Excerpts from Must Read Books & Articles on Mental Health Topics
Books, Part XV

 Wounded Healers
Thomas Maeder

"What asylum doctor has not had his own attack of madness by dint of continual association with madmen? ... But before that, what obscure inclination, what dreadful fascination had made him choose that subject?"-Marcel Proust

"I think that my parents were crazy, and I think that, somehow, being psychiatrists kept them in line. They used it as a protection. They're both quite crazy, but their job gave them a really good cover."- a child of psychiatrists

Alfred Adler, according to his son, once said, "I think I could make out of a sadist a good butcher--perhaps even a good surgeon." He would need to imbue the sadist with social interest and modify certain patterns of behavior, and he would end up with a constructive member of society who nonetheless retained the sadist's underlying personality pattern and motivations. One might wonder what sort of pathological type Adler would have selected as raw material for a psychotherapist.
    One does not need to search for pathology to explain career choice any more than one needs underlying scatological or sexual explanations to understand every innocuous bit of behavior. Altruistic people, who work hard to help others, should not be suspected ipso facto of harboring ulterior selfish motives. Nonetheless, the "helping professions," such as nursing, charitable work, the ministry, and psychotherapy, attract people for curious and often psychologically suspect reasons. Something is a bit odd about people who proclaim "I want to help other people"--the underlying assumption being that they are in a position to help and that others will want to be helped by them. Such people may be lured, knowingly or unknowingly, by the position of authority, by the dependence of others, by the image of benevolence, by the promise of adulation, or by a hope of vicariously helping themselves through helping others. Though some helping professionals have humbly and realistically perceived that they have something to offer and are willing to accept the responsibilities inherent in their calling, others use the role to manipulate their world in a convenient, simplistic manner, ultimately failing to take responsibility and using authority precisely to avoid it. For such people their job is not merely a way to earn a living: it is the essence of their lives.
    It is a commonplace that psychotherapists are crazy, and that this is probably what led them to their jobs. "What still strikes me," one woman I interviewed said, "is I'll go to a party in New York, and inevitably the craziest person there is a psychiatrist. I mean the person who is literally doing childish, antisocial things, making a fool of himself and embarrassing everyone else. I just shrug. That's the way it is." A president of the American Academy of Psychotherapists once said, in an address to the members of his organization, "When I first visited a national psychiatric convention, in 1943, 1 was dismayed to find the greatest collection of oddballs, Christ beards, and psychotics that I had ever seen outside a hospital. Yet this is to be expected: psychotherapists are those of us who are driven by our own emotional hunger."
    Psychotherapists often take a perverse delight in criticizing their peers, and the amount of abuse I have heard them heap upon one another is truly astounding. Psychiatrists often say that analysts are crazy. Analysts say that psychiatrists, being unanalyzed, are crazy. Both of them say that social workers and psychologists, whose training is more limited and subject to fewer quality controls, are crazy, and are particularly harmful because a little bit of knowledge is a dangerous thing. Social workers and psychologists accuse psychiatrists and analysts of being pompous asses--pompous crazy asses, so puffed up with theoretical abstractions that they arc out of touch with the real world.
    "I very rarely have found a healthy, well-integrated, happy person seeking this profession," one training psychoanalyst says. Another man, a clinical psychologist, told me, "I questioned your calling it a myth that therapists are crazy because the fact is that most of them are. If you need any proof, let me tell you that every patient who comes into this office who has had a previous experience with another therapist has some kind of horror story to tell, about some major failing on the therapists part, including, quite often, sexual abuse, verbal abuse, things that cross the boundary of mere bad technique and some pretty damn close to the criminal."
    Various statistical surveys of the psychopathology of therapists have been published, but this literature yields inconclusive results. In one study 91 percent of psychiatrists surveyed agreed that psychiatrists had "emotional difficulties that are special to them and their work as contrasted with non-psychiatrists." The psychiatrists said, however, that some of these problems were related to the personalities of people who went into the field, and others stemmed from the nature of the work. Few considered their "emotional difficulties" to be diagnosable clinical problems. But an interesting Swiss study compared the military conscription records of people who subsequently became psychiatrists with the records of those who became surgeons and internists, and found that significantly more of the eventual psychiatrists were declared unfit for military service because of psychiatric disorders.
    In another survey, this one of psychologists, social workers, counselors, and other nonmedical psychotherapists, 82 percent of respondents said they'd had relationship difficulties, 57 percent had experienced depression, 11 percent admitted to substance abuse, and 2 percent said they had attempted suicide. Again, the survey does not make clear how serious the relationship difficulties and depression were, nor does it give comparable figures for a nontherapist population.
    With respect to alcohol and drug abuse, a concrete measure of emotional problems, physicians in general show a higher incidence than nonphysicians, and a study that examined ninety-eight physician members of Alcoholics Anonymous found that 17 percent were psychiatrists, who constituted only 8 percent of physicians at the time. Though this has been interpreted to mean that a disproportionate number of psychiatrists (among physicians in general) are alcoholics, it may also mean that out of the total population of alcoholic physicians, psychiatrists are among the most likely to seek help. Other studies have found that alcohol abuse rates among therapists range from 6 to 11 percent, but in the absence of proper controls such studies seem inconclusive. When therapists are asked about themselves, 4 percent of them report drug or alcohol abuse serious enough to affect their work. When asked about their colleagues, these same therapists say that 18 percent of them are so impaired.
    Studies of suicide among psychiatrists also furnish contradictory results. "Among the specialties, psychiatry appears to yield a disproportionate number of suicides," said an article on suicide among physicians which appeared in the British Medical Journal as long ago as 1964. "The explanation may lie in the choosing of the specialty rather than its demands, for some who take up psychiatry probably do so for morbid reasons."
    Physicians in general do not seem to commit suicide at a rate significantly different from that of their nonmedical peers, although, perhaps because of their knowledge of drugs and access to them, their methods of choice are characteristically nonviolent: doctors poison themselves more than twice as often as the lay public, and shoot themselves less often. Psychiatrists, however, show a markedly greater tendency to commit suicide than the population at large or their medical peers. After several conflicting and methodologically flawed studies of suicide among psychiatrists were published, the Task Force on Suicide Prevention of the American Psychiatric Association instigated its own study of psychiatrists' suicides. Investigators examined the records on nearly 19,000 physician deaths from 1967 to 1972 and calculated the ratio of suicides to members for each medical specialty. They found that psychiatrists killed themselves about twice as often as other physicians. No other specialty showed a frequency significantly greater than average. Moreover, when individual years of the time span were examined, the rate was found to be constant, "indicating a relatively stable over-supply of depressed psychiatrists from which the suicides are produced."
    Some people have argued that many psychiatrists who commit suicide have good reasons for doing so. One view is that psychiatrists are more likely to kill themselves when they are terminally ill than are most other people, because they take a more realistic and enlightened view of human life and suffering. Some of the prominent early analysts are examples: Paul Federn shot himself when he was dying of cancer, and Wilhelm Stekel, faced with declining health, poisoned himself.
    Others suggest that the strains of the profession, whether practical or emotional, may drive practitioners to despair. Judd Marmor, a well-known professor of psychiatry, points out that the burden of constantly associating with depressed people, the stress of the transference-countertransference situation, the problems of role uncertainty, the burden of continuing education, and economic difficulties might be expected to take their toll on anyone. Fritz Wittels, originally an antagonist of psychoanalysis but later an ardent supporters wrote of analysts

". . .who involve their own unconscious in the dreams of others as in a distorting mirror; so that a gremlin catches them and drives them to death. Weininger was one of those who became involved in a bit of self-analysis, saw a distorted image of his unconscious that pressed a revolver into his hand. I have known three brilliant analysts, Schrotter, Tausk, Silberer, who voluntarily ended their lives. And in Vienna alone. Others will follow."

