experience, most of this spectrum of patients may be treated with psychoanalysis, thus constituting, together with the narcissistic personality, the important exceptions to the idea that psychoanalysis is not appropriate for the typical patient with borderline personality organization. However, in order for psychoanalysis to be indicated for an infantile personality, it is important that the patient present at least some motivation for treatment, some capacity for emotional introspection or insight, and a certain capacity for impulse control, anxiety tolerance, and for sublimatory functioning (non-specific aspects of ego strength). These requirements exclude from consideration for psychoanalysis the typical 'Zetzel type 4' patient with non-specific manifestations of ego weakness, apparently uncontrollable acting out, and a limited capacity for realistic self-reflection.
Some of the treatment failures of the psychotherapy research project of the Menninger Foundation (Kernberg et al., 1972) included patients of this kind, that is, with indications for analytic treatment, treated with what was apparently well-conducted psychoanalysis. I have since wondered whether what has since been discovered about the psychoanalytic treatment of borderline cases might explain those failures. I have therefore given considerable thought and attention to more recent psychoanalytic treatment of patients who might be characterized as Zetzel types two and three, and who had a more successful outcome. In what follows I present the salient aspects of two such cases, for the purpose of illustrating their technical management.
Mrs A
Mrs A, in her early thirties, was a skilled professional working in an industrial research laboratory exploring highly specialized circuitry design [whose main symptom, described below, I referred to briefly, in another context, in earlier work (1984) ]. She had entered the hospital because of a severe and acute depression, which responded rapidly to antidepressive medication, and entered treatment because she was dissatisfied with her relations with men and her obesity. She was a drug abuser and had phobic fears of driving on highways and bridges. She was not unattractive but dressed in a way that exaggerated her (moderate) obesity. She explained that she could be interested only in men who were unavailable. She was nonetheless interested in people and had close friends.
After great hesitation, she confessed to what she considered her most serious symptom: a tendency to falsify the results of her work in the laboratory, followed by several repetitions of certain experiments to demonstrate the error of the falsified findings that she herself had earlier presented, with the result that her actual contributions to her field were dramatically slowed down. She would work very hard, staying until late at night in order to undo the effects of a falsification of her work. Careful evaluation of her superego functioning in other areas—of antisocial tendencies—revealed only a transitory period of shoplifting in early adolescence; she was otherwise scrupulously honest.
She provided me with contradictory, even chaotic descriptions of her closest friends and relatives, and of herself. She presented identity diffusion, a predominance of primitive defensive operations, chaos in intimate sexual relations, and a multiplicity of neurotic symptoms—a typical borderline personality organization. I diagnosed her as an infantile personality with masochistic features, but her capacity for object relations in depth, the absence of anti-social features (other than the specific symptom at work mentioned), and the absence of non-specific manifestations of ego weakness seemed to justify attempting psychoanalytic treatment.
Mrs A had enormous difficulties in conveying a realistic picture of her parents and her two sisters. She described her father as distant and unavailable, cold and withdrawn and, yet, as warm and engaged with her—in fact, almost openly seductive. In the course of the treatment the patient remembered her own direct sexual seductiveness towards her father. In fact, it became apparent quite soon after the analysis had started that it was not clear to her whether
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It was almost impossible for me to obtain an image of her mother, who remained an almost mythical, unavailable person during several years of the analysis. In contrast, the image of a much older aunt, who carried out the functions of a maternal figure, became prominent from early treatment on, in the context of Mrs A's longing for the childhood relationship with this warm, understanding, and giving relative.
In the transference, there were long stretches during which she presented oedipal material, fears of and wishes for being seduced by me that gradually shifted into wishes to seduce me as a father figure, with a parallel uncovering of deep, dissociated unconscious guilt over this seductiveness, expressed in severely self-defeating patterns in her relationships with other men in her life. In fact, one might say that her oedipal conflicts showed up not in a dynamic equilibrium involving unconscious, repressed positive oedipal longings and guilt feelings over them, but in simultaneous, mutually dissociated or split-off acting out of unconscious guilt over good relations with men outside the analysis, and direct expression of conflicts around sexual seductiveness and fear of being rejected in the analytic situation itself.
