The Management of Aggression in Modern Psychoanalytic Treatment

Transcription

1 Page 1 of 7 Kirman, J.H. (1986). The Management of Aggression in Modern Psychoanalytic Treatment*. Mod. Psychoanal., 11: (1986). Modern Psychoanalysis, 11:37-49 The Management of Aggression in Modern Psychoanalytic Treatment Jacob H. Kirman, Ph.D. Human life is driven by two great forces: love and hate. As psychoanalysts, we must be concerned with both these forces even though some of us may have a predilection for one or the other. Freud himself, though he eventually accorded aggression as much theoretical importance as the libidinal drive, never fully integrated the concept of aggression into his theory of analytic treatment, nor did he give it adequate recognition in his account of the severe psychopathologies he referred to as the narcissistic neuroses. The modern psychoanalytic movement begun over 30 years ago by Hyman Spotnitz, has attempted, among other things, to correct this imbalance. At a time when the schizophrenic patient was seen as suffering from excess anxiety and overmuch self love, Spotnitz recognized the central role of aggression and defenses against aggression in the treatment of such narcissistic disorders. The emphasis on aggression has been necessary because most people don't like being on the receiving end of aggression, nor is it easy to acknowledge it in ourselves. But it should be pointed out that modern analysts are not interested only in hate and aggression; they try to help patients feel, tolerate, and verbally express all of their feelings and impulses, including loving ones. While different analytic schools disagree about the sources of human aggression, there is general agreement that it has both constructive and destructive aspects, and can be manifested either as destructive hatred or as self assertion. This is a revised version of a talk presented at the conference of the National Association for the Advancement of Psychoanalysis on May 3, * Our problem as analysts is with destructive aggression. First, because of its ubiquity. Neither we nor our patients can avoid having destructive impulses, though we may deal with them in various ways. Every frustration of human activity or wishes, and every narcissistic injury generates aggression. Secondly, intense hatred and its unhealthy channelling typically play an important role in severe psychopathology. Lastly, the arousal of too powerful aggression in either the patient or the analyst can have catastrophic effects on either party or on the treatment process, usually by terminating it. That is, after all, the nature of aggression, to control, drive away, or eliminate the other. Modern Analytic Technique Spotnitz and his collaborators developed their techniques through their work with severely disturbed patients suffering from narcissistic disorders, especially schizophrenia and borderline conditions. They came to view pathological narcissism as more than a failure to develop mature object relatedness or as an enduring defect in the structure of the ego or the self. Although these characteristics are recognized as significant, the unique contribution of modern analysis has been to focus also on the defensive function of pathological narcissism. The self-involvement and emotional disconnection from others is seen as a defense which protects the individual and those around him from intense preoedipal aggression, originally mobilized by a loved but enraging maternal object. The outward expression of this rage was felt to threaten the loss of mother or of her love, so it was directed inwards against the child's ego with damaging consequences. Since the modern analyst is dedicated to loosening the compulsive grip of this narcissistic defense, which will entail the redirection of aggression from the patient's ego outward to the object world, it is clear that his treatment plan must sooner or later release the powerful hatred of such patients towards the analyst. However, it is important that this defense be resolved in a controlled and careful manner so that the aggression is safely expressed in words rather than in actions that might injure the health or well being of either the patient or the analyst. It is reassuring to both parties when they get to know and trust that aggressive impulses will not have

2 Page 2 of 7 damaging consequences As part of the attempt to manage this situation, modern analysts find it useful to encourage the regular use of the couch whenever the patient can tolerate it. That is helpful for a variety of reasons. It helps the patient to train himself to experience very powerful feelings and to discharge them only in words. It is also reassuring to the analyst when, for example, a patient is in a very furious state, if the patient remains on the couch and does not show any motor tendencies to get off the couch. The lack of face to face visual contact, in addition to facilitating transference in the patient, at times also helps the analyst to manage his intense countertransference feelings more comfortably with a minimum of worry about inadvertent visual feedback to the patient and the unacknowledged reactions such nonverbal perceptions may induce in the patient. In addition to the couch, modern analysts use other methods to control the degree of disturbance to which the narcissistic patient is exposed. During sessions, the analyst achieves an optimal degree of frustration by following the contact functioning of the patient. That is, he usually speaks only when the patient contacts him. In this manner the patient is not exposed to excessive frustration, but neither is he given too much gratification. When the analyst does speak, he protects the patient's fragile ego by avoiding ego-oriented comments, but instead focuses on objects, including himself, beginning thereby the process of redirecting the patient's attention and impulses to the object world. He may ask if he is making the patient comfortable or disturbing him. If the patient is