After Wittels changed his opinion of psychoanalysis, he retracted this view, saying that Weininger was not really a qualified psychoanalyst, that the others had not been properly analyzed, and that these facts, in the end, were to blame. "An analyst who has not himself been analyzed is in danger, be it suicide or otherwise."
    On balance, however, with the significant exception of an apparent high suicide rate, the evidence that psychotherapists are disproportionately impaired is slight, and to accuse them of pervasive gross psychopathology would be foolish. Therapists are not crazy. Nonetheless, in terms of personality types, emotional weaknesses, and psychological motivations, a substantial majority of them may differ from the general population in ways more subtle than full-blown pathology yet more important than mere style.
    What factors lead people to become psychotherapists? On this, not surprisingly, such information as exists is poorly controlled, open to wide interpretation, and generally anecdotal, as is psychotherapy itself. A book by William Henry, John Sims, and S. Lee Spray, titled The Fifth Profession, presents statistics that are diverting but scarcely enlightening. Given a questionnaire asking why they had become interested in the field of psychotherapy, 15.8 percent of all polled therapists said they wanted "to help people," 14.4 percent wanted "to understand people," and 9.6 percent wanted "to gain professional status." Psychoanalysts and psychiatrists, which were considered separate groups, were more interested in "gaining an identity," whatever that means, than in any of the other possibilities, whereas this was of negligible concern to the clinical psychologists and social workers. And 24.4 percent of all therapists gave an "other" reason for their interest.
    Once one gets past the responses that invoke benevolence and civic-mindedness, one finds reasons that tend to involve a search for compensations and cures for the therapist's personal unhappiness. Freud theorized that a strong desire to help others stems from longings that are the consequence of childhood losses.. Indeed, several articles on related issues assert that many therapists grew up in rejecting or inadequate families and were thus led to what Karl Menninger has called a "professional interest in lonely, eccentric, and unloved people."
    One book that examines the lives of twelve psychotherapists concludes that most of them felt responsible for maintaining family happiness during their youth. In the cases the authors studied, the mothers were seen as pallid or uninspired women, notably indifferent to their children except insofar as the children could be manipulated for the mothers' own gratification. The fathers were typically weak and estranged, though their children admired them. "Since every study shows that [therapists] mostly come from disrupted or disjointed families, often with the father physically or psychically absent, the therapists-to-be were delegated the task of assuring the fate and fulfillment of the family. They became, and are, the family nurturer."
    Often the psychotherapist's secret goal is to continue in the role of family support. In analytic transference the analyst comes to represent aspects of the patient's parents, and the patient represents aspects of the therapist's earlier life. Unfortunately, however, patients are not trained to manipulate this curious relationship, nor is that what they have come and paid money to do. Meanwhile, the therapist treats a succession of patients not only for their own problems but also for other problems, belonging to another time and place in the therapist's life, that haunt his consultation room. One study describes several therapists who seem to have done this. A psychiatrist undergoing analysis became depressed when she realized that she would not be able to cure her mother, an idea that lay in the back of her mind and had been her most important motive for entering psychiatry. A psychiatrist who in childhood had been saddled with the burden of maintaining family harmony was found to harbor the fantasy that one day his father and mother would be happy together as a result of his efforts. Meanwhile, he had particular difficulty treating patients with severe marital problems, and his own marriage suffered from his tendency to treat his wife as if she were a patient. In a third case a medical student embarking upon his psychiatric residency broke under the strain of caring for his emotionally disturbed mother and dependent psychiatrist father; he had planned to work in' child psychiatry, and was especially interested in helping doctors' families.
    The children of psychotherapists seem to talk more than most people do about their parents' emotionally dismal childhoods. They portray their therapist parents as exceptionally lonely and unhappy, socially ostracized at school, and abused at home, either psychologically or physically. The parents were ill at ease with themselves and with others, and sought through association with the world of adults and a retreat into the world of the intellect, and ultimately through the field of psychotherapy, to understand and manage their misery and to protect themselves and, later, their families. In many cases, the therapist parents themselves had said that their unhappy early lives were the primary motivation for their choice of career. In others, the motive seemed so clear that the children drew the conclusion on their own.
    A host of other less-than-selfless motives may enter into the choice of psychotherapy as a profession: sublimated sexual curiosity, aggression, the problem-solving pleasure of clarifying emotional confusions, and a voyeuristic interest in the lives of others. These factors, which have been discussed by other authors, are very likely important, but they seem to be secondary rather than determining characteristics and will be considered here only insofar as they enter into what I believe to be the primary one: that of the wounded healer.
    The idea of the wounded healer has ancient roots. In Greek mythology, Chiron, the centaur who taught medicine to Aesculapius, suffered an incurable wound at the hands of Hercules. Saint Augustine was conspicuous but not alone among the Christian saints in using his own weaknesses and his struggle against them to help him find compassion and strength. Mythology and religion are fraught with figures who must learn to heal themselves before healing others--who must recognize and forgive their own sins before they can, with authentic humility and understanding, forgive anyone else. Many of Freud's significant early discoveries arose out of the scrutiny of his deeply buried memories and then heroic confrontations with the painful things he found. In case histories of his patients he drew upon his own experience often enough to show that he regularly put his own flaws at the service of the empathic process. Psychoanalysts in training are required to undergo analysis for two complementary reasons. First, they must try to rid themselves of their psychological problems, so that they will be less likely to project their preoccupations onto their patients and then mistake what they perceive in them for objective fact. Second, the painful analytic process is itself instructive: an analyst who ventures into the patient's world needs to know how analysis can hurt and how it can help, and to recognize that therapist and patient are made of the same mortal stuff. Having emotional problems may not actually be a prerequisite or an advantage for a psychotherapist, but, clearly, having had problems is not in itself a handicap, so long as these problems have been recognized, confronted, and successfully resolved.
    The danger occurs when the wounded healer has not resolved, or cannot control, his own injury. The helping professional's career can follow either of two paths. The more difficult, but ultimately more satisfying, road leads to a painful confrontation with his own problems and weaknesses, and ultimately to self-knowledge. Ideally, he overcomes the difficulties; at worst, he is forced to resign himself to insuperable handicaps. In either case, though, the end result is a clearer perception of his ambitions and needs and their relationship to the task at hand. He can approach others with honesty, compassion, and humility, knowing that he is motivated by genuine concern, and not by some ulterior motive.
    The other path is easier but often disastrous. The psychotherapist comes, consciously or unconsciously, to see in his profession a means of avoiding the need to deal with his problems. He gains authority and power to compensate for his weakness and vulnerability. He learns slippery techniques that enable him to justify his actions in almost all circumstances, and perhaps even to shift blame onto somebody else. In his work with his patients, the entire therapeutic relationship is perverted and turned to the service of his hidden purpose. The therapist is there not to treat the patient but, by circuitous and well-concealed means, to treat or protect or comfort himself. The patient is not an object of empathy and altruism but an unsuspecting victim who is taken into the therapist's realm of personal needs and subjective impressions and assigned a role there that he does not recognize and would not want. And in the course of this strange, unacknowledged process, the patient's own problems may be neglected.
    In choosing his profession, the therapist-to-be may even make his problems much worse, because he discovers a justification for divorcing himself from the emotions that have caused him so much pain. He is to become a cold, accurate instrument instead of a warm and vulnerable human being. He may console himself with the heady deceit that he is martyring himself for the good of others: rather than live a happy and self-interested life, he says, he will forgo his own satisfaction in order to transform himself into someone who can do greater good. The flaw in this idea is that he is not being selfless at all but seeking, through the very medium of ostentatious self-denial, a perverse gratification of his personal needs. For such a therapist, the wound has become sealed off, prevented from causing pain but left inaccessible to healing. Since his energy is directed toward defending the status quo, he is diverted from the arduous and humbling process of self-examination which might otherwise have made him whole, and is forced, continuously and forever, to work just to stay where he is. With this sealed-off problem now at the center of his personal and professional life, the further along he goes the more difficult and costly it becomes to try to correct the mistake. His situation is almost Faustian: he has sold his hopes of redemption in the future for power, comfort, and knowledge in the present.
    The parallels in the world of religion are conspicuous and instructive. The church has often been regarded as a haven for the emotionally disturbed. Like studies on the mental state of psychotherapists, studies of the clergy are contradictory and emotionally charged. Overall, however, they suggest a high incidence of family problems and narcissistic disorders, and a host of other problems involving interpersonal relations and self-esteem. In the course of my research, I spoke to several psychotherapists who had begun their careers as ministers, and who now specialize in treating the emotional problems of their erstwhile professional colleagues. Some of these problems are incidental to the occupation, or result from its peculiar pressures and strains, but others seem to be both causal and recurrent enough to rate as a mild but characteristic clerical pathology.
    One type of clergyman, like one type of psychotherapist, is a repentant sinner who has recognized his or her weakness and can therefore align himself with other mortal men in the search for salvation. Another kind, the sealed-off sinner in his most extreme form, is the rigid and damning preacher who exhorts and chastises his flock from above, who has no sympathy for their weaknesses, and who may hurt his congregants by condemning their transgressions, instead of helping by leading them, through understanding, to righteousness. These preachers are so deeply beset by uncertainty and unresolved problems that they have organized their external life through sheer brute force and imposture, but they have left their internal life untouched. They cannot understand their congregants because they cannot understand themselves, and they cannot constructively help with many emotional problems because the solution they have adopted themselves is to cap such tensions tightly and hold them unseen.
    Perhaps the most interesting and significant problem shared by many "healers," which has been described by a number of therapists, is that of the person, often a firstborn or only child, who was rushed through childhood too quickly without the warmth, the protection, and the love that children deserve, and who was obligated to become a little adult. Such people grow up believing that hard work and responsibility are the only things that give them value in others' eyes. They have a chronically low sense of self-worth and a stunted ability to receive genuine love or friendship from others; only their selfishly selfless labors make them feel satisfied with themselves. As a result, they may be driven into a veritable frenzy of wholesale helping, which is motivated not by altruism but by a desperate need to fill an inner vacancy--an effort that ultimately helps very little, because, like trying to fill a bucket with a hole in the bottom, it can never succeed until they have attended to the necessary repairs. As one man, a Jungian analyst and an Episcopalian minister who has treated many clergymen, describes the problem: "They give too much, without knowing how to take, and it has an effect on them as well as on their families. They build up even more of an inhibition against being able to appropriately take things for themselves, which is taboo. They can justify this attitude with all sorts of theological jargon that says 'It is more blessed to give than to receive,' and so on. They are into loving their God and loving their neighbor, but they forget that little, crucial, additional thing: 'as thyself.'
    "These people are pathological givers, and so they become servers, pastoral counselors, and so on, and they can even be good at it, to a degree, but they become impoverished after a while. They have given so much that they finally run out of spiritual and nervous energy, and what remains is the underlying resentment. You find a great deal of resentment and sourness among the clergy. Just go and interview your garden-variety Catholic priest in the parish. Get to know him a little bit, and you will find a lot of anger and bitterness, even though, he will maintain a facade of benevolence and contentment. He has given more than he had to give, and gotten very little back."
    In choosing the ministry as a profession, these wounded healers have embarked on an ultimately doomed quest, one that perverts the purpose of their work. One bishop summed up the issues quite neatly when he said that in screening candidates for the ministry, one of the questions he asks himself is, "Is this a whole person seeking to express his wholeness through the ministry? Or is this a person trying to find his wholeness in the ministry?"
    William Dewart, a clinical psychologist who works primarily with clergymen, points out another interesting, common problem. One of the lures that drew these people to the Church was a position of authority that might help them to compensate for their feelings of inadequacy and emptiness and to escape from painful impositions by others. "Some go into the clergy believing that 'in the end, I answer only to God.' That is a very nice arrangement, they suppose, because God is a spiritual entity, after all, and His love is unconditional. They won't have to deal with a foreman or boss, no changes of administration. It's Just you and God, who, after all, called you in the first place. At least that's what they believe when they begin. But before they know it, they find themselves running up against authority and issues of power everywhere, from the vestry of their own small parish all the way up to the bishop of the diocese. For example, in the Episcopal Church the canons provide for the bishop to make the final decision regarding the very question of one's calling to an ordained priesthood. So the poor individual unconsciously seeking the priesthood in hopes of circumventing issues of authority and power will certainly find himself walking straight into one of the more authoritative, political organizations in the world."
    Among psychotherapists this is rarely a problem, except among those entering a psychoanalytic institute, who may feel that the institute's teachers and training analysts hold despotic power over their fate. Indeed, the psychotherapist in private practice is responsible to no outside authority. Information about what he does comes only from what he chooses to tell and from the perceptions of his patients, who tend to mistrust their own judgment. The therapist truly has the independence that the clergyman hoped for; he is the solitary ruler of his microcosmic domain. This unusual circumstance tends to exacerbate whatever problems he brought to his profession and to add novel difficulties.
    In an important paper titled "The God Complex," published in 1913, Ernest Jones, a pioneer psychoanalyst now best remembered as Freud's biographer and chief English language ambassador, described a set of character traits resulting from a pathological unconscious belief that one is God. People with this complex do not wander the streets proclaiming themselves the deity but have both a concealed, insidious faith in their own importance and entitlement, and an inability to conceive of others as comparably important, which color every aspect of their relations with the world.

