The Broken Self: Injured States in The Transference-Countertransference Matrix

David

David entered treatment at age forty-two, a few months before my accident, when I still used but one crutch. When I returned to the office after the accident, he was relentlessly curious about the state of my injuredness. In the months after my return, he repeatedly asked how my leg was, wanting to know whether I would always be using the walker or crutches, and, if the latter, “How many sticks—one or two?” The answers never seemed to register. He would ask again and again. I wondered about that, both to myself and with him. What else might he be asking, or saying, or doing with the act of asking?

We came to understand that one aspect of his questioning revolved around his identification with me in my “injured” state, and around his general preoccupation with bodily injury. David was always going to doctors. Our sessions were filled with his discussion of his appointments to have a mole examined, or to have his arteries scanned by a new neighborhood machine. Not insignificantly, after I returned from my accident he fell down a flight of stairs and broke his foot.

I came to think about how my physical immobility represented for David an aspect of his psychic experience. My injured state seemed to reflect and contain an aspect of the difficulties that prevented him from moving forward in his life. I also began to wonder if his focus on my impeded mobility reassured him that I was stuck there with him. He was particularly dependent on his mother, whom he initially described as a very loving parent, in contrast to the distant, uncaring father he talked about for many years. But as he began to fill in the eventual cracks in the family portraits, he came to describe a very disturbed, chillingly disturbing mother who would threaten the patient’s nephew, her two-year-old grandson, to shut up and behave or he would be thrown away in the garbage and carted away and disposed of. Many more such revelations were to come.

The Genesis and Central Concepts of this Paper

It was during this period that I began to formulate the premise of this paper. It became increasingly clear to me that the idea of a state of injury resonated strongly with patients with disorders of the self, including those we classify as having borderline, narcissistic, or schizoid personality organizations with sadistic and masochistic features. In fact, the psychic life of the primitive patient is itself punctuated by experiences of injury. Injuredness is the very stuff of the treatment narrative. Themes of annihilation, castration, attack, insult, persecution, and retaliation fill many of the treatment hours and are enacted throughout the life of the transference-counter-transference.

I want to elucidate my understanding of certain concepts I will use to understand the clinical material I will present. I conceive of projective identification along the lines suggested by Melanie Klein (1946) and later writers who stayed close to the spirit of her work. In elaborating her ideas about primitive defenses, Klein describes the use of splitting to protect the primitive self from dangerous/unwanted/“bad” aspects and the subsequent projection of these warded-off aspects onto or into the object, necessitating the subject’s entry into that object in order to control the dangerous/unwanted aspects of the self that were expelled. The identification with the object who now contains the expelled bad self sets up the possibility for a more enhanced complementary experience between subject and object, or patient and therapist, that is in line with later thinking not only about projective identification but also about countertransference dynamics.

We can understand projective identification as used by Klein as a central defense employed to ward off experiences of injury, feared injury, and annihilation. It is in fact a predominant form of communication by the more primitive patient. Among other uses, this defense tends to ensure that self/other boundaries remain in a state of flux, keeping self and other entwined, thereby denying the need to experience them as separate entities.

It is not surprising then that the patient with disorders of the self might be prone to notice, experience, and use the visibly injured state of the therapist as a representation in the other of what is wrong with and within the self. Lack of self-cohesion makes it difficult to sustain and describe an internal, intrapsychic experience, let alone tolerate it. The mental representations that we construct during the first months and years of life, and through which we come to experience our self and others, originate from the interplay of our mind, senses, and body parts with our environment and its objects. First body ego, then body image, and eventually self-image all emanate from this early and ongoing interplay.

Freud’s declaration in The Ego and the Id (1923) that the ego is first and foremost a bodily ego is well known. According to Sletvold (2013), Freud argued that internal perceptions are more primordial than perceptions arising externally. In his opinion, the roots of both ego and id are to be found in body sensations and feelings, but he had to admit that very little was known about these sensations and feelings. Only much later was neuroscience in a position to offer evidence that feelings can be the direct perception of the internal state of the body (p. 1019). Sletvold notes that Damasio suggested that “the core of the self might be found in what he, like Freud, terms primordial feelings.” As Sletvold adds, “Not only was Freud able to conceive of the ego as the perception and feeling of our own body but also to conceive of knowing the mental life of another by means of recreating the bodily state of another through imitation” (p. 1019).

