רפואת הנפש
רפואת הנפש

פסיכותרפיה

The problem of Negative Therapeutic Reactions / ד"ר רפאל שפרינגמן-ריבק (בשיתוף ד"ר אלכס אביב)

הפרק השני מתוך "Dialogues with Schizophrenia" הפרק הזה והפרק שיבוא על "שלוש רמות של פירוש" - קשורים זה לזה והמחבר מפרט בהם את התפתחות המושגים בהם השתמש המורה שלו בטאוויסטוק, הנרי עזריאל - בהשראת מאמרו הקלאסי של James Strachey על הפירושים המוטאטיביים (גורמי השינוי) ואת השימוש בהם לבניית פירושים פרטניים בתיאוריית יחסי האובייקטים כפי שנהגתה על ידי עזריאל. את הספר השלם ניתן לקבל מהמחבר
תאריך פרסום: 12/9/2007
ד"ר רפאל שפרינגמן-ריבק
The problem of Negative Therapeutic Reactions[1]
[1] This Chapter is based on an article written conjointly with A. Aviv, M.D.
In order to correctly introduce Ezriel’s contribution into the theory and practical application of psychoanalysis, a detour must first be undertaken via a discussion of the problem of the negative therapeutic reaction. Freud (1918) was the first to call attention to this phenomenon when he stated: “The patient tended to develop temporary ‘negative reactions’ whenever a certain issue had been finally clarified. The patient attempted to nullify these achievements for brief periods by intensifying the relevant symptoms.” At that time Freud attributed the phenomenon to a kind of childish rebellion on part of the patient: “Just one more time.” In “The Ego and the Id” (1923), he attributed it to unconscious guilt feelings and in 1937 to the destructiveness of the death instinct.
An attempt to screen current psychoanalytic literature for unequivocal definitions of negative therapeutic reactions will usually result in a wide continuum of definitions. This continuum begins with a broad, general definition that contains everything that happens inside or outside the analytic situation and does not contribute to progress in treatment. It ends with quite narrow definitions, such as Kernberg’s (1984), who described the negative therapeutic reaction as an aggravation, represented by negative feelings reflected in the transference, despite the fact that the analyst was regarded at the same time by the patient as a good hearted object  who wanted to help.
For the purpose of this book the following definition of negative therapeutic reaction will be adopted, namely that the therapist's intervention results in one of the following:
1. Aggravation of symptoms.
2. The appearance of manifest anxiety or that of another intense negative affect.
3. Change of transference from positive to negative, unless this is a desired result.
4. Acting in.
5. Acting out.
Many authors have attributed importance to negative therapeutic reactions. Several of them, however, such as Rosenfeld, (1975), have expressed surprise at the fact that despite the general recognition of its importance to psychoanalytic practice, relatively very little had been written on it. Subsequently the subject remained relatively in the dark. The following is a brief, incomplete summary of the relevant literature.
Karen Horney (1936) emphasized that negative therapeutic reactions usually followed "good interpretations.” She offered several explanations:
1. The patient regarded the "good interpretation” as an incentive for competition with the analyst and needed to prove his superiority over him.
2. The patient experienced the“good interpretation” as a blow to his self esteem because it forced him to admit his weakness.
3. The "good interpretation" might trigger off success and success was accompanied by fear of failure.
4. The interpretation, despite being “good,” was experienced as an accusation.
5. The patient feared that he might improve and consequently be abandoned by the analyst.
In Envy and Gratitude,” Melanie Klein (1957) attached importance in the creation of negative therapeutic reaction to envy and its concomitant defenses. Fairbairn (1943) claimed that it might result from the refusal to part with repressed objects. Others, such as Olinik (1964), Valenstein, (1973), Asch (1976) and Loewald, (1972) attributed an important role to masochistic components and self-destructive tendencies with pain fixations, the origin of which was to be found in pre-genital periods. Rosenfeld (1971, 1975) claimed that narcissism played an important role in the creation of negative therapeutic reactions, stressing at the same time the part of envy. Kernberg, (1984) described destructive drives directed at the therapist resulting from feelings of envy and guilt.
All these authors highlighted the patient’s intra-psychic structure as the source of negative therapeutic reactions. Some of them went so far as to claim that the therapeutic obstruction it caused might lead to situations in which the patient had to be declared as un-analyzable. Negative therapeutic reactions seem, indeed, to have been perceived as clearly negative prognostic indicators. [Kernberg (1984) and Woolcott (1985).]