The type in question is characterized by a desire for aloofness, inaccessibility, and mysteriousness, often also by a modesty and self-effacement. They are happiest in their own home, in privacy and seclusion, and like to withdraw to a distance. They surround themselves and their opinions with a cloud of mystery, exert only an indirect influence on external affairs, never join in any common action, and are generally unsocial. They take great interest in psychology, particularly in the so-called objective methods of mind-study that are eclectic and which dispense with the necessity for intuition. Phantasies of power are common, especially the idea of possessing great wealth. They believe themselves to be omniscient, and tend to reject all new knowledge. . . . The subjects of language and religion greatly interest them. . . . Constant, but less characteristic, attributes are the desire for appreciation, the wish to protect the weak, the belief in their own immortality, the fondness for creative schemes, e.g., for social reform, and above all, a pronounced castration complex.

Oddly enough, this comes very close to being a description of many psychotherapists, or even a job description for psychotherapy. Some of the qualities are ones that psychotherapists go out of their way to cultivate as part of their professional persona, and the training process may encourage them. Indeed, Jones said that people with God complexes were more likely than others to go into psychology and related professions. He hastened to add that they were not drawn to psychoanalysis, his own specialty, for it required intuition and an ability to empathize with others. A great many analysts and analytically oriented therapists, however, plod through their jobs on the basis of dogma, with little empathy at all. Jones himself was notable for his lack of psychological intuition, and was a curious mixture of radicalism and conservatism. He left medicine and Wales, his native land, which threatened in separate ways to hold power over him, yet once he had embraced Freudian psychoanalysis he became its most inflexible defender. His belief in the powers of psychoanalysis, by his own admission, bordered on grandiosity:

Perhaps, indeed, in centuries to be, the medical psychologist may, like the priest of ancient times, come to serve as a source of practical wisdom and a stabilizing influence in this chaotic world, whom the community would consult before embarking on any important social or political enterprise. Mere megalomania, it may be said. Perhaps, but it is my living faith none the less, and only our descendants will be able to say if it was a misplaced one.

Freud himself had a strong element of grandiosity, insisting that he was not a man of science, an observer, an experimenter, or a thinker, but a conquistador. His bitter relations with Jung, Adler, Rank, and others who strayed from his patronage and guidance are in keeping with Jones's image of the man who can tolerate no god but himself.
    In any psychotherapist, for that matter, an unusual degree of self-assurance is essential. After all, the therapist's patients are people whose attempts to conduct their own lives have failed, to some degree, and who are seeking help from another. However much therapists may wish to play the part of mere mediators rather than guides, the situation forces them into a position of superiority in which, by whatever direct or subtle means, they must assert their notion of what is good for their patients above what the patients may believe to be proper in the management of their own lives. Moreover, therapists need self-confidence and poise, combined with a great deal of humility, to withstand the emotional onslaught of the patients' unreasonable expectations and assumptions. Patients force therapists into a position of superiority through their idealization: the therapists must have wonderful marriages, perfect children, cultured and profound interests, clear and correct understanding of issues. Many patients want to be like their therapists, to adopt facets of their therapist's tastes and mannerisms, and some patients go on to become therapists of counselors themselves, because the profession has emerged in their minds as the most perfect of all occupations. Patients do not simply want advice from their therapists: as children, they expected magic from their parents, and often with their therapists--thanks to the transference--they entertain similarly unrealistic hopes that their fears will be soothed and their problems miraculously resolved.
    The field of psychotherapy inevitably attracts people with God complexes, and it is custom-designed to exacerbate the condition when it exists. Psychiatrists sometimes expect, and are often expected by others, to address questions that lie well outside the range of their expertise. They are expected to do so simply because they study human beings and, by erroneous implication, are therefore supposed to understand all things human. Psychiatrists comment on the law, politics, art, literature, and ethical questions, which nothing in their training has qualified them to comprehend any better than any other intelligent and educated person. Above all, within the therapeutic situation itself therapists who do not have the personal strength and equilibrium to resist the temptations of power and to see the patients' adoration as the epiphenomenon of their actions that it is may subside into self-importance.

Each profession carries its respective difficulties, and the danger of analysis is that of becoming infected by transference projections, in particular by archetypal contents. When the patient assumes that his analyst is the fulfillment of his dreams, that he is not an ordinary doctor but a spiritual hero and a sort of savior, of course the analyst will say, "What nonsense! This is just morbid. It is a hysterical exaggeration." Yet -- it tickles him; it is just too nice. And moreover, he has the same archetypes in himself. So he begins to feel, "If there are saviors, well, perhaps it is just possible that I am one," and he will fall for it, at first hesitantly and then it will become more and more plain to him that he really is a sort of extraordinary individual. Slowly he becomes fascinated and exclusive. He is terribly touchy susceptible, and perhaps makes himself a nuisance in medical societies. He cannot talk with his colleagues any more because he is--I don't know what. He becomes very disagreeable or withdraws from human contacts, isolates himself, and then it becomes more and more clear to him that he is a very important chap really and of great spiritual significance, probably an equal of the Mahatmas in the Himalayas, and it is quite likely that he also belongs to the great brotherhood. And then he is lost to the profession. We have very unfortunate examples of this kind. I know quite a number of colleagues who have gone that way.

This description by Carl Jung is probably exaggerated, which is fortunate in one obvious sense, though unfortunate in another, inasmuch as therapists of the sort described are not necessarily lost to the profession but may continue to practice. They can justify their attitude to themselves and to others--but someone who wields power in the name of some perceived ultimate good is always potentially dangerous. The zealot can find a moral excuse for oppressing others that is unavailable to the mere bully or the charlatan.
    If viewed clinically, the God complex can be related to narcissism, a personality disorder whose chief features are well established. Those with narcissistic personality disorders have grandiose self-images, often entertain unrealistic notions of their abilities, power, wealth, intelligence, and appearance, and feel entitled to things they haven't earned, simply by virtue of their inherent greatness. This exalted view of themselves, however, lacking the comfortable and certain support of reality is very fragile. Narcissists constantly need admiration and praise from others and can be incongruously devastated by relatively unimportant failures, which threaten the fragile tissue of their belief. A paradoxical indifference to the wishes and feelings of others, combined with a simultaneous dependency upon their praise, is a particularly striking feature of narcissists. Many of them have a deep-seated sense that they arc frauds--as in many ways they are.
    Narcissists are much more concerned with the appearance of things than with the reality; thus their ambitions tend to have a driven quality but to be empty of genuine sustained interest or pleasure. They are ethically empty though their fundamental amorality is often masked by an intense but superficial show of morality and social, political, or aesthetic concern. Since these cosmetic ethics do not touch them personally, however, narcissists may readily change their views or entertain conflicting ethical beliefs.
    Their relations with others tend to be emotionally hollow and exploitative, since narcissists are ultimately interested only in the themselves (failing, in a profound way, even to perceive other people as separate from themselves) and are thus unable to maintain equal give-and-take relationships. They are insensitive and lacking in empathy; their views of others are chiefly projections from within themselves, and therefore vacillate between idealization and debasement. Frequently, they believe other people to be basically unscrupulous, unreliable, false, and opportunistic. Though they may make an extravagant show of generosity and concern for others, this behavior inevitably proves to be just that--a show, which serves to polish the fine image they strive to hold of themselves.
    Various schools of psychoanalytic thought postulate different origins for narcissistic disorders, but all agree on the fundamental outlines. Narcissists were deprived in infancy and childhood of the affections and deep emotional interactions with their parents which would have allowed the normal development of a distinct sense of the difference between self and other and a feeling of personal value. According to the psychoanalysts Heinz Kohut and Alice Miller particularly, pathology in the parents (who are often narcissistic themselves) kept them from treating the child as an independent person and responding to him on his own merits, and led them instead to use the child for their own gratification. As a result, the child's sense of self was stunted and his sense of' value was structured around his ability to comprehend and fulfill his parents' wishes. As Miller comments,

This ability is then extended and perfected. Later, these children not only become mothers (confidantes, comforters. Advisers, supporters) of their own mothers, but also takeover the responsibility for their siblings and eventually develop a special sensitivity to unconscious signals manifesting the needs of others. No wonder that they often choose the psychoanalytic profession later on. Who else, without this previous history, would muster sufficient interest to spend the whole day trying to discover what is happening in the other person's unconscious?

