Thick-Skinned Narcissists

There are other cases, however, where even careful, consistent interpretation of the defensive function of the grandiose self does not lead to a gradual shift into its internalized ideal self and ideal object components. Instead, severe splitting between periods of unremitting grandiosity and brief, dissociated, devastating experiences of self-devaluation, depression, and suicidal tendency requires very long term interpretive dismantling of a sadistically infiltrated grandiose self. The “thick-skinned” narcissistic personalities described by Rosenfeld (1987) belong to this group of patients.

These are patients who generally function quite well in their social and work life, but who are so bereft of an internal world of object relationships that they seem to be completely closed to the possibility of fantasy and daydreaming. They live in the concrete reality of their interactions with the analyst, which do not lead to any development of fantasy, desire, fear, or deeper conflict. The patients themselves may state freely that they see no reason why they should develop any particular emotional reaction to a relationship that, after all, follows the principles of a commercial contract in which “one person gets paid to take care of the problems of the other.” A patient assured me that although I seemed like a nice person, if I died suddenly, he would have no particular feeling about it.

The patient’s efforts to carry out free association may be severely distorted by his or her unwavering need to keep the analytic situation under control. Free associations are so well structured and orderly in sequence that they reveal an intentional effort to direct the analyst’s attention in a certain direction, preconsciously planned by the patient. Or the patient’s “checking” on the meaning of what he or she is saying while communicating it to the analyst may provide the patient’s discourse with an empty, intellectualized quality.

I have found it helpful to analyze the defensive function of this way of associating by focusing on the patient’s reactions to the analyst’s interpretive interventions. The patient may simply ignore what the analyst says, resuming his or her monologue after a respectful brief silence, or examine carefully all the implications of the analyst’s comments, speculate on their meaning, express agreement or disagreement, or dismantle the analyst’s statement altogether—anything, really, to avoid being impacted by the analyst in a way that is not totally under the patient’s control in an attempt to avoid a humiliating indication of his or her dependency on, and therefore inferiority to, the analyst. The interpretation of this constellation may allow the patient to become aware of his or her need to control the analytic relationship implied in the style of carrying out free association.

An additional helpful technical approach to these patients may be to analyze in great detail their difficulties outside the transference situation, the details of their difficulties in work, in intimate sexual relations, in their social life, and with their families. It is usually not difficult for patients, by sharply focusing on the areas of daily conflicts in their lives, to gradually open up their understanding of aspects of their interactions that are motivated by emotional pressures and deeper fears or desires, which can then be linked to similar manifestations that in subtle ways emerge in the transference. The “microscopic” analysis of extratransferential relations allows for gradual exploration of the transference itself. For example, behind the indifference toward their partners, one may detect the emergence of envy of the other person’s capacity for love and friendship and the freedom to have an interesting daily world of experiences from which the patient is excluded.

The indifferent patient I referred to above bitterly resented his wife talking animatedly for hours with her friends by phone, comparing it with his own restrictions and limitations in such interesting interchange with acquaintances. Similarly, behind the admiration and sexual excitement involved in their transitory infatuations, one may discover and highlight for the patient resentment of an exciting, teasing, and withholding other, and its repetition of past similar experiences with significant objects of childhood and infancy. The development of negative therapeutic reactions in the sessions, reflecting unconscious wishes to devalue the treatment following moments of envious recognition of the therapist’s capacity to help and be interested in them, offers another entrance into this transference development. Above all, these patients constantly need to compare themselves with others. The fluctuations between triumphant superiority and anxious fear of being devalued are dominant issues in the extratransferential relations to be explored, providing a bridge to the later exploration of similar issues in the transference.

Thin-Skinned Narcissists

Thin-skinned narcissists are more severely regressed and often fail in analytic treatments but respond well to TFP. They present both severe infiltration of the pathological grandiose self with aggression and a structural weakness of the pathological grandiose self, so that shifts from states of arrogance, superiority, and contemptuous feelings about the analyst to severe feelings of inferiority, humiliation, depression, self-accusation, and suicidal tendencies may occur frequently and rapidly. Such shifts, sometimes, are motivated by minor sources of triumph or defeat, and their hypersensitivity to any experienced criticism, real or fantasized. Their clinical presentation evinces severe characterological depression or chronic dysthymic reactions, suicidal tendencies, and marked identity diffusion—despite the pathological grandiose self, reflected in absence of goals, uncertainty, and confusion about their life direction and relations. Ego-syntonic sadistic features are both expressed and projected onto the therapist, who is frequently perceived as a seductive, scheming, and dishonest persecutor. These are patients with rapid changes in transference developments, extreme frustration for not being able to totally control the therapist in terms of his or her thinking or behavior, and angry outbursts of total devaluation of the therapist and wishes to interrupt the treatment. Their contemptuous attitude may take the form of accusing the therapist of not understanding anything, projecting onto the therapist the confusion in their own relationships with significant others, and heightened paranoid tendencies in the transference.