Wilhelm Reich (1934) was probably among the first to propose that negative therapeutic reactions might be the result of faulty technique, especially in the analysis of negative transference. Rivierre (1936) expressed a similar opinion and questioned the quality of interpretations that had led to it, especially in patients to whom she attributed narcissistic properties.
In the present book I wish to join these latter authors and represent a view, according to which negative therapeutic reaction can be attributed at least in most patients to interpretations regarded as incomplete. In so doing I will be following in the footsteps of James Strachey and Henry Ezriel.
Strachey, (1934) in his by now classic article, approached the problem from a new angle. He argued that whenever material was repressed, this was done with good reason; that repression had become necessary because the material to be repressed had become associated withan anxiety. The following is an example for the creation of such an association.
Ella was a healthy, four year old girl observed by her mother, a clinical psychologist. A baby brother had just been born. When the little girl first witnessed the baby being nursed at the breast she turned to him saying: “go on! Bite her, for my sake and for your own.” When asked the following day while witnessing the baby being nursed again whether she still wanted him to bite his mother, she answered: “Oh, no, not any more.” She also admitted her reason for having changed her mind: it was “because if mummy’s baby bites mummy, my babies will bite me.” Later the whole incident lost its importance.
In the present context it is relevant to note that it was not immediately forgotten, (i.e. repressed). The object-relationship “baby bites mother” had become causally associated with the anxiety “my babies will bite me" and hence became a topic to be avoided. In accordance with Ezriel’s theory, as expounded further on, the avoidance of a certain object-relationship is the primarily important goal, and repression is but one of the various means of achieving this goal.
Ella was a healthy young individual, reared in a facilitating environment that gradually enabled her to ameliorate the intensity of her oral aggressive impulses and her fear of retaliation. The conflict could thus be easily integrated into her psychic apparatus. Had this not been so, had one of the components of her conflict remained intensely cathected, further, potentially pathogenic defenses would have been called into operation. First and foremost among these mechanisms would probably be repression and a point of fixation for future psychopathology would have been created. (It seems to be needless to add that both components of the conflict would represent but two faces of the same coin).
The choice of other defense mechanisms, such as reaction-formation, displacement, projection or conversion, to be deployed in such a hypothetical situation would depend on the degree of Ella's maturity along the various axes of psychic maturation, as postulated by various theoreticians, on the question whether regression was called for and upon the intensity of anxiety attributed to the original trauma. In a future hypothetical situation, associated with the original conflict, (e.g. Ella breast nursing her own baby) symptoms, such as involuntary contraction the muscles of her jaw, phobic fear of sharp objects etc. might have necessitated psychotherapeutic intervention.
According to Strachey’s argumentation, an interpretation given to Ella in which her symptoms were exclusively attributed to her oral aggression, without adding an explanation of the reason for this aggression not to be recognized, would result in the appearance of overt anxiety or in the implementation of further defenses, in other words, an intensification of her symptoms. A negative therapeutic reaction would have been created.
Felicity and Ethan are actual clinical examples of the negative therapeutic reaction resulting from pre-Stracheyan incomplete interpretations given in real therapies.
Felicity suffered, among other things, from sexual inhibitions, including frigidity. She “had to hold herself in check” whenever sexual fulfillment was at hand. At a particular session she spoke about her hatred for poets. This hatred she attributed to the fact that poets had to be liars. How, otherwise, would they be able to express the intensity of their emotions and at the same time incarcerate and choke these emotions in the rigid formal rules of rhyme, rhythm and verse? She then spoke of her own need for fulfillment, how she would like to browse through “those big shops and buy all those beautiful dresses on display there.”
Some of these elements were combined into an (incomplete) interpretation that compared her imaginary buying spree with her wish to liberate her sexuality, which she had to incarcerate, like the poets, by imposing rigid control. At the following session she reported a change: she had started to notice men looking at her on the street and felt attracted to them, but on the other hand, whenever this occurred she was seized by acute anxiety.
In this case the (incomplete) interpretation had apparently evoked dormantsexual impulses and brought them to the surface. (“I like men, I want to be noticed by them and let myself go in their presence”). It had, however, not dealt with any anxiety that had necessitated the repression of these feelings in the first place and at this point this still unidentified and therefore nameless anxiety became (re) activated.
Ethan was a young schizophrenic who was being seen conjointly with his mother. In these sessions, as everywhere else during that period, the (identified) patient made all coherent communication next to impossible by filling every free moment in time with stupid, pointless jokes. At a certain point his mother was asked for some item of information about his past and it transpired that she was incapable of putting two sentences together in a coherent, meaningful way. Ethan was now addressed and some concern was expressed about his having to cope with this kind of garbled communication throughout his formative years. It was also pointed out to him that he might be doing his best by his constant, time consuming jokes to conceal his mother’s incoherence. This intervention had a double effect. On the one hand Ethan’s overt behavior immediately changed and his communications became surprisingly coherent and insightful, revealing an impressive capacity for introspection and the analysis and understanding intra-psychic and inter-personal transactions. On the other hand, however, when seen that same day on evening rounds, he was in a state of acute panic.