Thus the peculiar miseries of the narcissist's childhood have encouraged him to develop a sensitivity to others' needs and a knack for anticipating and dexterously catering to them. These are extraordinarily useful in the practice of psychotherapy, as is a need to exercise these talents and to achieve the approval of others. The very same qualities, however, ultimately hinder the therapist's ability to help patients or to raise children who are free of emotional problems, because the empathy and altruism are basically false. Meanwhile, the profession he has entered presses him further than ever from the chance of cure.
    One of the best ways to avoid or counteract feelings of grandiosity is to cultivate genuine human loves and friendships. By dealing with people as equals, in symmetrical relationships in which the corners tend to get knocked off people's fantastic monuments to themselves, and in which they may grow comfortable with their shortcomings through others' acceptance of them, they can learn to be real, solid human beings who take true pride in genuine strengths and are able to recognize and deal with genuine weaknesses. Healthy, loving marriages, in particular, wean people from lonely grandiosity, and also mitigate the effects of their particular problems on their children.
    Unfortunately, this is not the sort of marriage many psychotherapists seem to have or to seek out. When measured in superficial statistical terms, psychiatrists have a divorce rate insignificantly higher than the rate among other medical specialists, and considerably lower than the rate among the general professional population. Their marriages, however, according to one respected research team, often appear to be remarkably distant and formal, based on shared intellectual and recreational activities rather than on affectionate interaction. Moreover, considerable anecdotal evidence suggests that therapists, both men and women, tend to marry troubled and dependent partners who will not counteract their narcissistic disturbances but will supply the admiration they crave. It is said that they marry their patients--which is sometimes even literally true--and end up in relationships that are anything but equal. The psychiatrist Richard Robertiello, speaking from professional and personal experience, writes,

Therapists tend to be drawn to partners who have rather serious emotional problems and who are looking for a wise understanding person who will help, support and perhaps "cure" them. . . . They are drawn by their own feeling of grandiosity and omnipotence. They think they will be able, by their love and caring and wisdom, to make this person happy, especially one who has frustrated several previous therapists in their efforts to accomplish this. Of course, the therapists feel very noble and generous and altruistic in this endeavor. But their satisfactions are hardly only altruistic. They start off having tremendous adulation and admiration from their "sick" mates. They begin in an unchallenged position of superiority and control. They are always "right" or "healthy" and their mate is always "wrong" or "sick." In addition to all of the narcissistic gratification this provides, it also gives a perfect assurance of acceptability and a near guarantee against being abandoned.

Ultimately, this sort of relationship is not very profitable for either person involved. The therapist may eventually outgrow his spouse and come to resent the dependence that originally brought them together. "I used to complain that I saw outpatients all week long, and then had an inpatient on my hands every weekend," Robertiello says. But growth on the part of the spouse can pose a threat to the therapist. The couple may end up in a stale relationship, where even the gratification of adoration and dependence wears thin. Meanwhile, the whole household revolves around the initial narcissistic demands of the therapist, and the subordinate spouse may come to function more as a part of this pattern than as an autonomous entity. "My father was very shy and insecure," says one woman, a lawyer and the daughter of an analyst," and he insisted that the family provide him with a lot of reassurance all the time. He stayed very close to home in every way--his office was in the house--and there was this ritual that my mother had to tell him how wonderful he was even though he wasn't, and how great the things he did were even when they weren't. That seems to be why he needed her."
    Close friendships are the other curative, but psychotherapists, as it happens, tend to have very few friends. Therapists explain this away as a result of the tremendous demands of their professional lives--long hours, teaching, society meetings, but such rationalizations seem forced. Statistics show that psychiatrists have more free time than almost any other medical specialists and that compared with many lawyers and businessmen--people not noted for a paucity of friends--psychotherapists do not have demanding schedules. Moreover, having little time does not automatically mean that one cannot make friends.
    The real reason for the lack friendships often appears to be a much more unpleasant, unconscious one. Many therapists do not need friends, because they live vicariously through their patients, just as clergymen seek love and self-worth vicariously through devotion to a congregation. For people who are uncomfortable with others and with themselves, the therapeutic situation offers an unparalleled opportunity for asymmetrical intimacy. The rules of therapy demand that the patient tell the therapist everything, while the therapist is under no obligation to reveal anything at all and thus can minimize the risk of pain incurred in normal human relationships. Life in the office can be exciting. One therapist told me the story of an analyst who retired and looked forward to the joy of reading novels but was dreadfully bored after a few months, because fiction did not possess the immediacy and veracity of clinical cases. And therapists who are allowed entry into their patients' lives are repaid for this privilege by the patients' grateful adoration. "My father had an inability to relate with his family or other people," says an analyst and the son of an analyst, "and his way of being close was through his patients. It was a way for him to have an interaction, but there was always a wall, or a desk, or a couch to protect him."
    The Swiss psychotherapist Adolf Guggenbuhl-Craig describes the tragic consequences to the therapist of this kind of vicarious living.

His own private life takes a back seat to the problems and difficulties of his patients. But a point may be reached where the patients might actually live for the analyst, so to speak, where they arc expected to fill the gap left by the analyst's own loss of contact with warm, dynamic life. The analyst no longer has his own friends; his patients' friendships and enmities are as his own. The analyst's sex life may be stunted; his patients' sexual problems provide a substitute. . . . His own psychic development comes to a standstill. Even in his non-professional life he can talk of nothing but his patients and their problems. He is no longer able to love and hate, to invest himself in life, to struggle, to win and lose. His own affective life becomes a surrogate. Acting thus as a quack who draws his sustenance from the lives of his patients, the analyst may seem momentarily to flourish psychically. But in reality he loses his own vitality and creative originality. The advantage of such vicarious living, of course, is that the analyst is also spared any genuine suffering. In a sense this function too is exercised for him by others.

The particular danger for the patient, against which therapists must be vigilant but often are not, is that the therapy begins to settle in as part of the patient's life rather than remaining an active process through which he can reintegrate himself into living. The patient may begin to look forward to sessions excessively and to live his life for the unacknowledged purpose of interesting and pleasing the therapist. Problems may apparently be resolved and changes made because the patient feels that this is what the therapist wants; such changes have no profound or permanent effect, because they are performed more for dramatic value or the therapist's approval than from a sense of inner need. Patients do not want to leave the idealized therapist; nor, in the pathological relationship described above, is the therapist motivated to help the patient leave. In the worst case, the entire therapy is poisoned, because ultimately, unconsciously, the therapist cannot bear to cure the patient, for then he would lose him. He therefore perpetuates a curious relationship of a kind that he may have had with his parents and that he may inflict not only on his patients but also on his children.
    I have heard such stories again and again. One of the first and most dramatic accounts came from a respected psychoanalyst who had always admired and sought to emulate his analyst father, had gone to the same medical school and analytic institute, and had set up his practice in the same city. He dated the beginning of his most significant personal growth from the time his father, during a period of illness, asked him to take over some of his cases.
    "I agreed. I wasn't that busy. I was in analytic training and was getting some supervision analyzing, and I thought this would be more grist for the mill. Besides, I figured I could do it as well as anybody else, and I never thought about the possible consequences of this kind of involvement with him. But in the course of doing this two or three times, I began to realize that my father had a number of patients who were very dependent on him. He charged them low fees, for one thing. That should have been a clue. But then, more important, with a number of his patients I realized that he had no good idea of the difference between maintenance, support and cure. With some of them he had developed a kind of collusion; they needed him, and he needed them.
    What both alarmed and helped this man most of all was his realization that the same process was at work in the relationship between his father and himself. He idolized his father, and his father depended on this idolization, much as he did in his relationships with his patients. Though his father was willing to help him grow to a certain degree, and though the son benefited in many ways from his closeness to his father, at some point his independence worked against his father's interests--both the father's selfish interests and his inappropriate wishes for his son. "I saw the contrast in the relationships between my psychoanalyst and me and my father and me. My analyst was providing me with an opportunity to grow up, while my father, apparently, didn't want me to go through the same sort of pain he had experienced growing up." Gradually the son established his own independence: he divorced his wife, having married in part to please his father, moved to another state, and eventually abandoned full-time psychoanalysis in favor of a psychiatric practice whose orientation was altogether removed from that of his father's.
    Several teaching analysts and psychotherapists agree that what poses as professional dedication is often at heart a morbid addiction. A training analyst in New York has discussed with me the unwillingness of analysts to leave their practice even when they reach retirement age. "They may say that they can't give up the income, or offer some other explanation, but what they really miss is feeling needed. Personally, I think that it is unethical and immoral for analysts to practice beyond a certain time in life. You can say a word for experience, but how much experience is experience? You can't really say that a seventy-year-old's experience is better than that of someone who is fifty-five. There comes a time when you are simply repeating the same experiences. Yet analysts will not retire. They won't. Myself, I don't take on new patients anymore. I do consultations or see an occasional ex-patient, and mostly do teaching or supervising. But someone who is now in his eighties, a New York analyst whom everyone knows, said to me the other day, 'I have time, meaning that he wanted some referrals. I told a friend, and she said I should have replied, 'Not much.' What is someone like that doing for his patients? He can't see as well, he can't remember as well, he can't hear as well, but he's still in there, and nobody's going to tell him what to do, and since there are no rules or laws or need for operating-room privileges, nobody can stop him, and he'll just keep doing it. And, transferential feelings being what they are, the patient doesn't have enough sense to move on or move up. Sometimes patients actually-stay because they feel sorry for the therapist. I've known cases like that."
    For most patients the problems of the wounded healer are irrelevant. Most people who seek therapeutic help need the benefit of knowledge, experience, and objectivity, and the opportunity to devote a specific amount of time to the careful scrutiny of whatever is wrong with their lives. The narcissistic therapist's sealed-off wound and secret self-centered agenda may have no discernible effect on this simple program. But in cases that demand more from the therapist, or tread close to his own problems, or issue challenges that his therapeutic persona cannot easily handle, serious harm may be done.


