IV Impasse

Chapter 8

Three hypotheses on impasse in the case of Janine

Robert White, Siri Erika Gullestad, and Bruno Salesio

Introduction—Robert White

"Impasse" as a technical term to denote analyses that stalemate or end prematurely has come relatively late in psychoanalytic history. In the Oxford English Dictionary, "impasse" is defined as a road or way having no outlet, a blind alley or cul-de-sac, a position from which there is no way of escape, a deadlock or stalemate. In an impasse, setting and frame do not change: the patient associates and the analyst interprets, but the process neither advances nor retreats (Etchegoyen, 1991). Impasse is the opposite of working through, which, when arrested, leads to impasse. It is a far more difficult technical problem in a clinical psychoanalysis than other negative reactions and negative therapeutic reactions, which can often be addressed with the usual psychoanalytic techniques; they are obvious and belong to the patient. Impasse is often difficult to recognize, remains silent, belongs to the analytic couple, and, when recognized, admits of no easy solution. "It tends to perpetuate itself: the setting is preserved in its basic constants; its existence is not obvious as incoercible resistance or technical error; it is rooted in the patient's psychopathology; and it involves the analyst's countertransference" (p. 795).

There are various routes to enter into an impasse (Maguire, 1990). There may be a gradual and insidious withdrawal of affective investment or contact, a loss of vitality, from the process. It is often more complicated, as the withdrawal is disguised by a pseudo-involvement that may be very difficult to distinguish from genuine involvement. The discourse is characterized by a subtle movement away from free association, characterized by obsessive, circular, and endless monologues that feel empty and numbing. Often neither patient or analyst is consciously aware of this process, and it is recognized only in the counter-transference when the analyst can recognize the same process within, of boredom, of lacking fresh ideas about the transference and making mechanical and stale interpretations. Or overt hostility may be more present, attacks on the frame, often around attendance, stereotyped complaints, or challenges to the analyst's competency. Depression may be used as a vengeful weapon, to maintain distance. Attempts by the analyst to bring the patient's attention to an impasse are often met with indifference or denial. Eventually a chronic sense of failure and hopelessness settles over the analysis. Interestingly, patients are often quite comfortable with this arrangement, and it can go on for years, neither making real contact nor wanting to end it. Impasse should be differentiated from slow or stalled analysis, where struggle remains alive and potentially solvable. As psychoanalytic work has extended to borderline and traumatic cases, impasse has become more common. We think most analysts have in their caseloads patients who require extremely long analyses with periods of impasse or near-impasse, as well as analytic failures and premature terminations. The experience of impasse in our work forces us to examine technique and the limitation of our work.

The case of Janine

This case was presented to a 3-LM group in New York City in 2013. Janine was a 25-year-old single woman in her last year of university studies when she started a nine-year analysis. The analysis was conducted in Germany and in German by an American analyst who lived and worked in Germany. The analysis was four times weekly, lying down. None of the present authors participated in the original 3-LM group; this report is based on a review of the clinical transcript of the hours presented.

The analyst had told the patient on the phone that she didn't have a waiting room. Notwithstanding, Janine rang the bell early, disturbing the analyst and a patient who was particularly sensitive to the analyst having other patients. When the patient opened the door to leave, a woman who looked like a pre-pubescent girl bolted in, pushing him aside. The analyst was angry, feeling that she wasn't ready for her yet, and Janine was fuming. It was almost impossible for either of them to find a way into a mode conducive for an analytic consultation. That was the "violent beginning." From then on, for many years of analysis, "there seemed to be little movement and almost no emotional involvement whatsoever."

Just as Janine had barged into the consulting room, she had bolted into her parents' world far too soon. Her father was still a student and her mother was working to support him. As a baby, Janine was cared for by the maternal grandmother, who lived in the same apartment building. Every evening the grandmother brought the child to be with her mother for two hours, which, she said, "neither liked." The father spent many years building a house for the family. When Janine was 7, twin sisters were born, who lived with the parents from birth, but the family did not move into the new house until Janine was 9 years old. Moving away from the grandmother was very difficult for her. At about this same age she swore a secret oath with a couple of other little girls that they would never become women. She lay in bed all night, stiff as a board, trying to prevent her period from happening and felt devastated when it did.

Janine's sexuality seemed to be a mixture of pain and pleasure. She described her first experience of sexual intercourse, an event she had carefully planned, as a "rape," and phantasies of rape seemed to accompany all her sexual experiences. She was successful in her studies, but complained that she had not really chosen her career. In fact, she never made any decisions, but seemed to fall into situations and activities. She felt she was always in a temporary state of affairs—"in an anteroom of life." Decisions were a problem because she always seemed to have two areas that played themselves off, one against each other. This either/or situation constituted itself immediately in the analysis. As soon as she decided to do an analysis, her boyfriend, X, left her, and she was convinced it was because of her decision. X said that it was because she could not be passionate, and she agreed—it was true that she could not be passionate. She had never felt an orgasm, except as a simple mechanical happening. She thought X had constantly caused her pain, perhaps on purpose, by flirting with other women. It was the excruciating pain of the separation, however, that now made her all the more determined to proceed with the analysis. She also had a symptom that she felt embarrassed to tell the analyst about; she regularly pulled out the hairs on a small section of her head and—as she told the analyst much later—ate them.

