The Denial of Reality


CHAPTER 14




The Denial of Reality


 


 


What follows is the exploration of a frequent complication in the psychoanalytic psychotherapy of severe personality disorders, and one that we also encounter at times of significant regression in the psychoanalysis of patients with that level of severity of illness. While the analyst is attentive to the patient’s free association and the display of unconscious defensive operations and impulses in the patient’s fantasies and associations, a parallel, incongruent, or bizarre element of the external reality emerges in the patient’s discourse that points to potentially severe developments in his or her external life, which the patient seems to be ignoring or mentioning so casually that their importance easily may escape the attention of the therapist.


The analysis of the “total transference” includes the expression of the transference both in the developments in the session and in the parallel developments in the patient’s external life, sometimes clearly in the form of acting out or else in somatization. Here, however, it is only the therapist’s putting together in his or her own mind those fragmented, bizarre, or ignored aspects of reality that appear so puzzling and that would not become part of the information that the therapist receives directly from the patient if the therapist did not use his or her common sense in reformulating to himself or herself an aspect of the patient’s external reality beyond the patient’s apparent capacity to grasp it at that point. To put it differently, one aspect of the transference is acted out in such a way that an effective denial on the part of the patient requires an unusual effort of the analyst to understand something almost imperceptible within that reported external reality. The therapist’s common sense, at times, may leave him or her with new, unanswered questions about apparently strange aspects of that reality. Only direct inquiry of the patient about these aspects may permit the therapist to put together a totally denied, highly significant process that has been developing outside the sessions.


The ordinary interest of the analyst in listening to free association is to penetrate deeper layers of the patient’s mind, to establish contact with unconscious conflicts enacted in the here and now. In contrast, in these unusual, strange occurrences referred to, the therapist’s inquiry must include a clarification of aspects of the patient’s external life that ends up uncovering issues effectively eliminated from the patient’s awareness by his or her denial of reality.


Let me present a few examples of these kind of developments:



A female patient in her early thirties was a research scientist in a highly prestigious, complex research organization, where she headed a research team that was part of a larger project. Long-standing conflicts with authority figures, related to profound ambivalence toward an admired but feared authoritarian father, affected her relationship to men. Idealizing and submitting to powerful men first and then ending up in a rebellious rejection of such men was a central focus in the analysis of the transference. Her relationship with men had ended with a painful breakup on several occasions, in what, at bottom, was a masochistic intolerance of a good sexual relationship.


In the middle of a tumultuous relationship with what seemed to be a very nice partner, she mentioned to the therapist her anger with the mistreatment, as she saw it, of a member of her team by the financial office of the research institution. She had expressed her protest over this financial problem to her project leader, but without obtaining a satisfactory response. Over several weeks, she occasionally mentioned her discussion of this situation with coworkers on her team, who, it seemed, agreed with her and expressed their general resentment at the bureaucratic rigidities of her institution. The dominant affective situation in the transference involved her fantasies that the therapist would naturally always sympathize with the views of the patient’s boyfriend rather than with her, “the typical alliance of men in power.”


The occasional ironic or angry references to her research institution at first did not draw the attention of the therapist, who was used to her protests over social injustices. At one point, the patient mentioned, rather casually, that she had decided to ask for an appointment with the director of the research institution, and at a later session she announced with a triumphant tone that she had obtained that appointment for a near, future date. It needs to be stressed that all the relevant comments in the sessions were rather isolated bits of information, expressed in the current of free associations without an apparent internal continuity of these thought processes.


The therapist experienced a sudden sense of alarm as he was reviewing her latest session with the announcement of the appointment with the director. Was that a typical acting out of the patient’s rebellious protest against authoritarian powers, with a profound, unconscious masochistic implication? The therapist now raised the question with the patient as to what her intentions were and what process had led her to appeal to the ultimate authority of that large institution. In the following sessions, the therapist found out that, indeed, the patient was going to present a major complaint about faulty procedures in the financial management of her project, implying irresponsible neglect of this situation by the project director, the director of the overall program of which this project was a component, and the director of the division in which this entire development had taken place. The therapist asked the patient if she had discussed the situation with each of these superiors, whether she had expressed her dissatisfaction to them, and whether she had informed them of the next steps she was planning to take. She had not.


