An Antic Disposition

In 1915 in Observations on Transference-Love Freud discusses patients who abandon the collaborative work of examining relationships in treatment and insist on actual gratification, patients who insist they actually love the therapist and demand love back. The patient either must relinquish treatment or give up the satisfaction that is demanded. When such a patient refuses the standard work of treatment, Freud says the analyst may have to "acknowledge failure and withdraw." Such patients have "an elemental passionateness" and are "children of nature who refuse to accept the psychical in place of the material." Such an infantile patient understands only the "logic of gruel" and the "argument of dumplings." Baby food in other words. (p 166) 

By 1937 in Analysis Terminable and Interminable Freud has become even more pessimistic about psychoanalysis. Over the years he has encountered two obstacles to the removal of resistances and, hence, the impossibility of resolution of the transference. These factors confounding termination are (1) passive homosexual fears in the male and (2) penis envy in the female, both based on bisexuality and oedipal issues. Quaint -- but grant Freud his genius as a clinical observer. For the sake of argument, update classical terms with ego psychology: If "preoedipal issues" replaces oedipal bisexuality and penis envy, one might say the resistance he saw was these patients' incapacity to surrender an actual love relationship with the therapist, one which in fantasy would repair a relationship with the preoeodipal mother. 

Construction or reconstruction of childhood?

Several types of errors in technique predispose to runaway unanalyzable transference reactions. A major error is failure to create a very explicit, firm, safe frame for the patient before delving into the content of some therapies. Faulty framing -- and the therapist's failure to adequately analyze mutually defensive re-enactments -- hugely magnify errors in the treatment. When such therapies become untethered, there can be an loss of "observing ego" so that the therapist now becomes the significant object. The "as if" quality of the relationship is lost. In knowing how to interpret this psychotic transference, it is critical for the therapist to decide whether this is a necessary stage as Winnicott thought, or a threat to psychotherapy that must be eliminated quickly because of actual danger to the patient or therapist. 

Winnicott believes that in analyzing patients who suffer from a lack of "good enough mothering" there can be no transference neurosis because there is not enough intact ego to defend against the anxiety generated by primitive instinctual urges ("id-impulses"). If the environmental adaptation to the needs of the developing infant is not good enough, no ego comes into being which can experience id-impulses, but, rather, 

there develops a pseudo-self which is a collection of innumerable reactions to a succession of failures of adaptation. [W]henever the environment fails in its task of making active adaptation, however, it automatically becomes recorded as an impingement, something that interrupts the continuity of being, that very thing which, if not broken up, would have formed itself into the ego of the differentiating human being. [When such failures occur there evolves] what I call a true self hidden, protected by a false self. This false self is no doubt an aspect of the true self. It hides and protects it, and it reacts to the adaptational failures and develops a pattern corresponding to the pattern of environmental failure. In this way the true self is not involved in the reacting, and so preserves a continuity of being. This hidden true self suffers an impoverishment, however, that results from lack of experience. The false self may achieve a deceptive false integrity [but it cannot] experience life, and feel real. In the favorable case the false self develops a fixed maternal attitude towards the true self, and is permanently in a state of holding the true self as a mother holds a baby at the very beginning.... (pp 247-248) 

So the analysis of such a patient needs to be different from the analysis of a person with an intact ego, not in that the analyst fails to follow where the patient's unconscious leads but, rather, that the emphasis of the work changes from interpretation to careful attention to providing a good enough, "facilitating" environment. Such a framework is adaptable enough not to again impinge on the patient's developing ego but is firm enough for safety. This good enough analytic framework allows the true self of the patient (which lies under the protective false self) to begin to experience hope. Then the true self can begin to take the risks involved in object relating. "Eventually the false self hands [itself] over to the analyst. This is a time of great dependence, and true risk, and the patient is naturally in a deeply regressed state." (p 248) So how is this good enough setting different from the standard analytic setting? 

The patient makes use of the analyst's [unavoidable] failures [which must be acknowledged.] ...it is less harmful to make mistakes with these patients than with neurotic patients. The analyst may be surprised as I was to find that while a gross mistake may do but little harm, a very small error of judgment may produce a big effect. The clue is that the analyst's failure is being used and must be treated as a past failure, one that the patient can perceive and encompass, and be angry about. ... If he defends himself just here the patient misses the opportunity for being angry about a past failure just where anger was becoming possible for the first time. ... In this way the negative transference of 'neurotic' analysis is replaced by objective anger about the analyst's failures.... (pp 249-250) 

Observing ego and the therapeutic alliance

Just as Freud thought that unconscious conflicts become reborn within the analytic situation as a transference neurosis, some believe that an analogous "transference psychosis" can evolve in predisposed individuals. This term is used to describe transient psychotic episodes lasting from hours to months, with psychotic phenomena attaching themselves only to the transference and interfering very little with the patient's life outside therapy. Very common are reports of treatment of patients who develop a "delusional transference" in the course of which the patient literally mistakes the therapist for a parent. The transference has become indistinguishable from the reality. According to Nacht 

The neurotic reacts as if his father had been a bad father and as if his analyst serves as a substitute for the bad father, but if he has really had a monstrous father or an abominable mother, interpretations of this kind have no place. The patient unconsciously carried in him the presence of hateful and terrifying objects; the therapist is not likened to a bad object, he is for him a renewal of the bad object. (p 272) 

A neurotic patient can recognize the therapist as a real person who temporarily symbolizes his parents, as they actually were, or as they were experienced in childhood. The transference is delusional according to Little when "there is no such 'stand-in' or 'as-if' quality about it. To such a patient the analyst is, in an absolute way, with the quality of 'authenticity,' both the idealized parents deified and diabolized." (p 135) She says of treatment, 

It follows that the analysis depends upon breaking up the delusional transference. To do this reality must be presented undeniably and inescapably, so that contact with it cannot be refused, and in such ways that the patient does not have to use either inference or deductive thinking. It might be compared with the waking from a dream of a tiny child, but someone must be there to help the waking. (p 136) 

Frosch, in his summary at the panel on "Severe Regressive States during Analysis," expressed the consensus for dealing with regressive transferences. 

Certain guides for the therapy of such patients are suggested. Early in the treatment one should attempt to support the desperate struggle to maintain contact with reality and to preserve the object, the ego, and the self. Many [feel] that it [is] necessary to speak more often, to answer questions more readily, and try to support reality contact, perhaps by the face-to-face position. ... This may be done by making available to the patient the means of preserving some contact with the analyst by telephone or letter, etc. or, if this is not possible, to make available the assistance of another psychotherapist. (pp 618-619)

 Next:  current concepts of transference.