Tuesday, August 7, 2012

Irene Ruggiero - The Unreachable Object?

"It is well known that various models exist to explain the genesis and the structure of the borderline disturbance. One model emphasizes the role of aggression and of envy: they are thought to be characterized by an individual, constitutionally determined threshold (the so-called ‘conflict model’ which dates back to Kernberg’s thought). The other model instead gives prominence to a lack of attunement in the primary environment, which is thought to hinder the formation of those internal structures of self-regulation without which it is not possible to reach a sufficient level of cohesion of the self and become autonomous from archaic relationships with the selfobjects (this is the so-called ‘deficit model’ which emerges from the theories of Kohut). These models have led to divergent views about the most important factors in the therapy. In the ‘conflict model’, stress is placed on the steadfastness of the analytic setting (the stability of which reassures the patient that the analyst can contain and survive his destructiveness), and on the instrument of interpretation (this method allows confronting the patient on the issue of his aggression early in the process). However, the deficit model emphasizes above all attention to the ego-attuned subjectivity of the patient, and endorses the provision of the physiological fusion which was missing in the primary relationship.

Several colleagues (including Casement, 1990; Correale and Berti Ceroni, 1997; Modell, 1988; Monari, 1999), who highlight the opportunity to use both approaches, the ‘empathic’ and the interpretative, seeing these as the development of a single original matrix, believe that a sort of treatment in two phases may be particularly useful. In the early phase, the functions of containment, empathic mirroring and support predominate, with the use of interpretation being held back for the second phase.

This position, in which I recognize myself, is also borne out of the consideration that – as is often the case with traumatized people – in borderline individuals, behaviours and fantasies characterized by a certain level of automatism are present, accompanied by a reduction in the capacity to represent and the overdevelopment of the emotional components. In these moments of sensorial over-excitement, interpretative activities carry a risk of overburdening the patient further, who is already caught up in difficulties of mentalization. Meanwhile the activities of presence and connection assume great importance (Correale, 2006).

I share the position of those (Mitchell, 1993) who maintain that aggression, whilst having its own innate individual potential, is activated in relational and environmental situations that are perceived subjectively as being dangerous, a point which explains the particular sensitivity of borderline patients to minimal variations in the therapeutic environment. If, as I think, traumatic factors play an essential role in the genesis and the emergence of borderline functioning, we need to give particular attention to the microtraumas which can come about in the consulting room and to anti-therapeutic factors which can be attributed to the analyst’s difficulties (Ferenczi, 1932), as well as those activated by the difficulties of the patient. The specific contribution of my work consists in exploring the nature and possibility of using the countertransference in the game of symmetry and asymmetry which is created between the unconscious of the patient and the analyst. This is a game which works, more specifically, when the transference does not only manifest itself through words.

With borderline patients, in whom extensive areas remain unavailable to representation, it is necessary to work at length to cement a narcissistic tissue which is rather frayed. Before being able to use interpretative instruments, it is often necessary to undertake a long piece of analytic work which facilitates the transformation of as yet non-representable elements into representations that can be thought, dreamed and expressed in words.

One of the most specific difficulties that the analyst must confront in this work is the intense amount of destructiveness that these patients bring and activate. Whether this is determined by constitution or whether it represents the outcome of deficient primary relationships, the containment of the – sometimes raging – aggression of the borderline patient constitutes an unavoidable technical knot and a hard test for the analyst. Personally, I share the belief that it is fundamental to provide these patients with the potential to test the analytic setting as trustworthy and authentically containing before interpreting their intense destructiveness, which is often not yet available to thought."
(pp. 586-587)

Irene Ruggiero (2012) The Unreachable Object? Difficulties and Paradoxes in the Analytical Relationship with Borderline Patients, International Journal of Psychoanalysis, Vol. 93, pp. 585–606

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