Love & Hate in the Analytic Setting
Glenn Gabbard
Chapter Seven- Technical Approaches to Malignant Transference

It does not matter much what a man hates provided he hates something. Samuel Butler

Freud (1915a) once noted that the only truly significant obstacles likely to be encountered by the analyst are those involving the management of transference. Among the panoply of transference feelings directed at the analyst, intense hatred is one of the most difficult to endure. Analysts may be drawn to the field, at least in part, because the practice of analysis itself serves as a reaction formation against hatred, aggression, and sadism (McLaughlin 1961, Menninger 1957, Schafer 1954). The experience of being hated day in and day out tends to erode one's carefully constructed defenses against hating one's patient. Moreover, the analyst's conscious altruistic wishes to help others are also thwarted by the hateful patient, occasionally leading the analyst to question whether the whole analytic endeavor in this particular instance is a waste of time and energy.
    In Chapter 2, I distinguished benign and malignant forms of transference hate. As a general rule the benign form of transference hate, like its erotic counterpart, is more characteristic of neurotically organized patients, while the malignant variant, much like erotized transference, is more likely to be found in borderline patients. This distinction is not intended to be an absolute one, but it is clinically useful to conceptualize the predominant form of transference hate as related to the level of ego organization found in the patient. In so doing, however, it is well to keep in mind Little's (1966) caveat that normal, neurotic, and psychotic transferences may be observed in the same patient within a single session. Moreover, borderline patients as a group are characterized by a broad spectrum of ego-functioning, ranging from those who are analyzable to those who require extended hospitalization (Gabbard et al. 1994; Meissner 1988).
    Freud was certainly aware of this spectrum of hateful transferences from the benign to the malignant, although he did not explicitly make such a distinction. While Freud viewed hate as occupying a central position in the pathogenesis of the neuroses, his writings are remarkably sketchy on the technical handling of transference hate. He devoted an entire paper to transference love, but no comparable document exists to assist the analyst in dealing with the common situation of being hated by a patient. In his most extensive, though still limited, discussion of transference hate, Freud (1940) observed that the therapeutic successes derived from periods of positive transference may be drowned by the torrents of negative transference: "The danger of these states of transference evidently lies in the patient's misunderstanding their nature and taking them for fresh real experiences instead of reflections of the past" (p. 176). He goes on to say that in these states the patient "hates the analyst as his enemy and is ready to abandon the analysis" (p. 176). His recommendations for dealing with such intense states of hatred in the patient are relatively pedestrian:

It is the analyst's task constantly to tear the patient out of his menacing illusion and to show him again and again that what he takes to be new real life is the reflection of the past. And lest he should fall into a state in which he is inaccessible to all evidence, the analyst takes care that neither the love nor the hostility reach an extreme height. This is effected by preparing him in good time for the possibilities and by not overlooking the first signs of hate. [p. 177]

    Freud's straightforward recommendations may be more difficult to implement with the malignant forms of transference hate. I draw this conclusion based in part on the tenacity of the hatred encountered in such patients and in part on the formidable types of countertransference generated by malignant hatred. In this chapter I will focus on the challenges posed by malignant transference hate, and I will suggest strategies that allow the analyst to persevere long enough to engage the patient in a psychoanalytic treatment.

Pathogenesis of Malignant Hate
Some patients may transiently dip into malignantly hateful transferences, but otherwise maintain the "as if" aspects of the transference throughout the bulk of the analytic work. My focus here is the patient whose predominant transference is one of malignant hate, where moments of reflectiveness and relief from the intensity of the negative affect are the exception rather than the rule. One of the true paradoxes characterizing these patients is that they repeatedly seek out treatment despite their thorough dissatisfaction with each therapist. They often jump from analyst to analyst and quit each time with feelings of disappointment and resentment. They seem to seek out treatment because the very core of their being depends on having a relationship in which they attack someone who is trying to help them (Rosenfeld 1987). Kernberg (1984) noted that patients such as these, who are part of a larger group prone to negative therapeutic reactions, are often identified with a cruel, sadistic internal object that can only give some semblance of love if it is accompanied by hatred and suffering. In other words, their attachment always must come at the expense of hatred. The alternative is a state of nonexistence.
    This formulation, of course, suggests a repetition of a childhood situation in which abusive figures have been in the role of caregivers. Indeed, there is some empirical evidence that relates childhood abuse and this pattern of internal object relations. Nigg et al. (1991) compared a group of borderline patients with childhood sexual abuse to a group who did not have such histories. On projective testing, the presence of an extremely malevolent introject differentiated those who had been sexually abused from those who had not.
    Research at the Anna Freud Centre in London (Fonagy et al. 1994) has drawn a link between childhood trauma and the lack of the "as if" quality of transferential reactions. While not specifically addressed to the hateful patient, this type of transference, in which the analyst is not viewed as a current-day repetition of a past figure based on the patient's projections but rather is regarded as the original object of hate, is certainly characteristic of the malignant hate that is the focus of this chapter. Fonagy and his collaborators (1994) have concluded that childhood trauma may impair the development of what they call reflective self function in these patients, which they define as the "capacity to think of their own and others' actions in terms of mental states . . . [that is, the] ability to invoke mental state constructs: feelings, beliefs, intentions, conflicts, and other psychological states" (p. 241). This inability to "mentalize" appears to relate to intergenerational patterns of abuse in that the mother and father seem unable to develop working internal models of relationships and thus fail to pass on that reflective capacity to their children.
    While childhood abuse appears to be one pathogenetic pathway for the development of malignant hate, in other cases no clear abuse history can be discerned. Obviously, the possibility of an inborn temperament that is hyperirritable and easily provoked to anger may play some role in alternative forms of pathogenesis. In addition, however, certain patients seem to be suffering from smoldering resentment based on their experience or perception of chronic narcissistic injury. These patients to a large extent resemble the kinds of patients Kohut (1972) described in his explication of chronic narcissistic rage. They feel that their parents never validated or affirmed their feelings or perceptions, so they go through their lives forever misunderstood and always anticipating further misunderstandings. Often this rage is fueled by a desire for revenge.
    Regardless of the specific pathway of pathogenesis, the end result is that the expectable moderating effect of love over hate as one develops mature whole-object relatedness does not take place. There appears to be a dominant object relationship between a hated object-representation and a hating self-representation (Gabbard 1989b). These patients often seem to be consumed with venomous contempt in part because the good, loving aspects of the self and the corresponding object-representations are buried deep within to prevent their destruction by the all-consuming hate. Alternatively, they may be projected into figures in the environment who are regarded as entirely good or totally loving (Boyer 1983, Giovacchini 1975, Hamilton 1986, Klein 1946, Searles 1958).
    In this manner the islands of love and concern for others are further protected by safely storing them in others. This strategy may well backfire, however, because the perception that others are so saintly may produce profound envy. This development may lead the patient to project devalued and hated self- and object-representations as a way of "smearing" the saintly figure with undesirable aspects of the patient's internal world (Poggi and Ganzarain 1983).
    Patients with malignant hate, then, appear to be dominated by the paranoid-schizoid mode of experiencing. They lack the moderation of the depressive mode that can help them become more reflective and think about the way they are construing relationships. The result is a conviction of certainty about their perceptions of the analyst. Once the constellation is firmly entrenched within the patient, the analyst will encounter enormous resistance to shifting the patient's perceptions. Fortunately, some make forays into a more depressive mode of mental functioning that allows for analytic work to take place. A case example will illustrate some of the challenges posed by the malignantly hateful patient.

Case Example

Mr. H, a 28-year-old divorced man, came to analysis after an abortive two-year attempt with another analyst. That treatment experience ended with the analyst's move to another city. (I often wondered if that was the analyst's way of extricating himself from the unpleasant experience of spending an hour a day with Mr. H.) The most startling aspect of the opening phase of the analysis was the rapidity with which the transference hate developed and the conviction expressed by the patient that his perceptions were absolutely accurate. My overriding impression was one of being falsely accused. I was, of course, accustomed to being the target of negative transference, but rarely of this intensity so early in the process. I took flight from the daily barrages by retreating into diagnostic speculation: "Obviously a borderline feature," I would think to myself.
    His contempt was thoroughly justified, in his view, because of the structure of the analytic situation, which he perceived as unreasonable and inflexible. Mr. H resented my fee, and he unabashedly expressed his feeling that he deserved to be treated for nothing. One comment he made in the first few weeks of the analysis, in response to my observation that he was verbally assaultive, nicely captured his point of view: "I know you think I'm assaultive, but it's because of the way you treat me. You charge me, you even bill me when I choose to take vacations, you don't give me answers to any of my questions, and you rigidly enforce the end of the hour even if I'm in the middle of a thought. I see you as assaultive, so I react with hostility."
    All his feelings were the direct result of how I treated him, as though he had no role in re-creating an object relationship from his past. His partially developed self had no sense of active agency connected with it--no sense of "I-ness" (Ogden 1986). He was simply buffeted by malevolent forces in his environment. One of the most striking features during the early weeks of the analytic process was the absence of anger (or any other feelings, for that matter) directed toward his previous analyst. Working from the assumption that much of the venom directed toward me was a displacement and actually belonged with the memory of his last analyst, I occasionally would interpret this connection to him. He always reacted with scorn, suggesting that I was trying to "pass the buck" to someone else for my own failings. In his own way, Mr. H may have been tuning in to an attempt on my part to sidestep the heat of the transference by deflecting it elsewhere. When I was confronted with the absence of analytic space, with no gateway to forging a viable working relationship with the patient, I was tempted to develop an alliance by encouraging him to direct his wrath elsewhere. If I had succeeded, I could then have empathized with his hatred toward someone else and, in so doing, attempt to form an alliance around the shared anger toward an outside enemy."
    When, on occasion, I was not regarded as the hated internal object, I would become idealized. This turn of events, however, led him to hate me all the more because of the emergence of his envy. "I see all your books on those shelves, and I feel a sense of loathing towards you. I could never read that many books. I can't ever hope to have the amount of knowledge that you have. I feel like getting up and tearing down all your bookshelves."
    As the patient railed against me, he would often lightly pound his fist on the wall adjacent to the couch. He would exert some control over the pounding so that it would stop just short of being a disturbance to the occupant of the office next to mine. I could never be certain, however, and his behavior placed me in a disturbing dilemma. If I did nothing about the pounding, was I colluding with his "acting in" by allowing him to disturb my neighbor? If, on the other hand, I told him to stop the pounding, was I allowing myself to be manipulated by him into a nonanalytic position where he then could rightly see me as attempting to control him? He would also set up other situations that created the feeling that I was damned if I did and damned if I didn't. He would begin a session by asking if I would let him know when the session was half over because he had to leave early. When I pointed out to him that he was wearing a watch and would know when the time was up himself, he would become furious at me for refusing to help him.
    Most of all, he would repeatedly try to maneuver me into a corner where I would wittingly or unwittingly imply that I did indeed hate him. The barrage of contempt day in and day out took its toll on me, and I was not always able to contain adequately the patient's projected contents. I would occasionally make sarcastic, contemptuous, or counterattacking comments as I sought to survive in the lion's den that he had created in my office. On one particular day he was accusing me of not empathizing with his point of view. I responded by saying, "You treat me with contempt and then expect me to empathize with you. I wonder if it is part of a larger pattern of expecting others to love and take your side without earning their regard." The patient responded with glee: "So you do hate me. I knew I could get you to admit it." On another occasion the following exchange occurred:

