Erotic Transference and Countertransference in Patients With Severe Personality Disorders


CHAPTER 13




Erotic Transference and Countertransference in Patients With Severe Personality Disorders


Part II: Therapeutic Developments


 


 


 


 


Transference and Countertransference Developments With Borderline Patients


As mentioned in Chapter 12, the transference developments regarding the sexual life of borderline patients are characterized by dynamics that center on a condensation of oedipal and preoedipal issues, with prominence of preoedipal aggression. There is more frequent and sometimes dramatic acting out, so that the general technique of structuralization of the treatment to protect the treatment, the patient, and the therapist from dangerous destructiveness becomes relevant here. The dominant transference reveals the immaturity or severely damaged nature of internalized object relations, reflected in the incapacity of these patients to achieve a satisfactory love relationship. Their relationships are notable for split expressions of love and aggression leading to volatility, conflict, and chaos, with a poor object choice and an unrealistic evaluation of the partner. Given the patient’s difficulty in assessing realistically the commitment of a partner to him or her, the patient may choose a partner with limited capacity, and so there are many reasons that patients like these are prone to enter into unsatisfactory relationships. At the same time, an apparent sexual freedom and enjoyment of the sexual relation with the partner, a greater erotic freedom as compared with what evolves in neurotic structures, is actually a favorable prognostic indicator. The most extremely ill borderline patients may evince a primary inhibition of all aspects of sexuality, all capacity for erotic engagement, with an incapacity to enjoy skin eroticism, incapacity to masturbate, absence of sexual arousal, and incapacity for sexual excitement and orgasm. These are patients with more severely negative prognosis, and they present special complications in the treatment situations. Extreme sexual inhibition to the extent of absence of all sexuality is not secondary to repression, as is the case with neurotic structures, but derives from lack of stimulation of the primary erotic affect system. Erotic affect activation tends to be drowned by the predominance of severely negative, aggressively determined interactions with primary objects. In contrast, patients with a chaotic sexual life and sexual promiscuity, who do enjoy sexual enjoyment and do evince a general erotic capability, have a much better prognosis for treatment.


A frequent presentation of borderline patients is a condensation of erotic wishes and fears and conflicts around primitive dependency, typically shown in erotic behavior geared to gratifying dependent needs in the context of deep feelings of distrust or even despair of the possibility that anybody may be interested in them except in the context of sexual desire and excitement. Here, apparent sexual freedom may be a desperate measure to maintain a love relationship otherwise threatened by the intense splitting of idealized moments and periods of aggressive explosions. Even in cases in which this is not the primary motivation for a surge of sexual intimacy, love relations with their erotic component may be expressed with such demands for continuous, absolute dedication to the patient that a hostile intention of taking control and possession of the sexual partner becomes destructive and drives the partner away, leaving the patient feeling rejected, abandoned, and confused.



Sexual promiscuity of borderline patients, particularly those with infantile or histrionic personality structures, must be differentiated from narcissistic promiscuity. This becomes quite evident in the incapacity of any intense loving engagement on the part of narcissistic personalities, as their grandiose needs lead to transitory infatuations followed by rapid devaluation of their love objects. Patients with infantile or borderline personality have a much greater capacity for lasting, if also conflictual, engagements.


Borderline patients may present some degree of superego deterioration, such as irresponsibility or lack of concern for self and partner, but still show the capacity for guilt feelings in the context of their awareness of this aggressive acting out and mistreatment of their partner.


