III Foci of the analyst's interventions, mechanisms of change

"I don't want to be like my mother": Exploring changes in identity using the analyst as model

Siri Erika Gullestad,

Margaret Ann Fitzpatrick Hanly, and Mette Hvalstad

Introduction

In this chapter, we discuss gradual identity transformation in a 24-year-old woman—Kim—in an analysis lasting for three and a half years. Using the Three-Level Model (3-LM), exploring clinical material with analytic sessions from the beginning, middle, and late periods in the analysis, we examine how analytic process may create change. The 3-LM poses the question, How does the patient use the analyst, and does this change over the course of the analysis? Kim's analysis illustrates how attachment to unconscious identity-defining internal objects, revealed in metaphors, changed through use of the analyst as a new object (Loewald, 1960). In our discussion, we specifically emphasize the role of the analyst as a model (Gullestad & Killingmo, 2020), adding to the concept of the internalization of the analytic function (Rangell, 1987; Smith, 2007).

The case of Kim

Brief history

After having tried intensive cognitive therapy with little success, Kim was referred to analysis, diagnosed with depression and sleep problems caused by overthinking and excessive dreaming. Kim's parents and elder brother were in a group of boat refugees, picked up from the ocean by a Norwegian tanker before Kim was born. Together with the group of refugees, the family settled to form a Catholic minority society in a distant, rural part of Protestant Norway. Kim felt different, both from the Norwegians and from the refugees from the home country. Religion had a strong impact in keeping a closed community for the refugees, isolated from the Norwegians. While Kim's father became quite integrated, her mother held strongly onto her conservative and religious culture and traditions. In order not to bring disgrace to the family, Kim was expected by her mother to marry a husband chosen from their home country in an arranged marriage. In contrast, Kim's brother, mother's preferred child, was raised with a good deal of freedom, few responsibilities, and few expectations. The mother, who seems to have been seriously traumatized, was, according to Kim, unpredictable, attacking, unfair, selfish, and "the one who decided everything." Father was warm and caring, yet Kim was angry with him for being "weak and deceitful," always supporting mother in conflicts, thus letting the children down.

Kim's identity was tom by deep ambivalence in her affiliations, values, and faith. She experienced intense guilt and shame and a strong sense of the demands of duty. Wanting to be an ordinary Norwegian youth as a teenager, and describing herself as a "tomboy," she rebelled and broke with Catholicism. After high school, she was "thrown out" out of her home, because, according to mother, she brought shame on the family. At school Kim was an underperformer. Teachers and parents had low expectations of her academic performance, which hurt and offended her. In the opening phase of the analysis, she was proud of taking a master's degree in educational science, at the same time working as a leader in a kindergarten. Kim had been in short-term relationships, and one five-year relationship, all with Norwegian boyfriends. She had good friends and was close to her brother, his Norwegian wife, and their two small children. Most importantly, she had had one close early relationship with a neighbouring young housewife, J, with small children and a husband who later left his wife.

Presenting problems

Experiencing most things as unfair in life, Kim felt as if the whole world did not really want any good for her. She had to do everything herself and could not trust anyone. Talking about her life's problems, Kim told of breakdowns when she just wanted to die and had to lock herself up in her little bathroom and curl up in the darkness around the toilet, roaring loudly and crying. Rage, crying, and despair accompanied her descriptions in the sessions. Having no belief in future relationships, she often had the feeling that she did not want to live:

Relationships with boys, for example: I can't believe that I’ll ever manage to be with anyone! . . . [AJnyone I can trust without feeling like I'm doing something wrong. I think I'm like Mom, and that gets me down so much.

More particularly, Kim presented her reason for starting analysis as her anxiety about becoming like her mother. She did not want to have children, unable to bear the idea that she might put her children through all the "evil stuff" her mother had done to her:

Maybe having kids . . . will make my life meaningful. . . . But at the same time it's like, oh my God, I can't, I can’t. I feel so broken, broken. So, first and foremost, I won’t have a good relationship, and I won't be able to be a good mother... and I don't know if I can change now. I don’t know if it's just the way I am.