This led the therapist to become very concerned about the patient’s forthcoming interview with the director of the research institution: the patient had bypassed three levels of authority in planning to address her protest to the highest level of the organization, and this might involve a serious risk for her future in that very hierarchical workplace. She was a very promising but junior member of the staff and was still uncertain about the possibility of a permanent position. The total situation now could be explored in the context of her pattern of rebellious protest as an expression of deeper masochistic urges, in turn linked to unconscious prohibition against a happy sexual relationship with a desirable man, an oedipal conflict.


Another example involves the psychoanalytic treatment of a patient with a severe narcissistic personality disorder who had obtained a position in a very exclusive high school specializing in the education of outstanding and unusually gifted adolescents. This school had very high expectations of their faculty, and all new teachers were hired on a 1-year “mutual acquaintance” basis—that is, in a provisional situation that might lead to a permanent position or to the end of this teaching assignment after the probation year. The patient was a very gifted, charismatic teacher, fully aware of his capacity to activate adolescents enthusiastically and certain of his desirability for the school. After making a very positive impression on everybody, he felt secure in the job and expressed his subtle but definite arrogance and depreciative attitude toward authorities and colleagues in occasional humoristic remarks and unconsidered attitudes that led to a few incidents, which he referred to in his free associations as amusing illustrations of his superiority. The analyst became concerned whether this might threaten the patient’s position at the school. The patient calmly dismissed the analyst’s concern, with an attitude of possessing much greater experience of the school system than the analyst. The analyst interpreted the projection onto him of the patient’s own repressed and dissociated feeling of inferiority and concern over failure but did not trust his overall assessment of the dangerous situation in which his patient was finding himself. He actually missed the full clarification of incidents that, from a viewpoint of common social intelligence, should have alerted him and the patient of dangerous consequences following some of these negative interactions at the school. Toward the end of the year, the patient was notified that his contract was not going to be renewed, which shocked and depressed him. It emerged only now how unusually favorable and privileged the conditions of this job were that the patient, most probably, would not be able to replicate elsewhere. Here the patient’s omnipotent control blocked the analyst’s full experience of his own concern and the realistic assessment of the patient’s social situation.


A third example is apparently simpler but illustrates a lack of common sense by the analyst about the information from a patient working in an organization for social welfare that she was quitting her job because she was “bored.” The patient had been in analysis a relatively brief period, and the analyst knew that she had held an important position in that place of work over many years. Her categorical statement in one session that she had decided to leave this job because of “boredom” caught him by surprise, but he felt it prudent not to question the patient about the reasons that would lead her to leave the job at this point after so many years, and it was not clear to him what role transference developments might play in this decision. It did not occur to him to ask her what she meant by saying that she was bored (i.e., Bored by what? How did this boredom show? How come now when for many years the job was not boring?). The analyst felt he should not raise all these questions, because he felt that, in general, raising direct questions to patients should be avoided in analysis and that, particularly in this case of a woman who he felt was highly sensitive to any criticism, it would be experienced as a critical stance toward her decision.


Several months later, she announced that she had taken another job in an institution dealing with underprivileged families and that she hoped it would be a less stressful job than the one in the previous organization where she had worked. A few weeks later, she complained that people were talking about her and that, unfortunately, the same thing was repeating itself in her new job as had happened in the previous organization, where everybody talked about her behind her back, which had proved intolerable. Now the nature of the “boredom” became clearer—namely, a strong paranoid reaction toward coworkers, particularly female coworkers, and the direct linkage to paranoid developments in the transference became evident. This example may seem rather trivial in the sense that the exploration of what may have been considered an acting out by her sudden decision to resign from the other job did not take place. However, it is linked to the other examples by the lack of use of common sense in interpreting the situation and by not confronting the patient with a denial of reality implied in the patient’s behavior and recognized in the analyst’s countertransference.


In general, what these cases have in common is a distortion of reality usually totally ignored by the patient and presented in such suddenly rationalized or fragmented ways that it is difficult for the therapist to capture it. Often this goes hand in hand with the splitting off of aspects of reality that are recognized at times, or in theory, but are disconnected totally from the emotional life of the patient at other times. For example, one patient, a man with a severe narcissistic personality structure, who had reached an agreement with his wife to have an “open marriage” at a time when this was a culturally fashionable aspect of “liberation” in some social circles, seemingly enjoyed his own sexual promiscuity while theoretically granting the same rights to his wife. Emotionally, however, he was convinced she would never become interested in another man and that his attractiveness would override any such temptation on her part. She, however, also initiated an extramarital relationship that developed into an intense love relation. The patient was shocked: he had ignored her indignant reaction to his proposal that she interpreted as a devastating lack of commitment to their marriage and that triggered her questioning their relationship. The combination of his grandiosity, the devaluation of his wife, and the denial of the reality of her emotional reactions, all of which became clear enough throughout time in the discourse of the patient, led to his traumatic experience of her decision to end the marriage.