feeling anxious or self-attacking about his performance in a session, the analyst may ask, How am I doing today? With that simple question, he directs attention away from the patient's ego, with which the patient is morbidly fascinated, invites criticism of himself, and also communicates that he may have similar concerns about his own functioning, thereby facilitating a narcissistic transference. The modern analyst usually works to remove obstacles to the verbal expression of the patient's negative feelings as early in the treatment as possible. However the analyst must consider how much negative transference should be mobilized and when. If too little, the patient is deprived of the opportunity to relive crucial relationships and experiences. Some patients, when they cannot find a sufficiently negative object in the analyst, do not stay in treatment. In other cases, if too much negative transference is aroused too early or too suddenly in the treatment the patient may feel in the presence of a dangerous or persecutory object, and have to leave or act destructively. As modern analysts, we are not limited to the use of interpretations, nor committed to presenting ourselves as neutral blank screens. We have the freedom to use a wide range of interventions both to manage the intensity of negative or positive transference and to resolve resistances to feeling and talking. If verbal interpretations can do the job, the modern analyst is pleased to work that way. But if not, and usually interpretations don't work with pre-verbal resistances, we do not enjoin the patient's observing ego to share our reflections about his behavior. We engage rather in emotional communications designed to help the patient to experience his feelings and express them in words. The analyst may model for the patient the feelingful expression of some emotion or impulse, or he may mirror or join some defense to weaken the patient's need to use it. For example, a patient in a negative transference may have an unconscious determination to defeat the analyst's efforts and to prove that no good can come of their work together. Such negativistic wishes may be robbed of much of their destructive effect if the analyst communicates to the patient his feelings of hopelessness about the case, or indicates that he may not be the right analyst for the patient. The patient, having thereby achieved his goal, is less pressed to pursue it and may even now be in a position to recognize it. The communications of these feelings from the analyst are usually effective in proportion to their genuineness, but with patients like this, it is not too difficult to have such genuine feelings. If a resistance against the outward expression of hatred has been successfully resolved, the analyst accepts the patient's aggression and regards its verbal expression as cooperative. Repetitive attacks for purposes of gratification, however, are discouraged. The guiding principle is whether the patient is repeating old patterns or engaging in progressive communication. The Analyst's Aggression As for his own aggression, the analyst is well advised to be in touch with it in order to prevent its being acted

3 Page 3 of 7 on unwittingly, and to preserve his own mental and physical health. When objectively induced, it provides valuable information about the patient, as is generally recognized. In addition, the controlled communication of the analyst's aggression to the patient can serve other therapeutic functions. It can facilitate transference and model for the patient the acceptability of feeling and expressing anger. It can allow the patient to experience the analyst as sharing his badness, which a too kind or neutral analyst may force the patient to own totally. And in the later stages of treatment, if the analyst exposes the patient to carefully increasing doses of aggression, it can immunize him to the experience of a feeling which he could not originally tolerate. To be sure, the analyst's expression of anger should be under control and modulated, with careful attention to the patient's reaction. For some patients, it may be the only avenue for establishing genuine emotional contact. One of my patients claimed that I really got through to her for the first time one day when I expressed my fury at her in my office. She felt then that she really had had an impact on me, and that really had an impact on her. This patient was very withdrawn in the beginning of treatment, and was totally unable to make contact with me in a positive way. The first real contact was through hate, not love. I first saw her many years ago when she was in her late teens. At that time she was obese and totally antisocial, sleeping during the day and staying awake at night listening to the radio and eating. Her mental life was preoccupied with fantasy figures that traced back to her early childhood. At some point during her treatment, she had experiences of being possessed by spirits that spoke through her. Her aggression was enormous and much later would express itself in blood curdling screams which felt as though they would pierce through concrete (she once released such a scream at the door of my office that my continued occupancy in my building was threatened). But in the first few years of her treatment, her aggression expressed itself in a profound negativism. At one point, when she knew she was expected to lie on the couch, talk, and refrain from smoking or chewing gum, she sat up on the couch chewing away and smoking and saying not a word. She was unable to speak at all in most sessions despite her conscious efforts, and there was a series of sessions lasting over several months during which she uttered not a single word regardless of my varied approaches to that resistance. When she did speak she gave invariably negative responses to any request from me. I was able to deal with some aspects of this negativism by formulating my questions in such a way that a negative response was actually cooperative. For