Sexually traumatized patients who begin treatment with a phobic reaction to the possibility of exploring past traumatic experiences out of a fear of sexual retraumatization present a particular challenge. These patients may aggressively refuse to talk about past traumatizations, develop defensive affect storms in the context of paranoid reactions to the therapist, and implicitly reproduce a situation of sexual traumatization in the transference. It is important to differentiate these cases from cases of posttraumatic stress disorders in which there has been a relatively recent severe sexual traumatization (a few months to 3 years before the initial evaluation) but no indication of major personality disorder. In patients with posttraumatic stress disorder without the complication of personality disorder, the treatment indication is a careful, gradual working through of the traumatic situation in the context of an atmosphere of safety in the therapeutic situation. This is very different from the treatment of patients with sexual traumatization, which constitutes an etiological factor for a severe personality disorder and emerges either at the beginning of the treatment or during the psychotherapy. In these latter cases, one must assume the incorporation of the traumatizing experience as part of the character structure, with the patient’s unconscious, double identification with victim and perpetrator. In the transference, the patient enacts this relationship between victim and perpetrator in role reversals, so that the patient must be helped to realize the reactivation both of his or her role as victim of a sexual assault and the therapist as the perpetrator, and of the patient’s unconscious identification with the perpetrator while projecting the self representation as victim onto the therapist. This internal structure needs to be analyzed in the transference and resolved. There is a risk to treating a patient under such circumstances exclusively as a victim of sexual trauma, in that the unconscious identification with the perpetrator and the related intense activation of aggression in the transference are dissociated or repressed, leaving the patient in the victim stance, and reprojecting the perpetrator role prevents full resolution of the sexual trauma and causes continued difficulties in the patient’s sexual life.


Borderline patients present a wide range of sexual behavior that includes polymorphous infantile features; the freedom of fantasy; play and enjoyment in action of sadistic, masochistic, voyeuristic, exhibitionistic, and fetishistic features; and alternate heterosexual or homosexual identification in their erotic life. This implies a prognostically positive feature insofar as these patients, when their internalized object relations can be worked through, and as split-off or primitive part object relations become mature object relations (integration of positive and negative features), develop the capacity for realistic depth, interest, concern, and reciprocity in their relationships. They then are able to integrate the polymorphous sexual activity under the overall expression of their sexual involvement into a full, passionate relationship. The resolution of chaotic sexual behavior, therefore, lies in the transference resolution of the character pathology rather than in the specific analysis of the unconscious significance of each of these partial sexual trends.


In contrast, in cases of well-established perversion (paraphilia)—that is, when the capacity for sexual excitement and orgasm is restricted to the linkage with a particular polymorphous infantile feature—it is important that this particular perverse sexual relationship be activated, explored, and resolved in the transference, which permits the resolution of the perversion proper. Very often such patients, in the early stages of treatment, devalue ordinary sexual relations in the light of a total immersion in the idealization of their perversion. It is useless to attempt to “dissuade” the patient from this restricted idealization. Activation and resolution in the transference of this particular behavior provides the key to change. This requires the therapist’s openness to fully experience in his or her countertransference the empathy with the patient’s polymorphous perverse experiences as part of the analysis in the transference of the perverse scenario. This means internal freedom of the therapist to empathize, for example, with sadistic, masochistic, or exhibitionistic impulses of the patient, and be part of the disposition to tolerance of primitive regressions in the countertransference.


For example, I once treated a woman who would cut herself all over her body, becoming excited by the appearance of blood. At one point in the treatment, I developed disgusted and excited feelings from the sudden memory of a film I had recently seen that showed a sadistic murderer cutting the throat of a woman at the moment when she was reaching orgasm. I dismissed this memory as disgusting and shocking, and only became aware a few weeks later that this countertransference development corresponded to fantasies of this patient that I should shoot her. She felt that if I were to kill her, she would remain in my mind forever, and she would die happy with the idea that her existence would remain linked with my entire life.


Borderline patients’ strong tendency to act out the transference may create problems in the management of the treatment. For example, a patient may attempt to attack the therapist sexually, such as one of our female patients who tried to kiss her male therapist and to tear off his shirt. While the therapist had to keep her physically at a distance without engaging in a physical fight or an aggressive counteraction in his verbal behavior, he was also able to stop this session while keeping himself in what still may be described as a respectful and neutral, though controlling, demeanor. Another patient, who had been involved in a sexual relationship with a previous therapist and had a long history of masochistic relations with men, appeared in one session without any underwear, spreading her legs in an exhibitionistic acting out and had to be confronted with the fact that the treatment had to be carried out while preserving ordinary, socially appropriate boundaries.