Klein (1946), in elaborating her ideas about projection, introjection, and identification by projection, believed that our object relations and our capacity for relatedness are inextricably tied to these developing structures (id, ego, self ) through a series of primitive projective and introjective fantasies organized around our body parts. Hence, body boundaries are vulnerable to distortion as the fantasies are organized and cathected, distorted, rejected, decathected. Not only are our own bodies and body parts the recipient of our own projections and projective identifications, but so too are the bodies, in whole or part, of another person. In escaping what is wrong and projecting it onto (or into) someone else, the vague, invisible, unknown, mentally crippling state becomes a concrete, recognizable, nameable entity belonging to another person. As one female patient, the daughter of a severely narcissistically disturbed mother, told me after years in treatment that “at least with you, I can see your disability, I know where and what it is, it’s okay.”

A brief study by Lussier (1980) is of particular interest. Writing about ego development and deformity, he notes that in fact the children of handicapped parents were found to experience more castrative and disintegrative anxiety than the handicapped persons themselves. The finding suggests that the child suffers from some central aspect of experience in identifying with the handicapped parent. One can ask such questions as how much the child’s experience is shaped by a projective identification from the injured parent, or to what extent by the intergenerational unconscious transmission of trauma from the injured parent. In what way is the child’s experience driven by oedipally organized guilt that the child experiences over his or her unconscious fantasies of killing the parent, or more likely by failure to make reparation to the parent for the injuries? It remains to be seen why in fact the injury makes its greatest impact on the beholding child rather than on the handicapped parent.

The urge to project and expel what feels wrong is the flip side, of course, of aspiring to one’s ideal self and the search for the idealized other. In the best of all treatment worlds, the revisiting and permutation of various shifts in identification lead, eventually, to the building of a more cohesive self. A central challenge inherent in any treatment with a primitively organized patient is the holding and sustaining of the patient and the treatment through various real or imagined injuries, thus preventing an irreparable rupture. Transference-countertransference reenactments around injured states within the treatment are therefore central to the work. My basic thesis is that there is a specific resonance, posing a particular subset of nuances and challenges, when the clinician has a visible injury from the outset that the patient uses in his or her search to expel unwanted feelings, and to eventually glimpse a more acceptable self. Building on Lussier’s small but intriguing study, I will limit myself to presenting a few patients who seemed particularly focused on handicapped states and revealed significant family histories confirming Lussier’s observations. It is my belief that these patients are traumatized by their early identification (or attempted identification) with the deformed parent, and that the parent’s projection of shame around the deformity creates a compelling search by the patient to expel the parent’s projective identification and find a clearer reflection of one’s own identity. I believe that some of these patients are led to choose a therapist who has some sort of “injury,” a physical handicap or some other physical attribute to which the patient assigns a negative, “injured” value (e.g., old age, overweight, racial difference). I will focus on these patients’ use of the visibly handicapped clinician, whose injury is there from the outset of treatment rather than being incurred during the course of therapy or analysis—a situation that would raise a different set of issues.

I have given much thought to the vocabulary surrounding this topic. In our culture, “crippled”—Alan’s word—was replaced in our culture and profession by “handicapped,” then by “disabled,” then again by “challenged,” and then yet again by “ably disabled.” All are euphemisms used to describe a physically impaired state. This seemingly endless revision, this ever changing name-game, helps us avoid confronting and discussing the social and psychological discomfort occasioned by disability in theory and by handicapped people in the flesh. Similar euphemistic evasions are seen in discussions of race, ethnicity, gender, and sexual orientation and preference. It seems the more exposed we feel about our conflicted feelings toward minority groups, the more “politically incorrect” our labels become, the more we resort to new euphemisms, which may originate within the oppressed group itself or be imposed from the outside.