example, I would ask her if she would like to cancel the next session, and she would always say no. Since she did, in fact, want to continue the treatment, this was a means by which she could do what she wanted and have the added gratification of defying me. Nevertheless, my dominant countertransference feeling during this period was rage. I would have been glad to strangle her, but I didn't. She is lucky. For the most part, I contained my fury, but on occasions, when she seemed able to tolerate it, I let some of it out in words. I believe my verbalization of my own anger helped her to experience and then eventually to express her own. She has since informed me that during that time, she was totally out of touch with any feelings of anger. She felt paranoid and paralyzed. It took many years, during which she first expressed her own rage progressively in letters, then in phone calls, and finally by verbal expression in sessions. I will give you a sample of her feelings. Here is a quote from one of her letters: A fantasy: You were standing. I was lying down. I got up and bit you in the neck like a vampire. Biting, drinking your blood, taking your strength into me. I throw you down on the floor and drink and drink. Then I break your neck. Like in Burrough's Naked Lunch, you have an erection at the moment of death. I insert your penis in me. Then I slit open your stomach with a knife, and take bites of your liver and heart. I drink and drink your blood. I don't have clothes on. I smear your blood all over me. Then I take off your clothes and smear blood all over you. Then I put the knife into my own stomach. But I don't die. I am put in a padded room in a mental hospital. I bang walls with my fists. I throw myself time and again against the walls. I cry. I am so bad to have done this. Now you can never come back to me. You have gone away from me because I am so bad.

4 Page 4 of 7 I can't make you like me enough. If you liked me enough you wouldn't take a vacation. But you don't like me enough. It's my fault. I hate you with love. And that was her reaction to my taking a vacation! The session she identified as a crucial turning point took place several years before this letter was written. In that session, I expressed my fury at her because she wasn't talking. This patient has since told me that she remembers me as raging uncontrollably during that session. Personally, I remember myself as delicately administering a therapeutic dose of modulated objective countertransference. Who's to say who's right? She says my anger terrified her, she felt paralyzed by it, but it also reached her it showed her that she mattered to me enough to get me angry at her, even if not enough to get me to love her. She has since told me that prior to that session, her tie to me was based on anger, but that after it, she was able to experience caring feelings from me, and felt that I was willing to let her need me. My feelings towards her also changed after that. I was able to tolerate her silences more comfortably. She has also said that after that session she was never able to fully return to her fantasy world; she had made a definite choice for reality. It had taken my anger to penetrate into her barriered world, and through my anger, I became real to her. Since that time, she and I have shared many loving feelings and run the gamut of emotional communications. Needless to say, she no longer lives behind a wall of narcissism and has emerged as the talented and valuable person she always potentially was. Not all patients have their aggression hidden behind a narcissistic defense. Sometimes it's right out front, and may be part of an enduring pattern of relationships experienced early in life, or may serve as a defense against intimacy or feelings of need and vulnerability. One such patient entered treatment experiencing considerable anger and frustration in his family life as well as relentless pressure and anxiety in many areas of living. Both his parents had treated him in an unempathic manner, making demands on him with little regard for his feelings or for any difficulties he might have in meeting their demands. As might be expected, he presented himself in the beginning of his treatment in an angry and demanding manner, saying he expected me to take excellent care of him since he was certainly willing to cooperate in every way with the treatment. When I suggested that, in that case, he should get on the couch and start talking, he was outraged at this insensitive demand. He frequently experienced my behavior as insensitive and lacking in sufficient concern for his needs to which he responded with hurt and anger. He often asked for appointments at hours when I was not available and believed that I was withholding these hours from him for no good reason. On one occasion during this period, he came late to a session in a rage, saying that this was too much! Not only was his cab stuck in traffic, while he had to watch the meter ticking his money away, but he was further tortured by the thought that my meter was ticking away at the same time! This was all the result of my not having given him a proper hour. He aroused a good deal of anger in me, yet despite that, he evoked considerable fellow feeling in me. I had struggled with similar problems, at least according to my wife! Because of that, I was able to resonate with the fear, hurt, pain, and sense of helplessness he was defending against, and my empathy made it increasingly possible for him to express these feelings more directly. In addition to the recreation of his familiar sense of being badly treated, he also began to have a different experience that of being listened to and having his wishes and feelings considered. The more he experienced that, the more he reduced his angry demands. His behavior in turn had a positive effect on the way I felt and behaved towards him. A positive cycle was established, and he increasingly aroused unconflicted helpful and empathic feelings in me which we were able to share. It became possible to arrange our meeting hours agreeably with mutual consideration, and the vagaries of New York traffic no longer brought down on my head his accumulated sense of outrage. Another patient demonstrates a related use of aggression to maintain distance as a defense against intimate contact. This woman certainly had a lot of anger, and she began her treatment by raging at me. Since she had already had years of analysis with another analyst, I was not particularly cautious with her at first and responded to her aggressions in like vein with very unfortunate consequences. She only became more enraged and