Several months later a new theme emerged which gradually took over significant periods in the transference. Mrs A mentioned a colleague, X, who was carrying out work somewhat related to hers in the laboratory, a woman the patient found extremely attractive and, at the same time, a potential serious professional rival. Gradually, she developed strong homosexual feelings towards X, together with intense fear that X was trying to steal her ideas in order to promote herself.
Mrs A's fears of X impressed me as having a paranoid quality: X was a horrible witch with unusual powers, dedicated to destroying the patient by ruining her work, tampering with electronic circuits, and producing mischief in many ways. As I attempted to clarify to what extent the patient recognized all this as reality or fantasy, Mrs A immediately became suspicious of my attitude and intentions, and considered the possibility that I might either know X or have been approached by her in an effort to influence me against the patient. In any case, Mrs A felt really threatened of my becoming an enemy in alliance with X.
I first considered the possibility that an image of a threatening, revengeful oedipal mother was being projected on to X and on to me in the transference, but it was impossible to link these paranoid developments in the here-and-now with significant aspects of the patient's past. In fact, for extended periods of the analysis, for weeks at a time, it was as if Mrs A had no past, no personal history that I might work with in constructive or reconstructive ways, and as if everything was being played out in the relationship with X and myself. Indeed there were times that made me think the patient might be psychotic. Any efforts to link these developments in the transference with the patient's past not only failed, but ended up increasing the confusion in the hours, so that, in certain sessions, I felt as if I were being threatened by a crazy 'witch' who was attempting to transform my efforts to understand what was going on into a destructive scrambling of my own thoughts. Bion's (1959) description of the destructive attacks of the patient on anything which is felt to link one object with another, as an expression of the 'psychotic' part of the personality, seems pertinent here. The analytic situation would become totally chaotic, and now I might experience in my countertransference towards Mrs A (I was being bewitched …) what she was telling me was occurring in her relationship with that other woman, with a simultaneous loss of capacity on her part and, to some extent, on my part, to sort out reality from fantasy.
I would like to stress the confusing effects on me of rapid alternations in the treatment between 'crazy times' in which 'witch hunting' seemed to go on, with the dominant question being who was the hunter and who was the hunted, and 'oedipal times' when Mrs A behaved like a typical neurotic patient: associating satisfactorily while exploring the positive oedipal transference and her relationships with other people in the present and in her past in the light of these transference developments.
It was only after many months of clarification of these transference developments that I was able to interpret to Mrs A that regardless of the reality of X's behaviour, the patient had projected
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on to her an internal reality consisting of a mad 'witch' woman who was trying to steal her thoughts, destroy her work and her future, and whose power was related to the
patient's own intense admiration and sexual attraction for such a dangerous witch woman. That same 'witch' woman was forcing her to undo her own creative work in the laboratory. It was only then that very early memories came to mind in which Mrs A perceived her mother as both intensely protective and yet invasive—controlling the patient and implying that she could read her mind. It became apparent that Mrs A had always felt penetrated by this image of mother. She felt that her body, her movements, her speech, her intentions could no longer be trusted because they might really represent her mother's intentions.
Then the idealized figure of the aunt emerged as a split-off image of an ideal mother, loving without being invasive, and who would tolerate distance without aggressively punishing her daughter. Mrs A had lived in the fantasy (or reality) that her mother could not tolerate any independence or autonomy of the patient during her childhood years. The fear of driving on highways or over bridges now became clarified as fears of being taken over by a mother who would punish her with death for attempts to escape from mother by racing through highways or over bridges. I was now able to analyse with Mrs A the repetition of her relationship with mother in her relationship with me, experiencing me, on the one hand, as an invasive witch-mother who was assaulting her simultaneously in the sessions and in a replica of mine at her work place, while, on the other hand, without being aware of it, she herself was identifying herself with this invasive mother at other times in attempting to prevent me from contributing with my autonomous work to her understanding and from thinking independently at the same time. I suggested to Mrs A that the terrible confusion of whether her rival was indeed creating a 'gaslight' situation at work, or whether the patient only fantasized such a development, was part of this pattern. The analysis of Mrs A's identification with a primitive, overwhelming witch-mother who had parasitically taken over the patient's superego gradually led to the resolution of the symptom of self-defeating falsifications of findings in the patient's work.