Janine made two interesting points in a session soon after the start of the analysis. She differentiated conspiracies from relationships. A conspiracy appeared to be a shared secret that holds two people together but each remains quite detached and unstable. It could fall apart or deceive at any moment. She longed for a relationship—commitment—but it seemed impossible. Janine explained,

My feelings scare me, make me helpless, powerless, exposed—it's as if the ground is pulled from beneath me. It's embarrassing, really devastating to lose face like that. I'm sworn to a child-like nature, that's my mainstay in life. Absolutely uncompromising, smashing my head through walls—brutal, relentless, severe... adamant, ambitious. But also fear. Fear of failure pushes me forward.

All of this was fascinating, but the sessions were deadly. Janine lay completely still, session after session. From the analyst's perspective she seemed to have a huge head with a very tiny body below it, something like an embryo. Janine's clothes did not fall naturally around her body, but seemed to hover slightly over it, her bluish opal ring perfectly matching her dress. It was as if her body underneath were not alive. It was next to impossible to find a way to talk to her, the transference interpretations seeming mechanical and devoid of meaning. The analyst noticed how Janine would compliantly move into the mechanical interpretations she gave her, and often she would hear her saying things that were reminiscent of old interpretations from her. The analyst realized that counter-transference reactions (during the first two years especially) were missing, which made her analytic work, from her point of view, almost impossible.

In a series of hours in the second year, the analyst noted a persistent transference where Janine was dutiful and the analyst felt dead. The analyst wondered if she had gotten too close, and Janine described how she blocked any need by a rigid fantasy of being completely in control, by her defiance, and her feeling of being imprisoned. The analyst had an image of fighting a horrific prison warden. She tried to convey this sense in her interpretation of gnawing and nagging need—some awareness of wanting but catching hold of the punishing, hateful side as well. Janine responded with feeling understood—a sense of relief. In the next hour, she reported that she was glad to be heard and the analyst interpreted relief. But Janine responded with feeling tortured and the wish to be passive and dead. The analyst wondered about torture when there was silence. Janine disagreed; she did not allow any torture, she used the silence to move farther away and feel in control again. In the next hour, the patient reported how she destroyed any needs before they arose and suggested a paranoid transference—the analyst who withholds on purpose. Janine responded with self-torture, pulling out her hair, which brought relief. She was entirely self-contained; the analyst did not exist for her.

In the next five years, the analyst felt encouraged. Desire showed up in small ways and Janine began to talk about her hunger. In year eight, her father died unexpectedly. Janine had felt her father was the one and only person who had always stood by her. At the end of that month, the analyst found herself in a terrible conflict involving the bill: she did not want to charge Janine for the missed session on the day of the funeral, although they had the arrangement that all missed sessions were the patient's responsibility, regardless of the reason for her cancellation. She finally decided to charge for the day and withstand the horrible feelings of guilt and shame—she felt like a horrific monster.

In the next session, Janine responded with rage and the analyst said,

A.- I seem to have broken an unspoken agreement between us. I no longer am someone you can trust, like your father, who was always therefor you. Instead I have become like your mother who would seem to be very understanding but then suddenly turn on you and stick a knife in your back. You feel I have betrayed your trust.

P: Exactly. You ride your principles—put principles above needs. I can never forgive you, never! I'll never trust you again. And this analysis is over!

To the analyst's surprise, she did show up the next day and expressed relief that she could fully express herself. After this session, the analyst understood that what had happened between them in these two sessions was what Janine called an illusory analysis; in her mind, the analyst had promised she would never leave her, and she had held her in a special role above all other patients. However, over the remaining months of the analysis—it was a total of nine years—they drifted back into the illusory analysis again. The patient decided to marry her current boyfriend and moved to another country.

Impasse: An object relations perspective— Robert White

Janine fits Rosenfeld's (1987) description of destructive narcissism. In destructive narcissism, it is the omnipotent destructive parts of the self that are idealized. The self feels free to hate any positive relationship and any parts of the self that desires or needs objects. Both external and internal objects are permanently devalued. Envy is more violent, and there is a wish to destroy the analyst and any of the analyst's goodness. Such patients feel superior to the analyst in being able to control or withhold parts of their self that want to depend on the analyst. This is accomplished by a need to triumph over the analyst, through persistent indifference, withholding behaviours, or open belittlement. Yet this is quite frightening to the patient, who will then be entirely alone, resulting in violent selfattacks. Death can be idealized as a solution to all problems; patients may prefer to die, become non-existent, or deaden any desire.

In this sense, Janine rigidly controls her internal objects through shared secrets that bind but do not involve any commitment, any ties. She expects to be raped, deceived, and abandoned. Any physical or psychic growth threatens separation and abandonment—she remains as an embryo, never quite born. She cannot attack her objects directly, but indirectly through withdrawal and layers of protection by fluids and membranes. This is undoubtedly what the analyst feels in her counter-transference—nothing. Janine is dead and frozen—blue is the colour of death—she cannot be reached. She describes the violence in the fantasy of smashing her head—brutal and relentless. But at the bottom is persistent fear—of being deceived and humiliated, of being abandoned and left helpless and alone.