Patient: I don't understand why you give me no credit whatsoever for being able to hate you. Don't I get two points for expressing my anger?
Analyst: What do you see as positive about that?
Patient: Because all my life I've suppressed my anger. Now I'm finally getting it off my chest.
Analyst: You're speaking to a side of you that I have not seen. All I've seen is unrelenting hostility.
Patient: Then you must hate me! You can't handle me! I'm too tough! I get a thrill out of triumphing over you and being the only patient of yours that will not get better, that won't change in the way that you want me to.

    Mr. H, of course, had made a couple of good points. At times I felt I could not handle him, and at times I certainly did hate him. One of the most distressing aspects of the analysis was that Mr. H appeared completely uninterested in receiving help from me. He confirmed the accuracy of this observation when I pointed out to him that he repeatedly defeated any effort on my part to help him understand himself. His response was explosive. "I don't fucking want your help! I want you as a target! I attempt to provoke you. I have a fantasy of throwing up on your floor or shitting on your couch. I want to rid myself of all this. I hate it when I can't provoke you into taking my anger. Then I have to take it. I need a place to dump. I've been using you like a pay toilet."
    This outburst helped me to understand how Mr. H conceptualized the analytic process. It was indeed a toilet. It was a place where he could evacuate the bad aspects of himself and his tormenting and hated internal objects. From his point of view, projection of these mental contents was a far superior option to any other alternative. His behavior in the hours made me feel coerced into accepting the role of the hated object that hated him back. I resorted to numerous defensive maneuvers to avoid the role. At times I would withdraw and become more aloof, attempting to retreat into defensive isolation where I would be impervious to his attacks. At other times I would attempt to empathize with his need to hate as his way to survive emotionally. In still other instances I would shore up my occupational reaction formation by attempting to feel loving concern for the poor wretch. When I would shift into this mode, Mr. H would invariably experience me as being less than genuine, not to mention patronizing.
    My countertransference loathing of Mr. H reached a peak when I had a thorny scheduling problem and I asked him if he could change the hour he saw me on Wednesdays. He replied that while he could switch the hour to accommodate my wish, he was choosing not to do so. He said that it was important for him to assert his own rights rather than to allow others to "walk over me." He went on to say that it gave him tremendous pleasure to know that he could control me rather than having me always be the one in charge. His refusal to cooperate left me seething with resentment. I dreaded having to see him day after day, and I found myself wishing that he would quit. I even caught myself daydreaming about what I might do to make him quit.
    As fate would have it, I was fortunate to begin a much needed two-week vacation at this point in the analysis. As the vacation neared its completion, I found myself dreading my return to work because I would have to face the unpleasant experience of a fifty-minute hour with Mr. H each day. On the night before I returned, I had the following dream:

Mr. H and I were in an analytic session. I was growing increasingly anxious as Mr. H continued to pound the wall next to the couch with ever-increasing intensity. Quite unexpectedly, he turned around, looked at me, then stood up and stared down at me with a defiant grin. I felt frantic that I was unable to control him, and I unleashed my pent-up fury in the form of a lecture shouted at the top of my lungs: "Analysis is for people who can control their impulses and channel them into words. If you can't do that here, if you can't cooperate with what I am trying to do, you should not be in analysis."

    In my associations to the dream, I thought of the many times during the sessions when Mr. H pounded on the wall. I had often wanted to say just those words to him. The dream helped me to understand why I had not. For me to assert the customary expectations of the analytic setting carried with it a risk. Clearly, my unconscious concern was that my intense hatred of Mr. H and my sadistic wishes to control him, so evident in the dream would show through my efforts to clarify the nature of our task. I realized that my guilt related to these feelings was leading me to feel disempowered as an analyst. In this context I suddenly understood the meaning of my proposal of the hour change on Wednesdays as an option rather than as a decision that had already been made and with which he was expected to comply. At an unconscious level, I was equating the ordinary power and control inherent in the analytic role with omnipotent control driven by enormous aggression. Hence, my presentation of the change as a choice could be understood as a reaction formation against these powerful wishes within me.
    Another insight I gleaned from the dream was that the patient had been serving as a receptacle for that part of me that desperately needed to control him. I could disavow that part of me by thinking that it was Mr. H who was driven by the wish to control--not me. My self-analytic work with the dream brought me in touch with the fact that my analytic "work ego" (Fleming 1961) was being eroded by the intensity of the patient's projections. I was starting to share his propensity to view action--not understanding--as the solution.
    When we resumed the analysis after the vacation, it was clear that the break had done us both some good. The patient began by commenting that he had been worried ever since the ending of our last session: "I was afraid I'd pushed you into a breakdown where you would destroy furniture and attack me. I try to bait you to take on my characteristics. I hate it when you're calm--then I have to take it back in me. I feel like I want to explode. I want to rip up your office. If I can't be your best patient, maybe I can be your worst. But I'm afraid that I'll drive you crazy."
    I had seen occasional glimpses of movement into an analytic space where the capacity for self-observation was present, but always in the context of extra-transference relationships where he feared that he would hurt someone on whom he depended. I took advantage of this opening of analytic space and made an interpretation: "The feelings you have inside are unbearable, but if you dump them into me, you fear that you will get well at the expense of my going crazy. This worries you, because after all, feelings of hate are not the only feelings you have toward me."
    The patient responded to my interpretation by making the following observation: "If I don't hate you, I feel like a primordial soup that is waiting to be pulled together. I have no identity. I want you to take care of me. I have a pretense of being independent and self-sufficient, but underneath I'm incredibly dependent and needy. I don't feel comfortable having anyone take care of me. I feel diffuse, amorphous, like an amoebae. I feel like being sarcastic with others when I start to feel uncomfortably close."
    Changes had occurred on both sides of the analyst-patient dyad. I had recognized my own countertransference need to take action to control an analytic situation that was getting out of hand. In part, I was responding to a projective identification of the patient, but I was also reacting to my own anxiety in the face of a situation where I had very little control and where I felt de-skilled as an analyst because of my guilt related to my feelings of hate. On the patient's side of the dyad, a sequestered object relationship involving a concerned self-representation (with the capacity to love) and a loved object-representation (with the capacity to be hurt) had surfaced. It is possible that the patient's perception of my anger and hatred at his refusal to change the appointment time prompted the emergence of the other side of him, accompanied by depressive anxieties as the hating and loving sides of him were juxtaposed. He was also able to acknowledge the organizing effect of hate on his own sense of identity. In its absence, he felt amorphous. My interpretive effort to connect split-off aspects of himself further enhanced his capacity to look at what lay beneath the hate.
    As the analysis proceeded, the patient continued to operate predominantly in a paranoid-schizoid mode. However, with each foray into depressive concerns, there was usually an associated opening of analytic space. At these moments, I would make interpretive connections for the patient that he could use to further his developing reflectiveness. When the time was right, for example, I was able to interpret that his reluctance to change the hour was connected with his fear that I would replace him with someone else. I suggested to him that he had therefore been hurt by my proposal of a schedule change. He responded with a tearful observation that he'd never heard me acknowledge his proneness to feel hurt. He went on to say that no one had recognized his pain in the past. Building on my observation that he feared being replaced, he told me that his worst fear was that after termination I would not remember him. He imagined that he would call me on the phone many years after the analysis and I would not know who he was. This confession provided an opening for me to interpret the role of hate in maintaining connectedness and avoiding abandonment. As long as he continued to hate me, he knew that I would not see him as ready for termination and could not possibly forget him.
    The opening of analytic space in the process also allowed the patient to bring in genetic material that he had scrupulously avoided throughout the analysis. He spoke of his rage at his father for leaving him and his mother when the patient was only two. He spoke of a wish to take revenge against his father but also the fear that he had driven him off with his hatred. He was soon able to link his attempts to coerce me into controlling him with an earlier wish that his father had been present to control his powerful oedipal longings toward his mother. He also had a firm conviction that his mother was indifferent to him. He recalled numerous instances when he would act up as a way of trying to evoke a response from his mother. As an adolescent he would come home drunk at night and wake her up to be sure she was aware of his drinking. He felt that even such drastic efforts were often unsuccessful, and he went through life behaving in such a way that others could not avoid being affected by him.
    At the time of his successful termination, the patient experienced a resurgence of hate toward me because I would not stop him from terminating. The only way he could experience caring from others, he realized, was through their efforts to control him. If I did not stop him from terminating, I obviously did not care about him. He came to see that his hatred served to mask feelings of grief at the prospect of losing me. He made numerous reparative efforts during the last months of analysis, letting me know that he was embarrassed about the things he had said to me and about the way he had treated me. He was also able to let me know that the analysis had allowed him to grow up and experience gratitude in addition to hatred.