I don't want to lose control like Mom. I have no role model. Like a paedophile that doesn't know the difference between right and wrong because he has been assaulted himself. Someone must help to break out.

The analyst thought that Kim wanted to "repair" her childhood and herself through education, work, and psychoanalysis, and, through that process, find out whether she should be a mother or not—a choice that seemed central to her identity.

First impression

Kim looked typically Asian, with an androgynous beauty, small, tender, slim, and very fit. Appearing vital and energetic, she came in training clothes and sneakers for the sessions, as if ready, noted the analyst, "to escape from me or fight against me." When the analyst arrived for the morning sessions, Kim was waiting outside the office building; she hurried up the stairs and into the office, turned on the light, and arranged the practical rituals, placed the serviette on the pillow. She spoke in her local dialect, sometimes using a rough language including provocative words in dialect, swearing a lot. The pace of her speech was so fast that the analyst rarely made a comment about what she was saying before it was too late or irrelevant. We learned as the analysis progressed that Kim's identity included images of herself as stupid and not belonging.

Yet Kim was easy to like—she could really "lighten up the room." A dominant counter-transference in the initial phase was a feeling of being reduced to an attentive audience, entertained and vitalized by an energetic actor. The analyst felt she was confronting a manic defence that protected Kim against entering into a relationship. Very early in the analysis Kim met a boy, E, and they quickly got into an intense and challenging cohabitation. A year later, the relationship ended and she spent a lot of time in the analysis trying to understand what had happened.

Early years

During the two first years of the analysis, Kim talked about things in a way that was often chaotic and fragmented. Her life from one session to the next was described chronologically and in detail. The analyst noted that she focused primarily on the concrete and material, especially on the body and sexuality. When talking about her relationship with E, she often talked about performing in their sexual life. Speaking about her earlier relationships, she compared them, especially focusing her own role as a sexual partner—as if being in constant competition. Later on, E experienced Kim as a demanding, controlling sexual partner and felt frustrated and inferior. Kim in this early period seemed rigid and constantly defensive, trying to take control in the analytic situation—there was little room for reflection. The analyst reported, "I often experience myself as an empty container, without any identity, position or role."

The unconscious material, in most sessions, expressed itself through the ways Kim acted, how she looked, or through her dreams. It was as if her physical appearance "spoke" about her mental states. In one period, Kim became depressed and gained weight. One time, when the analyst came to get Kim from the waiting room, for just a moment she thought it was Kim's mother sitting there waiting. In a later period, Kim unexpectedly came to the session with her black hair dyed totally blond, which matched the colour of her analyst's hair (but which is also, it should be noted, a common hair-colour in Norway), and wearing a dress the same colour and style as her analyst's. Failing to get a job she wanted, she considered changing her name to a Norwegian one (which she did not do). We learned that her Asian female identity was filled with ambivalence about female roles as well as demands for submission to her mother.

During the early part of the analysis, Kim's dreams did not mobilize thinking or affects in her associations—but only in the analyst's. By the end of this phase, the analyst interpreted Kim's fear that she would not be able to bear her rage: "You have said . . . that you cannot get into a rage (lose control) here with me." Kim now elaborated an important metaphor: "Yes,... I feel like 'the Hulk.'" "My rage ... damages those I love. I have never shown these feelings to my parents ... In my family, all difficult feelings appear as anger." The Hulk is a cartoon figure, who is an orphan wanting to be kind, but harbouring a destructive monster inside. Eventually, Kim could integrate the analyst's understanding of rage as human, working through her childhood identity as a monster.