Gender, age, and the nature of the pathology influence the clinical characteristics of the activation of erotic transferences. Female patients develop more easily full-fledged erotic transferences with male therapists, repeating, in a way, the social gradient of traditional patriarchal culture, the relationship of a dependent woman with a controlling powerful man. Male patients in treatment with female therapists have greater difficulty in expressing their sexual feelings fully toward their idealized therapist, enacting the problem of the little boy who is not able to gratify the sexual implications of their idealized mother figure. Here, the acting out of sexual conflict in the form of displacement of erotic behavior to other people is more frequent and needs to be considered in the transference analysis. Male therapists generally tend to have greater difficulty with the sexualized transference of homosexual patients if the therapist is heterosexual, while heterosexual women therapists better tolerate sexual transferences of homosexual women that, usually, are condensed with strong oral-dependent features. Older male therapists may have greater problems with adolescent girls’ sexual activation in the transference than older women therapists, and, as we shall see, the situation changes completely in the case of narcissistic pathology, in which a different way of dealing with erotic transferences and activation of sexual conflicts in general dominates the scene.


As mentioned in Chapter 12, therapists’ erotic countertransference disposition to patients’ activation and intensity of erotic impulses in the transference and the correspondent countertransference fantasies are important diagnostic indicators and therapeutic tools. The sexual freedom and maturity—the capacity for passionate love of the therapist—become important therapeutic elements in the treatment. More experienced analysts and psychoanalytic psychotherapists tend to become accustomed to and more tolerant and capable of managing their countertransference reactions. There evolves an element of learning from experience that is enriched by the fact that the treatment of patients and the analytic exploration of their sexual life bring about the possibility of new life experiences that go beyond those of the ordinary sexual life of analyst and therapist. To treat this pathology opens up the broad spectrum of human sexuality and has a growth potential for the therapist. By the same token, patients’ acting out, fostered by the very treatment of cases in which significant inhibition had limited the patients’ potential of creatively dealing with the conflicts of their sexual life, also may become a source of new life experience for them. Sometimes, the boundary between an important positive new life experience and the acting out of the transference is difficult to establish.


Love Relations of Narcissistic Personality Structures


The most prominent problem of narcissistic personality disorder is the incapacity to love (Kernberg 1995). This deficit is regulated by means of promiscuous sexual conquests, characterized by a never-ending cycle of transitory infatuations followed by rapid disappointments and devaluation. Traditionally, we see this pattern more prominently in male narcissists. The cultural double morality in patriarchal social structures that fosters men’s sexual freedom, while restricting women to virtuous domesticity, is an important reason for this different expression of narcissistic pathology. Historically, women’s narcissistic pathology has been expressed much more in other areas of family life. However, with the development of the women’s rights movement, and the gradual equalization of social functions, sexual freedom, and workforce participation, this sexual pattern has become more frequent in women. Similar cultural influences affect other personality disorders as well, and the dominant cultural conventionalisms influence character formation and pathological personality traits. Thus, for example, while masochistic love relations are more frequent in women than in men, masochistic sexual perversion (paraphilia) is more frequent in men, and characterologically, men’s submitting themselves to chronically frustrating and suffering situations in the context of work and profession is more frequent than parallel masochistic tendencies in women.


Frequently, the severity of the narcissistic patient’s incapacity for stable object relations leads to casual sexual encounters and sexual excitement and gratification as his or her only open channel to involvement with others. There are patients with stable couple relations, from a conventional viewpoint, sometimes in a joint interest with a narcissistic partner who is comfortable with this arrangement but without real emotional involvement and generally with little sexual involvement as well. The increased frequency of “Internet sex” and ready access to pornography may gratify the experience of sexual excitement and provide the material for masturbatory gratification while avoiding the need to be “dependent” on any human relationship that would be experienced as a restrictive limitation of personal freedom. With some frequency, narcissistic personalities present a constellation of reverse triangulation—that is, a stabilization of their love life by having two or more partners in parallel over an extended period, an arrangement that protects them from total commitment to one person and from a sense of being restricted. It provides them with a sense of control over these relationships and, at the same time, constitutes revenge against the oedipal traumatization of having been the excluded child of the relationship between the parents. Thus, the unconscious motivational conflict typical of borderline organization—that is, a condensation of oedipal and preoedipal features under the dominance of early aggression—is replicated in this relatively frequent triangular pattern, which may provide an apparent stability to a couple within the limitations given by such an arrangement.