Sometimes little “tidbits” of information in a patient’s discourse seem strange and irrelevant enough not to draw the analyst’s attention to them. They should be considered as possible indications of an aspect of reality that is being denied by the patient and presented as part of a broader picture reflecting the patient’s defensive organization regarding his or her reality. Frequently, such denial tends to cover chronic self-destructive behavior that may accumulate throughout time and finally emerge as an unexpected traumatic situation or even a catastrophe. Only a retrospective review of all the information provides the data that clearly indicate a logical progression of developments in external reality. Sometimes an essential aspect of reality is suppressed, an apparently minor link in a chain is underlined, and the total picture is recovered only much later, sometimes too late.



The implication of what I have described is that in some severe cases of psychopathology, free association may be distorted unconsciously at the service of the denial of external reality, and the analyst’s task may be to interpret that denial of reality as an affectively dominant subject in the sessions. However, to interpret the denial of reality requires the analyst to formulate in his or her own mind a vision beyond the patient’s presentation of it, a construction of reality that permits the therapist to clarify its significance and reveal important mechanisms of denial at work in the patient’s communications. It means having to pay attention to the patient’s reality through the patient’s communication of it beyond the patient’s awareness and understanding, and being prepared to explore the meaningful blindness of it as part of the patient’s defensive operations. If denial of reality is accompanied by significant acting out outside the sessions that draws attention by itself to what is going on in the patient’s external life, the task, paradoxically, becomes easier. But when no major acting out seems to be occurring, and there are only relatively small, apparently unimportant happenings that seem strangely interspersed with other material in the patient’s free associations, the task becomes much more difficult. These forms of denial are frequent in cases of patients with borderline personality organization in which splitting mechanisms are dominant and point to the defensive use of free association against the awareness of external and not only internal reality of the patient.


The psychoanalyst’s interpretive interventions under such circumstances present a particular difficulty. As the case material mentioned already illustrates, the clarification of what has been masked or subtly distorted in the patient’s communication, the confrontation of implications of the information that the patient is denying, and the interpretation in depth of the total situation that the patient has created may appear to be an “intrusion” into the patient’s external life. The analyst may appear as taking a stand that is outside technical neutrality, and it even may appear to reflect countertransference acting out. In fact, in practice, in our experience at the Personality Disorders Institute at Weill Cornell Medical College, we have observed these concerns as a major difficulty of therapists working analytically with severely ill patients. In an effort to maintain a technically neutral stance, and to avoid acting out of countertransference reactions to patients’ denial of significant aspects of their reality, analysts and therapists are reluctant to intervene by interpreting the denial of reality.


The following is an important differentiation to keep in mind: the difference between a supportive or re-educative stance that may reflect an analyst’s behavior enacting countertransference problems, on the one hand, and the need to clarify systematically an external reality to interpret its motivated denial on the part of the patient, on the other. The difficulty of this differentiation may result from the lack of understanding of technical neutrality as interventions that are made from a position outside the internal conflicts of the patient—that is, they are supposed to be neutral regarding the dynamic forces in mutual conflict in the patient’s mind. Forceful, even, at times, categorical statements that clarify a reality may be technically neutral, whereas at other times, very carefully and thoughtfully pronounced interpretations that take sides in the patient’s internal struggles are not. Sometimes the analyst may feel reluctant to raise a set of related questions to clarify an obscure aspect of a situation, as if that represented an intrusion into the patient’s reality, an acting out of the analyst’ curiosity or his or her own interests, and, once again, an abandonment of technical neutrality.


It is a common assumption within analytic circles that the more an analyst can avoid raising direct questions, by means of thought-provoking interpretations of the relevant issues, the purer or more elegant is the analytic technique. Further, the assumption holds that much raising of questions reflects lack of technical skills, such as the trivial but so frequently heard question, “and how did you feel about that?” (Busch 2014).