Processes of transformation

Summary of the process

Kim began analysis as a deeply conflicted young woman. Torn between widely divergent cultural and religious values, she was furious with her parents and at the same time seriously depressed. The

Hulk—the unwanted, enraged monster—condensed an important aspect of her self-image. Appearing as a tomboy, Kim searched for an identity as a competent woman, different from her mother. Afraid of emotional intimacy—feeling that she could not trust anyone—sex was a preferred mode of relating. With her dominant, controlling way, she presented herself as quite masculine in her sexuality, seemingly a phallic mental position. An overriding relational scenario was one of being self-sufficient, managing rigidly on her own, not letting anyone come close.

Kim was in analysis for three and a half years, four times a week on the couch. By the end of the analysis, her relationship to her parents had changed quite radically. By then she could perceive that her father really did accept her. Moreover, she understood that he was in fact the one who also "carried" her mother—he was strong enough. Kim's thinking that they have done as well as they have been able to contributed to a reconciliation with her parents. While at the beginning of analysis she refused to accept anything from them, afraid of becoming dependent, she now allowed them to give her a deposit to buy her own apartment. Kim recognized and accepted her parents' relationship—the parental dyad— without feeling excluded. The analyst understood this as an expression of her having accepted both the parenting position and the generational difference.

By the end of the analysis Kim had opened up and resolved debilitating conflicts in her identity. She was now in the process of finding a job that matched what she considered her competence. Moreover, she clearly appeared more feminine, rarely coming to the analytic hours in sneakers, but rather wearing feminine outfits and with high heels. Proudly she told the analyst that her breasts were more beautiful than she had thought, and that she had bought her first bra. In this material, the analyst noticed an element of more robust competition with her, both in aggression and sexuality—as if Kim wanted the analyst to confirm her femininity, but also to affirm a connection between the two of them, as girlfriends.

Kim's way of being in the analysis changed visibly. In the ending phase, she appeared quite free, used humour and laughter, and worked confidently in the relationship with the analyst. The communication in the hours was characterized by free associations, wonder, and reflection.

Observing dynamics of change

What can account for the observed changes in Kim's inner states, psychodynamics, and ways of relating in her life after three and a half years of analysis? We cannot know to what extent the observed changes were due to the treatment alone. As with all therapies, there were interactions with real-life events. Nevertheless, through detailed analysis of session material we can articulate hypotheses about formative treatment processes. In particular, we focus how key dynamics related to presenting problems with conflicts in identity, self-image, and identifications were expressed in Kim's dreams and how these dynamics changed.

Initial dreams: Session 4

Although at the beginning of the analysis Kim appeared self-sufficient and controlling, she nevertheless expressed desire and hope in various ways. The analyst had the sense that Kim was very motivated to get help and to change. Coming to the fourth session, Kim started by saying,

P: You’re just waiting for me, are you?

A: Yes, it's not just. You are the main person here. It’s as if it's hard to think out loud.

P: It's unfamiliar, still; it's different.

Struck by the fact that someone was waiting for her—being there for her—Kim seemed touched, becoming aware that the analyst created a new space. In this same session, she said that she had a dream the night before—actually a recurring dream—about J in the house next door to her parents' house:

There is a large garden, with a small dollhouse and with a garage. The house has an ugly orange colour, and where you go in, there is a fairly steep hill down, if you want to enter the main door. Opposite there is the garage. Inside it's a staircase up to the living room and kitchen, and then there's a bathroom and two bedrooms and a master bedroom. ... The colours are not so good in the dream. . . . In the dream it's not bright and nice, the colours are a bit dark and cold, blue. It's cold to stay there. I see her there in the dream with the three kids. Sometimes her ex-husband is in the dream too.

Talking about the dream, Kim said that the relationship with J ended quite abruptly, which was very hard on her. Kim was left with a feeling of being utterly alone, suggesting that her sense of self, basic identity, was lost with the loss of the regard of this important m/other. Thus the dream seemed to actualize a theme of loss and sadness. The analyst commented,

A- I get a feeling that you are a bit sad or maybe longing for something there where you stand and look.

P: Yes, I have such a sad feeling. Feeling so heavy, yes.