Here, again, temporary negative therapeutic reaction was achieved. Although the patient’s constant silly joking had improved perceptively, the therapist had not gone deep enough into the reasons that had necessitated this behavior. [These could include guilt feelings for having ostensibly been the cause of his mother’s madness in the first place, etc. (Searles, 1959)]. This failure resulted in the appearance of the acute panic.
Strachey actually proposed a new kind of interpretations, the “mutative interpretations.” These should not merely evoke repressed (avoided) material, such as Ella’s oral aggressive impulses, attributed to the baby. Instead, they ought also to contain, (preferably in the "Here and Now" of the transference) the reasons, i.e. the anxieties that had necessitated this repression in the first place. Ella’s fear of being avenged by her babies or be punished in any other way by the representatives of her objects in any "Here and Now" are suitable examples for this inclusion of the anxiety in the interpretation. Strachey argued that failure to include the latter part of the interpretation was bound, as a matter of course, to result either in the re-appearance of the original anxiety or in the re-enforcement of defenses against it, i.e. intensification of symptoms. [For further examples for amplification of symptoms in these circumstances, see the cases of Ethan, above, and Gilbert, (first session) in this chapter.] It goes without saying that not all adverse developments in a patient’s states are necessarily true negative therapeutic reactions. In the case of Professor Hugo and in that of Igor, both of them deluded paranoids, described in detail in Chapter Eight, suffered schizophrenic de-compensation. In the first case it resulted from an unfortunate therapeutic intervention other than an interpretation and in the second one from an adverse life situation, created in that case by the patient.
A mutative interpretation ought to result in net improvement. The aggravation of symptoms or the appearance of overt anxiety, those negative therapeutic reactions that were considered by Freud as signs predicting the correctness of his interpretations, were now considered by Strachey as signifying their incompleteness.
In the meantime psychoanalytic theory and practice had developed considerably. Object-relations theory was being developed and the emphasis of psychoanalytic endeavors shifted more and more towards the analysis of the "Here and Now" situation within the framework of the transference. With the uncovering of long buried memories losing its primary importance, Freud’s comparison of psychoanalysis to archeology gradually lost its meaning and "predicting the past" could be replaced by "predicting the future.” The new process developed a theory of technique in which spontaneously produced material was to be used mainly as indicators for forces operating in the “Here and Now”. The re-appearance of hitherto repressed memories was regarded as indicators for the forces operating in the “Here and Now”. When this re-appearance occurred after an interpretation, it was regarded as a by-product (albeit generally an important, confirmatory by-product and proof of the validity of the analysis) of the psychic reality of the “Here and Now”.
Ezriel (1960, 1967, and 1972) adopted Stachey’s ideas and contributed further concepts that ought to facilitate their incorporation into the framework of object-relations theory. I have found these concepts very helpful in various treatment modalities and would like to sketch them briefly here. Ezriel emphasized the almost exclusive importance of references in the interpretations to the "Here and Now" of the transference and coined the term “calamities.” He reserved this term for those aspects of object relations, fraught with anxiety, for fear of which other aspects of object relations had to be avoided. These “calamities” included fear of castration, annihilation, being castigated by the object (e.g. by the analyst) and even being killed by him, etc. These latter aspects of object relations, the ones to be avoided for fear of the “calamities” he named “avoided relationships.” In the case of Ella, the oral aggressive object relationship of “baby will bite mother” was subsequently avoided, i.e. became an “avoided relationship” because it had become associated with the calamity “my babies will bite me.”
In order to be able to function in life with an acceptable amount of satisfaction without at the same time constantly arousing the fear of thecalamities, a third set of relationships was evidently required: the “required relationships.” The terms “avoided relationships” and “calamities” partially coincide with Strachey’s “repressed material” and “the anxiety that had necessitated the repression in the first place,” respectively. As shown in the case of Ella, repression was not necessary in order for an object relationship to become avoided, whereas the term “calamity" attributed a definite content to “anxiety.”