The danger for the analysis is illustrated in the first encounter. Janine, by disregarding the analyst's instructions, arranges to violently and intrusively attack the analyst's work, and, at the same time, feels abandoned and hated when the door does not open when she rings. We can easily hypothesize how this becomes a chronic but unrecognized enactment for the first years of the analysis. The analyst, in feeling nothing, is well protected against the projected hate, while Janine has withdrawn into a death-like state where she cannot be reached. Janine has arranged for a conspiracy of shared secrets. The enactment is likely that the analyst has secretly, even to herself, joined this conspiracy. To form a real relationship would be to experience shared rage and pain. Janine will resist any movement toward relationship, and the analyst passively accepts this. Only if a relationship can be established can we think of the analysis as truly starting, with a feeling of shared goals and shared work. The analyst reports Janine's persistent attitude: "boycott the analysis, block it whenever she could." Any other alternative would be "a catastrophe."

Two years into this work, the analyst reports a change. The work begins in the counter-transference. The analyst is struggling with her usual feeling of withdrawal and sleepiness when she suddenly has the image of herself as "a horrific prison warden" and she feels more free to respond. We guess that the analyst has started to get in touch with her own sadism. But, in speaking to Janine, she does not take up imprisonment, but rather what it must be like to feel abandoned:

When I am not there with you, your feeling of needing me is gnawing and nagging- Yuck, she's not there again... . Oh, how I wish she were here right now—it's punishing: Ugh! She's not there again. . ..

It is not just the words. The interpretation is playful, full of emotion, engaging. Note that movement in the dynamic engagement is possible only when the analyst can free herself from the persistent deadness. Janine responds:

It's all about how it should be because I feel entitled to it. ... I don’t think I actually know at all what my desires and longings really are. . . . [R]ight now I feel very understood by you. But that doesn't make me happy the way I imagine that I should feel. It simply makes me feel some relief.

We see in Janine's reply a condensation of the promise and the perils of analysis. She first restates her narcissistic position of total control, then admits to not knowing, a new feeling but more vulnerable, but then will use the analyst as a lavatory, without any concern for her, a move away from vulnerability (Rosenfeld, 1964). Janine in this period clearly outlines the impasse:

I really want to come to see you today. But I can feel myself destroying that before it really comes up. Right away I now have the feeling that you could give me what I want but that you don’t and won't do it—on purpose.

The absent analyst is quickly converted to an angry and attacking analyst, who must be immediately dismissed:

The only thing I know how to do is to damage and hurt myself and run away from it all.

Here is the central challenge: how to interrupt this endless and vicious cycle of hate and withdrawal. The analyst then notes several years in which there were slight movements. Janine could, at times, voice an idealizing transference, the mother who will give total care and never leave.

Here is an hour from the fifth year. Janine arrives tortured and feeling full of shit. She sees the analyst as withholding goodness. The analyst, too, feels tortured and says, "That's just what I was thinking—you constantly feel plagued by a tormentor." Note that already there is a slight move away from transference, a tormentor rather than me as tormentor. Did Janine unconsciously pick up on this, as she gets angrier and angrier, but also aware of hunger?

Can we see this hour at two levels simultaneously? The first level is what is talked about between the pair. The themes are paranoid, an internal persecutor, who is projected into the analyst, which we see in the beginning of the hour. But later in the hour, we see the other side of the split, the idealized maternal object who loves unconditionally:

P: I would like to... to force you to be helpful to me. Hmm—somehow it seems to me that you should have to prove how you're actually worth something . . . [the patient appears more comfortable]

A: Actually, it seems as if when I do say something, it evaporates into nothingness. ...

P: That's because I never get satisfied. Nothing is ever enough. I am endlessly hungry. Even if there were a whole buffet there, it wouldn't be enough. My hunger can't be satisfied—it will never stop tormenting me.

Throughout the hour, there is an exploration of these fantasies and Janine genuinely appears to feel better and more in contact with the analyst. At the end of the hour, she reveals details about a good interaction with her current boyfriend, which seems to confirm a positive shift.

The analyst reports further progress in the next two years. Janice vacillated between two versions of herself, one loving and feeling loved, and the other bitter, rejected, and unhappy. The analyst, too, has a new countertransference, feeling deeply jealous. Janice states,

If I try to get both together I get really frightened, and that's when everything gets cut off and the anesthesia comes.

The analyst comments,

She felt I betrayed her at the end of every session by sending her away. It was very painful, for it was as if I had promised her I would always be therefor her, but then threw her out after all. She told me how her grandmother had promised her she would never leave her, but then did. She also reported for the first time that there had been a great-grandmother in her first two years of life who actually had remained constantly at her side and whose sudden death caused a traumatic separation for the 2-year-old. She said she couldn't help it, she felt I was constantly betraying her and lying to her and when she was at home, there was a devil version of me constantly with her. The only solution would be that I would remain with her 24 hours around the clock.

We now see more elaboration of the transference, especially a greater awareness of the idealizing fantasies and their constant enactment at the end of sessions. Does the analyst get pulled into the enactment, of feeling she must be the ideal mother who never leaves?

Impasse often takes the form of what Bion (1963) calls "reversible perspective." Bion is referring to drawings that can be perceived either one way or its reverse. He applies this to analytic work of the psychotic parts of the personality—destructive attacks on any links and emotions.