Often these are patients who have been severely traumatized by physical or sexual abuse or gross neglect in their infancy or early childhood. Their unconscious tendency to reactivate these traumatizations in the transference both conveys important information about the past and poses difficulties because of their high potential for acting out. These are the patients for whom John Steiner (1993) recommended to interpret “in the projection,” clarifying their experiences and views of the analyst rather than interpreting what is being projected into the analyst. This corresponds to an extremely effective technical approach of TFP whereby the therapist points out, at every opportunity, the kind of relationship that the patient’s experience is activating in the transference, with attention to how the same relationship tends to get activated, again and again, with role reversals. In the role reversal, the patient experiences himself or herself in the role of the internal object representation, a role that he or she had previously projected onto the therapist while remaining identified with an aspect of his or her self. Now, however, the self-aspect is projected into the object, the patient can experience what he or she had previously projected into the object, and the full nature of what had been projected may become available to the patient’s subjective experience.

For example, a patient thought that the therapist showed a sarcastic and depreciatory behavior toward him. Enraged, he became extremely critical and derogatory toward the therapist, treating the therapist as totally worthless, dishonest, and not understanding. Again, 10 minutes later, the patient had a sense that he was being treated in exactly the same way by the therapist. By highlighting the patient’s grandiose, devaluing experience with a perceived worthless or despicable therapist, without attempting to directly explain this as a projection, but showing that it was a reversal of the patient’s experience of having been attacked by the therapist in similar superior and derogatory ways that preceded it, the role reversals could be interpreted and the interpretation of projective identification thus completed. Feelings of having been attacked motivated the counterattack by the patient, and the counterattack motivated fears that the therapist, in turn, would take revenge in the same way, so that vicious cycles were generated by which the same relationship got enacted, again and again, with such role reversals.

The patient’s contemptuous, derogatory attitude toward the therapist could gradually be interpreted as a protection against the activation of an opposite role relationship. It also became easier to interpret brief periods of idealized relations with the therapist as a combination of actual recognition of something good going on in the relation and an effort, on the patient’s part, to protect himself against the bad and frightening experiences at those other moments of alternating, mutual devaluation. In our experience, a consistent interpretation of the split transferences, with particular consideration of the involvement of an easily fragmented pathological grandiose self, has been very helpful with thin-skinned narcissistic patients. At the same time, whenever what occurs in the transference seems to be a practical repetition of past experiences that the patient has been conscious of at different moments, this lends itself to a complete interpretation of the genetic aspects of the patient’s conflicts that have become an emotional reality rather than a defensive intellectualization of the patient’s remembered or reconstituted past.

Rosenfeld (1987) suggested that thin-skinned narcissistic patients who had experienced severe traumatizations in their past might be retraumatized by the analyst’s interpretations of their aggressive conflicts in the transference. In our experience, the clarification of the dominant transference “in the projection,” without full interpretation of the projective identification at that point, permits completion of the interpretation once the reciprocal activation of self and object representation in the transference has taken place. This TFP-derived technique permits the therapist to carry out a systematic interpretive approach to extremely negative transferences without the patient’s experiencing this interpretation as an attack. Here, I agree with Steiner (2008), who questions Rosenfeld’s excessive caution in interpreting negative transference developments in these patients.