The set of Ezriel’s three relationships, “required relationship,” “avoided relationship” and “calamity” is more or less congruent with the set of “defense,” “impulse” and “anxiety,” as used e.g. by Malan (1979). Here again, it should be mentioned that avoided relationships are not necessarily impulses. They may be regression in service of the ego towards the basic fault (Balint 1968), such as in analysis, which has to be avoided for fear of nobody being there to pick up the pieces and integrate them once regression had occurred. Even maturational processes sometimes have to be avoided for fear of one calamity or another.
Ezriel’s concepts fit themselves conveniently into the theory of object-relations from an operational point of view. They seem to be applicable to any theory of developmental maturation. They are applicable in the Freudian axis of psychosexual development and in the Kleinian-Kernbergian axis of integration. As in the case of Arnold to be described in Chapter Six and that of Leonard in Chapter Eight, both schizophrenic patients, they were useful in Kohut’s axis of infantile grandiosity versus adult self respect. Kohut’s “Two analyzes of Mr. Z,” to be referred to more extensively later on in this chapter, is another relevant example in this context. These concepts are also applicable to Mahler’s axis of separation-individuation, as well as in Piaget’s formulation of the development of intellectual capacities.
Indeed, they seem to be applicable to any maturational axis formulated by others in the future. Any such developmental thrust might become associated with fear of a real or imaginary calamity on the same axis of maturation or on another one, and will consequently have to be avoided, (to become an avoided relationship). It will be excluded from being integrated into the repertoire of normal psychic development and replaced by a required relationship. The psychic distance of this required relationship from the original avoided one, would be in direct correlation with intensity of the anxiety incurred by the calamity and the nature of defense-mechanisms invoked.
As might be understood from the above, even intelligence might succumb in the same way. Herbert, a practicing male homosexual, initiated his analysis by complaining that his intelligence might not be sufficient for such a complex enterprise. He remarked at the same time that this might, perhaps, not be a disadvantage after-all. This was because I, the analyst, might be intimidated were Herbert more intelligent than he perceived me to be and this might have a detrimental effect on the analysis, perhaps causing the withdrawal of my affection and empathy.
Many months later it transpired that Herbert’s mother had allowed him to play with her exposed breasts until he stopped referring to them as ”balls” and started calling them breasts. This differentiation of his intellectual capacities resulted in his mother forbidding the game. Intellectual development had thus become associated with the calamity of loss of object-libidinal pleasure and turned from being an asset into being a liability. Following this disclosure Herbert remembered others. In each of them an intellectual development, or indeed, several other maturational thrusts in various directions were negatively re-enforced. After these facts had been revealed and Herbert had been repeatedly re-ensured by interpretations that being more intelligent than me would have no evil consequences, he was able to unfold the full scope of his sharp intelligence, acknowledge his ingenuity and participate actively in the therapy by self-analysis. The final outcome of this analysis was very satisfactory, not in the least as a result of Herbert’s applying his intelligence. (Springmann, 1970, a).
Another fact about Herbert deserves to be mentioned. After he had been partially separated from his mother in circumstances that are described in the original article, he built a little hut. There he used to imagine that he was once more united with his mother. He called this hut the Hebrew equivalent of joy. “Joy” and “gay” are, psychologically, not far from each other. This seems to imply that underneath the joy of being gay, at least in some homosexual individuals who call themselves “gay,” there might be an unresolved tragedy, e.g. of separation.
Herbert is an example in which not an impulse, but a thrust towards maturation, along, in his case, the Piagetian axis was met by a calamity along the psychosexual (Freudian) axis. Consequently it had, at least partially to be avoided, to become an avoided relationship. In this he was not unlike Ethan, described above, who also had to avoid his intellectual capacities for fear of a calamity.
Returning to negative therapeutic reactions, it may be maintained with Ezriel, that it will result especially in either of the two following instances.
1. When a “correct” interpretation either invalidates or threatens to invalidate a required relationship, without at the same time dealing correctly with the avoided relationship and its concomitant calamity. (Put in traditional terms: when an interpretation destroys or threatens to destroy a defense).
2. When a "correct” interpretation activates or liberates an avoided relationship without dispelling at the same time, preferably in the "Here and Now" of the transference or else in any other environment, the fear of the calamity.
In both instances, failure to do the latter part of the interpretation makes the“correct” interpretation an incomplete one; the avoided relationship has been exposed or has threatened to be exposed (first instance) or else it has been activated, (second instance). In both instances this will have happened without the reason for the avoidance, i.e. the calamity which was causally connected with it, having been nullified. The exposed or activated avoided relationship now activates the fear of the calamitous results that remain connected in the patient’s unconscious fantasy to these avoided relationships. This will either evoke overt anxiety or force the patient to re-enforce his defensive formations. A negative therapeutic reaction will have been achieved.