This interpretation of her longing for a warm maternal relationship created an early moment of meeting—a break into Kim's self-sufficient pattern.

Kim continued, saying that before this dream she had another dream— also a recurrent dream—which created a strong feeling:

P: There have been two, three times, maybe four, that I'm very pregnant, that I have a baby in my womb. That feeling is so strong, such a kind feeling. It's such a real love, like . . . Well, when I wake up, it's really strong. It's not mine, it's just a kid, a baby. . . . It's a feeling I've had for many years then. A really strong and good feeling, a strong love as well. It’s almost that I really will not wake up because it's such a good feeling.

We do not have Kim's associations to this dream. The analyst commented that perhaps the dream was about the analysis and the possibility of getting in touch with the child within—maybe a child they could love together? Kim responded with silence, but not defensively, and for the first time in the analysis she seemed to take in what the analyst communicated. Looking back, it seems likely that the baby represented an idea of being "born" again through the analytic treatment. The analyst interpreted that Kim's love for the baby was like her "strong feeling" for the mother/neighbour whom she "could not hold onto." Then Kim associated to the food and music they shared: "We could just relax and just enjoy a good lunch. Made lots of rolls (baked goods), put on music and drank tea and had a cosy time. That time, I remember it, it was so good. I miss it." This use of the analyst's interpretation of longing for maternal nurturance allows an important regression on the way to the formation of a new identity.

Dream of the doll: Session 26 (two months into analysis)

Two months into analysis Kim presented the following dream:

I had an interesting dream tonight. I don't quite remember how it started, but I remember going to the doctor. And my doctor, he's very kind, he's from my hometown.... He's very decent so I feel pretty safe with him.. . .

Then I looked around and then I saw that there was a doll there, who had a face, who had eyes like black buttons. She had blonde hair... which was made of fabric—a blue dress. They lay on the table and on the couch. There were several of them [dolls] in different sizes. It was creepy. What was this then?

As Kim had no thoughts about the dream, the analyst shared her associations to the dream with the 3-LM group. To this first part of the dream she associated:

I was touched by the content of the dream. Could it be that the vulnerable and feminine in her was "laid dead" and that the mother's interior as she experienced it was dead and that she had not reached her mother in the early stages of life, but met lifeless, black, and judging eyes? It was as if she placed maternal objects in "lifeless" positions while she got the man (libidinal-object), triumphing over the maternal object. She described one of the women in the dream as "blonde and with a blue dress." I thought it was me.

The dream continued:

P: Then I suddenly saw a picture. Then I saw that the doll was in the picture. Then he saw that I noticed it. He said, "It’s my mother—I do not have a good relationship with her." And suddenly he was gone with the other scientist. ... Then I got such a bad feeling that it was really heavy for him ... with his mother and that he had experienced lots, lots of heavy things. And then I got to know the feeling he had. And like he should try to explain what happened to his family . . . and then I turned away. And when I turned back, suddenly there was this artist LidoLido. Do you know who that is?

A: No.

P: Well I like his music quite a bit. He is a Norwegian artist then. Suddenly it was he who was there instead [laughing a little bit]. Then we sat holding hands and were very passionate, unable to keep our eyes apart. We just looked at each other to see each other deeply in the eyes. We were kissing and kissing, really deep kisses. And he filled the whole room, and the dolls had something to do with him. . . . Yes, I do not think I remember anything else. There was something more about the doctors and the dolls but I do not remember completely.

The analyst's associations:

The situation with the intense "deep kiss" made me think of the little child who sucks her mother's breast and holds her mom's eyes— where I was the mother she wanted contact with by looking deep into my eyes. And I noticed both a social and a sexual component both in her and in the mother (me). I resisted a strong urge to act, to interpret the dream for her and to show that I understood her.

