At the first meeting of the Mediterranean group in Prague

At the first meeting of the Mediterranean group in Prague

Introduction

Anna Potamianou (Grecia)

Congreso de Sorrento, 2004

At the first meeting of the Mediterranean group in Prague, I presented the case of a woman patient whom I named Helena, 37 years old, with  a severe mental and somatic pathology: the basic allergic-type organization was oriented towards discharge in actions; hypocondriacal preoccupations and various somatic disorders were centre stage (asthmatic-type attacks since infancy; a seborrhoeic dermatitis around breasts, face and hair; tachycardia; various gynaecological infections). Helena belonged to the category of patients whose polymorphous symptomatology coexisted with unstable differentiations of the inner / outer, as well as of the intrapsychic boundaries.
Defence mechanisms such as splitting, idealization, omnipotent phantasies were present from the beginning of our work and underlay Helena’s difficulties in thinking and in relating.  The fragility of the ego and the narcissistic deficiencies were evident, as was the anxiety which I have called delimitation anxiety (Potamianou 1992).  Reality testing held out as long as reality was not too frustrating, and, in spite of her difficulties, on the level of external activities the patient could cope reasonably well with the demands of everyday life.
When we started working together, three times a week face to face, the difficulties in thinking were evident. Helena often felt a loss of control, and plunged into castration enactments, while her unconscious ego maintained a striving for omnipotence. Concerning her objects, Helena oscillated between the “others” functioning as “doubles” or as anaclitic objects, and the “others” as objects to be annihilated, if recognized in their differences.
Each member of our group – all of whom were representatives of the Mediterranean Societies interested in working together – made extensive comments concerning the dynamics of the case, the therapeutic setting and the strategy of interpretations. E-mail exchanges preceded the Prague meeting and, of course, during it discussion continued.
After the meeting in Prague, we decided to go on working together, but with a different model, as we felt that the clinical work should be followed by a theoretical endeavour. It was decided that one of us would work on a paper tackling some questions raised by the case.   Another member decided to present a paper on applied psychoanalysis, attempting a cultural approach on our working together. The other members preferred to present their ideas in vivo in Sorrento. So, no prior meetings were scheduled.  As to the future, we cannot say. We will see what is decided by the group after Sorrento.
Coming now to the theoretical paper, the theme “Resistances and Transformations” was chosen because of a specific phase in the analytic work with Helena. After four years, things had changed progressively and psychic mobilization was evident.
By the term ‘psychic mobilization’, I refer: (a) to a certain mobility of psychic processes that permits the production of dreams and phantasies which are not fixed on reproducing the same themes, and which do not stick to perceptive stimuli, lacking displacements and condensations, thus preventing the emergence of new forms; (b) to the maintenance of temporal and spatial succession, when contradictory feelings emerge, whilst discriminating inner and outer; (c) to a growing capacity for the mutation of perceptive stimuli into functional representations that entail changes in imagos; and (d) to the possibility of sustaining the oscillations between progredient and regredient movements in thinking.
To sum up, we had modifications in the destiny of quantities, of excesses, of excitations, as well as changes of level in thought processing. So, one could say that transformations were evident in Helena’s case, but they were followed by a situation we all agreed belonged to the category of negative therapeutic reaction, which differs of course from other resistances by specifically connecting amelioration to aggravation of symptoms, and negative effects.
After an event which clearly showed a change in the negative imago Helena entertained concerning me, the patient entered a phase of confusion. She had the feeling that she might break into pieces, scattered in all direction; she was unable to think, she felt empty, had attacks of tachycardia and her eczema flared up.
This problematic naturally raised a question: Is there anything more to say about the negative therapeutic reaction as a clinical entity than what has already been said by well-known analysts like M. Klein, J. Sandler, A. Limentani, J.-B. Pontalis, D. Widlöcher, A. Green, R. Roussillon and many others, whose ideas are undoubtedly familiar to all?
The answer was not altogether negative. So, I undertook the task.