The denial of reality may represent one element of a broader splitting of reality into opposite segments of experience, reflecting massive projective identification of the intrapsychic conflict onto the perception of the outer world. However, when the process is gross enough to become manifest as the counter position of an idealized and a persecutory aspect of experience, the splitting operations are clear enough to lend themselves to interpretive interventions. The subtler aspects of denial of reality discussed here usually serve long-range masking efforts, particularly severely self-destructive ends, and the lack of their perception may seriously affect the patient’s life. In very severe cases, the analyst has a special function in addition to his or her attention to verbal behavior, nonverbal behavior, countertransference, and the subtle aspects of the analytic fields. Now the therapist also has the task of “scanning” the patient’s environment, reproducing in his or her mind an external world that may be distorted as a function of the patient’s defensive needs and unconscious acting out. This usually is a silent, quite obvious, aspect of analytic listening to patients with better-functioning ego and an integrated world of representations of significant others, patients within the neurotic level of structural organization, where analytic assessment of the psychosocial reality of the patient’s life can be taken for granted. Therefore, this is a problem that emerges relatively seldom in standard analysis of neurotic patients. It becomes predominant only in the pathology of severe borderline and narcissistic pathology and may require active attention on the analyst’s part.


An active attention to the reality of a patient’s life may seem to run counter to the principle of interpreting “without memory or desire” (Bion 1967). Perhaps this is the place to clarify once again that to interpret without memory or desire does not imply blindness to the history of the patient’s life and problems and to the nature of his or her external world. It means entering each session with a true openness, to be impressed and guided by the predominant affective issues now dominating the total therapeutic situation. However, during that evocative situation, with the activation of the patient’s unconscious reality and conflicts, relevant “memory and desire” also emerge in the therapist’s countertransferences as material to be understood, analytically worked through, and interpretively used.


A penetrating, systematic history taking and analytic exploration of the patient’s present reality at the beginning of the treatment, his or her reality in work and profession, love and sex, social life, and creativity, and the dominant conflicts in all those areas give fundamental initial information that at a certain moment of the treatment will prove helpful as it emerges in the awareness of the analyst’s mind during the sessions. Psychoanalysts traditionally have been well prepared to have such a potential vision of the patient’s infancy and childhood in their mind, but we have learned that this must be extended to a full awareness of the patient’s present reality—its intricacies, potentials, and dangers—because it is in that present reality that the patient’s unconscious conflicts and the transference are going to be played out. This knowledge facilitates the therapist’s alertness and awareness of the denial of reality we are exploring.


The interventions geared to clarify an obscure and denied segment of the patient’s reality may create the danger of effectively interfering with free associations, transforming them or reducing them temporarily to a therapeutic “dialogue” that in turn may be used for defensive purposes by the patient. Some argumentative interchanges that evolve during analytic sessions between patient and analyst not only indicate transference and countertransference acting out, but also may gratify the ongoing defensive effort by the patient to avoid the regressive experience of confronting deeper levels of unconscious conflicts in the transference. This is a risk increased by excessive questioning by the analyst, which orients the patient’s thinking defensively into the reality aspects of that obscure area of reality the analyst is interested in clarifying. Thus, the interpretation of the denial of reality must be applied sparingly and directed to areas of severe potential self-destructiveness by the patient in the interest of protecting the patient and the treatment.



The analyst’s view of the totality of the patient’s present life also acquires particular importance in cases in which a major life problem has become so chronically structured into the patient’s daily life, so routinely expressed with secondary defensive rationalizations that keep the total situation stable, that the analyst becomes blinded against the ongoing awareness of that problem. For example, difficulties may evolve with patients who present chronic distancing from their spouse or sexual partner, who find compromise solutions to life together that are practically comfortable for them both, within an unconscious collusion to bury any emotional intimacy, suppress their sexual life, or deny profound differences in overall values, interests, and ethical commitments.


Patients may come to treatment because of their sense of dissatisfaction with their life and in the initial evaluation clearly convey particular areas that are inhibited or paralyzed by unconscious conflicts. Throughout treatment this becomes covered again by a pattern of customs and routine. They may thus induce an unconscious collusion between patient and analyst not to explore the corresponding problems. This may be considered one example of the bastions of unconscious collusions in treatment described by Baranger and Baranger (1966). Acute conflicts, symptoms, and traumatic developments in a patient’s life may obscure these underlying long-term problems initially mentioned in the patient’s evaluation and then going underground. The analyst should be able to maintain an internal overview of the patient’s life, particularly from the perspective of what would be an optimal life situation for this particular patient that he or she has not been able to achieve—because of which he or she is suffering—possibly without clearly being aware of what he or she is missing.