Working with this dream, the group asked whether it might express an Oedipal sexuality, introduced by the counter-transference jealousy. LidoLido—his name easily associates with libido and the Norwegian term lidenskap (= desire), as well as with the cabaret scene Lido in Paris—seems to be a metaphor for sexual desire. Or did the deep gaze and kissing rather present a maternal infant scene? Or both? Concluding, the group resonated with the LidoLido as an anchor point for Kim's use of sexual experiences to deal with depression and the "dead mother."

Looking at the dream from a dynamics-of-change perspective, we notice how the person of the analyst was introduced in the dream— blonde hair and blue dress, as she was in reality. The analyst, associating to the dream, said that one of the women had blonde hair and a blue dress, while it actually was the doll with the black button eyes. Thus, it would seem that the doll conflated two female figures—the dead mother as well as the new analyst-object. It may be that Kim's unconscious here provided her with an embodiment of a transformational object, a hope for change.

Dream of the polar bears: Session 91

(eight months into analysis)

Coming to the session, Kim stated, "Today I can start with several dreams":

One dream: We are partying out on the town. There are not any familiar faces. I knew them anyway. One was E, but not him, in a way. We had to drive over a river, and there were polar bears under the water. We got over. The polar bears started chasing us at full speed. We were split. I and one other person could not hide—the polar bears were so clever—but they were unable to reach us. We managed to get over a 2-metre-high fence.

The second dream: We were in cafe—a group of friends. One of the girls I am closest with at school was with E and me. She started intimate kissing and stuff with E, who did not seem to think much about it. He gave her many compliments (also intimate). And that was enough for me. E gave me a friendly kiss. He explained he did not mean to hurt me—just take care of my friend (ours?). But I just walked away.

At this point in the analysis, Kim could associate more fully to the dreams: "I was in the middle in dream number two. I was not accepted or respected." The analyst, commenting on the clever polar bears, asked whether they expressed something about being smarter than people think. Kim responded, "It's familiar for me to feel tiny and stupid ... I'm not as stupid as people think." In this session, Kim was in contact with deep feelings of having been hurt by people devaluing and underestimating her (teachers in school). The analyst commented, "When you get hurt, you can get angry." And later:

A. You . . . cannot get into a rage [lose control] here with me, because you think I will not tolerate it very well.

P: Yes, but you know I feel like "the Hulk."

A: So those who think you are nice and cute, they should only have known what's inside you?

P: Yes, it damages those I love. I did not even dare to show E how angry I can be. I have never shown these feelings to my parents. I was not even allowed to pretend. I was so sorry that I was crying. . . . In my family, all difficult feelings appear like anger....

A: Maybe there was a relationship between the dreams, two ways to show aggression.

P: Yes, and when will I use either way? It will be so embarrassing.

A- Embarrassing? .. .

P: I do not want to lose control like Mom—I have no role model. Like a paedophile that doesn’t know the difference between right and wrong because he has been assaulted himself. Someone must help me to break out.

In this session, difficult feelings of jealousy, hate, and the intense, inhibited rage were brought into the therapeutic dialogue. Importantly, the analyst commented on how the fear of destructive aggression was actualized in the transference, thereby conveying that she could tolerate Kim's internal world.

Embodiments

The middle phase, about one and a half years into the analysis, was difficult. Kim became increasingly gloomy and depressed and made almost no eye contact. She wanted the frustrating relationship with her boyfriend E to end, but at the same time she was afraid of losing him. Full of doubt, she did not know whether she wanted to live or die. During this period she gained a lot of weight, wore loose, dark, formless clothes, and looked increasingly older. One day, meeting Kim in the dark corridor outside her office, the analyst thought she saw Kim's mother standing there, which provoked catastrophic feelings that Kim was dead or that Kim's mother was furious with her for having destroyed her daughter. Kim now seemed to look like her mother, as Kim perceived her—another embodied enactment expressing what was happening in her inner states in the analysis. The analyst thought that Kim probably felt increasingly vulnerable, and that the masculine, phallic defence was no longer working or useful.