Literature Review

Given the multitude of clinical and theoretical issues involved in patients’ responses to a clinician visibly handicapped from the very start of treatment, it is surprising and yet consistent with this discomfort that there is such a scarcity of literature on the topic. A notable exception is a paper by Anisfeld (1993). Instead, much of what has been written speaks to patient responses to changes occurring to the clinician’s body during a treatment in progress, whether from illness or accident. While pregnancy is not an illness, it is a visibly changing bodily condition of the clinician that has been widely examined (see, e.g., Lax 1997).

Various responses of the patient, the clinician, and the analytic community to the clinician’s visible bodily illness or changes during the course of treatment have been detailed by numerous authors (see Abend 1982; Dewald 1982, 1994; Pizer 1997; Schwartz 1993; Schwartz and Silver 1990; Durban, Lazar, and Ofer 1993; Clark 1995; Chernin 1976; and Dahlberg 1980). These responses include but are not limited to the patient’s rage about being abandoned, as well as guilt and fear that his aggressive wishes and thoughts have damaged the clinician. On the clinician’s side loom feelings of shame and rage, narcissistic injury, and fantasies of castration, as well as fear of being shunned by one’s professional community, a prospect threatening yet another dimension of injury. Tallmer (1992) and Weiss (1997) have taken a broader view of these feelings, noting our tendency to avoid talking or even thinking about aging and retirement, eventualities that raise the specter of our own illness and death.

The issues I am dealing with concern the initial reaction by a prospective patient to a clinician visibly handicapped from the beginning contacts. The presence of a visible physical handicap is but one of many possible features of the clinician’s appearance that may influence whether or not a patient stays for treatment. To be sure, age, race, gender, weight, bodily shape, attire, hairstyle—and, by extension, the appearance of the clinician’s office and the building it’s in—all factor into how prospective patients react and whether they choose to stay or not. In general, little has been written on these additional considerations, and I will say no more about them just now.

Two distinct patterns of patient reactions to a clinician handicapped from the start have been noted in the very scant literature that exists. Freeman (1993) notes, though only in passing, how some patients with a damaged sense of self may experience a resonance with the ill or disabled therapist. A New York Times article, “Disabled Psychotherapists Discuss Their Work” (November 1, 1982), describes how many handicapped therapists, themselves teachers of psychotherapy and psychoanalysis, experienced great resentment from the physically unhandicapped patients being referred to them. These clinicians described being met with rejecting attitudes by these patients, who complained of feeling more defective because of the association, and then meeting skeptical responses when they spoke to their supervisors about these rejections. One way to look at this is suggested by Asch and Rousso (1985), who think the analytic community perhaps avoids disabled clinicians; indeed, they wonder whether handicapped candidates are in fact welcome in training.

One can speculate then that the relative absence of dialogue on this topic both in the literature and the classroom is multidetermined; in part, it seems to reflect the anxiety generated by imperfection, vulnerability, defective self-image, aging, and death. Freud did not himself write about theoretical or technical aspects of treatment that might be impacted by his own visible and malodorous oral cancer and impending death.

Yet another factor in our silence seems to be our reluctance to talk openly about looking and being looked at. Lieberman (2000) notes that looking, being looked at, and talking about looking, are not comfortable topics for us. We are trained to listen, and to be listened to. Yet our patients do look at us, and we look at them, though often we do not discuss it openly. The role of the psychic mirror and the advent of developmental and attachment schools have advanced our thinking about these central issues in our work with patients.

The reluctance to look, be looked at, and talk about mutual looking can in part be traced to appropriate measures instituted by Freud to prevent the analyst’s seduction of the patient; it is also consistent with the broader cultural context within which analytic work developed. Additionally, our own impulses, instincts, and fantasies about peeking, looking, and exhibiting in general may reverberate more uncomfortably and heighten our conflicted feelings around physical imperfections, particularly as they resonate with castration anxieties (Greenacre 1947). The literature is also very scant on the topic of countertransference evocations in working with a physically disabled patient, as C. Reichenthal notes (2004). I believe that still another source of silence on the topic relates to feelings and fantasies we have about people who are different from us, and the cycle of shame, prejudice, anger, and guilt that can result. Archetypes of good and evil are often represented by beautifully formed, idealized characters as embodiments of good, and ugly, at times physically deformed, characters as representatives of evil.