At that point, Mrs A started to think more freely about what was going on at work, and both she and I discovered in the course of a few weeks that, indeed, X was actively attempting to undermine the patient's work, a fact confirmed by evidence from others where they worked.
It became apparent at the advanced stages of her analysis that the internal, unconscious submission to a mother from whom she could not differentiate herself represented the deepest acting out of oedipal guilt, the split-off counterpart to her conscious oedipal fantasies and wishes in the transference. Mrs A now became both more inhibited in the expression of her sexual fantasies towards me and consciously more fearful in her sexual involvement with men. The analysis evolved into the systematic evaluation of oedipal conflicts and ambivalence regarding both parents.
Mrs B
Mrs B, a moderately successful painter in her early forties, consulted me because after several failures in psychoanalytic psychotherapy she had heard that I was interested in painting and, in her fantasy, therefore represented a 'non-establishment' analyst. This somewhat flimsy rationalization for her decision to start treatment with me soon turned into a source of great anxiety for her as she started to fear that I might become very envious of her because she could paint and I did not and this might endanger her treatment with me. Mrs B suffered from moderate anxiety, conflicts in her current, third marriage, interpersonal difficulties with other women, lengthy periods of paralysis in her work, and discreet self-mutilating trends. She bit and chewed the mucosa of her mouth, the skin surrounding her fingernails, and compulsively pulled out her pubic hair. She had formerly been a heavy drinker, but this symptom was under control by the time she started her treatment with me.
She was the only daughter of parents who, while proudly referring to their aristocratic background, had undergone severe financial difficulties for reasons that were never made clear to the patient. Mother's resentment at father's incapacity to reverse these financial difficulties
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constituted a major theme of Mrs B's childhood. I learned very little about her mother: she was described as strong yet non-intrusive, 'always there' yet distant from the patient. Because Mrs B's father had lived in Latin America in his youth, the patient developed elaborate fantasies about my personality, linking it to his.
Father emerged as friendly but frail and incompetent, and the patient went into lengthy details to explain how she had tried to search for a more assertive and effective man in her own life but was always frustrated. She always ended up with men who were failures, which was a major source of bitterness. Mrs B's only daughter, from an earlier marriage, was away at college, and she missed her terribly. She thought her absence accentuated the difficulties with her present husband, a businessman who had not been able to sustain his own independent business, and was now working for a former competitor. The patient was teaching art in addition to painting, and was able to contribute significantly to their joint finances.
The initial impression conveyed by Mrs B was that of a woman with relative freedom from symptoms in the sense that I did not have the impression that her self-mutilating patterns were really severe, nor did her anxiety, mood swings, and interpersonal difficulties appear severe. However, after more extended evaluation of her I detected in her a sense of emptiness and confusion that conveyed a severe disturbance of her personality. Yet she had a capacity for introspection and motivation for treatment that seemed helpful for undertaking psychoanalysis.
While she was precise and clear in describing objective events or her past history and current life situation, she became diffuse and even chaotic when describing her family and closest friends. She described the important women in her life as fascinating yet threatening, close yet untrustworthy; men, in contrast—particularly her three husbands— as reliable but weak. Mrs B was pleased with herself for having maintained a good relationship with her former husbands, but they did not emerge as clearly differentiated from each other in her narrative.
Mrs B had difficulty in conveying her view of herself: while she enjoyed her art and teaching, she also wondered whether there was something 'fake' about her; she was troubled by her tendency to cling to relationships even when they seemed frustrating and produced conflict.
On the basis of all these elements, I diagnosed her as an infantile personality functioning in a borderline personality organization, and initiated a psychoanalytic treatment with her.
Again, what follows is a highly condensed summary of issues relevant to the main subject of this paper. Her intense fears that I might envy her artistic talents, an early transference development, reflected the projection on to me of her own envy of me and my professional work. She felt that I was an example of the successful man she admired and longed for and never could achieve having, a reminder of the bitter disappointment in her father and in her husbands, and she gradually became aware that it was hard for her to decide whether she would want me as a man or would want to be like me. Positive oedipal longings and penis envy, together with unconscious identifications with envied men, became a principal content of the early transference. In this connexion, the unconscious selection of men whom she considered as limited in order not to experience excessive envy and rivalry with them appeared as a first dynamic aspect of her marital difficulties. Later on we found out that she was unconsciously contributing to keeping her husband in a subordinate position in his own business.