The careful scrutiny of the patient’s external life situation in the course of the treatment brings up not only problems related to the denial of reality but the entire course of the patient’s changing relationship to work and profession, love and sex, social life, and creativity. It often raises in the therapist’s mind the question “Are there more or alternative or better ways this patient could enrich his or her life experience?” Obviously, countertransference reactions, guilt feelings, and rescue fantasies of the therapist may play a role, as does projective counter-identification with the patient’s own dissociated or guilty wishes to expand his or her life experience. However, the effect of social and political constraints also may play a role in a patient’s life, restricting the patient’s horizon, while the therapist may be aware of open roads of inquiry the patient is ignoring.


I treated a 27-year-old African American woman from one of the poorest neighborhoods of New York City with transference-focused psychotherapy. She presented an infantile-histrionic personality disorder, with drug abuse, sexual promiscuity, and irresponsibility in work situations connected with serious interpersonal problems. She lived with her mother and six siblings in a rundown apartment. Her father had abandoned the family when she was 4 years old, and the present home atmosphere was totally chaotic. Despite this, the patient had been able to graduate from high school with consistently high grades, a fact to which nobody in her family seemed to have paid any attention. They lived in extreme poverty. At one point in the treatment, it occurred to me that, given her success in high school and her financial situation, she might be eligible for a college scholarship, which would significantly improve her long-range employment possibilities. I raised that issue in the middle of our exploration of important masochistic features in her relationship with men, her self-devaluing and impulse-driven lifestyle. She obtained that scholarship and ended up studying and graduating from a local college, securing a growth-facilitating position in a local industry, and entering an educated middle-class social community. Her life situation improved greatly, and her opportunities for finding adequate men increased in parallel to her growing capacity for establishing object relations in depth.


The therapist’s position of technical neutrality may be compromised by such an intervention, but it should be possible to explore and interpret the consequences of such a temporary shift. Questions geared to clarify something the therapist does not understand, and which the patient is avoiding to clarify, reflect the authentic, task-oriented curiosity of the therapist that is part of his or her diagnostic and therapeutic function. A genuine interest in the patient’s well-being as the obvious objective of the treatment to help the patient improve his or her life experience and condition is an important, objectively required aspect of the analytic work. And so is the active exploration, in the analyst’s mind, of the patient’s entire present life situation, the denial of aspects of reality that need to be interpreted, and the unrealized life potential that the patient may be missing, even without an unconscious blinding about his or her potential. An actively engaged analyst may still be a technically neutral one.


The therapist’s creativity in imagining a better life for patients with severe personality disorders who unconsciously are so involved in enacting self-destructive tendencies in their life situations is an important function in the ongoing evaluation of external reality. During the very early diagnostic evaluation of a patient’s difficulties, it helps to be able to imagine oneself in the patient’s situation, in his or her skin and concrete life circumstances. What would we do in such a situation, to “get out from under,” to break through the barriers of self-restricting psychopathology? Such imaginary scenarios may expand the horizon of the therapeutic objectives beyond the expectations of the patient and protect the therapist’s stance against contamination by the patient’s self-destructive tendencies during the treatment. Such a disposition on the part of the therapist is totally compatible with a position of technical neutrality.


In short, denial of reality includes both denial of potential self-destructive acting out and blinding toward potentially healthy opportunities for growth and development. Technical neutrality facilitates full transference development and transference interpretation and, in turn, is protected by consistent countertransference analysis. The combination of these technical instruments permits the diagnosis and interpretative resolution of the denial of reality, a development particularly important in cases of severe personality disorders. Technical neutrality may be challenged but can be maintained under these conditions.


A patient may have sacrificed a creative talent and, over time, it turns out that this was a useless, unnecessary sacrifice and is related to his or her self-destructive tendencies. The patient may not, or no longer, be aware of this sacrifice; however, it still affects him. A woman may consult for treatment because of sexual inhibition but over the years rationalize this inhibition as being a reasonable result of many years of living together with her spouse and the loss of the romantic aspects of the couple’s relationship, reinforced by a husband’s loss of sexual interest under conditions of lack of response by her over an extended period. A patient may start his analysis with an expressed wish to resolve a problem, then not refer to it over many months, unconsciously managing the analyst’s attention to stay away from the problem as well. It is perhaps particularly under conditions of apparent trivialization of free association, at times when nothing seems to be going on in the sessions over a period of time, or when the nature of the patient’s discourse turns stubbornly to the external realities of daily life, that periods of countertransference reactions may evolve in which the analyst is distracted and matters unrelated to the patient intrude in his or her mind, when in fact he or she may be responding to what is now active in the intersubjective field rather than in the verbal interaction focused on free association. At such points it may be helpful for the analyst to activate, in his or her own mind, the total patient situation: What important issues are affecting this patient’s life and are not being taken up in the sessions? Is there any discrepancy between the apparent tranquility and affective superficiality of the patient’s communications at this time, the analyst’s countertransference contamination by this atmosphere, and the split-off, ongoing presence of a major unresolved problem?


