What happens to therapy when hatred in the transference becomes the dominant affect?
When the patient attacks precisely what he most deeply needs — and the therapist begins to feel exhausted, helpless, or subtly irritated?
On the eve of the launch of Module II, we invite you to consider the approach of Otto Kernberg, author and trainer of the program “Love and Aggression: From Normality to Pathology,” regarding the general considerations in the treatment of patients with severe psychopathology of aggression, particularly intense hatred in the transference.
In examining the spectrum of the psychopathology of hatred, Dr. Kernberg places special emphasis on the countertransference consequences of this affect:
The patient, particularly the narcissistic patient with antisocial features, hates most what he most needs to receive from the therapist: unwavering dedication to him. The patient also hates, because he envies it, the creativity contained in the therapist's efforts to gain understanding and to communicate this understanding to the patient.
The analyst's sense of being exhausted, that his efforts are going to waste, his sense of the enormity of the patient's lack of gratitude, may result in a countertransference that tends to perpetuate or even obscure the patient's acting out of hatred and envy.
The therapist may attempt to escape from his discouragement by emotionally disconnecting from the patient. The restoration of the therapist's tranquillity may be at the cost of an internal surrender that, not surprisingly, the patient often perceives but easily tolerates because he rightly experiences it as the therapist's defeat.
An uneasy equilibrium may ensue in which a surface friendliness obscures the “parasitic” nature of the therapeutic relationship.
Or the therapist may enter into collusion with the splitting process in the patient, facilitating the displacement of aggression elsewhere and fostering the creation of a pseudotherapeutic alliance that ensures a friendly surface relationship in the transference.
Another solution frequently adopted by the therapist is to absorb the patient's aggression, in full awareness of what is going on but without finding a way to transform this acting out into viable interpretations. This development, which amounts to a masochistic submission to the “impossible” patient, is sometimes engaged in quite consciously by a therapist who believes that with sufficient love most things can be cured.
The counterpart to such a masochistic submission to the patient is often the eventual acting out of aggression in the countertransference, either by dismissing the patient or by unconsciously provoking him to leave.
It is most likely, however, that the therapist, even the experienced therapist, will oscillate in his internal stance from day to day, from session to session, between efforts to resolve the activation of hatred in the transference analytically and giving up or withdrawing. These natural oscillations may actually reflect a reasonable compromise formation that permits the therapist to step back and evaluate the effects of his various interventions and gives him some breathing space before he returns to an active interpretive stance.
In all cases, I think it is extremely important to diagnose secondary defenses against hatred at the most pathological end of the spectrum of aggression in the transference—that is, the development of antisocial or psychopathic transferences. The patient's conscious or unconscious corruption of all relationships, particularly the therapeutic one, must be examined consistently, with the therapist fully aware that such an examination will probably shift the apparently “quiet” psychopathic transference relationship into a severely paranoid one and activate intense hatred in the transference. The therapist's normal superego functions, his being moral but not moralistic, will be experienced by patients with antisocial tendencies as devastating attacks and criticisms.
Working with intense hatred in the transference requires from the therapist not only technical precision, but also the capacity to tolerate complex countertransference reactions without losing the analytic stance.
Awareness of these processes — and their consistent interpretation — is essential for moving from a destructive dynamic toward an integrative one.
(c) Yuliia Holopiorova,
Ukrainian Association of Transference-Focused Psychotherapy