It may be stated here parenthetically, that free floating anxiety may appear whenever an avoided relationship either threatens to be activated or actually is activated spontaneously in circumstances other than therapy.
Felicity andEthancan now be formulated in Ezriel’s terms. In the case of Felicity it seems that while some aspects of the avoided relationship, (“I like men, I want to let myself go in their presence”) had been elicited by the “correct” interpretation, no calamity had been elaborated. The result was that the partial re-awakening of her sexuality was accompanied by the re-awakening of an anxiety, aroused the fear of the same as yet not identified calamity, which had probably caused its becoming avoided in the first place.
The dynamics structure ofEthan seems to be as follows:
Required relationship: In an attempt to conceal my mother’s incoherence, I have to fill every vacant moment in time. The best way I know of doing this in this particular dynamic situation is to keep being the silly fool myself.
Avoided relationship:I can be as rational as the next man, possibly even possess even more acute introspective and analytical capacities, however, I have to avoid implementing these capacities because…
Calamity :( at this moment in therapy only guessed, later, however, completed at evening rounds) I will feel excruciating guilt for having exposed my mother’s "craziness,” because deeply inside I feel to have been the cause of her "craziness" in the first place.
In the conjoined session only the avoided relationship had been exposed and activated but the patient was left without the calamity having been explained and disqualified. This resulted in the acute panic attack described above, a typical negative therapeutic reaction. Fortunately, the assumed calamity was explained to the patient that evening. It proved to be correct and the panic subsided instantly without Ethan having to give up his newly regained rationality. The completion of the interpretation had turned the negative therapeutic reaction into a positive one.
These points have been elaborated here in detail because they may be considered to be of important operational significance. They imply that whenever a negative therapeutic reaction is detected, efforts ought to be made to look for missing components in the intervention, the avoided relationship (or important parts of it) and especially the calamity.
Once thesecomponents have been divined from hints in the material randomly presented by the patient, the interpretation ought to be completed. If this is successfully accomplished, the hitherto avoided relationship, now liberated of the fear of the calamity, (“detoxified”), may manifest itself freely and the hitherto required, pathological, relationship be relinquished, having become expendable.
This point is to be considered to be of central significance in the presentation of Ezriel’s ideas and will consequently be demonstrated by a further clinical example.
Gilbert was a thirty year old patient with high-level borderline personality organization. At the relevant point he had been in therapy for exactly one year. He arrived to the first session of the two to be presented here all excited and upset, complaining that his colleagues at work kept taunting him to a point he could no longer hold himself in check and so he attacked them. “I have no luck. Whatever I do, I always end up finding a job where someone drives me mad and then I explode and have to quit.” At another point during the session he mentioned, ostensibly in passing, that he had by now been in therapy for a whole year. These elements were used to construct an interpretation:
Despite having been in therapy for a whole year by now, you sometimes feel as if no real progress has been achieved; you are still unable to withhold your impulses and consequently keep on making the same mistakes. You lose control and as a result you keep losing one job after another, either by having to quit orby being fired. This makes you feel deeply disappointed not with yourself, as you seem to be implying, but with me and with the therapy"
Although it seemed that the patient accepted the interpretation and left the session in a somewhat calmer mood, he contacted the therapist’s office two days later, demanding to be put in contact with him immediately because he was contemplating suicide. When contact by telephone had been established some hours later, he did not mention suicide but told his therapist that he had lost control at home and had beaten up his wife. His next therapeutic session was scheduled for the following day.
In the meantime a supervisory session took place and the material was presented and analyzed. It was surmised that the (incomplete) interpretation had threatened to disqualify the required relationship: “I am disappointed with myself,” which had been created by the defense mechanism of turning against the self it had also elicited the avoided relationship “I am disappointed with you.” All this had been done without offering the patient a calamity, a possible reason that might have made the latter statement ostensibly dangerous for Gilbert to make. Consequently he must have fortified his defenses, (deployed less adaptive, more pathological required relationships) lest this avoided relationship become manifest in the "Here and Now" of the transference. This had probably been accomplished both by turning the intensified anger against himself (suicidal thoughts), subsequently also understood to be a component of the calamity, and by displacing it on his wife. The following (complete) tentative interpretation was worked out:
Required relationship: I amdisappointed with myself because I cannot control myself at work and explode either there or at home, against my wife.
Avoided relationship: I am angrily disappointed with you, therapist, and with the work we have been doing for a whole year by now, because I see that so little has been accomplished. I cannot, however, acknowledge this angry disappointment because:
Calamity: If I do express my anger in the “Here and Now” of the transference, I might feel tempted to explode at you and leave therapy, or else, you might also feel disappointed with the job you have been doing with me and quit my therapy, just as I quit my jobs. Both alternatives might be felt to be tantamount to suicide.