In my work with Mr. H, I often thought of a piece of advice I had once heard regarding what to do when one encounters an angry grizzly bear in the wilderness. According to wilderness lore, one should neither charge the bear in a counterattacking posture that is designed to drive him off nor run away from the bear out of fear. If one simply stands one's ground, the bear will usually drop his threat of attack and go elsewhere. While I have so far had the good fortune to avoid having to test the soundness of that advice, it seems to me that one can think about the technical problems of handling transference hate in an analogous way. One must walk a fine line between the temptation to counterattack and the urge to retreat into aloof disengagement. Rather, one must be a durable object who holds one's ground and attempts to contain and understand that which is being projected.
    This strategy is difficult to sustain because powerful feelings of hatred, by their nature, impel one to action rather than reflection (Heimann 1950). The action chosen may include the use of interpretation as a weapon of counterattack--an attempt to put the patient in his place or suppress his hostility. These interpretations are also frequently an attempt to unload the hateful self- or object-representation projected into the analyst. However, it is usually an error of technique to return the projected parts of the patient prematurely via interpretation (Carpy 1989, Epstein 1977, 1979, Grotstein 1982, Ogden 1982, 1986, Rosenfeld 1987, Searles 1986, Sherby 1989). As in the case of Mr. H, the patient needs to keep the hateful object- or self-representation in the analyst because he is unable to integrate it within himself. Moreover, if the analyst cannot tolerate the transference role to which he has been assigned because of the unpleasant nature of the projected introject, how can he reasonably expect the patient to tolerate it? Searles (1986) warned that when the analyst tries to force the introject back into the patient through premature interpretation, there is an implied denial of any basis in reality for the patient's transference perception of the analyst. It is as though the analyst is saying to the patient: "Hate resides only in you, not in me."
    In the Menninger Treatment Interventions Project (Gabbard et al. 1994, Horwitz et al. 1996), we studied the transcripts of the audiotaped psychotherapy of three borderline patients in long-term psychoanalytic psychotherapy. Two teams of researchers tracked the linkages between the therapist interventions and the resulting shifts in the patient's ability to collaborate with the therapist. Premature transference interpretation of the patient's hate and aggression resulted in deterioration of the alliance (as measured by the ability to collaborate with the therapist) in those borderline patients who had experienced childhood trauma. These patients felt misunderstood because the therapist was not appreciating the fact that real external trauma had occurred and that they were expecting further mistreatment at the hands of a therapist.
    There are other compelling reasons to avoid premature interpretation of projected aspects of the patient. Unless the analyst has sat with the projected material and subjected it to the metabolizing, detoxifying process of containment (Bion 1962b), he will be returning it in the same form in which it was delivered. In its most extreme form, this variant of countertransference acting out may be as dramatic as the case of the young therapist described by Altschul (1979), who grew so exasperated at his borderline patient that he screamed "I hate you" over the telephone. While such eruptions of "countertransference psychosis" by a psychotherapist may seem unusual, I have observed them with some regularity among hospital staff engaged in the inpatient treatment of borderline patients. In these cases, the treater has been taken over by the patient's projection, and the patient's inability to integrate good and bad elements of self and object are re-created in the clinician (Altschul 1979). In the moment of countertransference acting out, the analyst, like the patient, sees action--extrusion or destruction of the "bad object"--as the only solution to the intolerable feelings of hatred within.
    My hatred of Mr. H and my wish that he would quit the analysis prior to the two-week break was a re-creation of the patient's object world within my own mind. Getting rid of the patient seemed to be the only solution to my tormented internal state. My interventions were not particularly effective at that point in the analysis, and there was more than a kernel of reality in the patient's perception that I hated him and was having difficulty handling him. As Gorney (1979) has noted, when the patient's entire effort is to transform the analyst into a bad object, there may be a real erosion of the analyst's technical competence as he reacts in a role-responsive manner by becoming "bad" in his choice of interventions and their timing. Both the analytic work ego (Fleming 1961) and the necessary split between the observing and experiencing aspects of the analyst's ego (Kris 1956) are compromised by the powerful projective identification process that accompanies the malignant form of transference hate. Fortunately, my self-analytic work and the actual break in the analysis gave me the necessary distance to get back on track with Mr. H.
    These considerations lead us to two crucial points in this discussion. The first is that analysts themselves may lose their own sense of analytic space and find it collapsing into a paranoid-schizoid mode of experience in which ill-advised action seems to be the only way of surviving. In the process of projective identification, the patient's lack of self-reflective function may be deposited in the analyst so that the analyst temporarily experiences the same incapacity as the patient. The second point is that interpretive work tends to be most effective when both patient and analyst are coexisting in an analytic space (i.e., both are functioning in a mode in which reflective observation is possible). From these two critical points it follows that long periods of containment that gradually allow for interpretation may be necessary to facilitate the convergence of patient and analyst in an analytic space.
    Numerous authors (Boyer 1986, 1989, Buie and Adler 1982, Carpy 1989, Chessick 1977, Epstein 1979, Gabbard 1989a, Giovacchini 1975, Grotstein 1982, Little 1966, Searles 1986, Sherby 1989) have focused on the centrality of containment in the treatment of severely disturbed patients. There is a broad consensus among these authors that (1) verbal interpretations may fall on deaf ears when the patient is harboring intense negative feelings toward the analyst, (2) a new set of experiences with a new object is necessary before the patient can accept interpretive interventions, and (3) the traditional role of the analyst as a neutral observer who delivers occasional interpretations from a position of evenly suspended attention is not an adequate characterization of the requirements for the analytic treatment of more disturbed patients.
    In the transcript of the psychotherapy processes studied in the Menninger Treatment Interventions Project (Gabbard et al. 1994), we consistently found a characteristic pattern of effective interpretation. A number of supportive interventions often paved the way for a transference interpretation that the patient could then hear and upon which he or she could reflect. By asking questions, clarifying the content of what one is hearing, and facilitating further expansion, the analyst creates a climate in which interpretation will be accepted.
    It would be erroneous to view containment as inferior to interpretation in terms of its therapeutic potential. It is a critically important ingredient in projective identification, which is the main mode of communication in the paranoid-schizoid mode and the principal method by which self- and object-representations are modified (Gabbard 1989b, Grotstein 1981, Ogden 1986). Through the processes of metabolizing and detoxifying (Bion 1962b, Boyer 1986), the patient's projections are modified and transformed in such a way that the patient can more readily reintroject them. As a modified internal object is reintrojected by the patient, the corresponding self-representation is similarly modified in keeping with the changes in the internal object.
    Containment should not be equated with a kind of passive inaction (Rosenfeld 1987). Nor should it be understood as a masochistic enduring of the patient's contemptuous attacks (Ogden 1982). It involves silent processing, but it also entails verbal clarifications of what is going on inside the patient and what is transpiring in the patient-analyst dyad. In addition, containment implies a number of other processes (Gabbard 1989a), including the identification of feeling states within the analyst, the diagnosis of the patient's internal object relations based on how they are played out in the analytic dyad through projective identification, an ongoing self-analytic process that seeks to delineate the analyst's own contributions to the struggles with the patient, the associative search for linkages between the disparate projected aspects of the patient, and the silent interpretation of what is going on inside the patient in preparation for later verbal interpretation.
    As described in the treatment of Mr. H, part of the analyst's task is to trace his own defensive maneuvers as he seeks to avoid hating the patient. Hate in the patient evokes hate in the analyst (Epstein 1977), but it also tends to produce denial of hate. As Winnicott (1949) stressed, the analyst must not deny that hate actually exists within himself and that he actually hates the patient. The patient will only be able to tolerate his own hate if the analyst can hate him. In this regard my sarcasm-tinged confrontations of Mr. H, which I viewed as countertransference-related mistakes," may have been useful in some way to the patient. In clinical discussions, it is often asked if an analyst can treat a patient he does not like. A more relevant question in the case of patients with malignant hate is whether the analyst can treat a patient he does not hate. Epstein (1977) noted that the analyst's most frequent error is to react to projections of hatred by attempting to be "all good." This, deprives the patient of his primary defensive mode of projectively disavowing hatred and seeing it in the analyst instead of in himself.
    Another defensive tendency that should come under scrutiny during the containment process is the temptation to collude with the patient's splitting by focusing only on the good or loving aspects of the patient (Kernberg 1984). As described in the treatment of Mr. H, one variant in this defensive posture is to encourage the displacement of hate onto an extra-transference figure so the analyst can develop a therapeutic alliance based on the extrusion of hate and badness from the analyst-patient relationship.
    A crucial turning point in the analysis of Mr. H was my discovery that his perception of me as a punitive figure invested in asserting omnipotent control over him was not entirely his own distortion. On the contrary, it resonated with actual wishes to control him that I was harboring within. Another defensive operation requiring monitoring during the containment process is the analyst's tendency to act as if the patient's perception is entirely a distortion, leading to a disavowal of all responsibility and a projection into the patient of qualities that actually reside in the analyst as well. In this context, Searles (1986) made the following observation:

It is essential that the analyst acknowledge to himself that even the patient's most severe psychopathology has some counterpart, perhaps relatively small by comparison but by no means insignificant, in his own real personality functioning. We cannot help the borderline patient, for example, to become well if we are trying unwittingly to use him as the receptacle for our own most deeply unwanted personality components, and trying essentially to require him to bear the burden of all the severe psychopathology, in the whole relationship. [p. 22]