The popularity and psychological draw of the “doppelganger” theme in literature speaks to these mechanisms and urges, and to our fascination with our double. Hence, Dr. Frankenstein’s monster in Mary Shelley’s novel is often mistakenly called Frankenstein, though Dr. Victor Frankenstein was actually the creature’s creator and ultimate victim, self and other. In this regard, I think also of Wilde’s The Picture of Dorian Gray.

Another source of potential bias may be further understood, by considering Freud’s trio of short essays “Some Character-Types Met with in Psycho-Analytic Work” (1916), which describe various forms of self-destructive behavior and the role—or lack thereof—of the superego. One of those character types, “the exception,” was personified by Shakespeare’s Richard III, whose handicap prevented him from developing a good enough superego. Here Freud professes that some cripples born with or developing a handicap early in life (and women, all of whom are born without a penis and are hence “impaired”) lack the capacity to develop as morally as those who are not so physically afflicted. While clinically useful in another context, this essay evinces a negative mindset toward the handicapped clinician from within the profession itself.

To return now to Alan: when colleagues initially registered their shock about his comment to me, I could not share their reaction, for several reasons. The first is that I reacted to Alan’s disclosure as a breath of fresh air: he could tell me what I believe many prospective patients cannot. In his need to do so, he didn’t euphemize the word “cripple” or hide the urge to flee. This was exhilarating in a way, as I was beginning work on this paper and reflecting on the various experiences I am describing. I came to better understand and contextualize the spectrum of patients and range of reactions I encountered. The first group of patients were like Alan, who could not tolerate sitting with me but did not blame me for their reaction and located the difficulty within themselves. In the second group were several patients with body dysmorphic disorder (BDD), who would call me within a few days of revealing their “deformity” issue and tell me that they could not work with me because I was a defective therapist (not “good enough” in a variety of ways they would describe). For these patients, and for those that Coen (1986) describes as having “a sense of defect,” I believe that my physically deformed leg and foot resonated too concretely with an unaccepted aspect of their own defective self, and I could not be entrusted to represent, contain, and help transform their sense of defectiveness. In the third group were the patients for whom my injured state seemed to provide an essential function. They are the ones on whom I focus here. In my experience, the patients in the BDD group and those who experience themselves as having a physical defect (whether they do or not ) do not generally stay for treatment. I do not know if there is a way to predict which patients would benefit by working with a clinician with a visible physical handicap, as there are far too many variables in the mix. Nevertheless, one can ponder the possibilities when encountering a patient who has fled another treatment.

Clinical Vignettes

All of the cases discussed in this papere are psychoanalytically informed psychotherapies, conducted at frequencies of once, twice, or three times weekly. David (presented earlier) and Cheryl came three times weekly, while Susan over the years came once weekly, and then twice a week. All were seen sitting up, face to face with me. Thus, my physical handicap was generally in view. Frame issues were maintained. While food was not allowed in the session, patients were generally allowed to bring in coffee or tea.

Discussion

In the vignettes I have presented, the bodies of Cheryl, Susan, and David seem suffused with the aggressive projections of their maternal introjects—the mental representation of the mother/object the patient has taken in. These were communicated in dreams, action, enactments, and acting-outs, as well as in hypochondriacal and somatized form. All of these patients needed to repeat mother-infant scenarios around nursing and feeding. They each brought in drinks, caused food-related messes, and re-created or reenacted with me a series of treatment messes around the feeding experience. David would set up his lunch in the waiting room outside my office, an open beverage on the floor next to his foot. As crumbs from his sandwich flecked the carpet, he would invite the beverage to soil the floor beneath his nervously thumping foot. As for Susan and Cheryl, both wreaked their own havoc with the beverages they brought in. All three had had a disabled or ill parent (David revealed later in treatment that his father, disabled from his son’s early childhood, died during the course of the treatment); one, even before meeting me, had had a fantasy of the “perfect” handicapped therapist. One dreamed of killing a lame dog and was surrounded at work with lame patients. All had fantasies of being invaded by illness.