The Syndrome of Arrogance

Bion (1967) has described the syndrome of arrogance in severely regressed patients, consisting of 1) an openly aggressive and extremely arrogant behavior toward the therapist; 2) incapacity for any cognitive reflection, so that the patient appears to be “pseudo stupid”; and 3) an inordinate curiosity about the therapist rather than one’s self. Bion describes the projection of these characteristics into the analyst and proposes as an essential dynamic of this situation: the activation of the frustrated baby’s rage at an impatient mother who would talk to him or her without really understanding the baby and “stupidly” expects the baby to respond as verbally as she addresses the baby. It implies the projective identification of a destructive, sadistic object interfering with the communicative aspects of projective identification. The analyst’s containing this projection of an extremely destructive internal object geared to eliminate all verbal communication would be the key to managing this situation. In our experience, it reflects the chronic enactment in the sessions of primitive hatred and envy, but with the characteristic that the aggression is acted out without the patient’s having any self-reflective awareness of it. The arrogant behavior expresses his or her combative aggressive needs: the need to not demonstrate any capacity for cognitive communication with the therapist, the desperate effort not to have to acquire any awareness of the significance of his own behavior, and the need to control the therapist to avoid the projected and feared aggression to return in the form of counterattacks from the therapist.

Intolerance of Triangulation

An extreme form of omnipotent control may evolve as part of the intolerance of triangulation (Britton 2004) in very regressed narcissistic patients. Intolerance of triangulation refers to a particularly severe distortion of internalized object relations, a regression within which the patient cannot tolerate any thoughts that are different from his or her own. The role of the therapist is to confirm the view of the patient and to assure the patient of the reality and stability of that shared experience. Any contribution from the therapist that is at variance with the patient’s thinking is destabilizing to the patient’s grandiose self and carries malignant implications. At bottom, it is the search for a perfect symbiotic relationship within a dyad that does not tolerate the disruption by a third, excluded object and represents the fragile omnipotence of a pathological grandiose self that attempts to maintain absolute control over experienced reality. Here, archaic oedipal conflicts (i.e., the intolerance of the relation between the parental couple from which the infant feels excluded) surface in the transference as the envious resentment of the therapist’s relation to an internal object of his or her own (his or her independent thinking, theory, or reflection about what is going on in the relation with the patient), making different perspectives intolerable to the patient.

Efforts by the therapist to bring in views different from that of the patient are experienced either as a total abandonment and rejection or as a sadistic intrusion, an aggressive effort to control the patient’s mind. This situation, originally described by Britton (2004), may even be observed in patients functioning at a relatively high level within the spectrum of narcissistic pathology, in which it is revealed in very subtle ways of rejection of the therapist’s independent thinking by highly sophisticated maneuvers that reassert the patient’s initial views and force the therapist into a temporary emotional retreat. But this condition emerges as well with extremely regressed narcissistic patients functioning on an overt borderline level, in which the patient’s experience of reality has such an extremely distorted quality that it is close to psychotic.

In this latter case, the patient may be totally convinced of the realistic nature of an emotional experience, within which the patient’s behavior may have been extremely inappropriate and practically psychotic in the context of its social surround. Here, any effort of the therapist to probe reality testing may be experienced as an attack, bringing about a rageful effort by the patient to shake off the intrusion.

One patient maintained an almost delusional conviction that a man, who was obviously exploiting her and showed his indifference at every turn, was in love with her. In turn, she treated the therapist who was trying to confront her with her illusions as if he had a totally unrealistic view of reality. This woman functioned remarkably well in other areas of her life. Another patient with severely overt borderline functioning created such a disruption at a family funeral that family members escorted him away from the grave. In the subsequent sessions, he raged against his family’s callous indifference to his intense suffering and would become incensed by any effort by the therapist to tactfully question whether, under the circumstances, the expression of his mourning had acquired characteristics that were, in fact, quite problematic and socially inappropriate.

A technical approach that has been helpful with these conditions is enormous patience and consistency in pointing out to the patient the fact that any view that is different from his or her own creates an intense pain, as if the patient’s thinking or very capacity to deal with reality were questioned, so that the patient has to protect himself or herself against such a dangerous assault. To the patient, it seems to be a case of the therapist trying to drive the patient mad. The analyst needs to spell out gradually the nature of the danger that is creating panic in the patient: the fear of a total disqualification of his or her capacity to think, of total abandonment and loneliness, and of the patient’s own intense enraged reaction to this dangerous situation, along with his or her fantasies of the sadistic intention of an imaginary outsider—who seems to be committed to destroying the safety of the patient’s earlier experience—and the therapist’s collusion with such an enemy. By its absence, in these cases the situation described points to the importance of the existence of a “three-person psychology,” which constitutes the basis of a therapeutic relationship, and the resolution of this severe regression marks an important improvement for these patients.