The negative contained enters the container in order to strip and destroy it, and feels the container will do the same to the contained. The analyst has one point of view while the patient takes the opposite point of view, a manifest accord and a latent discord. The aim is to avoid pain at any cost. The reversal, however, is silent, as the patient consciously agrees with the analyst's interpretations, but unconsciously holds to the opposite view (Etchegoyen, 1991; Hart, 2012). The patient is constantly reinterpreting the analyst's interventions in accord with his own ideas. This leads to what Bion (1963) calls "static splitting," where the splitting quietly operates in the background, never changing, insulated from the analyst's awareness.

Janine's father died unexpectantly, the one constant person in her life. The analyst had a "terrible conflict" about charging her for the missed time on the day of the funeral, wanting to maintain how she usually bills, but feeling like a horrific monster in doing so. Janice arrives the next day enraged, wanting to quit the analysis. The analyst is under great countertransference pressure, wanting to maintain the frame (agreement on fees) but invaded by the patient's projection of the internal monster. The patient predictably is enraged; we now see the split in the patient in full force, the idealized mother who will never leave, and the abandoning mother who hates and deceives. To her credit, the analyst does not back away from the frame and absorbs the full force of the patient's attack, verbalizing Janine's fantasy that she (the analyst) could turn on the patient and stick a knife in her back. Janine's dilemma is that she is dependent on the analyst whom she desperately wants to leave and get rid of. The analyst interprets a transference fantasy: "You think I am exhausted by you and want to get rid of you." Janine responds with what may be the key to the impasse: "Silence is the only means I have to distance myself from you." That is, she must silence herself, deaden and kill off any links to the analyst and any need in herself. The analyst misreads this as punishment, but it is more likely a primitive defence against an analyst who she does not feel understands her needs. What may be missing is the analyst's examination of her own counter-transference; is she in fact exhausted by the patient's never-ending wish for total care, a kind of fusion with no separation? Is there a hate in the counter-transference (Winnicott, 1947) and relief at the end of sessions? The analyst must find a way to move out of her own deadness, defending against her own hate, in order to truly reach this patient.

Gullestad calls this "deficit transference," leading to a loss of the "as-if" quality of transference: the rejecting and horrible analyst is really horrible, not a fear that may or may not be true. I fully agree. The only solution that the patient can see is total fusion, and anything else is felt as a real abandonment and hate. Gullestad suggests affirming as a partial solution. In my experience, affirmation, in this kind of case, verbalizing as deeply as possible the patient's inner state of hatred and pain, often fails. The patient thinks the analyst is using the same reversible perspective, pretending to be empathic, while secretly continuing to hate the patient and be glad to get rid of her. The patient is an expert at reading the unconscious of the other and will glean any hate that may be present even if the analyst is unconscious of it. I suggest what we try to do is offer a mix of affirmation, containment (not retaliating to the patient's attacks), and work in the counter-transference (being aware of the extraordinary strain of caring for such patients and finding genuine compassion for their pain). I have found that at these times of crisis it is my work on my own distancing and hate that makes the difference and needs repeated working through.

Janice does continue the analysis, but she has now deadened herself, and she imagines the analyst to be equally untouchable. I think this is where her true self resides, walled off, untouchable, silent. The noisy paranoid interactions are the illusion. She came to the analysis in silence and leaves in silence. The patient decides to terminate in order to marry and move away.

The analyst, at this point, has grasped something: she now thinks of an "illusionary analysis," where "I had promised I would never leave her, and in which I held her in a special role above all other patients." Janice is still organized at a psychotic level: both split-off transference fantasies are felt as equally real, the wish for idealized merger and the fear of being attacked and abandoned.

What seems true is the deadly silence where she really lives. The patient left the analysis in the next year. The analyst does not state how the ending came about, but the analyst was left "with a horrible feeling that I had not really helped her enough in this analysis."

Impasse: A plea for affirmation—Siri Erika Gullestad

Conflict and deficit

Janine's analyst admits to a challenge that I think we all recognize: to find a way to talk that gives meaning. Janine experienced that the transference interpretations were devoid of meaning. The question of what is meaningful for the patient is in the centre of Killingmo's (1989a, 1989b, 1995, 2006) discussion of affirmation as a form of intervention supplementing interpretation. If Janine's personality structure is characterized by developmental deficits (e.g., defective self-structure, lack of object constancy, identity diffusion, splitting, and lack of capacity for emotional relating to objects), she may not be able to profit from ordinary transference interpretations. A patient organized on a conflict level, implying that the self-representation has been constituted as a responsible centre of the personality, may profit from interventions to confront impulses and affects towards internalized object representations that are projected onto the analyst. Such an undertaking presupposes an alliance between analyst and patient in finding out, searching for concealed meaning. In contrast, working with derivatives of deficit,¹ the analyst cannot take for granted that the patient will experience her invitation to explore as a benevolent helping act. It is more likely to be interpreted in terms of critique, provocation, or attack, with the risk of weakening the working alliance, and ultimately threatening continuation of the therapy. In such cases, where the perspective is to bring about structuralization of aspects of object relations which has not been accomplished in the previous development, the therapeutic endeavour is not primarily to unveil repressed meaning, but rather to assist the ego in experiencing meaning in itself (Killingmo, 1989a, 1989b). Here, the interventions have to be, not interpretive, but affirmative.