Provided the assessment of the material had been correct, it was expected that this interpretation would enable Gilbert to express his angry disappointment in the "Here and Now" with impunity. It would prove to him that the manifestation of the avoided relationship did not inexorably incur either of the calamitous alternatives. This would, consequently, obviate the need to intensify defensive measures (activation of further non-adaptive, pathological required relationships). The negative therapeutic reaction would thus become expendable and dissolve, as had been in the case of Ethan. Fortunately, this proved to be the case.

Gilbert opened the following session still quite agitated. Expressing his indignant surprise at the therapist’s “allegations,” he claimed: "How could I have been disappointed with the therapy? Have I, after all, made any real suicidal attempt even once during the whole year?" On one hand, this could be understood as further denial of the avoided relationship. On the other hand it also contained a disguised confirmatory hint at one aspect of the surmised calamity. The interpretation was now spelled out again, this time in full, with all three components. Gilbert immediately relaxed, his agitation disappeared and it became possible for him to discuss his fear of being abandoned if he ever dared to speak out his disappointment in his objects.

It seems safe to assume that the negative therapeutic reaction, the exacerbation of symptoms that had followed the interpretation in the first of these two sessions might have at least endangered the continuation of the therapeutic relationship. This would have happened unless the interpretation had been completed in the second session. It also seems safe to assume that if some version of the full interpretation were given in the first session, the negative therapeutic reaction would not have occurred at all. Be that as it may, the completion of the interpretation in the second session turned the negative therapeutic reaction into a positive one. This was accomplished via the reality testing in the "Here and Now" of the transference of the imaginary, atavistic, causal relationship between the avoided relationship and the calamity. (Being angrily disappointed with the object and being forced to leave the object/being abandoned by the object, respectively). Thereby the former became detoxified. Therapy in this case has now been going on for several further years and quite considerable progress has been accomplished. (For a further case of a negative therapeutic reaction being turned into a temporarily positive one by completion of interpretations in the following session, this time in a psychotic patient, see Leonard in Chapter Eight).

One further particularly relevant situation deserves to be mentioned in the present context, a phenomenon that seems to be quite prevalent and that frequently misjudged often leads to erroneous consequences. It concerns patients with psychotic personality organization, who, especially upon being discharged from hospital in remission of an acute psychotic episode are in the initial stages of analysis or dynamically oriented psychotherapy. In these circumstances these patient quite frequently develop further psychotic symptoms, sometimes involving the therapist and sometimes in such severity that re-hospitalization, or at least intensified drug treatment have to be considered. This scenario often leads to the conclusion that these patients are un-analyzable, even that in these patients dynamically oriented “uncovering” psychotherapy is counter-indicated.

Both experience and theoretical considerations have shown that this is not necessarily so. They have shown that this phenomenon is to be considered a typical (albeit a spontaneous) negative therapeutic reaction, no more an evil omen to the final outcome of a dynamic psychotherapy or an analysis than any other negative therapeutic reaction.

Theoretically it seems logical to assume that the impending intimate relationship with another person, the therapist, often constitutes a covert unconscious promise of fulfillment and intimacy for patients with neurotic or borderline organization. Therefore it leads to initial amelioration of symptoms, the transference cure. This constellation of implied intimacy actually represents a threat to the patients with psychotic personality organization. For fear of calamities, such as being merged with the object’s personality, invaded, annihilated or inevitably ultimately abandoned by him etc, such close, intimate, trusting relationships are something these patients had previously made every effort to avoid.

This avoidance is almost regularly accomplished by deft deployment of schizoid mechanisms: “I have always surrounded myself by a wall of false sincerity” was the way one such patient described his particular required relationship. Another psychotic patient could initially relate to his therapist only by invoking a further, imaginary patient, in another ward as the one desperately in need to be listened to and understood. The circumstances of therapy, implying as they do closeness and intimacy, are consequently experienced as avoided relationships that are in danger of being activated, forced, as it were, on the patients. This is done without any reference to a calamity being possible at this early stage. As pointed out above, this kind of situation seems to make some kind of re-activation of a (psychotic) required relationship mandatory and a negative therapeutic reaction is, in these circumstances, almost inevitable.

This ought not, however, lead to the conclusion that these patients could not too undergo dynamic therapy. In many cases it could be shown that gentle persistence on part of the therapist, such as respectful empathic references to the patients' need for seclusion and their apprehension of their intimacy being violated, not infrequently lead to promising results. This phenomenon can be observed even if re-hospitalization sometimes becomes necessary.