On reacting negatively to therapy
Resistances in analysis, as is known, are attempts to stop or to slow down the analytic process. The situation is one of impeding psychic mobility and circulation between structures in the psychic apparatus, thus preventing, or slowing down, psychic transformative processes.
The psychoanalytic process is considered as an experience of transformations on the lines of progredient or regredient movements. Freud understood these movements as imposed on the psychic apparatus by the “ananke” channelled by the drives, as well as by the demands of external reality.
From the very first moments of the analyst/patient encounter, an apparently progredient movement, in the form of representations having to do with the “hope for change”, is expressed by analysands with varying degrees of explicitness. Yet, this desire does not constitute the grounds of a stable alliance between the two members of the analytic couple, because ideas of change mobilize in the patient images that attract, but also images that can terrorize him. During the course of analysis, the representations which are related to change activate alternating and complementary responses between a quest for transformations and a quest for repetitions that inevitably link psychic reformulations to resistances towards change. The various fixations to infantile solutions and compromises, play their role in this situation.
In cases where any accomplishment by the patient seems to be hindered, Freud and most authors point to the action of a superego that is restricting, forbidding, and opposed to success; loaded with conscious or unconscious guilt, it is hostile to movements of autonomy in the ego. The cruelty of the superego reflects the infantile agressivity, the fear of retaliation, and, in the case of negative therapeutic reaction, the enactment of castration anxiety. Part of the agressivity, directed against the objects, is turned against the self and is augmented by the destructive trends which the ego has not evacuated.
A Beetschen (2003, pp. 153, 176) is right when he says that each new psychic action is sustained by murderous wishes, which induce guilt and ideas of debts to be paid, encouraging dependency and fear of the new. But I think that in dealing with patients with narcissistic disorders other factors should also be taken into consideration.  In writing about the economy of borderline constellations, (1992) I stressed the point that the “new” is registered by these patients as something totally alien. By introducing rifts in the familiar, it transforms things and situations into the strange and unknown, and shakes the subject’s narcissistic omnipotent economy. The feeling of “unfamiliarity” is due to the interposition of the “unexpected” between the patient and the objects of his environment, which at such times can no longer be kept fixed and immovable.

Rifts in the “well known” cause secretions of panic and, depending on the individual, trigger defences whose aim is mental immobilization, or manic-type expressions or confusional states. The ego suddenly gets invaded by disorganizing anxieties.
But, even in less disturbed patients, in whom a neurotic superstructure covers up ego fragilities, we know how denial of mourning, of loss, and traumatic fixations are frequently not easily transformed. It is as if we are concerned here with something which refuses to give up.
For many patients change and transformation means giving up parts of themselves fixed on traumatic experiences, or sustained by omnipotent phantasies. For them, acknowledgement of the split parts of their ego means giving up or losing something valuable, because it escapes from their omnipotent control. Transformations and changes are literally catastrophic; they are not gains in terms of ego cohesiveness and continuity.
The configuration that analysts call a “negative reaction to therapy” constitutes an especially hard nucleus of combined resistances, stemming from various levels of the psychic apparatus i.e. from the ego, the superego and the id.
As I hope to show, this resistance presents itself in a variety of forms according to the dynamics and the economy of the psychic processing of each patient. My thesis therefore is that nowadays, we cannot conceive of the negative therapeutic reaction as just one clinical entity. We have to differentiate its forms and dynamics according to the ego organization of each patient.
When Freud (1923) used the negative therapeutic reaction as one psychic indicator – together with masochism and the compulsion to repeat – in order to support his thesis of the destructive drive, his main emphasis was on the strength of this resistance. Yet although his writings after 1920 had the stamp of pessimism, he also never denied the possibility of reversing the negative process. In fact he often referred to the potential for transformation of the drives that motivate our psychic movements.
My thesis is that though all patients presenting a negative therapeutic reaction make use of the mechanism of reversal of progress into its opposite, and although all negative therapeutic reactions are regressive entanglements tending to cancel therapeutic effects, we have to differentiate, as already said, types of negative therapeutic reaction according to ego organization and defences, also taking into account the relationship between analyst and analysand.