Affirmation

Affirmative feedback may be defined as a communication that removes doubt concerning the validity of the subject's experience (Killingmo, 1995). By using an affirmative mode of intervention, the therapist seeks to communicate to the patient that she understands what it feels like to be her, and that it is understandable that the patient feels the way she does.² Affirmation, communicating a sense of being seen, understood, listened to, and accepted, legitimates the patient's self-experience and strengthens the I-feeling (Killingmo, 2006; Gullestad & Killingmo, 2020).

Janine’s analysis

As a baby, Janine was cared for by the maternal grandmother, but brought to be with mother for two hours every evening. At the age of 9 the family moved away from the grandmother, which was "very difficult" for Janine. These early separations seem to have left Janine with a feeling of not wanting to grow up, of remaining a child—a feeling embodied in the way she looks (pre-pubescent girl) as well as in the manner in which she lies on the couch. The child within Janine is "endlessly hungry" for a mother who will give total care and never leave, and at the same time enraged for having been abandoned. Maybe there is a fantasy that by remaining a child— staying in "an anteroom of life"—she may, magically, get what she deeply longs for? Janine says about her feeling of self,

My feelings scare me, make me helpless, powerless, exposed. It's as if the ground is pulled from beneath me. It's embarrassing, really devastating to lose face like that. I'm sworn to a child-like nature. That's my mainstay in life: absolutely uncompromising, smashing my head through walls—brutal, relentless, severe... adamant, ambitious.

Commenting on this, the analyst says, "All of this is fascinating, but the sessions were deadly," Janine lying completely still session after session. Counter-transference reactions were missing, which made analytic work almost impossible: "It was next to impossible to find a way to talk to her, the transference interpretations seeming mechanical and devoid of meaning." It would seem that the analyst here understandably feels excluded and rejected by Janine's frozen attitude on the couch.

Of course, as an outside observer I cannot know how it felt being in the room with Janine. Nevertheless, in my reading, Janine's statement also contains an attempt at reaching towards the analyst. What she expresses is that to feel is extremely frightening: feelings imply shame and humiliation, and losing face. By saying this, she—slightly—opens a door to her inner world. To do so, however, makes her vulnerable. Implicitly, she also tells the analyst that in order to protect herself from this vulnerability, she has had to withdraw into a state where she cannot be reached emotionally. Although longing for a committed relationship she has settled for what she calls a "conspiracy"—a kind of relationship where the two people remain detached, thus guarding against the possibly catastrophic feeling of being abandoned. Could the analyst simply have affirmed that she understands Janine's fear, i.e., what it must feel like to be her—and that it is understandable that she feels this way? Given that expressing what she really feels is terrifying for Janine, no wonder that she has had to withdraw.

Arguably, Janine is not ready for "taking in" this kind of affirmative understanding. Later, the analyst in a most empathic way, comments on what it must be like to be abandoned: "When I am not there with you, your feeling of needing me is gnawing and nagging." Janine responds that she feels "very understood by you." However, that does not make her happy, it simply provides her "some relief." This statement seems to express a move away from the vulnerable position of closeness implied in feeling understood. At the same time the unconscious and aggressive message seems to be that the analyst shall feel that she is not able to really help her. Thereby, Janine punishes a hated mother-representation projected onto the analyst. Indeed, the analyst is faced with the challenge of handling pervasive feelings of distrust and destructiveness:

I really want to come to see you today. But I can feel myself destroying that before it really comes up. Right away I now have the feeling that you could give me what I want but that you don’t and won't do it—on purpose.

That the analyst is thus converted to an angry and attacking analyst, who must be immediately dismissed, White sees as "clearly outlining the impasse." But is this necessarily an impasse? As I see it, the analyst here should affirm the need to destroy along the line of "Wanting to come and see me today frightens you, because the feeling of needing me makes you vulnerable. So no wonder you protect yourself by destroying that feeling." Of course, I cannot know whether Janine would have felt such a comment as affirmative—the therapist never knows in advance. My point is that an affirmative strategy seems the best option is such a case.

The funeral crisis

A grave crisis in the analysis occurs when Janine's father dies and the analyst charges the patient for the missed session on the day of the funeral. Janine is enraged, claiming that the analysis is over: "I'm through with you." When the analyst asks what she has done, Janine answers,

P-. Yesterday in the session you said something to the effect that you thought that you found it impressive how I always experience you as having promised me you would never leave me, that you would always stay with me. I suddenly realized that if you can say that to me, all I am for you is a scientific object. Nothing other than that. You don't care about me at all! I’m nothing special for you—just another patient for you to examine and treat. ... I can never trust you again!

A: You feel I have betrayed your trust.

P: Exactly. You ride your principles—put principles above needs. I can never forgive you, never! I’ll never trust you again. And this analysis is over!