Carefully handled by therapists who feel well contained in supervision, such psychotic outbreaks quite regularly prove to be abortive, and once abated, the therapeutic endeavor can be continued with the same amount of cautious optimism as in any other case.
Jane and Katherine may be used as examples for this constellation, which I refer to as an initial spontaneous negative therapeutic reaction.
Jane will be described in greater detail in Chapter Six. She was a young woman of eighteen, just discharged from hospital were she had been treated for several months by electro-convulsive therapy and massive doses of anti-psychotic drugs because of acute catatonic schizophrenia. When she remitted and became communicative, she was referred to outpatient psychotherapy. Shortly after this therapy had been initiated she developed a new delusion; she was now constantly being hypnotized by people in the streets to take off her clothes in public. In therapy this was interpreted as her fear of the therapist forcing his way into her mind against her will in order to make her disclose her intimate secrets. After this had been conveyed to her, the delusions subsided. The reason for referring to secrets will be further discussed in the full description of this therapy in Chapter Six.
Katherine had been a chronic paranoid schizophrenic for many years. One of her central complaints was that certain sophisticated technologies had been implanted into her body without her knowledge and against her will. No information about the nature of these technologies was available, and when asked about them she gave elusive answers, sometimes mentioning the names of towns in Poland in which her, by now, deceased father had stayed during the holocaust, before her birth. She referred to these towns as possible places in which these technologies might have been manufactured. She was now in a re-habilitation ward and despite the chronic nature of her condition one of the therapists there (the one who also treated Doris) decided to attempt dynamic psychotherapy.
From the very initiation of this therapy Katherine fought off almost all of the therapist’s advances. In despair, the therapist tried to convince her that she might be able to help her if she, the patient, would stop to repulse her. This intervention was rewarded by a temper tantrum that lasted for more than a week. Resumption of the therapy, of the brittle relationship that had been established prior to the temper-tantrum demanded a great effort on part of the therapist. Only after many weeks of infinitely patient work did it finally transpire that any attempt at closeness was experienced by Katherine as a danger of being swallowed up by the object, in the present circumstances, the therapist.
After this calamity had been clarified and disqualified, the therapeutic relationship underwent a complete change and a first glance could be gained into the dynamics of Katherine’s delusions.
This started when she requested permission to water the plants in her therapist’s room. After this wish had been granted, Katherine commented that she had grown up in an environment she could only define as a stinking, festering dunghill. In a group session that I supervised, this sequence of events was brought up. As the case was being presented, it suddenly dawned on me (Being "one step removed") that the sophisticated technologies implanted in her might represent a process of purification, the task of which was to extract life-giving water from toxic dung. This would be the equivalent of the toilet breast, (Meltzer, 1973) but in a peculiar way, working in reverse, Katherine doing the chores traditionally attributed to the toilet breast.
Several weeks later, when Katherine brought up the topic of the implanted technologies once more, she was asked if these technologies might be a purification plant. She retorted: “A purification plant? Of course it is a purification plant! What else do you think I have been talking about all these years?”
This was but the beginning of a long therapeutic journey that became possible only after the hurdle of the initial negative therapeutic reaction, activated by the therapist’s attempt to overthrow her patient’s schizoid required relationship had been overcome. Katherine ceased to mention the sophisticated technologies, started instead to complain that she was being linked to a giant computer, which controlled and mainly inhibited her volition and initiative. The keys for activating and de-activating this computer were in the hands of her therapist. This delusion also gradually subsided side by side with Katherine gaining understanding of the connection between the implications of being controlled by a computer and being in control of her volition, of having the freedom to say “I want” or its equivalent and “I don’t want.” This freedom had been destructively crushed by her mother in Katherine’s childhood and was now gradually beginning to bud again.
It is intriguing to compare this process of the destruction of Katherine's volition to Niederland’s (1974) analysis of Schreber’s “soul murder,” signifying the brutal destruction of Schreber’s will by his father. It is also comparable to the references to the creations of deserts, often discovered in young schizophrenics. These allusions may be understood to constitute hints pointing to the existence of the calamity of annihilation. These fantasies will be briefly discussed in Chapter Three and seem to indicate a pathogenesis similar to that of Katherine, as well as that attributed to Schreber in “Soul Murder.” (Shengold, 1998).