A new shift, in embodied form, occurred one year later. After the third summer holiday Kim came to the session, slim, beautiful, and full of energy. She had probably lost 10 kilograms in three months and looked more feminine and agile. At the same time, having stopped living with E, she was struggling with heartbreak, suicidal thoughts, and, with loss of E's "regard," she regressed to an identification with the mother who loses control:

P: I started to get stupid thoughts. "Nothing can be worse than this life. I can quit it and die ..."

The analyst tells us, "I'm feeling here that she's pretty scared and wishes that I'll do something," but she contains the anxiety and urge to act.

P: I've gone all the way down—I want to die. I think I'm losing control. I need something really there, to help me. ...

A: Then you come here and I just sit here.

P: That's important. . . that you just sit there. . . . It takes time to find my way back. I lost my identity when I lost E.... He does not answer me.

A: It hurts you. . ..

P: Yes, "Hello, can you answer me!"

A: A feeling you have here in the analysis too—that I do not answer.

The analyst here gave space for Kim to bring the "impatient" internal object that could not put up with her into consciousness, and to differentiate this object from the analyst, a new "patient" object.

P: Yes, you are putting up with me. But I often find it difficult. I'm incredibly glad you're putting up with me.

A: You're glad I've been putting up with you.

P: You must be incredibly patient. You know the answers a year before I do.

I do not think I would have managed to wait a year for you to figure it out.

Kim projects her own inability to put up with her feelings, thoughts, and impulses (in part, an identification with her critical, traumatized mother) onto the analyst, using the analyst to digest and elaborate her fears.

A: I get the impression that you think you can be replaced at any time. Here in the analysis too.

P: Yes, I’m so scared that you cannot put up with me. That I'm wearing you out.

[She starts to cry.]

A: And you might think it’s difficult to give me a really hard time—to criticize me.

P: Yes, it is.

Here we witness a crisis of identity (with loss of the object), resulting in suicidal thoughts. Here-and-now transference interpretations addressed Kim's fear of being replaced and fear of aggressively criticizing the analyst. At the same time there seemed to be a movement in Kim towards increased openness and gratitude to the analyst, who apparently was now experienced as an admired, benign parental figure—the one who "knows."

Termination

Approaching termination, after three years of analysis, Kim met with her dearly loved friend J with whom she lost contact a long time ago.

P: I got so calm. I got back my life—the meaning. . . . It's good not to be lonely anymore—and allowed to be angry. ... I was very angry. I spoke up.

A: As if it was safer to say what you meant after last weekend with J.

P: I was inspired by her. She is so vulnerable—but strong.

It would seem that Kim was now more able to contain and express her anger. A new psychological "position" now seemed possible, that of being strong and vulnerable at the same time.

Just a couple of months before the end of analysis Kim dreamed that she and the analyst formed a lesbian couple who were having a child together, a girl. Kim thought the child might symbolize her, and that she was getting to know the child in her through the analytic process. In the transference the analyst also felt a wish for something creative in their relationship—a feeling of strong love from Kim, which she believed was mixed with erotic feelings. In this period, Kim started to copy the analyst's feminine style. One session she came with blond hair, blue dress, and blue eye makeup just like the analyst's—apparently an external, embodied expression of Kim's identifying with the analyst's ways of being emotionally present and in control. Gradually, the analyst noted that Kim found her own style, different from that of the analyst.

Discussion

What accounts for the changes obtained in Kim's treatment? What were the curative factors? While the state-of-the-art of psychotherapy research is that therapy helps people, to identify mechanisms of change, now framed as question of mediators, remains a challenge. Examining the course of Kim's analysis on a phenomenological level, bottom up, through detailed verbatim session reports, allows us to establish hypotheses about processes of transformation in her treatment.

