Abstract
We suggest that when diffucult patients attack our grandiosity and sense of self, we are vulnerable to countertransference anxieties similar, if not identical, to the kind existentialists refer to as “ontological”. The latter refers specifically to a threat to our psychological equilibrium and is meant to describe the utter ambivalence we associate with death anxiety. In this paper, we are proposing the presence, in certain therapeutic situations, of just such counter-transference reactions to so-called “aversive” patients. We believe that terms like “aversive”, “obnoxious”, or “impossible” are professional euphemisms used to mask the degree of anxiety we often feel, and that there is a collusion present both within and without our profession, especially in psychotherapeutic and psychoanalytic centers, which keeps us from exploring death-related issues within ourselves as well as in our patients.
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References
See Mahler, M.; Pine, F.; and Bergman, A.,The Psychological Birth of the Human Infant. New York, Basic Books, 1975.
Among the exceptions we cite Becker, E.,The Denial of Death. New York, The Free Press, 1973; Burton, A., “Fear of Death as Countertransference.” InModern Humanistic Psychotherapy. San Francisco, Jossey-Bass, 1970, pp. 106–124; McCarthy, J.B.,Death Anxiety: The Loss of the Self. New York, Gardner Press, 1980; Moss, D.M.; McGaghie, W.C.; and Rubinstein, L.I., “Medical Resistance, Crisis Ministry, and Terminal Illness,”J. Religion and Health, 1978,17, 99–116; Searles, H. S., “Schizophrenia and the Inevitability of Death.” InCollected Papers on Schizophrenia and Related Subjects. New York, International Universities Press, 1965, pp. 487–520; Wahl, C. W., “The Fear of Death,”Bulletin of the Menninger Clinic, 1958,22, 214–223; Yalom, I.,Existential Psychotherapy. New York, Basic Books, 1980; and Zilboorg, G., “Fear of Death,”Psychoanalytic Quarterly 1943,12, 465–475.
Rosenberg, H., “The Fear of Death as an Indispensable Factor in Psychotherapy,”Amer. J. Psychotherapy, 1963,17, 619–630, 620. We believe not one session goes by in which death is not alluded to. Its ever-present reality, however, is often expressed metaphorically, i.e., through patients' symptoms or complaints. We can detect the fear of death, for example, in agoraphobia, panic attacks, fears of abandonment and individuation, even depressions. See also Becker,op. cit. The Denial of Death. New York, The Free Press 1973; McCarthy,op. cit. Death Anxiety: The Loss of the Self. New York, Gardner Press, 1980; and Yalom,op. cit. Existential Psychotherapy. New York, Basic Books, 1980.
This stand is in harmony with other clinicians and psychologically-minded theoreticians. Among others, we cite Abraham Maslow and Karl Menninger. Both address the defensive purposes to diagnosing patients. Irvin Yalom concludes: “The standard diagnostic formulation tells the therapist nothing about the unique person he or she is encountering; andthere is substantial evidence that diagnostic labels impede or distort listening,” op. cit., p. 410 [emphasis ours]. See also Maslow, H.,Toward a Psychology of Being Princeton, N.J., D. Van Nostrand Reinhold, 1968, esp. ch. 9, “Resistance to Being Rubricized,” pp. 126–134; and Menninger, K.; Mayman, M.; and Pruyser, P.,The Vital Balance. New York, The Viking Press, 1963, esp. ch. 2, “The Urge to Classify,” pp. 9–34.
May, R., “Contributions of Existential Psychotherapy.” In May, R.; Angel, E.; and Ellenberger, H. F., eds.,Existence, New York, Basic Books, 1958, p. 50.
Winnicott, D. W., “Hate in the Countertransference.”In Collected Papers: Through Paediatrics to Psychoanalysis. New York, Basic Books, 1958, pp. 194–203.