What was the difference, the extra dimension, that Cheryl brought to bear that in her case disabled the treatment? I think in part it was this: that the impaired maternal introject itself contained and condensed a complex set of projective identifications from her mother relating to the mother’s own physical defect—a defect her daughter did not wish to see, which for years I was not allowed to “see,” and which, we can hypothesize, Cheryl’s mother did not wish to see in herself. My psychic blind spot resulted from two sources. The first is that I was extraordinarily taxed in trying to rid myself of the unbearable identifications the patient was projecting, which I myself was struggling to evacuate from my own being. This contaminant overloaded an already painfully difficult treatment. In trying to rid myself of this overdetermined aspect of Cheryl’s hatred, and that of her mother (which I believe was an unconscious transmission of her own trauma), I rid myself of her as well. The second, interrelated source was, I believe, the overdetermined role that seeing and not seeing played for the patient, for her mother, and for me.

In an unpublished manuscript, Kronish (2000) enumerates the various uses of projective identifications. Following the work of Caper (1999) and others, he describes how for some patients communication in the treatment may eventually be furthered through the transfer of unconscious fantasies encoded in the patient’s projective identifications. Other patients use projective identifications for the purpose of “ridding” affect, and blocking communication and empathy. Cheryl seemed to do both. Hiding and seeking, seeing and avoiding, played an even more dominant role than I recognized during our work.

I understand in retrospect that being with Cheryl during this last phase of treatment brought about a collision of her projective and my introjected identifications, leading to my being virtually blindsided. The sequence of my injuries in an accident, followed by her revelation first of her mother’s abrupt weaning of her and then of her mother’s physical defect, resulted in a gradual shedding of our injured selves. My need to rid myself of feeling disabled, and her need to insist on how defective I was, did not at first allow me to understand the progress that should have been evident in her attempt to shed the maternal projective identifications through which she had been damaged. Her frequent need to hide and then exhibit herself, her need to constantly reassure me and herself about her prettiness, and all of the enactments around hiding and not seeing were, I believe, unconscious communications from her mother, who seems to have split her own self-representations into the patient and her sister, and into split responses to the patient. Witness the ricocheting series of projections from Cheryl to her obese, bedridden patient to me and to her sister. While clinical material over a longer treatment, or an analysis proper, may well have better substantiated some of these ideas, I present them as useful and informative ways of understanding the clinical events.

The coffee shop enactment with Cheryl thus reflected all of the following: her not seeing her mother, her mother not seeing her, and my not seeing her mother within her. It also encapsulated her not wanting to see her injured mother, and my not wanting to see my injured self. Lilliputians all, we could maintain split and hence partly false representations of ourselves as long as we did not see anyone seeing us in these ways, and so long as they did not see us not seeing them. Cheryl’s coming in with her clothing inside out truly reflected these inside out psychological states. Ironically, it also suggests the kind of transpositions that occur in mirror-images. We never truly see our own bodies as a whole, as Greenacre (1958) recognized. We see reflections, images, and an externalization of our self-image, a distillation of mental representations and fantasies of ourselves that we have taken in alongside and through the mental representation of the other who helps form this psychic picture for us. The coffee shop encounter in which I did not see my patient sitting next to me thus became a paradigm of other, less visible enactments around hiding and seeking, blinding and looking.

This confusion reverberates with Fonagy and Target’s description (1998) of the difficulty facing the young child who has experienced an empathic failure by its mirroring object. The child, continually seeking to find him- or herself in that object, instead finds aspects of a projected defectiveness transacted again and again between self and object. Fonagy and Target call attention to this series of sadomasochistic transactions as a special category of projective identification, one paralleling the confusion and externalization seen in the creation of a monstrous alter ego and the simultaneous destruction of self/other relations. This is the very experience described in Shelley’s Frankenstein.

It is the clinician’s ability to tolerate the projection of the patient’s monstrous or distorted self that Fonagy and Target consider crucial for the patient’s capacity for mentalization and developmental progression. This accords with what we know from Winnicott, Kohut, and Fonagy and Target: the process parallels what the “good enough” mother must do in giving the baby appropriate moments of holding, containing, and mirroring. The failure of his parents to accurately see their child, Victor Frankenstein, or later of the adult Dr. Frankenstein to see his monster, results in the tragic, murderous arc the monster embarks upon. Not being seen, not being recognized, not being given a self, leads to pathological narcissism and disastrous omnipotence.