How can we understand Janine's extreme rage and despair? The analyst tells us that Janine felt that she (the analyst) "betrayed her at the end of every session by sending her away, for it was as if I had promised her I would always be there for her, but threw her out after all." Janine's wishto have a mother always there, 24-hour hours a day, and available, leads to a dominant symbiotic transference, exerting a pull on the analyst. The analyst is dragged into feeling that she ought to provide such mothering and feels like a failure when she does not—expressed in the feeling of being a "horrific monster" if she charges Janine for the missed session.

To be sure, the analyst does not act on this feeling—she bills as usual. Nevertheless, it seems to me that the analyst is "trapped" by the pull to be the good mother in a way that hinders her from analyzing the symbiotic transference pattern as comprising needs that must be comprehended as understandable, given Janine's history, and affirmed as such, yet without being gratified. Distinguishing between different patterns of transference (Killingmo, 1989a) is important here. Obviously, in the case of Janine we are dealing with a transference pattern derived from structural deficit, the so-called deficit transference, which has to be distinguished from conflict transference (pp. 68-69). For a patient to function on a conflict level means that aspects of the object have been internalized and transmuted into personal enduring structures, implying that the patient has obtained a relative independence from the direct presence and gratification of the object. As affirmative functions of the objects are structuralized, the compulsive dependency on the object's approval will diminish. Most significantly, the patient is, in principle, able to recognize the object representations projected onto the analyst as her representations; that is, she is able to recognize them as transference.

In contrast, if internalization of object representations and object functions has not been completed, the patient will remain more or less in a functional relation to the object—the essential aspect of the transference originating from deficit. Importantly, the patient in this kind of transference pattern will not be able to recognize that object representations projected onto the analyst are her own representations and projections. There is a lack of mentalization (Fonagy et al., 2002), implying what Fonagy calls an equivalent mode of psychic functioning. This means that the patient will have problems recognizing her relational pattern as transference. The rejecting, horrible analyst is horrible. No transference interpretation seems possible.

To my mind, this is exactly what we see in the funeral episode. Janine tells her analyst, "[Y]ou said something to the effect that you thought that you found it impressive how I always experience you as having promised me you would never leave me, that you would always stay with me." It seems that the analyst, probably with the purpose of pointing to a transference need, must have said something (in the previous session) like "You always feel that I promised never to leave you, and that I will stay with you forever." However, Janine is not able to use a comment of this kind to explore her inner world. Rather she feels criticized for having such childish, unrealistic needs. Feeling as if she is being treated like a "scientific object" whose needs are just "analyzed," she feels humiliated and enraged.

Could a more affirmative mode of intervention have been an alternative, conveying to Janine that it is understandable ("no wonder that. . .") that she has an insatiable hunger for someone to hold her without leaving, as she has never experienced this? Affirmation, by establishing a causal relationship between current experiential states and life history legitimates the subjective feeling. The analyst simply communicates that this is how it is and that she can contain the intolerable feelings, be it greed or rage, without demanding that the patient should have felt otherwise.

What about the rage? We can imagine that even if the analyst had tried to communicate affirmatively that she understood Janine's longing for the 24-hour mother that she never had, she might still have been furious for being billed for the missed hour. The challenge, then, would be to contain the anger and hate. When Janine—in fury—exclaims, "I can never trust you again," the analyst responds, "You feel that I have betrayed your trust." This is "exactly" how Janine feels—betrayed. To have her feeling put into words does not, however, provide relief. At this point, functioning on a deficit level, in an equivalence mode, there is no "as if" to the distrust—the analyst is a traitor. Again, my feeling about the dialogue is that Janine would have needed to have her feeling of betrayal validated as understandable and legitimate, e.g., by the analyst conveying that when she charges the missed session, she becomes just like the mother— not being there when Janine most needed it. No wonder that Janine feels betrayed—she never felt that mother really was there for her.

Conclusion

Destroying what is good, or making the analyst a persecuting tormentor, expresses actualizations in the transference of inner relational scenarios that must be worked with as part of the analytic process. Moreover, there seems to be no difference between White and me in understanding the patient's destructiveness as expressing primitive self-protective relational strategies. Janine's statement that "silence is the only means I have to distance myself from you," White states, is likely a primitive defence against an analyst whom she does not feel understands her needs. I agree. I would like to add that his is the only kind of relationship that Janine is able to maintain, given her level of functioning—and this needs to be understood by the analyst.

As the analysis is presented in this chapter, it seems—sadly—to have ended in chronic but subtle enactments. It is the privilege of an outside observer to be able to reflect, post hoc, on possible alternative therapeutic strategies. White points to the need to work with one's counter-transference, to be aware of the extraordinary strain of caring for such patients and of finding genuine compassion for their pain, and to work on one's own distancing and hate. I agree, this is a precondition for affirmative interventions to have a chance to be taken in by the patient. Affirmation is not about "saying the right words"—it has to be felt by the analyst as a genuine stance (Gullestad & Killingmo, 2020).

Impasse: Anal narcissism in the analysis— Bruno Salesio

I will attempt to introduce examples from a psychoanalytic point of view that corroborate or are related to the impasse, sensu lato and sensu stricto.

In the comments below I use my experience as a Three-Level Model moderator. I will emphasize the theories that most resonated with me. Clinical material can be seen by various theories, each addressing a partial point of view. Like Green (1995), I think the role of theory is not to resemble the clinic, but to think it. "Theory" is a word that represents the thing (Das Ding), but the word itself does not look like the thing.