The development of perversions in narcissistic personality structures is potentially more serious and dangerous than the development of perversions under conditions of nonnarcissistic borderline and neurotic conditions. Here, the intense sadistic impulses that may constitute an important aspect of narcissistic personalities, related to inordinate envy as a dominant psychodynamic of the development of the pathological grandiose self, may be expressed as dangerous sadistic perversions that are not controlled sufficiently by adequate superego features, and that under the most severe circumstances, in cases of malignant narcissism, determine objective dangers for partners in sadomasochistic involvements.


In this connection, it needs to be kept in mind that patients with pathological narcissism function along a broad spectrum of severity: from very highly functioning patients with good surface impulse control and stability in the capacity for work and in ordinary social life, in whom the narcissistic pathology is expressed only in problems of sexual intimacy, to the other extreme, patients with a total breakdown of the capacity for work and profession, social life, and any object relationship involved in their sex life (see Chapter 9, “An Overview of the Treatment of Severe Narcissistic Pathology,” of this book). More than anything else, the severity of the narcissistic pathology determines the prognosis for the specific problems in these patients’ love life. There are narcissistic patients who present significant inhibition of their capacity for sexual excitement, intercourse, and orgasm, related to unconscious distrust and projected aggression interfering with the engagement with potential partners. Narcissistic men may present various syndromes of premature and retarded ejaculation, and narcissistic women may experience various degrees of sexual inhibition. However, in women as well in men, the most frequent situation is the maintenance of the capacity for sexual excitement and orgasm in the context of a severe limitation of the capacity for an object relationship in depth—that is, an incapacity for love and for passionate engagement. The most extreme cases of pathological narcissism, which present a total deterioration of superego functions in their social interactions, often involve a completely uncontrolled “sexual freedom” and the possibility of life-threatening sexual perversions. One of our patients with an antisocial personality structure reached excitement and orgasm in masturbating while throwing bricks from rooftops on women walking below on the street.


In diagnostic interviews, patients with narcissistic personalities typically reveal their incapacity to love, admitting that they have never fallen in love and have only had experiences of brief infatuations. The exploration of their unconscious dynamics reveals intense conflicts around envy and devaluation, also expressed in conscious reactions of envy, excessive competitiveness, and devaluation of others that may disturb their sexual life. For example, with some frequency they may be concerned about who is obtaining more pleasure in sexual intercourse: they themselves or their partner? They feel resentful if their partner seems to obtain more pleasure or be a more effective lover than they are. These patients cannot tolerate being very dependent on a love object, because dependency signifies a humiliating inferiority. Under the control of a pathological grandiose self, their security and well-being depends on maintaining a sense of superiority and freedom from envy by being able to devalue what others are or have. Their inability to depend on anyone goes hand in hand with the incapacity to let anybody else depend on them: they cannot tolerate that a partner depends on them, because to depend on them means that the other person is inferior, which pulls them down, and which in addition is felt to be an exploitation of them. They project their own tendency to greedy exploitation onto the partner and perceive any dependency on them as a dangerous restriction and exploitation. The partner should not be inferior to them—that would pull them down—but the partner cannot be superior, either, because that would generate their envy. The partner must be equal to them in some way and yet submissive to their omnipotent control. To keep a potential partner at that level creates an implicit strain on the developing relationship that militates against the initial infatuation and leads to the gradual deterioration of any intimate relationship.


In the transference, these problems are replicated in narcissistic patients’ incapacity to depend on the therapist or analyst. They convey the impression of an apparent lack of transference developments by keeping the therapeutic relationship coldly objective and uninvolved. By the same token, however, they provide most important evidence for the development of a severe narcissistic transference relationship. These patients may present a fragile idealization of the therapeutic relationship as a “learning experience” that they wish to incorporate to resolve their difficulties by themselves. At bottom, their incapacity to depend on the analyst is expressed in their attempt to appropriate for themselves the analyst’s knowledge and make it theirs but without having to acknowledge any dependency or gratitude. The interpretations they receive are easily dismissed or are absorbed as part of a “learning process” that leads to no further deepening of what they have received and no further initiation of self-exploration in the light of the analyst’s interpretation. The unconscious envy of the analyst is also reflected in a particular negative therapeutic reaction. Precisely at points when these patients feel that they have been helped significantly, they feel worse: a paradoxical development that protects them from experiencing envy of the analyst’s capacity to help them. In general, narcissistic patients have much greater difficulty in acknowledging their envy of the therapist than in acknowledging their envious reactions prevalent in all other relationships.