Bouchard, Normandin, and Seguin (1995) note that countertransference is both an instrument to further treatment and a potential obstacle to it, and classify the types of mental activity involved. In so doing, they take into account both the more restrictive classical definition, where countertransference is related solely to the clinician’s unresolved transference issues, as well as the more comprehensive definition advanced by Kernberg (1975) and others. In the latter, the clinician’s response to the patient, and to the patient’s unconscious communications, distills and condenses the unconscious fantasies of both patient and clinician. When countertransference is used appropriately by the clinician, previously unavailable material can be accessed to further the treatment. Central to this comprehensive model is that the therapist is not only receiving and containing the projective identifications of the patient, but that once the projection is taken in, or received, it becomes an introjected identification and at that point belongs to the clinician as well as the patient. How that is used and deconstructed is essential, as it encapsulates essential aspects of the clinician’s personal history and how that is impacted by, and in turn impacts, the patient’s history.

Katz (2005) has described how a series of enactments may flow beneath the surface of a treatment until erupting in a critical incident she calls the “geyser.” That paradigmatic eruption gains its momentum from the multiple layers of enactment it contextualizes and contains. So it was at the coffee shop that day with Cheryl. I did not recognize the full import of the implicit rupture occurring as she sat near me, and thus was unable to decode the situation in time to help her sustain her presence in the treatment. However, as I have formulated and elaborated my understanding of what happened since that point, other treatments have been able to progress. Additionally, my own sense of self has been reintegrated; I am now both less needful of ridding myself of the “injured” label and better able to decipher the countertransference aspects of treatments with primitively organized patients.

Moving away from the difference in these cases provides a useful clinical summary. All three of these patients—Cheryl, Susan and David—present a picture consistent with Ogden’s description (1977) of excessive maternal projective identification. I believe that the psychological defectiveness with which in each case that excessive identification was suffused led these patients to fantasies that they had, or wished to have, malignancies within themselves; they experienced their minds, or insides, as attacked and rotten. These patients each had a preoccupation with their skin. David, touching and wiping various moles and sweating continuously, was at the edge of his body “envelope.” Susan scratched at her skin’s surface, while Cheryl constantly touched and rubbed her face, arms, and legs. Each of them struggled to stay on the edge of themselves, to sustain an experience of being boundaried and contained, but at the same time had difficulty looking “in.” Their fragile sense of self made it difficult, at times impossible, to feel the inside of their self, the contents of their mind, and, I would suggest, the inside of their body. Rather, staying at the skin’s surface allowed them to remain joined with me, and to deny their own sense of internal emptiness and damage. The compulsive need of these patients to touch, to confirm, their physical boundaries and boundedness is consistent with Ogden’s description (1989) of those in the autistic-contiguous mode who must defend against the terror of disintegration. At the same time, repetitive engagement with their physical selves seems to represent struggles with yet unconscious identifications and disidentifications with the impaired parent.

It is here therefore that we begin to think about the difference in treatment with patients less psychologically impaired than those I have presented. In the treatments with Cheryl, Susan, and David, much of what was learned came though projective identification and enactment, rather than through verbalization. The early work with such patients—sometimes lasting years—is largely around helping them mentalize and begin to own the affect they are attempting to expel. The work is driven largely by the dyad’s surviving and decoding a series of reenactments. This is not to suggest that a more oedipally organized patient does not enact or reenact. When that occurs, however, it generally is around very early experiences that are not yet remembered with cohesive words and symbols, or are repressed. The hope is that analytic work will eventually enable those memories to emerge. For instance, another patient—a young man in his early thirties—often withheld critical pieces of information from me, as well as from colleagues and friends, and conveyed a sense of haughty superiority in knowing things none of us were even aware of. Often people felt tricked by him. His revelation, after eight years of treatment, that his mother was physically handicapped eventuated in an understanding and reformulation of the defensive functions of his withholding information from others: he could not bear to look at his mother’s impaired body. He held a memory (probably a screen memory) of first seeing her deformity as a toddler, and kept this childhood discovery a secret from himself that he rediscovered only in adolescence. As in Cheryl’s case, his mother was described as having been able to hide her deformity, though, again as with Cheryl, it is unlikely that this was entirely so. The patient played a trick on himself, as he played tricks on others, repeatedly withholding information and leading others to feel—and be—handicapped. When a more useful and accurate interpretation could be made of his behavior, we could begin to work on his hurtful and self-hurtful behavior, linking it with how he needed to hide from himself his experience of seeing his mother’s deformity. Notably, years after he entered treatment, but long before he revealed the fact of his mother’s deformity, he disclosed that he had felt an instant sense of simpatico, a kind of “twinship” with me, on our very first meeting. Only later would I come to understand this twinship as an identification with me, and with his mother, in our injuredness. But this understanding came only after his revelation of his mother’s handicap.

