D. W. Winnicott
An analyst has to display all the patience and tolerance and reliability of a mother devoted to her infant, has to recognize the patient's wishes as needs, has to put aside other interests in order to be available and to be punctual, and objective, and has to seem to want to give what is really only given because of the patient's needs.
There may be a long initial period in which the analyst's point of view cannot be (even unconsciously) appreciated by the patient. Acknowledgment cannot be expected because at the primitive root of the patient that is being looked for there is no capacity for identification with the analyst, and certainly the patient cannot see that the analyst's hate is often engendered by the very things the patient does in his crude way of loving.
In the analysis (research analysis) or in ordinary management of the more psychotic type of patient, a great strain is put on the analyst (psychiatrist, mental nurse) and it is important to study the ways in which anxiety of psychotic quality and also hate are produced in those who work with severely ill psychiatric patients. Only in this way can there be any hope of the avoidance of therapy that is adapted to the needs of the therapist rather than to the needs of the patient.
In this pa-per I wish to examine one aspect of the whole subject of ambivalency, namely, hate in the counter-transference. I believe that the task of the analyst (call him a research analyst) who undertakes the analysis of a psychotic is seriously weighted by this phenomenon, and that analysis of psychotics becomes impossible unless the analyst's own hate is extremely well sorted-out and conscious. This is tantamount to saying that an analyst needs to be himself analysed, but it also asserts that the analysis of a psychotic is irksome as compared with that of a neurotic, and inherently so.
Apart from psycho-analytic treatment, the management of a psychotic is bound to be irksome. From time to time23 I have made acutely critical remarks about the modern trends in psychiatry, with the too easy electric shocks and the too drastic leucotomies. Because of these criticisms that I have expressed I would like to be foremost in recognition of the extreme difficulty inherent in the task of the psychiatrist, and of the mental nurse in particular. Insane patients must always be a heavy emotional burden on those who care for them. One can forgive those who do this work if they do awful things. This does not mean, however, that we have to accept whatever is done by psychiatrists and neuro-surgeons as sound according to principles of science.
Therefore although what follows is about psycho-analysis, it really has value to the psychiatrist, even to one whose work does not in any way take him into the analytic type of relationship to patients.
To help the general psychiatrist the psycho-analyst must not only study for him the primitive stages of the emotional development of the ill individual, but also must study the nature of the emotional burden which the psychiatrist bears in doing his work. What we as analysts call the counter-transference needs to be understood by the psychiatrist too. However much he loves his patients he cannot avoid hating them, and fearing them, and the better he knows this the less will hate and fear be the motive determining what he does to his patients.
STATEMENT OF THEME
One could classify counter-transference phenomena thus:
1. Abnormality in counter-transference feelings, and set relationships and identifications that are under repression in the analyst. The comment on this is that the analyst needs more analysis, and we believe this is less of an issue among psycho-analysts than among psychotherapists in general.
2. The identifications and tendencies belonging to an analyst's personal experiences and personal development which provide the positive setting for his analytic work and make his work different in quality from that of any other analyst.
3. From these two I distinguish the truly objective counter-transference, or if this is difficult, the analyst's love and hate in reaction to the actual personality and behaviour of the patient, based on objective observation.
I suggest that if an analyst is to analyse psychotics or anti-socials he must be able to be so thoroughly aware of the counter-transference that he can sort out and study his objective reactions to the patient. These will include hate. Counter-transference phenomena will at times be the important things in the analysis.
The Motive imputed to the Analyst by the Patient
I wish to suggest that the patient can only appreciate in the analyst what he himself is capable of feeling. In the matter of motive; the obsessional will tend to be thinking of the analyst as doing his work in a futile obsessional way. A hypo-manic patient who is incapable of being depressed, except in a severe mood swing, and in whose emotional development the depressive position has not been securely won, who cannot feel guilt in a deep way, or a sense of concern or responsibility, is unable to see the analyst's work as an attempt on the part of the analyst to make reparation in respect of his own (the analyst's) guilt feelings. A neurotic patient tends to see the analyst as ambivalent towards the patient, and to expect the analyst to show a splitting of love and hate; this patient, when in luck, gets the love, because someone else is getting the analyst's hate. Would it not follow that if a psychotic is in a 'coincident love-hate' state of feeling he experiences a deep conviction that the analyst is also only capable of the same crude and dangerous state of coincident love-hate relationship? Should the analyst show love he will surely at the same moment kill the patient.