1.    What Freud, and other analysts after him, have described as negative therapeutic reaction had primarily to do with psychic constellations in which the resexualized relations between ego and superego introduce a masochistic ego-compliance to punishment. The masochistic trends take over the unconscious guilt, which ends by being channelled and diluted into an enjoyment of punishment and pain. When masochism prevails, the question is no longer simply a matter of paying off debts. Ego offerings (Potamianou 1995) are multiplied, so that the sadomasochistic game can continue.
2.    Another type became evident when analysts became sensitive to situations in which negative therapeutic reactions are not related to a need for punishment, but rather to renunciation of desires and to evacuation of pleasure in order to fulfil an ideal of purity or an ideal of sacrifice (A. Green 1983). In these cases, success and satisfaction have no place, as renunciation becomes an ideal and “enduring” is twinned with suffering. Pain becomes a guarantee of the reality of the quest.
3.    In another category of patients, the alliance between masochism and narcissism produces the feeling in the patient that he is the most ill-fated and most miserable of beings. Under the avalanche of complaints one can see in these patients how their objects, seen as torturers, promote the ideal of “being the one elected” for the greatest misfortunes. We are certainly not dealing here with unconscious guilt which concerns sexuality and forbidden erotic and aggressive wishes. We are perhaps closer to the very primitive guilt described by R. Roussillon (1999), which is related to early traumatic experiences.
4.    In 1988 I described still another form of negative therapeutic reaction, in which one can see that the negativating process leads to severe decathexes, affecting the objects and the ego itself, sidelining thinking, and leading to confusional experiences. The depressive symptomatology is cold. There is no suffering, no accusations, but a kind of anorexia of “being” and “having”, apathy, and even aversion for the external world.
The decathecting movements – which A. Green long ago and recently too (Green 2002) relates to the autodestructive drive and to the work of negative (Green 1993) – are accompanied, or followed, by somatic disturbances, which show that the masochistic dimension has kept little, or nothing at all, of its potential to nourish sexual co-excitation. Here, drive diffusion neutralizes the bipolarity of pleasure/unpleasure, leaving the body exposed to attacks of unqualified energy charges. Psychic retreat, indifference, as well as the somatizations signal the failure of the masochistic component, even if, momentarily, some secondary gains are drawn from medical care or hospitalization. Object decathexes envelope the analyst too, who becomes an object to be ejected.
As a patient said after emerging from such a phase in his analysis, “Nothing was of interest to me. What I wanted was silence in myself.”
The adventures of the ill soma may, more and more, take centre stage and in that case it is hoped that somatic fixations will block the road to further disorganization. Illness can in fact constitute a stopping point from which a reorganization process can start. But I want to underline that in these cases the negative therapeutic reaction does not derive its strength from the ego’s demand for punishment by the superego; nor is it solely dependent on narcissism alloyed with masochism. Here, the hard core of the assembled resistances stemming from id, ego and superego is ultimately unable to keep the situation within the psychic realm. The degradation of masochism tends to reduce erotic excitations to zero, leaving open the field of somatic affects.
The case presented in Prague belongs to this category
Of course, it is not always easy to distinguish between the deeply buried pleasure of the grandiose triumph in destroying the image of the envied object within, from the self-destructive movements in which masochistic degradation tends to silence the libidinal element. However, this last situation is the one in which the libido is disqualified and inactivated to a greater or lesser extent.

Finally, I will add some observations from my clinic regarding patients who seek therapy after a somatic illness has declared itself. Of course, the somatic factors impose parameters that hold the therapy in a specific setting, very far from that of a classical analysis. But I want to stress the point that during the psychotherapy of such patients, when illness and pain are no longer denied, when the soma becomes a body acknowledged by the patient through representations that circulate more freely, and when the somatic symptomatology has receded, manifestations of negative therapeutic reaction can set in that induce a sudden aggravation of the situation. For me, this situation must be understood in terms of two phases (Potamianou 2001, pp. 66-68). During the first one, due to the therapeutic relationship, a re-erotization of the situation reactivates the masochism that colours the relation to the analyst, as well as the relation with the medical staff. The situation opens up the desire to capture and totally control the objects. If the ego finds such motions unbearable, the problem is solved by ego restriction and followed by decathecting motions. Thus, a second phase starts, in which the intrication of drives does not hold, and gives way to motions that neutralize the libidinal energy and silence psychic excitations. Somatic symptomatology again holds sway.