5 Page 5 of 7 wanted to leave treatment. When it became clear to me that her main concern was with earlier experiences of being much too controlled and intruded upon, I decided to follow her directions and to control my contacts with her according to her wishes and abide by her contact functioning. I spoke to her only when she requested that I do, and that has turned out to be seldom. As she said once, her biggest problem in analysis was keeping the analyst out of her business and out of her mind. This careful handling and respect for her need for distance has markedly reduced her anger and has permitted loving feelings to tentatively emerge. She has been doing very well without any effort whatever on my part to help her express any aggression. That's not the focus of her treatment, but rather to provide her with an environment in which her need for space and control is respected, and in that environment she is really blossoming. And as she gets more reassured that she can control the degree of contact with me, and is progressively less frightened of annihilation, her aggression has attenuated. And in recent sessions, she has announced that she wants more interaction with me, and wants me to talk more in response to her communications. Another patient demonstrated that her narcissistic defense was directed towards the protection of her positive connection with me as a positive object, while other objects in her world served as the focus for her bad feelings. The intrusion of negative feelings from either of us was intolerable to her, destroyed me as a positive object in her mind, and left her feeling bereft of the secure loving attachment which sustained her and enabled her to grow. In the early years of her treatment I behaved as an ego syntonic object, and we enjoyed a mutually loving and admiring relationship, occasionally punctuated by powerful depressive states that seemed to intrude with no warning, as if from another world. During this early phase, she wrote: I am struck by the power that I invest in you. When you are nearby, I am entranced, aware of everything around me the miracle of creation, movement, color, scent. I experience the world in a new way I am filled with joy at being a part of life. When you are not with me, I feel lost. I find myself in a world I don't understand, and fear. I am greedily sucking you in with my eyes. I am a woman, but I see and feel with the intensity of a child. My interior self feels completely foreign to me. At a later time, after she experienced an upsetting frustration in our relationship: What an awful rejection! I didn't understand then, what I do now. I thought you didn't love me when you said that. It was so painful. I could hardly leave your office that day. I felt so weak and distraught. You didn't love me. That was all I heard. This event introduced some negative feelings into our blissful relationship, and some intimations of distance as well as resentment towards me began to appear. I feel that our connection is being threatened and I feel robbed of my life energy I wish I were as powerful as you, my oppressor. I do not like to be reduced to being a helpless child. I wonder if my feelings of harmony and wholeness were merely grand deceptions. You attacked me by accusing me of leaving analysts when I experienced negativity You were cruel and it made me feel desperate and bad, alone and betrayed. I never wanted to see you again. Yes, one cruel remark and I want to flee. Some time later, when I frustrated another of her wishes, she got openly enraged and ran out of my office in the middle of the session. Her subsequent communication sounded stronger: I heard your words telling me that I was angry when things didn't go my way that I become enraged when they don't. All of this is true but that isn't what was going on then. I felt distraught, frightened and confused. While driving home I thought, What a tactless bully. The following quotation from this patient shows her increasing acknowledgment of her aggression, along with its continued disturbance within our relationship: I returned after last week's fiasco and was able to tell you how I felt. We tried to analyze what propels me to run away. Your criticism stabs at my wounds which have not healed because I am not digging out the poisons lodged there, just covering them over with a salve that is no longer effective. It is painful for me to experience the distance between us when negative feelings are aroused. I yearn for closeness and find it hard to believe that bad feelings will not interfere with our relationship and my remaining whole. I hate saying words that distance me from you. Why don't you understand that? I have been fighting to keep us fused, but energy is bound up in my attempt to do

