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Ingrid Masterson: Impasse

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Comments and Reports: Trauma, Body, Impasse

 » Ingrid Masterson: Impasse

Ingrid Masterson:  October 2006
In this short paper I would like to focus on the nature of Therapeutic Impasse, and the factors contributing to it in the context of a patient’s early experiences.  I want to raise for discussion the question of whether a primitive fear around existence is what leads to a stagnation in the analytic work, or causes an a kind of ‘undoing’ in therapy that blocks further growth of the personality.  I would like also to raise the question of whether failure of embodiment is an important factor in perpetuating an obstacle to forward movement, and to consider if or when this should be addressed.
The main important underlying themes are the question of agency, its lack or distortion (which, of course, is about a compromised subjectivity); and which may or may not support the potential for personal desire or protest, denoting individuation and separation, The word ‘In-divid-ual’ might pre-suppose an undivided self, of course no-one is undivided, as our Lacanian colleagues will remind us.  But we might ask if there is even a trace of a ‘core’, an inner part in the subject that can express and sustain a personal impulse. In relation to this, we might consider whether the embodiment required to experience an impulse is so minimal and tentative that there is no consolidated sense of oneself as an entity.  Awareness of, and being grounded in, personal sensation is a foundational element of a ‘body-ego’.
J.de Sassure (1979 referred to in Limentani’s NTR [Negative Therapeutic Reaction] paper) describes how persons who lack sensory experience resort to fantasy images of themselves in order to have any sense of personal potency; she writes of persons who   “most easily feel narcissistically wounded by their insight are those who have been least successful in building images of themselves based on their own sensations and feelings…they look for signs which can give them, in fantasy rather than in experience, images of themselves as triumphant and all powerful”. She maintains that this leads them to fear becoming dangerous as a result of therapy.  Such a patient may well be facing a developmental task of ‘coming into being’; a process that by its nature must include embodied experience. How a psychotherapist functions in such a situation requires thoughtful reflection and debate.
Winnicott (1962) focussed on personal embodiment as an elaboration of Freud’s ‘body-ego’;  ‘personalization’, handling by mother, is what enables indwelling and psychosomatic integration, which contributes to ego strength. In his writings (1949) on the psyche/soma split, he described how traumatic memories remain unintegrated and stored in the body, contributing to dissociation.
For Winnicott, (1950/52) existence, “the sense of real comes especially from motility and its’ corresponding sensory roots”; “summation of motility experiences contributes to the individual’s ability to start to exist”,…“to repudiate the shell and become the core”
In trauma, both physical, sexual, and also the more subtle, and sometimes unconscious, emotional trauma, we are dealing with what Winnicott describes as ‘Impingment’ on the infant’s ‘spontaneous gesture’ of reaching out to the world to discover it in her/his own way.  Reaching to discover the environment is what enables motility to exist in the individual’s subjective efforts, as opposed to existing in reaction to an impinging environment. In the worst situations of psychic impingement, (which could include non-abusive events from an observer’s perspective), “the individual develops as an extension of the shell rather than of the core, as an extension of the impinging environment”.   Here we have the basis of the frequently encountered split between an individual’s suffering and helpless ‘victim’ self, which remains attached to a tantalizing, seductive but abusive internal object repeatedly externalized.
The trauma element underlying impasse is more concretely graspable in cases of gross physical/sexual abuse in that an outside observer can get some kind of handle on imagining it’s effects, this is manifest in health board provision for such categories of person, [often with concomitant expectations of the therapist]; however, the much subtler trauma to the attachment network, to an internal relational container, and to the ‘Personal Spirit’ as Kalsched (below) would describe, which can also occur in the absence of concrete physical/sexual abuse, has a profound effect on the developing child’s sense of self which is much harder to recognize, without a long period of therapeutic engagement with such an individual, that very slowly enables softening of necessary protective defences. Some babies are faced in the earliest weeks/months of their life, even ‘in utero’ with an emotional atmosphere containing the mother’s internal anxieties, toxic projections or her own unprocessed traumatic experiences, therefore they come into the world already seriously influenced by alien ‘not-me’ elements with which they may nevertheless identify.
Clinical instances occur in which persons come to an emotional realization of their experience as a small child in which they were felt to be a threatening presence by, or felt they were an enormous disappointment to, a significant parental figure, and in varying degrees were viciously attacked, emotionally, (and sometimes also physically/sexually), in a grossly traumatizing manner, without supportive emotional or practical intervention from the ‘bystander’ parent who was felt to condone this experience.  As an adult such a person remains extremely fearful of and compromised in their own personal impulses, be they sexual, affectionate, or constructively aggressive, or even of any simple expression and desire, which might be different from another’s, imagining that what might emerge from inside them will be similar to the expressions of a monstrously destructive internalized object, which had attacked, or required burial of, their potential growing self from inside.  In this more or less global identification with an internalized Other, they have become the shell [to use Winnicott’s term] in their sense of themselves. We all know that embodied gut-level emotional experiencing is necessary for forward movement to occur; here we have a formidable defence against such an experience.
This begs the important question of what enables, or what precludes, such embodied experiencing in therapeutic work? 
Is it different from the true NTR [Negative Therapeutic Reaction]?  In my experience there can be attacks or undermining of the therapist, particularly following insight, but insight that has not been bodily and emotionally taken in, i.e. has not taken root. There can be stagnation and circularity of the treading water variety, where the patient stops dreaming, not much work is done, the person goes back to focus on external issues or repeats already familiar material; a brake has been put on progress.