Some metapsychological considerations

The logic of Janine's narcissism was that she lived in fear, the threat of losing her organization, the intense fear of depending on someone, the loss of trust in relationships, the vulnerability, the anger, the boycott, the conspiracy—all this was deserving of the analyst's attention and care. Janine's analyst wrote "... and she was fuming" and "[She smells strongly of nicotine]." In the first session Janine associated to a secret language, secret words for "secret smoke" and for "masturbation." I think (1) the analyst was not comfortable with Janine's narcissistic expressions; (2) Janine expected to be accepted and understood; and (3) there was a lack of mental space/reverie in the analyst, which could have contributed to the impasse.

To consider sphincter control as having a role in psychic structuring means taking into account both the sources of erogeneity and one's own narcissistic constitution (Janin, 2017, p. 150). The delicacy is important for developing the ability to exchange anal bodily functions for dirty substitutes (in the child/mind) and for neutralizing aggression through language acquisition. A relationship of containment, an eroticism in experiencing the passage of content, an opposition to passage or a retention of passage—all are feelings based on anal mucosa and feces (Green, 1993). The transaction between "child"/Janine and "mother"/analyst, implies the analyst could understand Janine's nicotine language as a gesture of confidence, a gift to be understood and appreciated.

In the stage of anal narcissism, the child gives the body's internal contents as a valuable gift to the mother (Freud, 1905). In the transference Janine was actualizing her primitive trauma—through a secret language expressed in the sessions. Janine's language can be understood as an action, when "she smells strongly of nicotine" and, at the same time, as a primitive experience of exchanging "feces and urine" for language. When the anal narcissism progresses smoothly, the child symbolically recovers the lost objects that were lost by naming them—exchanging one pleasure for another. When Janine's analyst interprets that the analytic relationships could be exciting, but also threatening, she adds that the analyst's role would be to help her remember the forgotten pieces. To remember means to put her primitive traumas into words. Words and speech allow detachment and symbolic possession (Janin, 2017). But in Janine's speech one can see wishes for closeness mixed with feelings of being threatened: vulnerability and dependency. Janine suffered traumas that resulted in failures in the formations of her psychic stability and, consequently, in the structuring of her ego functions. What was not symbolized appears as a deficit in mental capacity. The analytic function will need first to comprehend and second to explain (Winnicott, 1956; Kohut, 1984; Killingmo, 1989a; Storolow & Atwood, 1992). To comprehend is a kind of understanding, the process of structuring. Frequently the analyst interpreted in a way that Janine could experience as a demand for a symbolic functioning that she did not yet have. Current theorizations go beyond thinking about narcissism as a phenomenon from libido to ego; neither are they centred on grandiosity; nor do they equate narcissism with an aggressive ignorance of the other (Bernardi & Eidlin, 2018). Narcissism has its own evolutionary line (Kohut, 1984). The antinomy between narcissistic and object libido is only a part of our clinical thinking. It is necessary to include in the narcissistic pathology painful experiences of vulnerability, inferiority, emptiness, annoyance, fear, and lack of confidence in oneself. Before interpreting, it is necessary to create meanings.

As intersubjectivity in childhood is initially pre-verbal (Stern, 1985), Janine didn't understand her analyst and felt that she was inappropriate. Children show an intuitive awareness of the other's feelings and purposes; this is innate and may or may not have cognitive or symbolic elaborations. I think Janine's speech presents two kinds of events: Janine's reliquat (a residue) of the primitive trauma that was enacted in the transference, and her repetition of the same trauma (Storolow & Atwood, 1992); I suggest that her analyst didn't understand these two levels of functioning.

Anal narcissism is a crossroads where narcissism and object relations are constructed. Janine felt she was "not worth it" for her analyst. In her words, "Quit your silence! . . . Ach! It's so hopeless! . . . How can I convince you that you should do something? ... I can't force you. I would like to—to force you to be helpful to me." Janine felt lonely and received no response to the messages she delivered to her analyst (five years into analysis). Janine did not receive "affirmation" (and validation) from the analyst of her needs, as pointed out by Gullestad. The process for establishing a relationship (affirmation of the self and validation by the other) was interrupted, causing pain and intra-systemic failures. In such cases, opposition is a key defence for Janine: it further delineates her identity and makes her feel alive.

On a rare occasion when the analyst recognized her impositions, Janine calmed down:

A.- I think that I'm asking a lot of you by sending you away every day according to what the clock says and not according to your needs.

P: [She is very moved, and she calms down and is silent awhile] You don’t know how good it makes me feel to hear you say that. It's as though I have waited an eternity to hear you say it.

What was conveyed by the imposition of a schedule can build a need that can lead to a reaction/protest or to a masochistic submission.

Janine lived a fusional relationship that coexisted with a secret and internal communication. To name or reflect on her primitive bodily experiences and to symbolize them was linked with the feeling that this would bring to an end her symbiotic omnipotence.

A: And when you do have a good moment with me and feel I understand you, then I suddenly throw you out and—

P: [interrupts] —and all of it is then erased. None of it was good, it was all a lie. That's just it, that’s exactly what happens. And so nothing can grow and nothing can become solid and stable. [Associates with her mother.] It was terrible. I would trust her and confide in her, and then she'd turn around and stab me in the back.

