Character Analysis

Character analysis refers to the exploration of the patient’s dynamic organization as exhibited by his or her habitual behavior patterns, idiosyncratic reactive or inhibitory traits, and chaotic or fragmented repertoire of character traits. This approach practically coincides with the analysis of the patient’s dominant defensive mechanisms and his or her mutual reinforcements (Kernberg 1993). In patients with neurotic personality organization, the “classic” cases for psychoanalytic treatment, defense mechanisms tend to emerge as blockings or distortions of free association. In fact, this is how the ego’s mechanisms of defense were discovered and described. The analysis of defensive operations, their manifestations, their motivation, and the unconscious impulses against which they are directed may appear as specific contents of the analytic situation.

Defense analysis coincides with what used to be called resistance analysis—that is, the analysis of clinical manifestations of defense operations. Psychoanalytic technique has evolved to consider “resistances” not as forces to be overcome, but as defensive operations to be understood for their unconscious meanings, motivations, and functions (Busch 1996). Such exploration constitutes a central aspect of interpretive interventions. From the perspective of contemporary object relations theory, these defensive operations may be translated into unconscious, defensively activated object relations (dyadic self and object representations) in the transference, which are directed against opposite, and unconscious, impulsively dominated dyadic units of self and other representations. These defensive and impulsive object relations jointly represent the activation of the presently dominant unconscious conflict (Kernberg 2004).

Dream Analysis

Although dream analysis is no longer considered the exclusive “royal road to the unconscious,” it continues to be an important source of information about unconscious processes and represents a focus of interpretation. Dream analysis also has acquired additional importance in the present time as renewed attention to the consistent psychic activity of daydreaming has gained attention under the heading of “waking dreaming” in Bion’s formulation (Civitarese 2014; Ferro 2009). The neo-Bionian approach tends to treat free associations as equivalent to the manifest content of dreams—that is, it attempts to transform even patients’ talking about aspects of their daily reality as if those aspects represented symbols of unconscious psychological processing. This development has led to a renewed emphasis on the value of dream analysis.

In its classical technical approach, dream analysis deals with the manifest content of dreams as surface material to be divided into meaningful partial segments, inviting the patient to associate to these segments of the dream with the expectation that latent content of each of these segments of the manifest dream would emerge. The interpretive integration of the latent meanings of the manifest segments, explored by means of the patient’s free association and the analyst’s corresponding “reverie,” then would lead to the deeper unconscious meanings of the dream.

This general approach to the technique of dream analysis assumes that the manifest content of dreams is the product of unconscious elaboration, by means of “dream work,” of the original, primarily wishful feeling fantasy expressed in dreams. The elaboration of unconscious dream thoughts involves exploring them as reflecting primary process thinking: logic that ignores the principle of contradiction, collapses time and space, tends to represent ideas visually, and uses condensation and displacement as the dream thoughts are undergoing secondary elaboration by the dream censorship, usually leading to a more rational or representational manifest dream narrative. Dream analysis, therefore, involves deconstructing the manifest content while considering all these distorting elaborations and considers the impact of day residue previous to the dream that may have stimulated unconscious infantile wishes. At the same time, it expresses these wishes in the context of the dominant transference situation. Contemporary stress on the stylistic and communicative aspects of dream narratives and Fairbairn’s (1952) proposals that self and object representations may emerge in split forms and through multiple characters of the dream content add further complexity as well as informative value to dream analysis. Dream contents and other characteristics of dreams may point to specific meanings, such as in anxiety dreams reflecting the incapacity to control threatening unconscious impulses fully, examination dreams, dreams that provide gratification of immediate physiological needs frustrated in reality, and so on.

Important questions involve when and how dreams should be interpreted, to what extent they always or at times reflect an affectively dominant issue, to what extent dream analysis needs to be integrated in the analysis of the presently predominant transference, and so on. Chronically repetitive dreams very often deal with various aspects of an essential conflict of the patient and deserve particular attention, because their modifications in the course of treatment may reflect the transference modifications and elaboration of the corresponding conflict. In general, dreams should be interpreted when they seem affectively dominant in the sessions rather than systematically explored whenever they emerge. Dreams have a seductive quality, and their narrative may serve defensive purposes. Very confused dreams may, in fact, be closer to the possibility of their analytic understanding because they reflect a reduced secondary elaboration, whereas some very clear dreams with ordinarily unconscious content erroneously may convey the impression that repressions have been lifted. Undoubtedly, there also are good dreams, in which a significant conflict is being elaborated in an emotionally meaningful way, profoundly influencing the wake life of the dreamer.