The concept of the three-person psychology refers to the consideration of the therapeutic relationship as determined by, at a minimum, the transference, the countertransference, and the analyst/therapist’s position as an “excluded third party”—that is, that part of the analyst’s personality able to explore the transference/countertransference relationship without being immersed in it (Kernberg 2012). It is a reflection of an internal split in the analyst’s ego in relating to the patient that gets “obliterated” again and again in countertransference enactments and in the developments of projective counter-identifications (Grinberg 1979). At a deeper, symbolic level, the three-person psychology refers to the oedipal structuralization of the analytic relationship and the potential for intolerance of the oedipal situation in regressive, symbiotic transferences. At this symbolic level, the patient becomes the excluded third party, the infant excluded from the relationship of the parental couple. This is the case of the patients described by Britton (2004).

Severe Narcissistic Suicidality

It usually is not difficult to differentiate the chronic suicidal and parasuicidal behavior of patients with severe personality disorders without dominant narcissistic features from that of narcissistic personalities functioning on an overt borderline level. Nondepressive suicidal behavior of patients with borderline personality disorders usually is impulsive, an equivalent or symptom of an acute affect storm, related to a frustrating, enraging, or traumatizing experience, or an effort to influence or control a close family relative or love/hate object. Conversely, chronic suicidal or parasuicidal behavior of patients with narcissistic personality disorders evolves slowly and in a determined way over a period of weeks or months and is prepared and carried out in what impresses an observer as a cool and deliberate plot, quite often in the context of surface behavior that is seemingly friendly and relaxed. Patients with this extreme degree of severity of narcissistic pathology differ from the constellation in whom suicidal behavior is part of severely disturbed, aggressive, and shifting moods with strong depressive features. Here, in contrast, suicidal and parasuicidal behavior—even severe self-mutilation—punctuate a generally stable, seemingly normal behavior.

From a psychodynamic and transferential perspective, this behavior reflects a deep and consistent aggressive devaluation of the external world, a radical devaluation of significant others and the self, a “negative narcissism,” in Green’s (1993b) terms, with a patient’s profound sense of superiority derived from overcoming all feelings of fear of pain and death, all feelings of needs involving others, and a sense of omnipotence by controlling one’s own death as a final, absolute power and freedom. This general transference disposition takes many different forms. The therapist’s capacity, within his or her countertransference reaction, to empathize with this terrible psychological reality of the patient, with that part of the patient identified with a self-murderous grandiose self, may become a crucial aspect of transference interpretation. The therapist is a natural enemy of that internal object, and a major question arises as to whether the therapist has any ally in the patient’s mind: Is there some way to contact the patient’s oppressed, tenuous wish to survive? Highlighting this potential internal conflict in the patient’s mind as it becomes activated in the transference, a true struggle between the death drive and the wish to live, is a major therapeutic task in these cases.

For example, one of our patients chronically ingested rat poison to try to kill herself. Despite careful searches, carried out during her hospitalization at our service, it was not possible to find the source for obtaining the poisonous substance. The patient denied her continuous ingestion of the poison, while the serum prothrombin gradually increased over days. She had a history of severe internal hemorrhages that required extensive diagnostic and therapeutic interventions, and, in the middle of all this, she maintained an apparently calm and almost cheerful attitude that belied the extreme gravity of her condition.

Another patient carried out severe self-mutilations, cutting tendons, which led to the loss of fingers, and attempted to set herself on fire, creating a near catastrophe that threatened the life of numerous people living in her apartment building. Sometimes her self-destructive attempts were serious parasuicidal behaviors, such as profound self-cutting that occurred in the middle of what seemed perfectly relaxed and adaptive behavior by the patient. Still another patient went out with her sister to go shopping, spent what appeared to be a very pleasant afternoon with her, and, after getting back home, retired to her bedroom. Her sister approached her to share with her some of the objects they had bought and found her sister with multiple cuts on both arms, bleeding heavily, and requiring major interventions at an emergency service.