A second theme that soon emerged reflected her relationships with other women. She was active in a women artists' group and worked closely with a few women having similar professional backgrounds and interests. She selected women to work with whom she considered very aggressive, and she would at first admire and submit to them and later develop intense rage reactions and terminate the relationship with violent arguments. This pattern had repeated itself often enough for the patient to be fully aware of it, of her fascination with these powerful women, of her tendency to put herself into a position where she would be exploited by them, and her subsequent intense resentment and, in her own view, exaggerated violent reactions.
In fact, while Mrs B could diagnose these patterns in retrospect, she was unable to diagnose them in the course of their development. My focus on why she could not recognize these difficulties while they were in progress brought
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Now, it was striking to me that any effort to link her growing awareness of a pathological pattern of interpersonal relations in the present to the patient's past proved fruitless. Quite similarly to what occurred with Mrs A, all such efforts at construction or reconstruction ended in confusion or a sense, on my part, of partaking in a sterile intellectual exercise. In contrast to Mrs A, however, Mrs B was acutely aware of her confusion between the motivation of herself and her friends, and of her fear that this confusion would prevent her from any possible understanding about herself and her difficulties and would also prevent me from understanding her. In fact, during such confused states, even the patient's verbal communication in the hours became somewhat disorganized. In dramatic moments during some sessions, with intense anxiety, Mrs B said that her main problem was that she really was not a person separate from others, but so totally immersed in and influenced by relations with others that it was impossible to sort herself out, and she could not see how I would be able to help her to do this. Eventually, I told her that I thought she was afraid that I could not tolerate her in her 'unglued' state, a comment she experienced as very helpful. She now felt that she could 'fall apart' in the sessions without being threatened by either getting me to fall apart as well in my understanding, or in provoking me to try to 'put her together' in a forceful way that would limit her freedom and expose her to becoming an artificial product of my mind.
A long period now followed in which the patient became chaotic in her comments in the sessions, and in which certain themes emerged that never came up at other times. These themes included the patient's sexual excitement with biting and chewing her mucosa and the skin of her fingers, the fantasy of sadistically attacking her body while controlling that attack and being able erotically to enjoy the pain it caused. At one point, Mrs B was able herself to formulate the fantasy that it was as if she were engaged in a sexual perversion in which she was enacting the role of sadist and masochist at the same time, with a sense of humiliation, of humiliating herself before me as well as being humiliated in a sexual delivery of herself that was eminently exciting.
Another issue that came up in fragmented ways during such periods of confusion was the thought that in many ways she was imitating her mother in gestures, in her clothing, or that her mother was imitating her as if there were a telepathic communication between them. I need to stress that it was extremely difficult for me to obtain a realistic picture of the mother during extended periods of Mrs B's analysis, a problem similar to the one experienced with Mrs A. At times, Mrs B used her mother's colloquialisms in ways that were slightly bizarre: she also used her mother's recipes for cooking with slight modifications that typically resulted in a ruined product. I was never clear about whether the disastrous result was caused by Mrs B or by her mother's having deliberately modified the recipe.
It eventually became very clear that the patient's unconscious identification with an overpowering and dangerous mother could be undone only by means of an internal fragmentation, a generalized splitting operation, which reflected the fantasy that there was no danger in letting mother take over because there was no person there to be taken over—that mother would just get lost in the course of this takeover! By the same token, projecting Mrs B's own defensive sense of fragmentation on to mother brought about the fragmentation of mother's image and was an effective defence against fears of her. We now learned that Mrs B's fearful concern over my getting lost when she felt fragmented in the hours was actually an active effort to make sure that I would not be threatening her in an invasive manner: my comment that she was afraid that I would not be able to tolerate her sense of fragmentation was reassuring to her because it meant that I acknowledged her fragmentation, and that I was not going to be able to overcome it. In other words, what I had experienced as my tolerating her sense of regression without prematurely intervening interpretively, she experienced as a protection against me as a dangerous primitive mother trying to mould her after me. In addition, my own sense of confusion, of fragmented thinking in many sessions of the patient's regressed state could now be understood as her projecting her
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'endangered self' on to me, while unconsciously she enacted what she saw as her mother's invasively controlling behaviour.