Dream analysis depends on the patient’s capacity to carry out free association and optimally is carried out in the context of standard psychoanalysis. In psychoanalytic psychotherapies, dream analysis also requires the patient’s capacity for free association. In TFP with individuals with severe personality disorders, dreams in the early stages of the treatment tend to be explored in terms of their manifest content, linking the meanings of the manifest content to the presently predominant transference. In the middle stages of TFP treatment, partial analysis of the latent content of dreams may be attempted, and in advanced stages, full-fledged dream analysis may be carried out (Yeomans et al. 2015). Dream analysis is usually contraindicated in supportive psychotherapy, except in the utilization of manifest content in terms of the elaboration of the conscious conflict that is explored at that point.

It is rarely possible to elaborate and analyze fully a complex dream within one session. Sometimes the analysis might stretch over several sessions, because other issues may become affectively dominant during that time. Some patients use dream narratives to escape from a realistic examination of their lives. Narcissistic patients may eagerly “interpret” their own dreams in terms of their assumed knowledge and understanding of the meaning of particular contents, and the effect of such self-analysis in the countertransference reaction of the analyst is usually one of empty speculation.

An essential attitude of the patient that may indicate his or her capacity to participate in the analysis of dreams is an authentic curiosity about the unknown that may emerge in the patient’s mind, in clear contrast to his or her competitive intellectualizing attitudes regarding dream analysis, or transference-related devaluation of dream contents.

Acting Out, Enactment, Repetition Compulsion, Working Through

Negative Therapeutic Reaction

Negative therapeutic reaction refers to the paradoxical reactions of patients in psychoanalysis and psychoanalytic psychotherapy expressed by worsening of the symptomatology or destructive transference regressions after becoming aware of the helpfulness of the analyst. Patients get worse after clearly having experienced something good coming their way. It typically involves any one of three potential developments in the psychoanalytic situation. First, it may be the expression of unconscious guilt; second, it may be the expression of unconscious envy of the analyst; and third, it may represent an unconscious identification within a primitive sadomasochistic relationship (see Chapter 9 of this book, “An Overview of the Treatment of Severe Narcissistic Pathology”).

The first case, negative therapeutic reaction as an expression of unconscious guilt, frequently can be observed in cases of depressive-masochistic personality as an expression of profound guilt over being helped by the analyst. The patient harbors the unconscious conviction that he or she does not deserve to be helped or that to be helped implies an implicit injustice carried out regarding a third person, or regarding others who would be more deserving of such help. Unconsciously, the patient may fear that the analyst is not aware of the depth of the patient’s unworthiness or the severity of the patient’s unacknowledged aggression. The unconscious fear of the loss of the dependence on the analyst if the patient were to improve sometimes may be involved. Unconscious guilt over the good relationship with the analyst experienced as a forbidden oedipal triumph is another dynamic one may observe in this development.

The second possibility, negative therapeutic reaction from unconscious envy of the analyst, is a typical development in the psychoanalytic treatment of narcissistic pathology. Here, negative therapeutic reaction expresses the need to deny any dependency on the analyst and an effort to avoid the experienced inferiorization and humiliation perceived as part of the analyst’s “triumphant” capability to help the patient. In a deep sense, the patient’s unconscious envious reaction also expresses the intolerable experience of acknowledging the creativity of the analyst, who has been able to continue helping the patient despite the patient’s resistances and negativity. This dynamic unconscious envy is by far the most frequent form of negative therapeutic reaction and replicates narcissistic patients’ difficulties to learn from others as a major cause of their difficulty in learning and progression in work and studies.