Often the analyst can experience this anal opposition as negativity: an unconscious negativism, unperceived by the subject. But this can mean the repetition of a wounded narcissism that seeks a "solid and stable" relationship in the transference.

The deep resistance to carrying out what has been proposed sounds as if the analyst were the prisoner subject/poop of a constricting mother/ mucosa.

To give up the primitive bodily experiences and to exchange them for language, Janine needed to work through the mourning of the "thing" before the symbolization (Roussillon, 1995). In the analytical relationship, Janine lived out the impossibility of this mourning process because there was a heightened helplessness of not being recognized. As a consequence there was a permanent splitting between her and her analyst/world. The ambivalence was not in question but a decision to defend her narcissism:

P: I don't want to choose; I want both the thing and its opposite.

A: [In fact, she never made any decisions, but seemed to fall into situations and activities].

For example, the "violent" beginning of the analysis may have been a silent/speechless enactment (Benjamin, 2009) of a dramatic situation between analyst and patient in which both participated. When the analyst couldn't understand, decipher, or interpret, the communication occurred more through what was being acted out than in actual words; Janine brings her real problem of much anguish to her non-place, which is also repeated throughout the transference. We can imagine that the analyst was probably experiencing a complementary and indirect countertransference (Racker, 1953; Borensztejn, 2009), feeling undervalued and incompetent (Bernardi & Eidlin, 2018).

In the first session, when the analyst said that Janine might also be frightened of growing up, Janine says "Very!" "She's frightened that she will lose her structure, that she will be vulnerable at someone else's mercy, that she will lose confidence, that she will be totally vulnerable"—a description of the outcome of her anal primitive and narcissistic exchanges with her primary objects. She seeks conspirators rather than real friends.

Janine says that she uses detachment to protect herself against panic, "But at the price of feelings." I think these paranoid feelings express Janine's conviction that she is not being taken into account, but is only seen as an object of study by her analyst. Would this explain the dilemma between the secret and the conspiracy as a pathology of hidden meanings and how to experience feelings?

After two years of analysis, the analyst noticed Janine's static psychoanalytic process and lack of desire. Janine would say, "Boycott the analysis"... ",.. refuse to allow analysis." Janine found herself in a desperate impasse and unable to find what she was looking for. In terms of anal narcissism, everything Janine gave to her analyst, seeking to establish a relationship, did not find a receptivity capable of establishing the place of a meaningful and stable experience (Rosenfeld, 1988; Baranger & Mom, 1983). The primitive impossibility of creating a narcissistic relationship was repeated. She considered herself very "bad" as a result, and the analyst couldn't help.

Around the eighth year of analysis, Janine misses a session when she attends her father's funeral and the analyst decides to bill her, as was their agreement:

P: All I am for you is a scientific object. Nothing other than that. You don't care about me at all! I'm nothing special for you—just another patient for you to examine and treat.

To put principles above needs! Principles are impersonal, an object, dead, not emotion or love, just hate. Needs are expressions of an extreme and humiliating dependence. But the analyst is in an impossible situation: if she charges her patient, she is greedy and unloving, but if she doesn't, she is weak and powerless. The patient feels at a similar impasse. Again, the situation presents a frustration and an offence to Janine's narcissistic needs: principles above needs! Janine expected more an affirmation of her uniqueness, more than of originality. In this experience, the analytical relationship began its end.

Janine complains about the analyst:

I have the feeling that I am imprisoned here by yon and by the analysis. You make me have bad feelings—and it's always when you're not there— although if you were there, then I wouldn’t be able to complain.

Janine perceives her analyst as withdrawn, like her father, and in reaction, she demands a good mother. Janine's transference may seem paradoxical, with opaque, empty, stagnant, talkative bitter sessions of complaining. The analyst experiences very strong feelings of aggression caused by the boredom and seeming uselessness of their work. The transference is the past; the present goes back to the past. Counter-transference usually reflects the subject's problem as in a mirror. The failure of the analyst must be understood as a failure of the past.

Final comments

I commented on the possibility of understanding the impasse as rooted in a pathology that has to do with anal narcissism. This term refers to the characteristics of a previously wounded and destroyed narcissism that is shaped in the moment when the patient has to live the experience of delivering or not delivering (retaining, keeping) her internal contents, to someone outside herself or to a space outside of her narcissistic body. I call it an "other/space" because the other might be a person, but will always be another space, outside the subject's narcissism. Janine struggled to build an identity of stable meanings. Janine felt the analyst's interpretations as a failure of understanding, as criticism and as distancing. This analyst couldn't be internalized with her implicit theory and her way of listening. I think this was reason for the analyst's failure.

Notes

• 1 In clinical practice we are faced with combinations of derivatives of deficit and conflict, in complex patterns of character. It is almost impossible to distinguish the one sharply from the other. We are always in the world of "both/and," constantly dealing, and in turn, both with the Oedipal, where there is a coherent self, and the pre-Oedipal, where there may not be (Killingmo, 1989a, 1989b).
• 2 Affirmation should not be confused with praising or complimenting a person's achievement or self-image, which is better characterized as gratification.

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Chapter 9

Change and impasse in a systematic case study