The clarification of all these issues in the transference brought about further clarification of her difficulties with women. The patient was able to assess and resolve
more realistically the temptations to become involved in neurotic interactions with dominant women. At the same time, reconstructions of the early relationship with mother became possible, particularly the relationship with mother during the rapprochement stage predating the major oedipal involvement with father.
It was only then that the infantile version of a powerful and desirable father emerged behind the disillusion and disappointment with a weak and frustrating father, a later image in which realistic aspects of childhood experience and unconscious oedipal guilt feelings coalesced.
The fear of mother's envious attacks could then also be related to the patient's fantasy of becoming the powerful mother and, by using that powerful mother's controlling force, to take over father 'from inside' and become both of them, a combined and powerful primitive father-mother. This fantasy, in turn, further clarified the unconscious need to relate to men whom she experienced as disappointing but whom she was able to control in subtle ways. This led to changes in her relationship to her present husband and to her capacity to support him in his efforts to improve his business situation.
TECHNICAL IMPLICATIONS
Perhaps the most striking feature in the analysable cases of infantile personalities that I have personally treated or supervised is the sudden development of a transference regression—brief or extended—that may not be immediately apparent because the patient continues to free associate, the manifest behaviour on the couch is not radically different, and it is usually in the countertransference that the analyst first observes the fundamental change that has taken place.
The change consists in a sudden, dissociative shift into a type of free association that enacts a primitive relationship in the transference while disconnecting it defensively from its antecedents in the past and, at times, even from external reality. It is as if the patient, ordinarily functioning on a neurotic level, suddenly began to function at a typical borderline level, with a shift from total-into part-object relations, from a stable sense of identity (which facilitates the description of past and present object relations) into a state of acute fragmentation which distorts or breaks up all communication about significant object relations other than that enacted in the present with the analyst and which first becomes apparent for the most part in the analyst's countertransference.
At this point, it is as if the analyst were forced to shift his pace of work, to focus sharply on the current transference relationship while having to accept that the cues will come predominantly from his countertransference fantasies and affects rather than from the manifest content of the patient's verbal and non-verbal behaviour. It is the suddenness of this shift that is so impressive and potentially disorganizing to the analyst.
At such points of regression, it is as if the transference 'channel' (see Kernberg, 1987) represented by the content of the patient's subjective experience, and the transference channel represented by the patient's non-verbal behaviour in the transference fade out, and the only channel remaining is the 'analytic space'. The 'analytic space' refers to the relatively constant, yet silent background configuration of the relationship between patient and analyst that enacts both a realistic and a fantastic object relation. The latter impacts the analyst's countertransferential disposition directly.
I have found that if the analyst now attempts to continue his ordinary way of working with the content of a patient's free associations, increasing periods of confusion ensue. A real danger exists of artificially organizing the patient's communications in intellectual ways which, in turn, the patient unconsciously interprets as an invasive takeover. It is, in fact, the very absence of dramatic acting out, of communication by means of the non-verbal action channel of communication that tends falsely to reassure the psychoanalyst that he may pay maximum attention to the content of the patient's verbal communication. This assumption leads to premature efforts at interpretation,
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while the main issue being played out in the silent space between patient and analyst goes underground.
The clinical characteristics of these states of regression are subtle and yet dramatic in their effects on the analyst's countertransference. The patient may continue to free
associate with affectively invested narratives of what is going on currently or talk about the past, and there may be references about the analyst, without, however, the possibility of clarifying the deeper transference implications of these feelings. On the contrary, sometimes the patient may seem unusually 'healthy' and 'reasonable', and the central issue is the analyst's sense, over a period of days and weeks, that it is not possible to deepen the exploration of anything the patient says, or that there is no depth at all to his material. Also, experience will teach the analyst that any efforts to penetrate to deeper levels, utilizing previously acquired knowledge about the patient's unconscious processes, will lead into a strange confusion, which will be detrimental to the analyst's very efforts to understand what is going on. The issues that finally emerge are typically the patient's concern over being taken over, over his mind being scrambled, over the analyst's being 'lost' (as a consequence of projective identification) and therefore the patient's feeling threatened of being abandoned.
