Does your patient never miss a session, but start each one with accusations, insults, or threats to quit therapy?

Otto Kernberg, MD, notes that at the same time, the patient's fantasies and fears reflect his assumption that unless he consistently fights off the therapist, he will be subjected to a similar onslaught of hatred and sadistic exploitation and persecution from the therapist. At this point, even the therapist’s silence may be experienced as an act of violence, while empathy may be perceived as a hidden trap.

Obviously, by means of projective identification, the patient is attributing his own hatred and sadism to the therapist; the situation illustrates the intimate link between persecutor and persecuted, master and slave, sadist and masochist, all referring in the last resort to the sadistic, frustrating, teasing mother and the helpless, paralyzed infant.

Basically, the patient is enacting an object relation between persecutor and victim, alternating these roles in his identifications while projecting the reciprocal role onto the therapist. 

In the most pathological cases, it is as if the only alternative to being victimized is to become a tyrant, and the repeated assertions of hatred and sadism would appear to be the only form of survival and meaning, aside from murder, suicide, or psychopathy. 

According to Otto Kernberg, in milder cases, an additional dynamic factor, envy, emerges—intolerance of the good object who escapes from that savagery and who is hated for willfully withholding (as the patient fantasizes) what could transform the object from a persecuting one into an ideal one. In this situation, the therapist is experienced as someone who could give—but does not give—love, rescue, or ideal maternal acceptance.

In still milder cases, with more sophisticated and elaborated types of sadomasochistic behavior within a neurotic personality organization. In these dynamics, Otto Kernberg points to an unconscious potential for pleasure in pain, the temptation to experience pain as a precondition for experiencing pleasure, in the context of castration anxiety, unconscious guilt over oedipal strivings, and as the ultimate transformation of passively experienced pain into an active compromise solution of the corresponding unconscious conflicts. Here, pain ceases to be merely suffering. It becomes a way to experience control, arousal, or even a sense of closeness.

All these dynamics may emerge intimately condensed and combined, with differences in degree and proportion. What they have in common is the intense motivation to maintain a link with the hated object, a link that gratifies these various primitive transferences and is, in my view, responsible for the powerful fixation on primitive object relations. For hatred, in this context, is not the opposite of love, but its distorted form.

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(c) Yuliia Holopiorova,

Ukrainian Association of Transference-Focused Psychotherapy