    The analyst must walk a fine line between blasting the patient with his own hatred and denying its very existence. After hatred and anger are processed and metabolized through the containment process, they can be more constructively expressed in a way that is useful to the patient (Epstein 1977, Searles 1986, Sherby 1989). Moreover, the tolerating of intense feelings in and of itself may produce change in the patient (Carpy 1989).
    During the months prior to the two-week break in the analysis of Mr. H, the patient bore witness to my numerous struggles to maintain an analytic posture in the context of his using me as a "toilet" for his unacceptable parts. My struggles were manifested in my countertransference enactments, in which I made sarcastic comments, withdrew into aloof silences, demonstrated by my guilt-ridden reluctance to enforce the schedule change I proposed for fear that it would betray my aggressive feelings, and attempted to transcend my hatred by assuming a saintly position vis-a-vis the patient. As Carpy (1989) noted, the patient's observation of his analyst's attempts to deal with feelings regarded as intolerable by the patient makes these feelings somewhat more tolerable and accessible for reintrojection. Projective identification begins as an attempt to destroy links between the patient and his feelings because the feelings are unbearable. Observing the analyst's capacity to bear those same feelings restores the linkages. Mr. H, for example, began to "re-own" some of the feelings he observed in me with the comment, "I try to bait you to take on my characteristics. I hate it when you're calm--then I have to take it back in me."
    One other aspect of containment is the message conveyed to the patient that the analyst is a durable, persistent object that is not destroyed by the patient's attacks. Winnicott (1968) felt that the analyst's survival of the borderline patient's destructive attacks is a crucial element in helping the patient to make use of the analyst as a truly external figure outside the patient's omnipotent control. He drew a developmental analogy in this regard by noting that the mother must survive the primitive attacks of the infant for the child to proceed with development and maturation. Winnicott stressed that in both situations survival means avoiding retaliation, and he specifically cautioned against using interpretation in the midst of attacks by the patient. He viewed interpretive interventions as dangerous under such circumstances and suggested that the analyst would do better to wait until the destructive phase is over, at which point the analyst can discuss with the patient what transpired during the attacks.
    To get to the most primitive transference issues, one often has to go to the brink of despair with the patient, where one questions whether or not he can continue and whether or not he is being effective as an analyst. As the case of Mr. H illustrates, the pivotal breakthrough occurred only after I reached the point of wishing that the patient would quit. In commenting on destructive transferences, Bird (1972) noted: "This dark and ominous time, when both patient and analyst are about ready to call it quits, is, according to my thesis, perhaps the only kind of transference in which the patient's most deeply destructive impulses may be analyzable" (p. 296).
    Finally, as the analyst contains the many feelings arising within the patient and within himself, he will begin to become aware of the multiple functions of hate in the transference. Brenner (1982) has pointed out that while one can speak about positive or negative manifestations of transference feelings, transference as a whole is always ambivalent just as erotized transference may conceal enormous aggression toward the analyst, hateful transferences may conceal longings for love and acceptance. Mr. H was finally able to reveal that he had established an intense dependency on me and wished to preserve some form of connectedness to me through his hating.
    In Chapter 2, I noted Bollas's (1987) term loving hate as an example of how some individuals bind others to them with intensely hateful feelings. Mr. H, for example, lived with a dread of indifference, the kind of nonresponsiveness that he had experienced with his mother. Only through hate could he coerce objects in his environment into passionate involvement with him. Only then did he feel alive and connected.
    In a subsequent communication, Bollas (1994) noted that some patients have no confidence that they can use the analytic object to develop their own erotic self-narrative and thus attack the object in hopes of dislodging the analyst from a neutral stance. They may feel that if the analyst actually responds to such attacks, they have finally gained access to the real person of the analyst and thus feel they have broken through the analytic barrier with hate. This breakthrough may then enable them to feel connected in an erotic way.
    Other functions of hate became apparent as well in the analysis of Mr. H, including its organizing effect on his amorphous sense of identity, its role in defending against grief, and its defensive function in the service of dealing with envy. Many of these functions that are mentally noted while containing may subsequently be interpreted.
    The postponement of interpretation in the analysis of the malignantly hateful patient is required for several reasons. First and foremost, the patient is unlikely to be capable of making use of interpretation early in the analysis. Interpretations will be experienced as confirmation that the analyst is like everyone else--a persecutor attempting to attack or victimize the patient.
    The analyst needs to wait before he interprets for his own reasons as well. It is imperative that he has a preliminary understanding of his own countertransference and has processed the patient's projections sufficiently so that he has restored his own analytic space. Only then can he be therapeutic with his interventions. Bollas (1990) has aptly noted: "And as some psychotic patients sponsor the regressions in the analyst, rather than within themselves, analysts will endure regressive episodes from which they recover through time, patience, and reflective work. When this is so, analytic insight and interpretation are in the first place curative for the analyst, who gets better first" (p. 352).
    When the analyst has accomplished this self-curative task, he needs to wait patiently for a signal from the patient that he is accessible to interpretation. This readiness will be indicated by evidence of the development of a sense of "I-ness," where a mediating subject is present, an observer who views feelings and thoughts as intrapsychic creations rather than incontrovertible factual perceptions (Ogden 1986).
    When Mr. H made comments such as, "I hate it when I can't provoke you into taking my anger," or "I try to bait you to take on my characteristics," he was indicating some opening of analytic space. He was thinking symbolically about what was happening in the analyst-patient relationship (i.e., he was distinguishing between symbol and symbolized). When he expressed open concern that he might drive me crazy, he had clearly arrived at the depressive position and its associated anxiety that he might harm someone he had grown to care about. He had begun to think about what he was doing to me as analogous to the climactic scene in William Friedkin's 1974 classic horror film, The Exorcist, where the demon possessing the little girl leaves her and enters the psychiatrist-priest, leading him to plummet to his death. Mr. H felt he could only get over his "madness" at the cost of driving me mad. Carpy (1989), who also has advocated the postponement of interpretation, pointed out that the patient is capable of using the interpretation only when he can recognize aspects of himself in the analyst.
    When the split-off and sequestered aspect of the patient's self-containing feelings of love and concern finally surfaces, the analyst's task is to reconnect the split parts through interpretation (Gabbard 1989b, Kernberg 1984). I pointed out to Mr. H, for example, that his hatred coexisted with feelings of concern for me. The integration of the loving and hating aspects of the self will be threatening at first, and the patient will continue to revert to hate. Resistance to integration or, for that matter, change of any kind can be related to a host of factors (Gabbard 1989a):

1. The denigration of others prevents the patient from being aware of painful feelings of envy.
2. The refusal to link up more positive representations with the negative, hateful representations prevents the loving aspects of self and object from being contaminated and destroyed by the influences of hate. There is a pervasive attack on linkages to good objects in the environment as well as internal linkages between good and bad self-representations and between good and bad object-representations (Bion 1959, Grinberg et al. 1977, Grotstein 1981).
3. The fantasy of revenge may be the greatest pleasure of all to the patient, and to give up the hate may carry with it the loss of the revenge fantasy.
4. As implied before, the patient's identity may be organized around hatred, and the modification of the hating self-representation or of the hated object-representation is often experienced as a form of annihilation.
5. The patient may preserve a sense of meaning by hating, and change may cause the patient to confront a sense of living in a meaningless state.
6. A hateful relationship is better than none at all, and a modification of the patient's internal object relations may be experienced as the loss of any sense of connectedness to both external and internal objects. Hence, resistance to change may also be understood as an avoidance of separation anxiety.

    Some or all of these resistance factors may have been noted during periods of containment. Those observations made while containing the hate may then be brought forth through interpretation because the patient can acknowledge the existence of unconscious determinants. In the case of Mr. H, I was able to help him see the role of hate in avoiding feelings of abandonment and loss. The function of hate in reducing envy may also be interpreted, but only with caution. Too often such interpretations are experienced as "put-downs." The analyst is likely to get further by focusing on how the shame and pain of envy prevent the patient from expressing his full capacity to love (Rosenfeld 1987). The feeling of being accepted by the analyst for what one is may in and of itself do more to reduce envy than excessive interpretive activity.
    With each interpretation that connects the islands of love with the hateful core of the patient, the patient gains a greater sense of subjective agency. A different mode of analytic work is now within the patient's grasp as a result of his entering and sustaining an analytic space. As Ogden (1989) has observed, one result of analysis is that the patient will begin to feel understood and will begin to regard the analyst as someone who is capable of concern as well as hate.
    The goal of termination with these patients is not to eradicate their hate, only to temper it with love. At the end of the analysis of Mr. H, he still hated me and told me so. He hated me for letting him grow up and leave. But he also told me that I was the first person who'd ever really listened to him and that he would miss me. I also harbored feelings of hate toward him and was relieved by his departure. Yet I had many other feelings as well. I would miss him, too.
    Altman (1977) has conjectured that analysts tend to place an excessive emphasis on love because of their need to disown hate. He cautioned that love is not a cure-all and that the experience of love would give us greater pleasure if we did not use it primarily to mask underlying hate. He even suggested that the more openly we allow ourselves to hate, the more completely we might be able to love. In Chapter 2, I identified eight different reasons that analysts might hate their patients "from the word go." This preexisting subjectivity will then be acted on as analysts immerse themselves in the malignant transference hatred of the patient described in this chapter, and all the preexisting reasons for hating the patient will be exacerbated and intensified because of the patient's overt contempt. In the eye of this tempest, it is useful for the analyst to remember Altman's words of wisdom and know that the patient, too, may be finding a way to love through open expressions of hate. Perhaps there is even a sense of hope in malignant transference hate in that the patient is hoping the analyst can tolerate being a "bad enough object" until the patient can risk the realm of love and tenderness.