Rosenfeld (1987) describes two different kinds of Impasse:

*Transient, near end of analysis, where patient’s symptoms return in exaggerated form; this is a frequent occurrence based on anxiety about impending separation in the therapeutic relationship, and is an opportunity to consolidate the previous work on the disturbing forces in the patient.
*True NTR following progress in analysis when in various ways the work is sabotaged, or previous insights are forgotten, perhaps with incidences of lateness, or missed sessions.  Rosenfeld initially attributes this to hidden envy of analyst, but also emphasizes the importance of having evidence in the material before interpreting along these lines.
Factors contributing to Impasse:
Externally: These may occur in the therapeutic setting, e.g. psychiatric systems, lack of constructive networking, a psychiatrist may not understand purpose/method of therapy, with the consequence that a patient may be put on medication if s/he becomes depressed or more anxious.  In context  of the patient’s life: relationships, or other areas of status quo may seem threatened.  In the therapist: theoretical rigidity, or counter-transference difficulties may influence the therapeutic relationship.
Factors in analyst or in the therapeutic relationship:
Warren Coleman (2006) writes of the tendency in analytic circles to undervalue or even see as seduction, any importance given to the ‘real relationship’ between analyst and patient, and that in particular circles, a view is held that allowing the analyst to be perceived as a ‘good object’ is a defensive manoeuvre, and allowing this to go on is a collusion. He explores the difference between an idealized object and a good enough object; for certain traumatized patients the latter is a necessary experience in therapy, which requires eventual internalizing.  He writes of the ‘analytic superego’; and how compulsive attempts to either be, or to avoid being, a good object are both equally unhelpful, and that a sincere and genuine helpful attitude, which the patient can eventually use, is paramount.  Rosenfeld holds that misdiagnosis by the analyst of a patient’s internal attitude is a factor promoting impasse.  Lack of flexibility in an analyst who adheres to one model of analysis may leave very important aspects of a patient’s inner world unrecognised and unanalysed; Rosenfeld emphasizes the necessity to know as much of a patient’s early history as possible so as to be alert for repetition in the therapeutic relationship.  The danger of rigid theory, and a one model approach is particularly acute in narcissistic patients with early traumas who may be thin skinned and very sensitive, or suffer underlying depression, and where shame and humiliation are likely experiences in response to even minor criticisms they construe as coming from their therapist.  A wrong interpretation of envy or destructiveness leads to a situation where the patient feels the analyst is out of touch with his/her inner reality and will only increase the impasse, as will counter-transference difficulties such as an unconscious critical or hostile attitude in the analyst. This could indicate a repetition of an early mother/infant relationship, where the mother has felt a failure and reacted with hostility to her baby; in the current situation, if the analyst comes to feel a failure it might provoke a countertransference repetition of this dynamic with her patient.
When this is combined with non-recognition or undervaluing of positive narcissistic achievements the patient may have made in compensation, it could compound the impasse; (a situation where a person could feel envied and robbed by their analyst!)  Does interpretation convey to a patient that they are destructive and disturbing? Or that they have been disturbed and are compelled to carry these unbearable experiences within themselves?
Factors in patient’s inner world:

A.Limentani (1981) summarizing ideas presented at a 1979 Conference of the European Federation of Psychoanalysis on NTR, pulls together recent work on this concept; in addition to Freud’s early ideas on unconscious guilt and masochism, in offering alternatives to the rather prevalent idea of extreme envy, Rosenfeld cited:
*a narcissistic organization mounting attacks on the dependent self through identification with a negative mother, and the importance of counter-transference experiences arising out of this constellation; i.e. the possibility of analyst induced negative reactions;   (as I have described above) *the individual may be more concerned with survival than living, and may harbour fears of fusion with the maternal figure, which are difficult to bring to conscious awareness.
*the intense psychic suffering associated with integration beyond ego’s capacity to bear.  The pain of integration may be considered greater than that of disintegration. Limentani stresses the importance of not fostering a too early or too sudden integration, which could ask the patient to give up the only trusty survival mode he knows, or to again grow up precociously toward a premature independence. A reverse process occurring in the transference based on complex struggles around dependence/independence, if not recognized, can lead to interminable analysis.
*De Sassure’s ideas noted above on fantasy as a substitute for embodied experience.
However, some valuable aspects were attributed to the NTR:
*as an expression of the ‘No’ required for detachment from the analyst; this expression of autonomy ought to be seen as an opportunity to rework faulty early detachment in the mother/infant twosome in the transference.
*perhaps in process of analysis there develops an increasing tolerance in both analyst and pt of attacks.