First, let us summarize the structure of Kim's problems. Starting analysis, Kim was in search for an identity, first some aspects of a "personal identity" (McDougall, 1992), and then more specifically an identity as a woman. Was she Asian or Norwegian, or neither—or both? Was she able to be a university student and become a strong, competent woman, or was she destined to work in a shop, as her teachers as well as her mother thought? How was she to live her sexuality? Kim's identity seemed to be that of a rebelling tomboy in training clothes and sneakers, controlling and with manic activity—and deeply afraid of emotional intimacy. Theoretically, we may speak of a phallic-narcissistic mental position characterized by self-sufficiency and omnipotence developed as a defence against the feeling of being rejected by a non-affirming mother and deceived by the father. This self-sufficient position seemed to shield an underlying lack of coherent self—the "heart" of personal identity (McDougall, 1992)— related to deficits in self-other differentiation. Due to lack of separation/ differentiation between self and object representations, primitive aggression against a destructive mother-introject also became directed towards Kim herself, resulting in devastating feelings of being a monster that did not deserve to live. At the same time, the phallic-narcissistic position protected against a traditional female role, as defined in her family and culture. Such a mental position would seem to imply a fantasy of the phallus (Birksted-Breen, 1996) denying the Oedipal triangulation—a distorted version of the paternal function, with no room for capacities traditionally associated with the feminine/maternal function, such as receptivity, reverie, bearing children.

What were the curative factors? Certainly, the containing function of the analyst experienced by Kim as "You are putting up with me" was essential. Transference expectations of being rejected, as well as fear of the raging internal monster able to destroy the analyst, were not met in ways Kim's psyche expected. The analyst, not responding with the expected strictness and reproaches, thereby became an "auxiliary superego" (Strachey, 1969), which manages more realistic and current ideas than those stored in archaic superego introjects. In Kim's analysis we have seen how here-and-now transference interpretations (e.g. "I get the impression that you think you can be replaced at any time—here in the analysis too") enabled Kim to "take back the projections" (Gullestad & Killingmo, 2020).

Another factor that we think should be particularly emphasized in Kim's analysis is model learning (Gullestad & Killingmo, 2020). In a long analysis, changes in the ego's organization are made possible through dialogue with an object that has a more nuanced and differentiated ego-repertoire than the patient herself. Identification is an essential mechanism in this process, usually discussed, within different theoretical traditions, as the identification with the analytic function of the analyst (Rangell, 1987; Lander, 2007; Smith, 2007). Central to this process is that the patient "takes in" more adaptive ways of thinking, such as the therapist's reflective mode (Fonagy et al., 2002). The patient may also identify with the analyst's attitudinal patterns, ways of being, and alternatives for action (Gullestad & Killingmo, 2020). Identification with the analytic function of the analyst as a curative factor implies that emphasis is put on what the analyst does (as opposed to discussing the therapeutic action of analysis without referring to the analyst's activity; see Smith, 2007)—thus indirectly focusing on the person of the analyst. This is in line with contemporary psychotherapy research, which in recent years has increasingly emphasized the importance of the qualities of the person of the therapist—therapist effects—for therapeutic outcome (Baldwin & Imel, 2013; Nissen-Lie et al., 2017; Heinonen & Nissen-Lie, 2019; Johns et al., 2019).

For the therapist to be "a model," of course, does not mean that the patient becomes like the therapist. To be like the other means that otherness is lost, as well as the capacity to discriminate, and the asymmetrical relationship with the analyst (Lander, 2007). In this context, it is relevant to distinguish between identification with persons as opposed to identification with modes of functioning. The wish to "resemble"—to imitate—as well as the need to admire and idealize the therapist, and in this sense to identify with the therapist as a person, should be subject to therapeutic working through. Rangell (1987) here speaks of identification as defence. Identification with modes of functioning, on the other hand, refers to "taking in" specific ways of functioning—such as more nuanced treatment of problems, a more realistic attitude, a greater tolerance in interpersonal ways of being and more independent self-representation (Meissner, 1973; Gullestad & Killingmo, 2020). In the analysis of Kim, however, we observed that, at least for a period, there was a process of actually trying to be, very concretely, like the analyst. How shall we understand this imitation?