One might ask, whether we are working with a primitively organized patient or a more oedipally organized one, why the “blind eye” in the transference-countertransference matrix recurs? That blind eye has, in my opinion, been co-constructed between me and each of the patients I have discussed as a projective identification transmitted unconsciously and across generational boundaries, when it then finds a space in which it reverberates with me.

It is here that Lussier’s point about the castration or disintegrative anxiety suffered by children of handicapped parents seems especially relevant. I suggest that this extreme anxiety arises from several sources. First, I believe the predominant source of this anxiety is the presence not only of a physically handicapped parent but, preceding that and far more important, of a not good-enough mother or mothering figure. This absence of good enough mothering sets the stage for an experience of empathic failure that leads to the internalization of a psychically defective introject and a resulting inability to contain primitive anxiety and feel whole. This then complicates the child’s journey from Klein’s paranoid-schizoid mode to the depressive position. In a related development, seeing the handicapped parent reinforces for the child the fantasy of having physically damaged the parent. The discovery and sight of the parent’s disability or deformity is too much to bear, and no mention is made of it or conscious awareness kept, except perhaps in a very split-off space. I hypothesize that that these factors account for the very long delays in my patients’ revealing their parent’s handicap.

A third source of the child’s anxiety regarding the physically handicapped parent is related to shame. This shame is twofold: (1) shame felt by the child upon discovering his or her difference from the parent and (2) shame resulting from the child’s identification with the deformed body of the parent (on the child’s identification through his body with the body of another, see Sletvold 2013, p. 1019). We thus have the handicapped clinicians who spoke in the New York Times article of their patients’ anger at assignment to a handicapped therapist, making them feel ashamed and defective themselves.

It is striking that in the cases of Cheryl, David, and Susan the father was essentially absent: deceased early in the child’s life (Cheryl); passive via alcoholism and neglect (Susan); factored out by illness and disability (David). Thus, the emotionally aggressive maternal introject does not seem to have been neutralized in any meaningful fashion during my patients’ development. David vacillates from injuredness to monstrousness, perhaps identifying with his impaired father and then with his monstrous mother.

Of course, we cannot know to what degree my handicap’s visibility keeps knowledge about a handicapped parent from being remembered or revealed for a longer period than it would be with a clinician who is not visibly handicapped. Is the patient more embarrassed, and/or do I substitute for the patient’s parent in a way that defers the necessity of acknowledging or confronting the parent’s disability? This is something for future thought.

These ideas lead naturally to speculation about how “this” patient—one who experiences an impaired or injured self—would use a clinician who is not visibly handicapped from the outset of treatment. Colleagues often share how certain patients attack or compliment them on various manifestations of their appearance, or the appearance of their office, or the “appearance” of their accomplishments—a paper or presentation, a book, whatever. Latent material suggesting idealization or denigration represents various projections from the patient that may resonate with some of the issues I have presented. Some patients who cannot stay with me do not need the concrete physical representation of what feels injured within them; rather, they seek its polar opposite: the idealized, restituted, more perfect concretization. For these patients, any perceived deficiency in the clinician’s outward appearance—overweight, signs of aging, unfashionable hair style, drab office decor or undesirable location, and so on—could be cause for rupture. Klein (1946) noted that the narcissistic projection of idealized or unwanted parts of the self can result either in an object who is loved and admired, or one from whom the self must withdraw in order to prevent both a destructive intrusion into them and the danger of retaliation from them.