I think it will now be clear why I believe we have to differentiate between the dynamics at work in the different negative therapeutic reaction constellations.
Another point to consider is the following:
Up to his last text, the Outline, Freud qualified the negative therapeutic reaction as a struggle by the patient against the analyst and against analysis. So, one could say that an object-relation conflict is implicated here. In fact, I believe the situation to be a most complex one.
Winnicott said that the analyst is actually made to fail in his work with the patient just as the environment had failed the patient in the past. But by actively inducing the analyst’s failure, the patient puts him in the position of a powerless and incapacitated child, whilst at the same time on a conscious level he himself feels equally devoid of capacity.
Unconsciously, the patient is holding the external object in a capturing grip, as evidence that the object has not been annihilated; but the situation is clearly a witness to the blocking of interiorization and of identificatory processes. C. Chabert (2002) describes the refusal to be loved as the rejection of a position of passivity and receptivity. I would think that if guilt and the superego are re-sexualized – as they are in the masochistic erotization of the relationship, where the ego seeks punishment by the superego and not by the object – we have to adhere to the idea that the energy that flows into the masochistic configurations is an energy that has, at least partly, disengaged itself from the give-and-take with object representations. The liberated libidinal component nourishes the masochistic schemata that operate between psychic structures, while the enraged attachment to the external object tries to cover, in an envelope of suffering, the process of object disengagement and the free flow of auto-destructiveness, as R. Roussillon said (1999, p. 165).
I will add that whenever the negative reaction is accompanied by thought disturbances and episodes of confusion, and when repetition compulsion manifests itself as a truly “demonic force”, as is the case in the fourth type of negative therapeutic reaction described, we have to go even further.
It is obvious that in this situation, we are dealing with patients in whom the limits between inner and outer reality are not stable. Their narcissistic grip on an impassioned hate for the object cannot be given up, since to do so would mean the ego having to let itself go along with the object. In such cases hate/love and suffering sustain the ego. This implies that the loosening of the negative therapeutic reaction configuration may open the way to even more important drive defusion and to psychic energy being disqualified. At such moments the masochistic component is no more part of the game. Repetition compulsion remains strange to the pleasure principle, retaining only the character of a brutal discharge.
These are times during which the analyst has to respect the patient’s resistance, otherwise a breakdown (Winnicott 1974) is apt to occur and the patient will really pull to pieces all that has been accomplished. Gribinski (2002), in referring to the risk of psychic collapse, describes it as a point where the patient “encounters his own psychic death”.
A final issue on the problematic of the negative therapeutic reaction concerns the analyst. Some countertransference manifestations that emerge in coalescence with the patient’s transference, and converge with the latter’s unconscious desires, may contribute to the perpetuation of the treatment (Potamianou 2001).
One should not forget that negative therapeutic reaction constellations absorb affects and emotions, not as conducive to repression but as forces promoting enactments. Actions have a perceptive presence in the psychic apparatus, but cannot acquire the status of representations nor become integrated in the patient’s history. The same holds for the analyst, whenever his unconscious desires converge with those of the patient, without his realizing it.

 

Countertransference actions, here, are responding to the actions of the analysand. The analyst cannot differentiate himself from movements of primary identification with his patient. If he does not realize what is at stake, he is caught in a situation that secretes panic in him and feelings of helplessness. One can say that the negative countertransference of the analyst encounters the negative transference of the patient and introduces confusion.
At such moments psychic immobilization also threatens the analyst, who is unable to go on associating; even worse, he sometimes loses his figurative and phantasying capacities.
At other times, the closeness and the adhesive tendency of the patient cannot be tolerated by the analyst because they echo his own needs. Sadness and discouragement follow the compulsive repetitions. One can hypothesize that what is activated are doubts and aggressivity relating to remnants of the analyst’s transference towards his own analyst. The situation leads to counter-actions by the analyst enrobed in omnipotence: “You don’t want to let go, I will hold you captive” or ” You want to destroy me… I will keep you here… to death”. The full positive and negative implications of the analyst’s masochism may, thus, emerge in a mirroring relationship to his patient that leaves practically no area free for transformative inscriptions. In such exchanges, the negative therapeutic reaction celebrates a “capturing” and deadly embrace. Analysis itself becomes a compulsion.
How does one break the vicious circle?
In such difficult situations for the analyst, I think the only possible answer is for him to come back to questioning what is happening to him. Such questioning goes far beyond what Faimberg (1966) has described as “listening to listening”, because the interrogation concerns the general psychic functioning of the analyst, and is based on the awakening of an anxiety that escapes the void of psychic paralysis. It is hoped that the analyst can disentangle himself from the regressive course since he does not walk in the path of regression as his analysands do (Potamianou 2001, p. 148).
As regards the patients, many suggestions have been developed for modifications to the setting and changes in technique during phases of negative therapeutic reaction. I will not go into them again, as they are well known. I will only refer to what I consider to be two main prerequisites for the analytic work to proceed further.
First, the introduction into the situation of the sense of alterity, through oscillations in the analyst’s countertransferential attitudes between the evenly suspended attention and the “watching” function (Potamianou 1992, 1995). From this perspective watching does not have to do with the superego. It refers to the attention given by the analyst to the psychic functioning of his patient, so as to encourage and orient cathexes in areas other than those imposed by the cycles of compulsive repetitions.
Here interpretations and constructions, are retained (Potamianou 1999) until such time as the basic transferential relation described by Parat (1995) provides a sufficiently good narcissistic base for the acceptance and containment of interpretations.
In these situations the analyst has to use optimal seduction (Potamianou 2001) in order to introduce an erotic tonality in what is experienced by the patient as overwhelming his ego. By the term ‘optimal seduction’ I refer to the capacity of the analyst to stimulate excitations about “unknown elements”, without these having a disorganizing effect on the patient, because they emerge in a setting that has become familiar through its repetitive use. Through the solicitation to think and to elaborate, the call of optimal seduction becomes an opening towards expectations of something that has never been experienced before. It favours circulation and exchange between the me/not-me and between psychic structures. Therefore, one can expect that fixations, resistances and defences will soften up.
On fulfilment of these prerequisites, the binding symbolic activity may reverse its failings, thus transforming quantity into quality. Excitations can be channelled into elaborations of binding constellations, which can make an agent of change from the compulsion to repeat the negative.