During the time that has elapsed since these lines were first being written, Katherine began showing initial indicatory signs of the purification process assuming its proper direction. For months on end she had refused to change her clothes, particularly one cardigan that gradually acquired an unbearable stench. When finally convinced by the nursing staff to have this cardigan cleaned, she insisted that before being sent off to the laundry, it first spend some time with her therapist: “Let her brood on it for a few days,” were her words. This was tentatively understood as an indirect expression of a disguised, symbolized wish that her therapist now be part of the purification system, in other words, that the toilet breast now begins to function in its proper direction.
Later this became even more un-ambiguous. For hours on end Katherine horribly abused her therapist verbally. The therapist withstood this abuse with great anguish, sometimes having to resort to reminding herself that the abuse was actually not aimed at her but rather through her at Katherine’s persecutory internal objects. And in fact, at the conclusion of many such an abusive session, Katherine addressed her therapist most ceremoniously, asked her forgiveness for having abused her. This, she explained, was the only way open to her to cleanse her psyche of all the filth that had been implanted in her during her formative years. The purification plant had now turned into a figure of speech, well on its way to becoming a metaphor. As Katherine put it in one session, “I still have a long process of purification in front of me before I dare face the outside world.”
Recently I spoke with Katherine's therapist. She told me that the management of the hospital had changed. Under the policy implemented by the new management all chronic patients were discharged. Among them was Katherine. By now she was too far along in her therapy to react by becoming psychotic. This was despite having been left by her therapist a long time before. If information I received is correct, Katherine now lives at home. During the therapy it had become clear that she had been using her psychosis to protect her brother. This seems to be an example of the denied, covert covenant, intended to keep up intra-family equilibrium, mentioned in Chapter One.
BothJaneand Katherine reacted negatively when psychotherapy was initiated. In the first case it turned out to be the result of fear of the calamity of being intruded. In the other it was the result of fear of the calamity being ultimately lost, swallowed up in the personality of the therapist. In both cases these reactions could be related to unintentional violation of the required relationship that demanded distance. The “imposition” of the hitherto successfully avoided closeness had necessitated the re-deployment of psychotic required relationships. In both cases these initial negative therapeutic reactions (delusions, temper-tantrum) receded, either immediately or else eventually, when the relevant imaginary calamities could be understood. Dr. Kid, also a schizophrenic patient to be described in further detail in Chapter Eight, was another example of such initial spontaneous negative therapeutic reaction. In that case this happened for fear of the calamity being inevitably and ultimately abandoned by any object he attempted to approach.
Not all initial negative outcomes at the initiation of therapy of schizophrenic patients are true negative therapeutic reactions, as defined here. Deterioration may sometimes be attributed to blatant mistakes on part of the therapist. These mistakes may be understood in the context of the ideas posited in these pages.
Moses was paranoid schizophrenic who had been hospitalized several times. At the relevant time he harbored the delusion that all mental health practitioners were involved in a conspiracy to help him. In an attempt to encourage them in their work he regularly visited every mental-health institution he could think of and loaded the workers with gifts of sweets that he insisted they eat in his presence. When hospitalized at his own request, the Consultant of the open ward in which he was hospitalized immediately forbade this activity. Notwithstanding this injunction, Moses did his best to persist in his “good deeds,” taking care not to be discovered for fear of being transferred to a closed ward.
At this time one of the residents decided that such a preserved patient deserved dynamic psychotherapy. During the first several sessions the patient presented his therapist with his self-made sweets and cookies, and otherwise filled the sessions with material that the therapist considered unworthy of interpretation. He referred to this communication in supervision as “empty blabbering.” Later he did try an interpretation, asking Moses if perhaps he felt it necessary to fill the sessions with continuous “blabber” in order cover up a feeling of emptiness inside him.
Regarded from Ezriel’s point of view, two mistakes had been made. Bribing the psychiatric institutions constituted a required relationship, the deeper dynamic structure of which could not be understood at the time. It had been endangered and Moses had now to undertake it under the threat of being penalized. Thus, even if nothing else, at least an unnecessary conscious conflict had been created. The feeling of emptiness had also to be considered as a required relationship. The avoided relationship and the calamity it covered could not be guessed at that time. The therapist’s intervention disqualified this required relationship without providing the patient with a clue for its necessity. At a much later stage, such an intervention would have been justified, but only in case the avoided relationship and its calamity had been divined from hints in the material and could be spelled out in one way or another.
The challenging of the feeling of emptiness at the early stage it was done, an intervention that would be tantamount to its disqualification was, therefore, undertaken much too early. No wonder that the patient surprised his therapist by saying: “What is it with you, Doctor? Do you want me to commit suicide?”
Fortunately this situation was also brought to supervision shortly thereafter, and the resident was helped to find ways to retract his extremely premature intervention before permanent, irreversible damage had been done.


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