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Faculty Forum Report:  Monica Carsky Presents on Overwhelming Patients and Overwhelmed Therapists

By Debi Roelke

What makes patients begin to seem overwhelming? How do we as therapists end up feeling overwhelmed? At the CPPNJ Faculty Forum on November 4, Monica Carsky presented her recent paper addressing these very questions. She described her work with Frank Yeomans and the Kernberg research group involving many years of consultation with therapists who often feel they have reached the end of their rope.

Carsky’s work is grounded in the object relations model of Transference Focused Psychotherapy. TFP was first designed by Kernberg and his group to structure psychoanalytically oriented treatment of borderline personality disorder. More recently, they have focused on work with severe narcissistic character disorders. The crux of this treatment approach, grounded in a solid assessment of character structure and ego functioning, is the identification of internalized dyads: self and object representations in affective relation to each other. This here-and-now focused treatment aims to track which internal dyad is activated for the patient at any given moment in the transference relationship with the therapist. Quite often, in more severely disordered character structures, these internal dyadic roles shift back and forth between who is experienced in what role at any point in time. Although the therapist is experiencing the projections of these roles in the interaction with the patient, she seeks to maintain a reflective stance on these moment-to-moment transitions. The therapeutic goal is to identify which internal dyad is being activated and use interpretation to help the patient begin to understand how his internal world is determining his experience of relationships in the present moment.

Key to this process – and what can lead it to become overwhelming for both parties – is the presence of powerful, disavowed emotions that are intolerable to the patient, and which come to feel that way for the therapist as well. At this point, the therapist is overwhelmed in her ability to contain, reflect and interpret the patient’s internal object world. Carsky finds that aggression is most often the central issue. Many times, the aggression is also being acted out in other areas of the patient’s life, and as a result, he is doubly unable to become aware of the disavowed affects and internal dynamics involved. Anger, hate and devaluing are the kinds of powerful negative affects that become disavowed and projected in various forms. The resulting projective identifications are often the only way for the patient to communicate his need to defend against intolerable feelings of fear, envy, longings for dependency and/or closeness. This can create a sort of vicious cycle for the therapist in which there are intense and conflicting feelings of responsibility for the patient at the same time as feelings of being exploited. The tendency is to counter this with providing more flexibility and support to the patient, but with the therapist increasingly feeling trapped, “…like a prisoner of the patient.”  As the therapist relaxes the limits of the treatment frame in an attempt to respond supportively to the patient, the patient just seems to become increasingly worse.

Carsky describes the process of intervening to short-circuit this vicious cycle. The most important step is returning to the clear boundaries of the treatment frame. Extricating oneself from the web of projected, disavowed affects that has created this vicious cycle is difficult and may require consultation: often, the therapist working in isolation without supervision or peer support sets up a treatment situation that is vulnerable to this process in the first place. Carsky notes that the therapist can be unconsciously pulled to join the patient in seeing the outside world as hostile or dangerous; once embedded in this way, the therapist has increasing difficulty identifying and interpreting this as disavowed aggression in the transference, and the reflective stance crucial to treatment is lost.

There are several other risk factors for overwhelming impasses in treatment. A limited or incomplete assessment is an important one: Carsky emphasized the importance of including family members and previous therapists in this critical treatment phase, another aspect of making sure that therapist and patient do not become an isolated couple who get lost in the patient’s internal object world.  Stress in the therapist’s own life which taxes her resources is another source of risk.  

Consultation can be necessary in helping to break an impasse and allow the therapist to regain enough distance to return to a reflective, interpretive stance. The intensity of the affects involved is what makes this so difficult; as Carsky says, “we have to bear it so we can help them become able to bear it.” The goal for therapists is to survive and manage the intense forms of projective identification that are playing out. Becoming the target of negative transferences challenges us to tolerate being seen differently from our cherished and familiar self-images, and these images can be very difficult to let go of. The end result, though, with a patient who can slowly become less ruled by his tyrannical inner object dyads, is an increasingly reality-based personal relationship in the unvarnished here and now.