The third type of negative therapeutic reaction is relatively rare. It is experienced by patients who have had a chronic, severely sadomasochistic relationship with a parental object and chronically traumatized patients who have developed the conviction that the only way in which a needed object expresses his or her interest in them is by sadistic attacks or mistreatment. The analyst’s interest in the patient cannot be trusted unless it is motivated by rage or resentment. The conviction that only somebody who hates the patient is really interested in him or her tends to evolve hand in hand with severe self-destructiveness as well as a tendency to attack the analyst or therapist with chronic dangerous acting out. These usually are patients for whom psychoanalytic treatment proper is contraindicated but who may respond to TFP if strict control and limitation of self-destructive behavior, and at times careful supervision of the patient’s life outside the sessions, become part of the conditions under which psychotherapy is undertaken. Here, the need to establish strict parameters around the treatment and abandonment of technical neutrality required by the need to protect the continuation of the treatment and the patient’s life may color the essential nature of the transference. Consistent interpretation of the patient’s needs to have the analyst control his or her life as a condition for survival, as well as a confirmation of the patient’s fantasy of the therapist’s sadism, needs to be carried out again and again as varying circumstances reactivate this transference in ever new forms.

The technical approach to negative therapeutic reaction consists in the interpretation of the respective underlying dynamic and, in the most severe type of negative therapeutic reaction, in the establishment of conditions and control that protect the stability of the treatment. Negative therapeutic reaction out of unconscious guilt is the easiest to detect and resolve analytically. Negative therapeutic reaction reflecting unconscious envy usually requires long-term working through and, in the analyst’s countertransference, the tolerance of negative countertransference reactions within which the analyst may experience a sense of revengeful superiority over the patient who envies the life and capability of his or her therapist.

Somatization

Somatization is a broad spectrum of manifestations of physical symptoms related to psychological conflicts. It is important to differentiate the organic manifestations of illnesses that may present a psychological component as part of their etiology, the so-called psychosomatic disorders, from the direct physical manifestations of psychological conflict that emerge in the psychoanalytic situation under conditions of the activation of these conflicts. These latter physical manifestations of psychological conflicts, which may be properly called somatization in the narrower context of transformation of psychological conflict into somatic expression, include 1) the physical manifestations of anxiety and depression; 2) the symbolic expression of psychic conflict in the form of physical symptoms—that is, the broad spectrum of conversion reactions; and 3) the generalized hyperalertness and concern over physical illness in the syndrome of hypochondriasis. I am referring to hypochondriasis as a stable psychiatric syndrome, in contrast to the occasional hypochondriacal manifestations that are part of what are clearly manifestations of anxiety.

These physical manifestations of anxiety and depression, conversion symptoms, and hypochondriacal concern need to be interpreted in the context of the affectively dominant material that is the interpretive focus in the sessions. They need to be interpreted as part of the defensive and impulsive manifestations of the internalized object relations activated in the transference and are of particular importance in combination with the focus on acting out as combined efforts to avoid the emotional awareness of psychological conflict in the session. Physical symptoms as manifestation of anxiety and depression are most easily identified as part of the patient’s total emotional reaction. Conversion symptoms tend to become prominent in the activation of the corresponding conflicts in the transference and, of course, have more complex relations to the unconscious conflict dominant at any particular time.

Chronic hypochondriasis constitutes a relatively rare but extremely difficult and prognostically reserved form of severe personality disorder, usually within the spectrum of borderline personality organization. Hypochondriacal symptoms typically represent the projection of paranoid defenses against aggression onto the interior of the body. These “internal enemies” protect the patient against imaginary external ones. An unstable equilibrium is achieved by fear of illness and magical procedures to control it. Medical professionals who attempt to assure the patient become allies of the internal enemies. The analytic interpretation of hypochondriacal symptoms typically transforms hypochondriacal pathology into severe paranoid transferences, at times to the level of psychotic regression in the transference. In fact, if an interpretive approach to hypochondriasis is attempted, the analyst or therapist needs to be aware of the extent to which the patient will be able to tolerate an analytic approach without a psychotic regression, which quite frequently may require a shift in the treatment approach to a supportive psychotherapeutic modality.