This is a different situation from the more specifically focused denial of reality we were exploring before. Now it is the total life situation of the patient that becomes the focus of the analyst’s concern, and the question can be raised: What is the relationship between that major unresolved chronic issue and the present “triviality” in the sessions? Simply raising these questions in the analyst’s mind often changes the nature of the intersubjective field, increases the analyst’s awareness of how, in subtle ways, a neglected subject is emerging in transference and countertransference thoughts and fantasies. This may become the affectively dominant subject of the sessions as it gets connected with other aspects of transference/countertransference development. It represents another expansion, I suggest, of Betty Joseph’s (1985) concept of the “total transference,” which includes mental realities not directly expressed in the sessions but painfully recovered by the analysis of the total relationship between the treatment at this point and the patient’s external life.


Interpretive interventions that bring this issue into the content of the therapeutic hours may be experienced by the patient as a traumatic intrusion and disturbance of his or her present equilibrium. It is important that such interventions clearly correspond to important problems in the patient’s life, whose resolution may improve his or her effectiveness and well-being, and do not represent the analyst’s own ideological assumptions of perfect life arrangements artificially imposed on the patient’s present equilibrium.


The comments about denial of reality and the analyst’s concern about the total reality of the patient’s life point to the delicate balance between the analyst’s interests in helping the patient achieve a better life experience and his or her respect for the equilibrium that the patient has established for himself or herself. It may become a conflict between commitment and discretion, and should not be an acting out of furor sanandi. It points, however, to an implicit analytic task of helping the patient to improve his or her life beyond the resolution of the symptoms and difficulties that brought him or her into treatment. Often this expanded goal cannot be achieved, but the very fact that sometimes it can points to the therapeutic potential of this analytic approach.


The technical modification proposed in this chapter within the overall technical approach of transference-focused psychotherapy involves an actively focused questioning about strange or bizarre bits of information that may reflect silent or masked severe acting out of a patient’s self-destructive tendencies. Unconsciously, the patient may attempt to prevent the therapist from becoming aware of the preparation or expression of dangerous self-destructive behavior on his or her part. That is what is involved in the need to clarify, confront, and interpret the denial of reality. In addition, self-imposed limitations the patient establishes or enacts regarding his or her expectations, aspirations, and goals in life constitute a broader, subtler, but eminently important expression of self-defeating tendencies that the therapist should raise questions about when relevant. That also is implicit in the denial of reality.


Conclusion


The questioning and confronting interventions discussed in this chapter may be considered to present advantages and disadvantages. Among the disadvantages, one may cite the potential interference with free association and the temporary transformation of the therapeutic work into a dialogue between patient and therapist, and this may be exploited as a defensive maneuver on the part of the patient. Raising questions also may reveal intentionality on the part of the therapist, reducing the position of technical neutrality. In the same context, raising questions may facilitate acting out of countertransference disposition. All of these are negatives.


On the positive side, raising questions in the context referred to earlier expands the field of investigation to acting out of transference developments in external reality, even beyond the field signaled by Betty Joseph. Raising a focused question about an area in which severe self-destructive behavior is being enacted may gain time and protect the patient from acting out that would result in serious damage. Raising questions about patients’ self-restrictive and self-limiting life objectives may contribute to expanding and enriching patients’ lives. At the end, this approach is harmonious with the overall transference-focused psychotherapy approach that proposes “impatience” in every session and consistent patience over the long run.


References


Baranger W, Baranger M: Insight and the analytic situation, in Psychoanalysis in the Americas. Edited by Litman R. New York, International Universities Press, 1966, pp 56–72


Bion WR: Notes on memory and desire. Psychoanalytic Forum 2:272–273, 279–290, 1967


Busch F: Creating a Psychoanalytic Mind: A Psychoanalytic Method and Theory. London, Routledge, 2014, pp 78–87


Joseph B: Transference—the total situation. Int J Psychoanal 66:447–454, 1985


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Mar 29, 2020 | Posted by in PSYCHIATRY | Comments Off on The Denial of Reality
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