See, for example, the works of Adler, G., “Valuing and Devaluing in the Psychotherapeutic Process,”Archives of General Psychiatry, 1970,22, 454–461; “Helplessness in the Helpers,”British J. Medical Psychology, 1972,45, 315–326; Gorney, J. E., “The Negative Therapeutic Interaction,”Contemporary Psychoanalysis, 1979,15, 288–337; Groves, J. E., “Taking Care of the Hateful Patient,”The New England J. Medicine, 1978,298, 883–887; Maltsberger, J. T., and Buie, D., “Countertransference Hate in the Treatment of Suicidal Patients,”Archives of General Psychiatry, 1974,30, 625–633; Masterson, J.,Countertransference and Psychotherapeutic Techniques. New York, Bruner/Mazel, 1983; and Poggi, R. G., and Ganzarain, R., “Countertransference Hate,”Bulletin of the Menninger Clinic, 1983,47: 15–35.
Seeop. cit.; Lipsitt, D. R., “Medical and Psychological Characteristics of ‘Crocks,’”International J. Psychiatry in Medicine, 1970,1, 15–25; and Martin, P., “The Obnoxious Patient.” In Giovacchini, P. L., ed.,Tactics and Techniques in Psychoanalytic Therapy, vol. 2. New York, Jason Aronson, 1975.
The list of those authors adhering to this stand is too long to enumerate here. Among others we findop. cit., Brown, N.,Life Against Death. New York, Vintage Books, 1959; Feifel, H., “Death-Relevant Variable in Psychology.” In May, R., ed.Existential Psychology. New York, Random House, 1960, pp. 58–71; Heidegger, M.,Being and Time. New York, Harper and Row, 1962; Lifton, R.,The Broken Connection. New York, Simon and Schuster, 1979; Rank, O.,Will Therapy. New York, Alfred A. Knopf, 1964; and Sartre, J. P.,Being and Nothingness. New York, Pocket Books, 1956.
Tillich, P.,The Courage to Be. New Haven, Yale University Press, 1952, pp. 35, 38, and 39.
Death anxiety in the countertransference is also akin, we believe, to the experience of disintegration anxiety of which Kohut speaks. Such experience, for him, has two equally powerful and inextricably intertwined components. The first, as the term “disintegration” suggests, is the dread of the dissolution or breakup of the self; and the second is the anxiety of having no one to be reassured by or who can empathize with our terror. In its essence, disintegration anxiety is nothing else but an anxiety of finding oneself completely annihilated. Cf. Kohut, H.,How Does Analysis Cure? Chicago, The University of Chicago Press, 1984. See also Laing, R. D.,The Divided Self. New York, Penguin Books, 1965, esp. ch. 3, “Ontological Insecurity,” pp. 39–61.
—, p. 36.
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See, for instance, Freud, S., “Thoughts for the Time on War and Death.” (1915) InThe Standard Edition of the Complete Psychological Works of Sigmund Freud, vol. 14. London, Hogarth Press, 1957, pp. 289–302.
—, pp. 27, 186. Yalom concludes, convincingly we believe, that there are two specific and interchangeable defense mechanisms used to ward off the terror of death. The first is the assertion of one's own specialness (“the belief in one's personal inviolability”), and the other involves an attempt to transcend the fear by merging with someone or some cause (“the need for a rescuer”). With regard to therapists, some authors speak of the “God complex,” of “the tendency to cloak oneself in mystery,” even of the eagerness to find mentors in an effort to cope with their insecurities and disintegration anxieties, yetnone of these authors acknowledge death anxiety as a potential trigger to these attitudes or behaviors. As Yalom says: “A sense of specialness is one of the most common and potent death-denying defenses. ... To the extent that one attains power, one's death fear is further assuaged and belief in one's specialness further reinforced,” Yalom,op. cit. Existential Psychotherapy. New York, Basic Books, 1980, pp. 47, 121. See also Farber, L. H.,The Ways of the Will. New York, Basic Books, 1966; Greenson, R. R., “The ‘Real’ Relationship Between the Patient and the Psychoanalyst.” In Kanzer, M., ed.,The Unconscious Today. New York, International Universities Press, 1971, pp. 213–232; “Beyond Transference and Interpretation,”International J. Psychoanalysis, 1972,53, 213–217; Jones, E.,Essays in Applied Psychoanalysis, vol. 2. London, Hogarth Press, 1951., esp. ch. 12, “The God Complex,” pp. 244–265; Marmor, J., “The Feeling of Superiority: An Occupational Hazard in the Practice of Psychiatry,”American J. Psychiatry, 1953,110, 370–376; Sharaf, M. R., and Levinson, D. J., “The Quest for Omnipotence in Professional Training,”Psychiatry, 1964,27, 135–149.