There are patients who deny their suicidal intentions and preparations and convey a sense of triumph in their capacity to shock the unsuspecting therapist with their behavior. Other patients may talk freely about their suicidality, while implying that it is beyond their control and that for the time being they are not in touch with that part of themselves that wishes them to be dead. The implicit attack on family and on the therapist in such behaviors often remains unconscious, but at times is accompanied by a sense of sadistic satisfaction and triumph. At the same time, patients may unconsciously bring about situations in which their suicidal behavior would seem to reflect some neglect or insufficient alertness on the part of the therapist, and families may become enraged at what they perceive as the therapist’s failure to contain or prevent the patient’s behavior. Some patients triumphantly point out that their behavior is not only not under their own control but not under the therapist’s either and thus reflects the therapist’s impotence and incompetence. We have all seen cases in which family members unwittingly collude with the patient to blame the therapist and then move on to find another. The patient, in the role of a “serial killer” of therapists, thus experiences an unconscious sense of triumph at having “killed off” another therapist.

The combination of severe self-destructive tendencies and antisocial tendencies may be expressed in provocative and litigious behavior, blaming the therapist for not having been attentive to the risk of a severe suicidal attempt by the patient, indirectly exerting an omnipotent control over the therapist by means of induction of paranoid fears and guilt feelings. Here, the aggressively infiltrated pathological grandiose self provides the patient with an illusionary power, not only over the therapist, but over life and death over pain and suffering, and opens an escape into a “liberating” death from a world that cannot be controlled.

In a randomized controlled trial comparing TFP, dialectical behavior therapy (DBT), and supportive psychotherapy based on psychoanalytic principles (SP), we found that TFP was as effective as DBT in reducing suicidal and parasuicidal behavior, in contrast to SP, which was less effective. Only TFP increased mentalization (Kernberg et al. 2008).

I believe that it is important that the therapist accept honestly, in his or relationship with the patient and the patient’s family, and in the elaboration of his or her countertransference, the possibility that the patient may commit suicide and that the treatment may not be able to prevent it. The therapist may have to acknowledge openly, in diagnostic sessions with the patient and the family, that outpatient psychotherapeutic treatment carries a serious and unavoidable risk of suicide, given the patient’s severe condition, and yet may be still preferable to the long-term, indefinite duration of hospitalization. The fact that here suicide is neither predictable by the presence of severe depression nor preventable because of its deep characterological basis may have to be made explicit verbally and, at times, in documentation that protects the therapist legally. At the same time, the patient’s knowledge that he or she will not be able to blackmail the therapist with suicidal threats may reduce the secondary gain of this symptom and limit the patient’s sense of omnipotence. The therapist needs to be assured of his or her own physical, psychological, and legal safety to be able to be dedicated to helping these extremely difficult patients.

In all these cases, one must interpret openly and calmly that the patient, while willing to undergo a psychotherapeutic treatment that he or she hopes to bring about improvement of his or her condition, is nonetheless under the sway of powerful and destructive internal forces. An acknowledgment of objective concern (the excluded third) for the patient’s self-destructiveness conveys the possibility of discussing destructive impulses openly to assure the patient that one respects the severity of his or her condition and the power of this part of him or her. The need to protectively dissociate the destructive part of himself or herself from the apparently “cheerful” participation at other moments in the treatment can be clarified and resolved, and the patient’s open acknowledgment of his or her dominant self-destructive motivation becomes the main issue to be explored in the sessions.

An important related technical requirement is the exploration of the patient’s apparent absence of concern over this terrible control that the part of him or her wishing to die has over whatever part wishes to remain alive and the reasons for the devaluation and implicit hatred of that part that wishes to be alive. Here, the gradual discovery of the dangers of remaining alive, the terrible suffering related to the implied loss of control and superiority that is implied in identification with death, having to experience oneself alone and abandoned, having to face envy toward people not condemned to such self-induced destruction—all may emerge in the context of more specific aspects of the patient’s infantile and childhood history. Sometimes, the patient unconsciously hopes for an omnipotent good object that will rescue him or her from that desperate state and projects his or her own omnipotence to an illusional godlike rescuer. This fantasy, in turn, needs to be explored for its potentially self-destructive implications.