The Psychoanalytic Field

The “psychoanalytic field” is a relatively new addition to the repertoire of technical psychoanalytic concepts. It stems from the original contribution of Baranger and Baranger (1969) about “bastions,” unconsciously conflictual areas that by unconscious mutual collusion of patient and analyst are excluded from analytic exploration in the sessions. This contribution signaled the importance of exploring the intersubjective processes in the treatment situation occurring in parallel and split off from other transference elements, an interest that also was fostered by Winnicott (1971), who pointed to the symbolic importance of the “frame” of the psychoanalytic situation. He stressed the importance of the stability of the analytic setting and its symbolic function in reproducing, particularly in severely regressed patients, the earliest “space” involved in the intersubjective relation between mother and infant. Ogden (1986, 1989), in turn, generalized the concept of the intersubjective space as an “analytic third” and described the intersubjective field, constructed by projective contributions of patient and analyst, asymmetrically insofar as projective identifications stemming from the patient by far predominate over those introduced to the field by the analyst. Ogden suggested a technical approach to this intersubjective field by utilizing the analyst’s reverie, his or her fantasies involving the emotional experiences of this field, to gain access to the co-constructed “third subject” of analysis. The analysis of the intersubjective field was further expanded in relational psychoanalysis by the analyst’s focusing on the importance of the contribution of the analyst’s personality and countertransference to transference developments, so that a two-way street of transference/countertransference dominates the intersubjective space to be explored.

Neo-Bionian analysts, particularly Ferro (2009) and Civitarese (2014), have further developed the concept and analytic utilization of the psychoanalytic field, assigning major importance to the intersubjective creation of a constantly varying field of emotional experience that the analyst should attempt to capture by his or her alertness to the ongoing development in the analyst of “awake life dreaming” reflecting the transference/countertransference situation. The analyst’s reverie or daydreaming becomes an important source of information determining the interpretive process. As mentioned before, the complementary consideration of the patient’s free association as also representing a form of awake life dreaming to be understood as reflecting deeper unconscious thoughts contributes to an atmosphere of mutually induced narratives by patient and analyst that signals the potential for direct, mutual unconscious communication. The analyst’s evocative, nonsaturated interpretive comments would foster this process. It seems fair to say that this theoretical and technical approach may be a significant departure from standard psychoanalytic approach to interpretation and transference analysis, separating from what I have called the psychoanalytic mainstream, including contemporary Kleinian analysis. In any case, as we have seen, both the relational approach and the neo-Bionians have underlined the importance of this analytic approach to the intersubjective field.

Termination

The psychoanalytic technical approach to termination deals with two main issues: the first issue is the criteria for the termination of the psychoanalysis, involving resolution of the pathology that brought the patient to treatment, normalization of the patient’s personality functioning in all major areas of his or her life, and the assumption of autonomous growth and development. It has been abundantly documented in the literature that such an ideal goal often may not be achieved, and there are varying degrees to which the patient may obtain a significant improvement of his or her personality structure and functioning (Firestein 1974).

The second issue regarding termination is the process of termination itself. It has particular characteristics that must be evaluated and interpretively approached. Termination activates processes of mourning, the respective conflictual aspects regarding mourning derived from the general dynamic of the evolution of paranoid-schizoid defenses into depressive mechanisms, and the tolerance and elaboration of depressive defenses and related sublimatory functioning. Here, Melanie Klein (1950) has provided essential technical criteria in her proposal that, under conditions of the combined and alternating emergence of paranoid and depressive defenses connected with the analytic process following setting a date for termination, it is important to first analyze in-depth paranoid mechanisms and only later the corresponding or related depressive mechanisms. Premature focus on depressive mechanisms may drive paranoid defenses reactivated in the transference underground, whereas full elaboration of paranoid mechanisms and related unconscious conflicts linked to them permits a full-fledged emergence of the processes of the depressive position.

Ideally, the patient’s capacity for analytic work should be reflected in a self-analytic function after the end of the analysis. The general criteria of symptomatic improvement, characterological change, and satisfactory functioning in love and sex, work and profession, social life, and creativity should become evident in concrete aspects of individual functioning. The tolerance of normal mourning processes; aggressive, sexual, and dependent impulses; anxiety; and conflicts around those impulses should go hand in hand with realistic self-affirmation, predominance of sublimatory mechanisms, affect maturation, and, of course, fully satisfactory object relations in depth.

The technical approach to mourning processes first involves their diagnosis. Psychotic intolerance of mourning—with loss of reality testing and emerging psychotic symptomatology—represents the pathological extreme of a spectrum of mourning reaction that includes, at the most severe but nonpsychotic end of the spectrum, the narcissistic incapacity for mourning reflected in the self-protective devaluation of object relations that must be abandoned, including the analytic one. We see this in narcissistic patients who report having no affective reaction to the ending of the treatment. Patients with borderline pathology (but with no narcissistic pathology) and unresolved mourning processes typically present predominantly paranoid reactions with severe separation anxiety, reflecting the unconscious experience of separation and loss of the analyst by projection, as an attack. They evince paranoid fears regarding the attitude of the analyst toward them.