We are well aware of the controversy surrounding the definition of “projective identification.” By such a concept we are here referring to Robert Langs's understanding of this interactional process. He explains: The word identification is used in a very unusual way in projective identification. Usually identification is an intaking process: I take in from you something of yours, an attribute or whatever, usually unconsciously, and modify my own selfrepresentation, psychic structures, and self based on this incoming identification. Projective identification is an outgoing process, in which I attempt to have you identify with me, I evoke in you something of my own inner state so that you will experience it and identify with me. (Langs, R.,The Listening Process. New York, Jason Aronson, 1978, p. 124.)
Much, in fact, has been written about acute anxieties in the countertransference with “aversive” patients, butnone of these contributions, to our knowledge, has linked such reactions with death anxiety. Among many other references we cite the following: Altshul, V., “The So-Called Boring Patient,”Amer. J. Psychotherapy, 1977,31, 533–545; Cohen, M. B., “Countertransference and Anxiety,”Psychiatry, 1952,15, 213–243; Dean, E., “Drowsiness as a Symptom of Countertransference,”Psychoanalytic Quarterly, 1957,26, 246–247; Gorney,op. cit. “The Negative Therapeutic Interaction,”Contemporary Psychoanalysis, 1979,15, 288–337; Kulick, E.M., “On Countertransference Boredom,”Bulletin of the Menninger Clinic, 1985,49, 95–112; McLaughlin, J. T., “The Sleepy Analyst: Some Observations of States of Consciousness in the Analyst at Work,”J. Amer. Psychoanalytic Associations, 1975,23, 363–382; Wangh, M., “Some Psychoanalytic Observations on Boredom,”International J. Psychoanalysis, 1979,60, 515–527.
Indeed, sometimes the anxieties and acute unpleasant states must be attributed more to the therapist's personality than to the patient being treated. We often see such obvious dynamics in beginning psychotherapists, for instance. People they counsel often appear “aversive” to them because their patients do not get “cured” quickly enough or reveal themselves at a slower pace than these helpers expect them to. In supervision, the therapists complain of slower pace than these helpers expect them to. In supervision, the therapists complain of helplessness, impotency, even anger at their patients for such slow pace, without recognizing their own contributions to the therapeutic process.
“Empathy,” says Ralph Greenson, “[is a] tentative form of identification.” “Empathy and its Vicissitudes.” In Langs, R., ed.,Classics in Psychoanalytic Technique. New York, Jason Aronson, 1981, p. 248. See also “The Struggle Against Identification,”J. Amer. Psychoanalytic Association, 1954,2, 200–217.
Kohut, H.,The Analysis of the Self. New York, International Universities Press, 1971;The Restoration of the Self. New York, International Universities Press, 1977.
Becker,op cit.
E.g., see Searles, H. S.,Countertransference and Related Subjects. New York, International University Press, 1979.
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He is Director of Psychological Services at the Parkside Weight Loss Clinic, an interdisciplinary eating disorders program affiliated with the Lutheran General Health Care System.
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Lacocque, PE., Loeb, A.J. Death anxiety: A hidden factor in countertransference hate. J Relig Health 27, 95–108 (1988). https://doi.org/10.1007/BF01532067
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DOI: https://doi.org/10.1007/BF01532067