I will close this presentation by going back to the clinical material.
Helena’s case was not just a case of reversing progress to its opposite. Success and pleasure were followed by a breakdown. The level of mental functioning – which was in any case precarious – changed. A functional opening was succeeded by a drive explosion, which signalled the failure of analysis and the failing of the analyst.

Epilogue
Winnicott pointed out that the analyst may be used for his failings, but in Helena’s case destroying the object became doubly effective as it entailed both the fading of objects’ representations and the loss of her spatial-temporal references and of her ego coherence. The regressive course brought about the degradation of the masochistic component – active in the negative therapeutic reaction – as well as the quality of the libido that cathected the patient’s psychic morphemes.
In my work with Helena the repetition of episodes similar to the one reported made the reference to the negative therapeutic reaction understandable. These episodes lasted for brief periods, after which her psychic functioning became freer again and circulation between structures replaced the confusional episodes.
Such cases test to the limits the analyst’s countertransference. Here, the optimal seduction has to be used in order to induce a well-tempered re-erotization of the situation, through a solicitation addressed to both members of the analystic dyad to persist in thinking and in elaborating.
Concerning Helena’s case the question which persisted in me was the following: were the repetitive negativizing manifestations connected to a “yes”, supposed to express the desire of the therapist for expected changes? Or was it a “no” addressed to that part of the patient’s self that started to function in identification with me?
I tended to adopt the second point of view, as the manifestations of the negative therapeutic reaction emerged whenever there was evidence of drive-urges, transformations or changes in object relationships, imagos, anxieties etc. The link with me had to be destroyed as it entailed reactions on different levels:

(a)    The-non neurotic organization of Helena was subject to anxieties of intrusion and the occupation of her psychic ground, which was not firmly delimited because of the narcissistic character of her object relations. To throw me out resulted in losing her ego coherence and continuity.
(b)    The catastrophic exclusion of the benefits of the therapy was not devoid of the idea that the infinite of the therapeutic situation would result in us remaining together for a long time in the attachment of a love-hate bond.
(c)    On another level the therapeutic processing, which introduced psychic mobilization, was experienced by the patient as a loss of control, endangering the psychic economy she maintained. The fragility of her psychic defensive system and the defects in the linking capacities of her preconscious during moments of tension, were indicated by the frequent somatizations that punctuated the life of Helena. Such moments of tension and fear corresponded to the mobilization provoked by our working together. The analytic “productions” reactivated the fantasy of a primal scene in which she was a participating agent. The scene secreted unbearable excitations. To stop the processing was, then, a necessity.
The negative therapeutic reaction constellation indicated the explosive character of our working together, as Helena experienced it, and the risk of its internalization. It also showed her attempts to immobilize it, thus proving how incompetent and unable I was to help her.
And here one meets, of course, the question of the analyst’s capacity to endure the storm of such a relationship. I often asked myself if I really wanted us to go on; or if I too wanted to stop the procedure both because of the fear that some traumatic nucleus might irradiate, enthralled by the excitations provided by the situation, or because of fantasies having to do with the scenarios of castration that secreted constant excitations.
L. Urtubey, at a Conference at the Paris Society in 2002, spoke of the link between negative transference in the negative therapeutic reaction and negative countertransference, when the analyst ignorant of his affects continues with pseudo analytic work.  D. Quinodoz ( 2000) referred to the loss of interest and the apathy of the analyst. I will add the decathexis of the analytic function, which protects the analyst, and operates in synergy with the negative transference of the patient.
At such moments, the hatred of alterity in both members of the dyad is combined with feelings of an annihilating incapacity. What is annihilated is the creativity of the psychic apparatus in representing and in giving a meaning to the “unknown” and to the “unexpected”.

Anna Potamianou
Hellenic Psychoanalytical Society
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