Only gradually will the underlying primitive part-object relationship become clearer, in the context of rapid interchanges of the enactment of self-and object-representations. In the psychoanalytic psychotherapy of borderline patients, the analyst may be prepared to deal with the unconscious implications of the dominant object relation in the here-and-now only—consciously postponing any effort to link the unconscious in the here-and-now with its genetic antecedents—and is therefore, paradoxically, better prepared to deal with such severe regression. In contrast, in the analytic treatment of the infantile personality these regressions are masked by the patient's apparently remaining within the frame of the analytic process that proved so productive and helpful earlier, thus temporarily—or permanently—confusing the analyst. If there is extensive acting out, the analytic exploration of this situation is facilitated by the possibility of examining primitive internalized object relations in a more specific scenario of action, whether this action is with the analyst or others. In the circumstances I am describing, which are characteristic of patients who are being analysed precisely because, among other reasons, acting out is not so great as to preclude analysis, the seeming continuity of the analytic process masks its underlying discontinuity.
Often, in the countertransference during such states of what might be called a silent regression typical of these patients, the analyst may feel that this is really not an analytic case, that the patient is talking emptily without any possibility of transforming the communication into useful material; the analyst may simply withdraw with a sense of helplessness. Underneath such helplessness may be an unconscious identification of the analyst with the patient's projected regressed self. I have had the opportunity to examine cases where the analyst broke off the analysis because of extended periods of this kind. On the other hand, an analyst with a strong bias towards believing in a specific genetic origin for such states of regression may be tempted to interpret the verbal content in the light of such a genetic hypothesis, and the patient may respond with contents corresponding to such a genetic interpretation while unconsciously acting out the fantasy that he is being taken over and that only further fragmentation will protect him.
In fact, the dominant reason why these frequent, sudden regressions in the transference of infantile patients occur at all may be the patients' conscious or unconscious awareness of the analyst's understanding of them, with the implication that any emotional understanding is equivalent to a dangerous invasion, takeover, or even sexual penetration against which the enactment of transference regression becomes a ready-made defence.
My main point is that a helpful approach to such periods is precisely not to interpret specific verbal contents at such times, and gradually to prepare the interpretation of the dominant object relation enacted in the transference in an atemporal fashion, that is, without any effort to link this development to a specific timetable, to a specific period of the patient's past. Analysing what is going on unconsciously in the here-and-now while tolerating the disconnexion of this material from the patient's immediate external
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reality and from his unconscious past constitutes, in my experience, the best guarantee for meaningful information that, eventually, will make it possible to link the unconscious past with the unconscious present and other aspects of the patient's present external reality.
The type of regression I have described requires, one might say, a different type of
listening, or rather, an awareness on the part of the analyst that the patient's channel of communication has radically shifted from verbal communication of subjective content and from non-verbal behaviour towards the most subtle and intangible one of movement in the analytic space, the implicit but constant relationship between the analyst and the patient, and that communication within that space reaches the analyst first through his countertransference. There is, of course, the danger that countertransference problems in a narrow sense, that is, derived from the analyst's transference dispositions, bring about periods of failure to understand; the analyst will first have to tolerate such a period and then examine whether it stems from his own activated conflicts or whether it corresponds to the sudden and radical shift in the nature of the communication from the patient. I should like to stress how long it took me to become aware of what was going on in each of the two cases mentioned; this was also true in the other patients of this type whom I have treated. These difficulties also presented themselves in the case of supervision, when the supervisee communicates lengthy periods of apparent stagnation in the analysis of his patient, or lengthy periods of non-understanding, with the additional difficulty for the supervisor of opening up the exploration of countertransference problems without invading the supervisee's privacy. The overall distance from the material in the latter instance was, however, helpful.
One aspect of the reconstructive work of interpretation that emerges from the experience with infantile patients is that reconstructions involving the regressive transferences can only be attempted belatedly, namely, after analytic work has been completed with the unconscious meanings in the here-and-now carried out on an atemporal basis for an extended period of time. Such constructive work leaves open threads into various directions and interrupted pathways of the interpretive work carried out during the stages of what might be called neurotic transferences, pathways that eventually need to be linked to the open threads. If the analyst can tolerate these discontinuities, these cut-off threads to the past, eventually, new patterns evolve that impress him with logical, one might say, almost unavoidable connexions between the two sets of information coming from periods of 'borderline' regression and periods of more advanced or 'neurotic' functioning. Only then has the possibility for connective genetic interpretations emerged for me in those cases.