6 Page 6 of 7 so. I know I would be much freer if I let in the negative impressions and responded to them instead of fleeing. I believe that my destructive impulses are terrifying, never having been confronted. It seems as if I am gaining access to another part of myself. I could rant and rave all day at all the injustices, or I could push it all down and become mum, paralyzed and rigid. I find I have to make a hasty retreat to my room. My romantic, beautiful, flowered, pink-walled room. Here I am safe spared irritation, frustration, fear, anger, and chaos. Let me stay here forever. I cannot hurt anyone here, especially the innocent This obviously intelligent and sensitive woman has since made considerable progress in integrating her negative and positive feelings, both in the analytic relationship with me and in her family life. These cases are meant to illustrate some of the roles that aggression can play in pathology and treatment. For some patients, hate and anger work as defenses against experiencing a need for love and intimacy, for others love functions as a defense against hate, and for others, hate is itself a harbinger of love and opens the door for its entry into the treatment relationship. All patients sooner or later need to experience both loving and hating feelings and to be able to integrate them both within the same good enough, even if not ideal, relationship. Just getting a patient to experience his hate is not a sufficient therapeutic goal, though it is often an essential step along the way. If a patient can get in touch with and bring his aggression under ego control, it need no longer be sensed as an intolerable danger to be avoided, and can lend its strength to his increased capacity for self assertion. But if his love is wholly focused on one object and his hate on another, he needs to overcome this split. Modern analysts do not attempt to achieve the integration of love and hate by interpreting or confronting the patient with his splitting. The patient needs a good enough object with whom he comes to feel secure enough so that his hate does not ruin the value of the object for him. If the transference begins in a mainly negative way, positive feelings will eventually evolve from the continued persistent interest and fidelity of the analyst, as illustrated by the first patient I discussed. If the transference is at first predominantly loving, as in the last case presented, aggression must be slowly introduced after the patient's ego has been sufficiently sustained by a prolonged positive relationship. Training If the analyst can undefensively experience his hatred toward a patient without losing his overriding therapeutic intent, it will help the patient to integrate his own hatred within the context of a surviving, reliable and good enough relationship. This process may be hampered by the analyst's wish to experience himself as good and benign, at least in work with patients. A personal need to feel helpful may have been a factor in his choice of career, or he may be influenced by the conventional image of the psychoanalyst as mature, rational, unruffled, and benevolent. But how can he not feel hurt or enraged when a patient is viciously attacking or torturing him, subjecting him to total domination or controlling his very breath. (I remember a patient once saying to me, If you don't stop breathing like that, I'm going to get up and never come back! ) It can also be irritating to be treated as though you do not exist or have no feelings. (I remember another patient, who had been pouring out the most insulting diatribes at me for many sessions. When I asked her in one of these sessions, how I should feel when she was going on like that, she said, What do you mean? You don't feel anything. You're an analyst! ) If the patient has a need to create a mutually hating relationship (or a need to experience himself or the analyst as bad, rejecting, uncaring, hateful, crazy, etc.) and the analyst has a need to present himself as good, caring, helpful, rational, and mature, he is in fact rejecting the patient and invalidating his organization of self and world. As Lawrence Epstein has aptly put it, by maintaining his good, rational, mature, and superior stance, the analyst forces the patient to contain all the badness in their relationship, and to continue to direct his aggression against his own ego. Modern analysts are concerned in the training of candidates to help them to acknowledge and accept all of their feelings, including their hateful ones. And since tolerance for one's own aggression goes hand in hand with tolerating it in others, to the extent that this effort is successful, graduates of such training are able to work effectively with aggression, their own and their patients.

7 Page 7 of 7 Conclusion Like most therapies, modern analysis attempts to widen the range of feelings, thoughts, and behavior available to the patient, and to integrate them into a coherent and relatively stable self. While the analyst may have to engage in an almost infinite variety of cognitive and emotional interventions to bring it about, if the patient is enabled to talk about everything to an emotionally engaged analyst who is consistently available and interested in hearing everything, then as Spotnitz has said, he must get better. Long ago Bishop Berkeley, the British philosopher, said that to exist is to be perceived. The analyst's willingness and ability to perceive everything in the patient, both his loving and his hating, similarly enables him to come fully into existence. This is a difficult business. Both the analyst and analysand must experience and recognize feelings, thoughts, and impulses that most people would rather avoid or keep out of awareness. There are times when both parties may question not only what they are doing but why on earth they are doing it. But for the patient, the reward can be the opening of new avenues of living. And for the analyst, he may not only make a good living and have the pleasure of being effective in his profession, but in this continued striving toward genuine communication, he may experience with his patients a degree of psychic and emotional reality only rarely encountered in social life. Confucius once said, Heaven is real. Man is coming-to-be-real. The psychoanalytic experience helps to further that process in both parties Article Citation [Who Cited This?] Kirman, J.H. (1986). The Management of Aggression in Modern Psychoanalytic Treatment *. Mod. Psychoanal., 11:37-49 Copyright 2008, Psychoanalytic Electronic Publishing. Help About Report a Problem