Narcissistic patients’ sexual seductiveness evinces a quality of possessiveness and control. They attempt to take possession of a potential love object they experience as exciting and desirable, with an initial idealization of the sexual object; but, once they feel the new partner really loves them and wishes to give himself or herself totally over to them, these patients’ internal devaluation of what they admired, desired, and envied destroys the attractiveness of what they first wanted to acquire. At a deeply unconscious level, narcissistic personalities envy the other gender and want to acquire all the capabilities and possessions of both genders. This may be the underlying dynamic of some homosexual narcissistic patients, and there also are other cases of narcissistic pathology that are particularly centered on the need to deny the envy of the other gender. At severe levels of narcissistic pathology, the aggressive possessiveness and devaluation of partners may take the form of openly sadistic behavior, an ongoing effort to devalue and control the freedom of behavior of the other that is quite frequent in cases of malignant narcissism.


One patient, with deep envy of his wife, who was successfully developing her profession and social standing and who he felt was overshadowing him, suggested to her an open marriage. He used their participation in group sex to induce her to have simultaneous sexual relations with five men while he watched her, and in the process devalued her completely as “a piece of meat.” This led to the end of the marriage in the context of brutal divorce proceedings. In many cases, the repetitive cycles of temporary idealization and rapid devaluation of partners decrease over the years, and, in contrast to the enjoyable playboy or playgirl attitude in their 20s and 30s, an erosion of this pattern may set in, with boredom and indifference in their 40s and 50s. This development may lead to a total breakdown and loss in the interest of sexual intimacy, and a practical abandonment of all efforts to establish some form of sexual intimacy with a partner.


In the treatment of narcissistic personalities, the first obstacle, of course, is the analysis and resolution of the pathological grandiose self, which should be deconstructed into its component internalized real and ideal self and object representations, gradually leading to the emergence of the underlying borderline structure, the severely split idealized and persecutory object relations that reflect more directly the condensation of oedipal and preoedipal conflicts. Typically, in favorably evolving cases, the analysis of the narcissistic transferences occupies a major period of the total analysis or psychoanalytic psychotherapy, and it is only in the context of the transference analysis that their concrete sexual fantasies and conflicts may be understood and resolved.


A frequent development, although not exclusive to narcissistic pathology, is the syndrome of perversity—that is, the unconscious transformation of something good and valuable the patient receives in the treatment into an aggressive acting out against others. It is one more expression of unconscious envy that parallels the development of the psychotherapeutic process, one more form of negative therapeutic reaction, and it may lead to intense negative countertransference reactions. Obviously, it is one more manifestation of the conflicts around unconscious envy that need to be worked through in the treatment.


Total Apparent Obliteration of Sexuality


I refer here to cases of total absence of sexual activity, fantasy, and relations, possibly affecting a patient’s social life to the extent that there may be no social life at all. There are different cases involved here requiring a careful differential diagnosis. First, there is a syndrome that includes the most severe cases of borderline personality organization, but without a narcissistic personality proper, in which a primary, total inhibition of all erotic potential has taken place. It is the case of such severely temperamentally negative predisposition, and overwhelmingly negative affect activation in the context of a traumatizing environment, that the erotization of the body surface and the erotically stimulating aspects of normal attachment have not taken place (Laplanche 1970/1976). Negative, particularly aggressive affects, override the possibility of primary erotic stimulation. It is only in the context of the treatment, with the activation of chaotic relations with others, self-mutilating behavior, sadomasochistic relations, the breakdown of social relations, and the absence of the capacity for intimacy, that the typical condensation of oedipal and preoedipal problems of borderline patients may be worked through in the transference of these patients. This gradually permits the emergence of the erotic impulses that were practically obliterated in the first few years of life. In these patients, after a long period, primitive sadomasochistic sexual fantasies may emerge in the sessions that provide important views of archaic idealized and persecutory early relations with related sexual implications of bodily penetration, incorporation, and destruction.