This coincidence of love and hate is something that characteristically recurs in the analysis of psychotics, giving rise to problems of management which can easily take the analyst beyond his resources. This coincidence of love and hate to which I am referring is something which is distinct from the aggressive component complicating the primitive love impulse and implies that in the history of the patient there was an environmental failure at the time of the first object-finding instinctual impulses.
If the analyst is going to have crude feelings imputed to him he is best forewarned and so forearmed, for he must tolerate being placed in that position. Above all he must not deny hate that really exists in himself. Hate that is justified in the present setting has to be sorted out and kept in storage and available for eventual interpretation.
If we are to become able to be the analysts of psychotic patients we must have reached down to very primitive things in ourselves, and this is but another example of the fact that the answer to many obscure problems of psycho-analytic practice lies in further analysis of the analyst. (Psycho-analytic research is perhaps always to some extent an attempt on the part of an analyst to carry the work of his own analysis further than the point to which his own analyst could get him.)
A main task of the analyst of any patient is to maintain objectivity in regard to all that the patient brings, and a special case of this is the analyst's need to be able to hate the patient objectively.
Are there not many situations in our ordinary analytic work in which the analyst's hate is justified? A patient of mine, a very bad obsessional, was almost loathsome to me for some years. I felt bad about this until the analysis turned a corner and the patient became lovable, and then I realized that his unlikeableness had been an active symptom, unconsciously determined. It was indeed a wonderful day for me (much later on) when I could actually tell the patient that I and his friends had felt repelled by him, but that he had been too ill for us to let him know. This was also an important day for him, a tremendous advance in his adjustment to reality.
In the ordinary analysis the analyst has no difficulty with the management of his own hate. This hate remains latent. The main thing, of course, is that through his own analysis he has become free from vast reservoirs of unconscious hate belonging to the past and to inner conflicts. There are other reasons why hate remains unexpressed and even unfelt as such:
1. Analysis is my chosen job, the way I feel I will best deal with my own guilt, the way I can express myself in a constructive way.
2. I get paid, or I am in training to gain a place in society by psycho-analytic work.
3. I am discovering things.
4. I get immediate rewards through identification with the patient, who is mak-ing progress, and I can see still greater rewards some way ahead, after the end of the treatment.
5. Moreover, as an analyst I have ways of expressing hate. Hate is expressed by the existence of the end of the 'hour'.
transference. The analyst takes over the role of one or other of the helpful figures of the patient's childhood. He cashes in on the success of those who did the dirty work when the patient was an infant.
I think this is true even when there is no difficulty whatever, and when the patient is pleased to go. In many analyses these things can be taken for granted, so that they are scarcely mentioned, and the analytic work is done through verbal interpretations of the patient's emerging unconsciousThese things are part of the description of ordinary psycho-analytic work, which is mostly concerned with patients whose symptoms have a neurotic quality.
In the analysis of psychotics, however, quite a different type and degree of strain is take by the analyst, and it is precisely this different strain that I am trying to describe.
Illustration of Counter-Transference Anxiety
Recently for a period of a few days I found I was doing bad work. I made mistakes in respect of each one of my patients. The difficulty was in myself and it was partly personal but chiefly associated with a climax that I had reached in my relation to one particular psychotic (research) patient. The difficulty cleared up when I had what is sometimes called a 'healing' dream. (Incidentally I would add that during my analysis and in the years since the end of my analysis I have had a long series of these healing dreams which, although in many cases unpleasant, have each one of them marked my arrival at a new stage in emotional development.)
On this particular occasion I was aware of the meaning of the dream as I woke or even before I woke. The dream had two phases. In the first I was in the gods in a theatre and looking down on the people a long way below in the stalls. I felt severe anxiety as if I might lose a limb. This was associated with the feeling I have had at the top of the Eiffel Tower that if I put my hand over the edge it would fall off on to the ground below. This would be ordinary castration anxiety.