Under the condition of healthier neurotic personality organization, mourning regarding termination may be present but excessive, with a development of idealization, clinging, and a sense of loss of an ideally needed object combined with feelings of unworthiness. When the patient reaches the capacity for more normal mourning, a more realistic mournful remembering of all the positive experiences of the treatment may be activated under the presence of impending separation and constitute the material that needs to be worked through. Mourning reactions at the end of analysis have already been analyzed preventively in patient’s separation reaction to weekends, vacations, or illness during the treatment. The patient’s affective reaction to separations such as depression, anxiety, or rage needs to be explored during the treatment in terms of the specific object relations activated in them. A patient’s tolerance of normal ambivalence in intimate relations, also experienced in the relation to the analyst, is a good indicator of his or her capacity for working through of the depressive mechanisms of the mourning reaction. The analyst’s corresponding countertransference reactions also indicate the extent to which paranoid-schizoid mechanisms have been shifting into depressive ones.

By setting a date for the end of the analysis within a prudent time period, the reactions of the patients may be observed, and a full-fledged analytic approach to the corresponding mourning processes achieved, in preference to a questionable “tapering off,” or gradual reduction of the sessions of the treatment. The patient’s mourning process will not end with the end of the treatment, and he or she must be prepared that under optimal circumstances a process of 6–12 months may be needed for full completion of the mourning over a successfully terminated analysis.

In psychoanalytic psychotherapy, because of the severity of the reactions to traumatic losses and separation and the severity of the incapacity to tolerate ambivalent feelings toward intensely hated parental objects, who quite often objectively may have presented important sadistic features, pathological mourning is frequently present. Narcissistic rage or paranoid reactions are more intense and frequent than those found with patients presenting neurotic personality organization, and these reactions practically become part of the ordinary treatment situation from the very beginning of the treatment. Paradoxically, then, the working through of the mourning reaction related to termination may offer lesser problems with severely ill inpatients. Traditionally, it used to be thought that very ill patients have greater difficulty to end the treatment than healthier ones, but for the reasons just mentioned—the importance of exploring separation reactions during the treatment, and the treatment of narcissistic pathology—we have found that this is not the case. In clinical practice in which severely ill patients are treated with psychoanalytic psychotherapy by therapists who see them as part of their training experience and as part of rotations and then transfer them to other therapists, the analysis of mourning reactions becomes much more important as part of these periods of transition, and the frequent neglect of such reactions is a major cause that determines these patients to stop treatment.

It is of great interest that contractually time-limited, brief psychoanalytic psychotherapies may permit the specific analysis of mourning reactions to termination as part of the overall approach in such a brief psychotherapy. In fact, there is clinical evidence for the effectiveness of such an approach, which constitutes an important application of present-day knowledge of the technique of dealing with mourning processes applied to termination in such brief therapeutic endeavors.

Conclusion

A broad spectrum of psychoanalytic techniques may be used in the conduct of psychoanalytically informed psychotherapies. There is a clear differentiation of the modification of some of these technical instruments required in the case of psychoanalytic psychotherapy, and an overall conceptual integration of the technical approach in psychoanalytic as well as in supportive psychotherapy based on psychoanalytic principles is needed. The basic components of psychoanalytic technique of interpretation, transference analysis, technical neutrality, and countertransference utilization have an important role in all psychoanalytic modalities of treatment, but they imply a precise awareness of the required modifications, particularly as far as depth of interpretation, degree of technical neutrality, and restrictions of transference analysis are concerned. The potentially contradictory effects of the use of psychoanalytic and supportive techniques are an additional important aspect of these applications of psychoanalytic technique to a broad spectrum of psychoanalytic psychotherapies. A supportive psychotherapy based on psychoanalytic principles may be more effective than a chaotic combination of techniques on an ad hoc basis, which is more prone to significant overrun by countertransference developments and problems in the setting up of indispensable protections for the therapeutic frame.

It is hoped that a clear and comprehensive definition of the instruments that characterize standard psychoanalysis and the modifications employed in psychoanalytic psychotherapies will contribute significantly to the empirical evaluation of the efficacy of the entire field of psychoanalytically based treatments and the possibility of its practical application to a broad spectrum of psychopathology. This chapter is a tentative, modest effort to move in the direction of these objectives.

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