I referred earlier to a patient who developed the intense erotic fantasy of wanting to be shot and killed by me in order to be fused with me by means of my guilt feelings for the rest of my life. Another patient, in an advanced stage of her treatment, fantasized that she was lying naked in a stadium, as part of a convent, with the entire stadium filled with nuns surrounding her, while Mother Superior penetrated her at center stage with a huge metallic penis. The nuns, while watching, would get sexually excited, and that, in turn, would excite her sexually. This fantasy facilitated the patient’s reaching orgasm through masturbation for the first time in her life. Still another patient developed, in the course of her treatment, the capacity to masturbate while she rested on a bed covered with a rubber sheet. She would urinate while masturbating and be able to achieve orgasm with a fantasy she was being bathed by her father, who was touching her genitals while lovingly bathing her. At an advanced stage of treatment, with an emergence of sexual fantasies in the context of such sadomasochistic scenarios, the full exploration in the transference of the patient’s sexual life becomes very important and potentially may bring fundamental change.


There are some patients with total inhibition of erotic responsiveness in which the addition of sex therapy by a psychodynamically savvy therapist collaborating with the analyst or psychoanalytic psychotherapist of the case may be able to bring about significant change. It needs to be stressed that this refers to extremely severe cases in which the patient has total nonrepressive inhibition of his or her erotic potential, and it is generally undertaken in the latter stages of the psychotherapy treatment.


A second type of patient with practically total loss of the capacity for erotic response is the patient with narcissistic personality who, after many years of sexual promiscuity, has lost his or her capacity for temporary infatuations and sexual involvements and whose sexual life gradually has become practically extinguished. Here, the analysis of the narcissistic personality structure should reactivate the patient’s erotic potential in terms of the capacity for sexual arousal, excitement, and orgasm.


A third case is that of the “dead mother” syndrome, patients with a severely narcissistic personality structure in which the dismantling of all internalized object relations, including the concept of self, has become so dominant that their internal capability for emotional relationships seems to be erased. Originally described by André Green (1993), these patients have a history of severe chronic depression in the mother in their first few months or years of life, an unconscious identification with such a mother experienced as a dead image, and the wish to maintain or reestablish the relationship with such a mother by accompanying her in that emotionally dead union. Consciously, these patients are characterized by a remarkable lack of interest in life. Life becomes a burden, given their total lack of motivation. On the surface, their capacity for ordinary social object relations seems to be appropriate, but basically their relationships are extremely distant and empty: all the aggression has been vested in the destruction of their internal life. Some of these patients can be helped to reconstruct their earliest conflicts related to a deeply frustrating mother. They may be able to reactivate their rage at having been ignored and abandoned in the transference: if that stage of treatment can be reached, the prognosis improves. Other cases simply end in a profound sense of frustration and disappointment by both patient and therapist because of the impossibility of activating a regressive transference relationship.


Under all these circumstances, in cases of obliteration of sexuality of the kind mentioned, there may develop an absence of erotic elements in the therapist’s countertransference as well, a tendency to abandon all thoughts and feelings of erotic implications relating to that patient. The therapist should be alert to the problem of total absence of any erotic feature to his or her reaction to the patient and make use of it to explore with the patient the correspondent deficit in his or her life as a major issue to be resolved, if possible. This is as important as the patient’s relationship to work and profession and to friendship and social life. In such cases, it is essential to maintain alertness to any, even the vaguest, manifestation of an erotic activation that potentially may emerge. Again, this emergence may only occur in the context of the activation of severely sadomasochistic features that already represent an advantage in this situation. In other cases, patients may evince a potential for an erotic component in their reaction to art or other cultural manifestations that evoke in them a sense of diffuse, longed-for opening of a space and of “letting oneself go.” Here, the basic dilemma of life, the oscillation between the rational and the ecstatic aspects of existence—referred to initially in context to the contributions of Bataille (1957; see Chapter 12, “Erotic Transference and Countertransference in Patients With Severe Presonality Disorders, Part I”)—becomes relevant.


References


Bataille G: L’Erotisme. Paris, Minuit, 1957


Green A: On Private Madness. Madison, CT, International Universities Press, 1993


Kernberg OF: Love Relations: Normality and Pathology. New Haven, CT, Yale University Press, 1995, pp 143–162


Laplanche J: Life and Death in Psychoanalysis (1970). New York, Johns Hopkins University Press, 1976


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Mar 29, 2020 | Posted by in PSYCHIATRY | Comments Off on Erotic Transference and Countertransference in Patients With Severe Personality Disorders
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