Two aspects seem relevant. First, in the beginning of the analysis Kim had little capacity for reflective functioning—she was a woman of few words and much action. Entry into her internal world was not primarily through associations. Rather, dreams expressed Kim's unconscious dynamics—and, not least, her ways of being, carrying implicit relational messages. With Kim, the analyst captured how non-verbal affects and unsymbolized experiences manifested in bodily action language— the analyst was sensitive to find the mind in the body (Gullestad, 2015; Leuzinger-Bohleber, 2015). Importantly, the analyst addressed Kim's lack of self-other differentiation and her primitive conflicts over aggression, threatening her basic self-identity. It was striking when, after a year of analysis, Kim brought her guilt and shame about not taking care of her mother into the analysis: "I'm tired-no, not sad—I'm guilty of everything that has happened to Mom and Dad. I blame myself constantly and feel a lot responsibility for them. It will never be enough for them, they will never get enough."

Two years into the analysis, the analyst took on being the unresponsive, dutiful maternal object in a questioning way:

A.- A feeling you have here in the analysis too—that 1 do not answer.

P: Yes, you are putting up with me. . . . I'm incredibly glad you're putting up with me.

Working through the negative transference, the analyst allowed Kim to find her as a new object, integrated in functions by Kim by ending the analysis. Kim worked through guilt and shame about her mother, sufficiently to go back and find a loving object in the neighbour/mother/ friend. It would seem that the analytic work on personal self-identity later allowed Kim's feminine identity to emerge, and her use of the analyst as model, a strong female professional (McDougall, 1992)

Second, being the child of immigrants, rejected and with a sense of belonging nowhere, it seems that there was in Kim a hunger to find someone to accept her identity as a monster and as an aggressive polar bear, and then to act as a female, Norwegian role model. She was in need of what Lacan (1966) calls the sujet supposé savoir (subject supposed to know). As it turns out, her analyst became a model, not only as concerns containment of affects and ability to reflect instead of acting, but also for being female. It would seem that Kim, in searching for a more secure identity, needed to incorporate the feminine qualities of the analyst quite concretely. Wille (2008) also points out that sometimes imitation cannot be avoided and might sometimes even function as an intermediate stage towards identification (p. 1201). It should be underscored that in Kim's analysis, the physical imitation was a passing process. In the end, she found her own style.

What about having a child, a central theme in Kim's presentation of her life's problems? At the termination of the analysis, Kim said this was no longer a pressing problem—the idea of having a child (or not having a child) did not frighten her anymore. It would seem that in Kim's analysis, the analyst had been especially receptive to and welcoming of the erotic dimension of Kim's transference. The analyst noted that in the transference relationship she could feel Kim's wish for getting "into my femininity, to my womb" (Chasseguet-Smirgel, 1984), to identify with me and my maternal care (fusion), but also to create life together with me— to make me pregnant—thereby binding us together." The early dream about LidoLido seems to represent identification with the analyst/doctor's capacity to bear difficult feelings involving the mother. An odd phrasing in the dream—"I got to know the feeling he had"—suggests a magical use of the doctor's "experience" as her own: "Then I got such a bad feeling that it was really heavy for him, like .. . with his mother and that he had experienced lots, lots of heavy things. And then I got to know the feeling he had." The dream about the lesbian couple being creative and having a child expressed identification with the analyst's creativity and capacity to love in a transference fantasy (a reimagining of a mother/ daughter love?).

In conclusion, the analyst let herself be taken in as an introjected or fusional model and then used as a role model with whom to identify in Kim's search for identity. We remember Kim's words starting analysis: "I do not want to lose control like Mom—I have no role model." She conveyed a self-image as a "paedophile that does not know the difference between right and wrong because he has been assaulted himself." "Someone must help me to break out." Kim found somebody who helped her to break out.

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Chapter 7