The fact that in my two examples the dominant object relation enacted in the severe though apparently silent regression was with an unconscious aspect of the pre-oedipal mother points to a prevalent aetiology of such regressive states, but should not be taken to mean that this is the interpretive line the analyst should attempt to follow. There are other cases in which a regression occurs to a condensed father-mother figure, as with Mrs B, the unreality of which requires much more elaboration in the unconscious here-and-now before it can be traced back to the more realistic aspects of the parental images.
It is important to carry out analytic work along ordinary interpretive lines during such other times when the patient seems to be functioning on a neurotic level. At these times, patients with infantile personality present a more direct expression of transference relationships that have a 'total' in contrast to a 'part' object-relation quality. The transference relationship relates more easily to other object relations in external reality and in the patient's past and therefore lends itself to constructive and reconstructive efforts. What is important is that the analyst should tolerate the discontinuity between the analytic work during the 'neurotic' times and the analytic work during times of deep though subtle transference regression.
The severe transference regression I have been describing may be confused with the chronic resistance against transference regression so typical in narcissistic personalities. In fact, the analyst's protective withdrawal, his sense of impatience and boredom, which may signal the activation, in the countertransference, of regressive
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transferences in infantile personalities, may be confused with similar reactions to narcissistic transference resistances. The principal difference is that an intense, clinging dependency of the patient on the analyst persists throughout the regression in infantile personalities, in contrast to the sense of distance and lack of emotional involvement with the analyst in the narcissistic transferences.
The nature of the confusion that emerges when the analyst attempts to deepen the understanding of the material presented during these types of severe regression in the transference raises another question. Is one faced with loss or blurring of ego boundaries, so that it is no longer possible for the patient to ascertain whether thoughts are originating in his mind or in the analyst's mind? And is a similar confusion contaminating the analyst's thinking as well? Or is this degree of confusion the
consequence of intense activation of projective identification, in the patient—and,
possibly, in the analyst as well—so that by rapid alternation between projective and introjective mechanisms there is an interchange of a sort between patient and analyst which tends to bring about a confusion of who is who, but with clear delimination between the two, without ever reaching a condition of actual merger or confusion between them? In
my experience, the situation is almost always of the second case, in clear contrast to authentic merger in the transference that can be observed in the psychoanalytic approach to psychotic patients (Kernberg, 1986).
As I have pointed out in earlier work (1975), loss of reality testing in the transference consequent to the activation of projective identification must be
differentiated from authentic merger experiences. The latter are typical of psychotic, particularly schizophrenic patients in analytic modalities of treatment. Borderline patients in deeply regressive transferences maintain their capacity to differentiate themselves from the therapist, even when they temporarily seem to be 'exchanging their personality' with him.
Bion (1957) described 'psychotic personalities' as the psychotic part of clinically non-psychotic patients as well as the characteristics of schizophrenic patients in psychoanalytic treatment. These psychotic personalities or psychotic aspects of any personality, according to Bion, evince a predominance of extremely destructive impulses, hatred of reality expressed as aggressive destruction of the patient's own capacity for awareness of reality, predominance of projective identification and pathological splitting of projected material into minute fragments that constitute 'bizarre objects'.
While I believe that Bion underestimated the differences between psychotic transferences proper and severe regression in borderline and other character pathology, his stress on the predominance of projective identification and other primitive defences as a manifestation of aggressive attacks on the very apparatus of perception conform with the characteristics of the transference regressions I have illustrated. But the severity of these features varies from case to case, and particularly the aggressive attacks on the perception of reality may be quite limited. I think that Bion, in lumping together schizophrenia and character pathology, underestimated important differences in their respective transference regression and, even more importantly, in their technical management.
The analysis of the dominant object relation during severe transference regression proceeds very slowly and gradually. The unconscious fantasies throughout periods of severe transference regression may become clarified by means of the here-and-now, 'atemporal' mode of interpretation I described earlier. Typically, such regressive transference relationships appear with rapid role reversals between self and object—that is, a rapid shift from moments in which the patient identifies with his own self and projects his object representation on to the analyst to other moments where the patient identifies with his object representation and projects his self-representation on to the analyst. Both clinical cases described illustrate this rapid shift. In contrast, during 'neurotic' transference periods such shifts are much slower and less frequent.