Finally, in trying to formulate the central conceptualization of this paper, I wondered about my use of injuredness as a metaphor. Metaphor implies the presence of, or capacity for, symbolic process; yet the patients described here are not inclined to symbolized thought, or even much inclined toward thinking at all. They are instead inclined to action—to acting out, enactment, concreteness, and somatization—as opposed to thinking about themselves, their feelings, their fantasies, and formulating psychological and symbolic process. So if I hypothesized that my injured state serves as a focal point for an identificatory process, could that be? Interrelated responses to this question speak to many issues.

Both patient and clinician will sometimes lose the ability to think clearly; faced with an overwhelming series of projective identifications and reenactments, they may turn a “psychic blind eye” on the goings-on. At times this is necessary and unavoidable; deconstructing these experiences and episodes are what may ultimately decode, sustain, and repair the treatment and move it forward. When this cannot occur, the treatment derails.

I suggest that in these states a number of processes are occurring. First, a powerful projective identification from the patient temporarily threatens the mental and affective capacity of the therapist. Aspects of that projection are based on the patient’s identification with an injured or ailing therapist. The injuredness of the therapist is thus seen as occurring on multiple levels: (1) Her body organizes and serves as a physical representation of the psychic pathology/fantasy the patient has disowned. (2) This representation has been disowned by the patient in the form of a projective identification and becomes an introjected identification of the therapist, complete with mental, physical, and affective meaning for the clinician. (3) However suffused with the patient’s aggression the projection originally was, it now belongs to the therapist; it thus becomes further complicated and may become deformed by the intensity of the clinician’s history. Resulting countertransference pressures may then lead to the clinician’s urge to disown aspects of her own disabled self. (4) In attempting to shed the many layers of toxic and disabling introjects, the therapist may expel not only aspects of the patient, but the patient him- or herself, who has become enmeshed in this complicated process. Recognizing, understanding, and intervening in the consequences of this expulsion allows treatment to proceed in some cases. In other situations it will result in the disabling of the treatment.

Conclusion

My premise has been that a certain subgroup of patients with disorders of the self experience a particular resonance with the “injuredness” of a physically handicapped clinician. Certain of these patients may use that clinician in particular identificatory stances, trying to rid themselves of the damaged maternal introject that has made them feel injured or defective. The handicapped clinician may at times be unable to use the introjected identifications of these patients to understand treatment dynamics. In such situations, a series of enactments may cause the disabling of the treatment itself.

At other times, the therapist may work with countertransference projections and introjections more successfully. When that occurs, decoding the meanings and functions of an injured identification may enable a richer and more successful treatment experience for both partners in the therapeutic dyad. Where treatment does proceed and succeed, disavowal and projective identification are less needed as defensive maneuvers, and a less injured, more cohesive self may emerge over time. I believe that much of this work occurs with the clinician’s ability and willingness to tolerate accepting, holding, and containing the defective introjects that make the patient feel full of impairment, monstrousness, and malignancy, without too quickly returning them. In this way, over time, the patient’s capacity to develop and tolerate metaphor, shed toxic identifications, and emerge from a series of complex mergers with injured and injuring introjects has a chance to take hold.

One can wonder how the course of treatment, the richness and profundity of the data, and the outcomes would have differed had these treatments been analyses rather than psychoanalytic psychotherapies, which are more limited in scope and more influenced by the patient’s primitive organization.These are speculative questions. Hausner’s paper (1994) on the limitations and difficulties of analytic technique and issues of abstinence with preoedipally organized patients is useful to consider. Nevertheless, the resonance of the material and the repeated evocation of the psychic blind eye in the transference-countertransference matrix suggest the relevance of the ideas I have presented.

If we can learn anything from Gulliver and the Lilliputians, it is this: in our mind’s eye, we are shamed when we “see” ourselves being seen as defective. We wish to be blinded, at least psychically, rather than witness and experience the unbearable shame attendant on seeing ourselves as damaged in the mirror and mind of the other. This is, of course, the very reverse of the more optimal outcome that Winnicott (1965) describes as facilitated by “good enough mothering.” In its presence, what we may expect to see in the psychic eye of the beholder is a “good enough” version of ourselves, which is then reflected back for us to experience. I hope I have provided a useful lens through which to look at these issues.