The “Dead Mother” Syndrome

A related group of patients, who on the surface seem much less severely ill but at a deeper level evince a relentless determination to destroy all relationships, the efforts of the therapist, and even their own sense of being alive, is reflected in the syndrome of the “dead mother” described by André Green (1993a, 1993b). Under these conditions, there is a rejection of any significant relationship out of identification with an internalized imago of a dead mother, frequently derived from the early experiences with a severely depressed, unavailable mother. The patient unconsciously attempts to maintain the relationship with this absent, nonresponsive mother, unconsciously enacting the fantasy that in his or her own emotional death and loss of self, he or she will be reunited with an idealized mother and protected from any further suffering. To give up one’s own existence as an autonomous self, one’s own need to depend on anybody else, to devalue completely all representations of significant others would, in the fantasy of these patients, provide definite restfulness, security, and equanimity. These are patients who may, on the surface, attentively listen to the therapist’s interpretations and then react, saying, “All this is very interesting, but doesn’t touch me at all.” Their attitude of “So what?” in response to interpretations is persistent and unmovable. By the unconscious dismantling of all relationships, what Green (1993b) calls “de-objectalization,” they obtain the same effect as patients whose repeated severe attempts at self-destruction reflects their dominant motivation in life.

De-objectalization refers to an extreme manifestation of the death drive, whereby an attack is leveled against the very structures of the mind that sustain introjective processes and permit the establishment of representation of self and object within an internal space. As an ultimate defense against intolerable dominance of aggression over libidinal investments, the patient’s very capability to experience an internal world is attacked: the sense of time is frozen, the aggressive and libidinal investments of object and self are dismantled, and a total void occupies the mind (Green 1993b, 2010). This self-destructiveness, in Green’s view, goes far beyond masochism. In our experience, these patients are remarkably free of conscious awareness of both aggressive and libidinal impulses. Often effective in their work and superficial social relationships, they are basically loners and convey a sense of total isolation and lack of interest to live. They are not depressed, and the initial depressive countertransference reaction they evoke in the analyst shifts, over time, into a sense of exhaustion and emptiness. If it becomes possible during lengthy treatment to unmask their unconscious efforts to deaden the relation with the analyst as a defense against severe frustrations in their need for love and dependency, and to explore the aggressive resentment of the analyst’s alleged indifference, self-centeredness, and unconcerned enjoyment of his or her own life, there may be hope. Under the most favorable circumstances, intense primitive hatred and envy may become reactivated and a “revival” of internalized object relations possible.

Severe Sadomasochistic Transferences

Another group of patients, who are somewhat less severe in the manifestations of their self-destructiveness, unconsciously attempt to transform all relationships into hostile interactions, or severely sadomasochistic involvements. It is as if the only way in which they can trust that someone cares about them is to provoke an attack from that person. Within the frame of a psychotherapeutic treatment, this need to provoke attachment through hostility may lead to disastrous stalemates and breakdowns. These patients, at least, still attempt to maintain some sort of relationship with the therapist, in contrast to patients with the “dead mother” syndrome (discussed below), in which the destruction of all relationships seems to be the overriding goal. Here, the therapist’s interpretive clarification of this consistent attempt to provoke the therapist to attack the patient may open the possibility of modifying this pattern. These cases, in fact, represent the most severe form of negative therapeutic reaction.

Regarding these most severe cases described, we have found that technical requirements include, first, the establishment of realistic conditions under which the treatment can be carried out. The structure of the treatment, as determined through contract setting, must create conditions in which the therapist is protected physically, psychologically, socially, and legally. The involvement of the family in the process of setting up the conditions for the treatment is essential. During the treatment itself, it may be necessary to maintain ongoing family contacts to maintain and reinforce the treatment frame and realistic expectations. In a litigious culture such as the United States, it is particularly important that the therapist be solidly protected from any risk of being involved in threatening lawsuits related to a patient’s attempted or completed suicide. If the safety of the therapist cannot be established and maintained, the treatment is not possible.

Amid all these struggles, the patient’s attempt to destroy the therapist, spoil his or her reputation, expose his or her impotence, and blacken his or her image to his or her family members needs to be explored as an expression of that part of the patient that, at bottom, is attempting to destroy himself or herself. The exposure of a sadistic, murderous internal object and the patient’s fascination with, submission to, and identification with that object, and the savage suppression of his infantile self and aspirations for love, are frightening aspects of the transference. They also may emerge as very disturbing aspects of countertransference developments. This, again, requires a combination of objective security of the therapist and “space” for working through one’s countertransference reactions. The therapist’s survival despite a patient’s consistent unconscious efforts to transform him or her into a sadistic and devalued object and the tolerance of the feelings of frustration, delusion, envy, triumph, and loneliness dominant in the intersubjective field, are the heavy price for carrying out these treatments, as well as the material on the basis of which understanding may be gained, and both success and failure evolve.