Mrs A's alternation between her identifying with the 'witch' and at other times projecting such a witch image on to me illustrates this process. Mrs B and I alternately enacted both sides of the invasive nature of the powerful overwhelming mother in relating to the defensively fragmented child. This characteristic of
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rapid alternation of part-object relations is typical for borderline personality organization. In the course of analysing such part-object relations in the transference it is possible gradually to integrate mutually split-off part-object relations and thus to bring about an integration of the self and an integration of the representations of significant others and, with it, self constancy and object constancy. The consolidation of object constancy, in turn, tends to reinforce and clarify the nature of both pre-oedipal and oedipal conflicts further. Both cases also illustrate how the early analysis of oedipal material could be deepened later on, after the working through of the transference regression.
From a theoretical viewpoint, one might think there is nothing unusual about defensive regressions in the transference from oedipal to pre-oedipal periods of development. What is of interest, however, is that the regression in these cases is a structural one, reflected in the activation, in the transference, of the syndrome of identity diffusion. In these cases, as typically occurs in psychoanalytic psychotherapy of non-analysable borderline patients, the transference developments oscillate rather abruptly and sharply between advanced or 'neurotic' and regressed or 'borderline' transferences.
The dangers facing the analyst in treating patients who have such dramatic, radical shifts in their mode of communication are the following: first, by staying exclusively at
the neurotic level of regression in the ordinary transference developments that these patients present in common with standard psychoanalytic cases, one may lose the connexion with deeper, more primitive levels of development. As a consequence, these treatments may end in a stalemate because the basic character structure is not changed, and these patients may surprise one again and again with bizarre, sometimes even violent acting out, and with a lack of integration in their external life which seems to defy all the analytic work done. Under these conditions, the analyst may well conclude that this is a patient with basic ego weakness, without real insight, with very early deficits that cannot be repaired, et cetera.
Second, if the analyst remains at the level of severe regression in the transference
without being able flexibly to go back to analyse ordinary neurotic conflicts, there is a danger of losing the contact with the healthy aspects of the patient's functioning, and of either maintaining the knowledge acquired about the patient's primitive functioning in a suspended state, unrelated to the healthier level of the patient's functioning, or there exists the danger of 'indoctrination' of the patient with interpretations at a primitive level that bypass the healthier levels of functioning and prevent the patient from full integration of the primitive with the advanced, the more fantastic with the more realistic layers of his mind. Some endless analyses in which the patient seems almost artificially regressed by consistent primitiveness of the analyst's level of discourse and interpretation and, by the same token, the patient remains strangely unrealistic in dealing with ordinary levels of day-to-day functioning, may illustrate this danger of lack of a full integration, as part of the psychoanalytic technique, of the primitive with the advanced, of the regressive 'borderline' with the integrated 'neurotic' levels of the patient's conflicts. In some cases, chronic psychotic transference regression ensues, and may spill over into the patient's ordinary life.
In conclusion, I believe that the technical approach proposed in this paper may selectively and significantly expand the field of indications for psychoanalytic treatment of severe personality disorders.
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SUMMARY
This paper describes a particular form of 'silent' regression during the psychoanalytic treatment of infantile personalities (a type of character pathology related to the hysterical personality). This regression is characterized by the development of rapid interchange in the roles enacted in the transference and projected on to the analyst, an apparent 'disconnexion' of the transference material from that dominant when the patient is in non-regressed states, and the intensification of the analyst's countertransference reactions. The diagnosis and management of these regressive transferences requires a particular interpretive style and strategy outlined in this paper and illustrated with two case vignettes.
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TICHO, E. 1966 Selection of patients for psychoanalysis or psychotherapy Presented at the 20th Anniversary Meeting ofthe MenningerSchoolofPsychiatry AlumniAssn.Topeka,KS(unpublished).
ZETZEL,E.R.1968The so-called good hysteric In The Capacity forEmotionalGrowth NewYork:Int.Univ.Press,pp. 229-245
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Article Citation [Who Cited This?]
Kernberg,O.F.(1991). Transference Regression and Psychoanalytic Technique with Infantile Personalities. Int. J. Psycho-Anal., 72:189-200
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