Countertransference hate & love in psychosis psychotherapy
December 25, 2004
In a recent email communication with Ann Silver in which I was discussing the current status of some of my patients, she pointed out that at this time of year, (with the holidays) there is often an increase in transference hate (which is reflected in my increase in countertransference hate). Ann and Bert Karon, in a recent conference call, were very encouraging in my writing a new article on this subject. This has been spurred on by a significant increase in my feelings of murderous hatred for one of my delusional patients who in the past became convinced he needed to kill me before I had a chance to kill him (causing him, in one session, to get up from a sitting position to attack me - a quick reaction on my part threatening to call the police resulted in a stabilization of the crisis).
Currently this person is visiting his family for the holidays resulting in a resurgence of fears of being taken over, controlled and killed off by various family members (i.e., the permeability of his ego/self boundaries has increased as symbiotic wishes for fusion and containment has increased). We are doing phone sessions since he is in another state (safer for both of us to contact deeply repressed and dissociated paranoid hatred).
In one particularly difficult session in which I felt utter hate and contempt for him as well as fear for my physical and mental safety and a deep despair over his eventual recovery, he recounted numerous somatic delusional experiences involving his family (and me in the transference) in which they were stealing different parts of his body and psyche in order to build themselves up at his expense resulting in a murderous rage in which he threatened to axe his brother to death. .I worried over whether I should have the family contact the police to prevent such a catastrophe (unconsciously, I probably was wishing for such an event in order to get rid of the lot of them). I sat with my sense of disturbance while remaining in close emotional and mental contact with him (frequent phone calls etc). The crisis, as the previous one, resolved with my being firm yet receiving of his murderous paranoid hate. I told him that we would see this thing through together and continue to work on this when he returns to my office. In fact, I asked him if he might return immediately to New York so we could work on this in person.
In the next phone session, his delusions were much abated as was his murderous hatred. He expressed tender feelings for me and his family. I was encouraged by his capacity to endure his sense of vulnerability. He was able to draw upon enough ‘good object’ experience to counteract his profound sense of helplessness.
Gaetano Benedetti related that countertransference hate is a necessary and useful form of emotional contact in working psychoanalytically with psychotic patients. The key to therapeutic action is to also maintain one's love for the person so that if we can integrate the hate and love (love often mitigates the profound countertransference anxieties one feels in working in depth with very paranoid and delusional persons) in ourselves it helps the psychotic patient in their counteridentifications to do the same thereby easing the fount of their psychosis.
Brian Koehler
New York University
80 East 11th Street #339
New York NY