S.Grosz (seminar in 2000) elaborating on Limentani’s paper, spoke of possible confusion between NTR ..(in a particular situation with a particular analyst), and other mental states;
*negativism in the patient’s disposition going back to very early life, around feeding/ taking in;
* defiance in not accepting what the analyst has to offer; which may be a much more discrete reaction, and emphasizes how the therapist has to be careful not to have expectations of their client which foster an unhelpful repetition; an example would be a situation where the patient feels his success in life would be a gift to the parents which he cannot bear, or afford, (wish?), to give them; this illustrates the dilemma often felt with such persons, is it a matter of capacity or willingness?  The book ‘Bartleby’ by Herman Melville illustrates this concept very well.
Limentani’s summing up of the likely deeper anxieties underpinning NTR: An attack on analysis and the analyst, is the best line of defence against
* a catastrophic threat:  that of loss of the self;
* unbearable psychic pain, which could be that of (premature) separation & losing the analyst, perhaps the first anchor in a person’s life; 
* maintaining a non-integration state as an extreme defence.[Gaddini];
anxiety around integration can be greater than that of non-integration; “a passage from survival, even if precarious, to the final catastrophe”.
[Winnicott’s view that pathological anxiety of the loss of  self is also fed by the tendency towards integration, which implies a fearful recognition of separation forever]. This very early disturbance predates  the oedipal situation. Limentani sees NTR as a particular form of acting out when no other way seems open to the patient to communicate.  (I can think of clinical situations where integration, without a container, a psychic skin, would be an unthinkable agony, a raw exposure to which the intense shame of a wholesale identification with bad object is preferable).
Ogden (1983)addresses this area of  pathological attachment to the internalised parental ‘objects’ which the patient cannot relinquish, in his paper on internal object identifications, he describes how in his view internal objects are not just mental representations but are “unconscious sub organizations of the ego capable of generating meaning and experience”; i.e. are dynamic entities capable of thought , feeling, and perception.  These stand in relation to the ego as aspects of the ego. “ The object identification is so thorough that one’s original sense of self is almost entirely lost”   I feel that this goes well beyond the familiar concept of identification with the aggressor, as Ogden describes how the fully active nature of the internal object in relation to the self is more than a fantasy. “An object- representation becomes experientially equivalent to a self-representation”, and, I would add, even more powerful. 
Ogden maintains that the difficulty in relinquishing such pathological internal relationships is due to certain not yet fully understood forms of resistance:
* Need of the self to maintain the tie to the bad object to survive annihilation, but also the hope to change it into the longed for better object.
* The tie of the wronged self to a rejecting denigrating object, manifesting as a crusade to expose its wrongdoings , usually externalized (an example would be a personality structured around grievance).
* The need of the  object identified part of the self for the self is just as great, and accounts for the demonic aspect disguised as a benevolent protector.
Ogden is  stressing that resistance comes from not only fear of abandonment  on both sides, but that change of the bad object into good is experienced as annihilation of the ego, a loss of identity, of self , expressed as:  ‘There will be nothing left of me’…… ‘I can’t become somebody else’… ‘There might be nothing else there’... hence an NTR as a solution to the patient’s dilemma.  He also mentions envious feelings in the object component towards the self-component that could begin to grow & experience new life, and how this manifests in self critical or destructive attacks just when the patient realizes the possibility of turning to persons in the external world.
Clinically, I feel that often the experience of overwhelming shame at a person’s core and the associated compulsion to hide, is a critically important emotional experience that is often not given enough attention in psychoanalytic circles.
Steiner’s(1983)concept of  psychic retreat from unbearable paranoid or depressive anxieties, is very much an elaboration of Rosenfeld’s ideas , but positing an intermediate limbo place to which a patient retreats when anxieties are too much to bear.   I have found with some persons who lose any satisfaction from progress made both internally and in outer life, who fail to build up constructive change following on insights, and who find disorder and chaos to substitute in the space where a reflective process could occur, that clinical experience elicits their notable lack of a third term, a constructive internal father/other, a symbolic entity which  they could imagine and elaborate, that might offer alternate possibilities. They are very limited in their ability to allow a potential space, where playing with imagined experiences could develop; often we discover the underlying need to keep viable a tight unconscious bond to an internal object as they first and always experienced it; rather than confront it in a conscious way through establishing their separateness, e.g. when an experience or a dream evoking pain and loss occurs, they pull back at this crucial moment of facing loss in relation to their object, returning to the fantasised ‘hopeless hope’ which is kept alive, while good experiences in reality are either devalued or minimized/distorted.  The enormity of their loss cannot be faced and often hidden resentment is a stronger and more persistent dynamic, which keeps the bond in place.  
Jan Wiener (1998) in her paper on varieties of anger, differentiates between aggression in defence of the self, and aggression with an aim of punishing or hurting the object.  Elaborating on resentment, both Steiner & Wiener explore the rigid fixity in the personality where grievance (from wrongs felt to have occurred in early life) structures the personality consciously or unconsciously, and is held to and nurtured, conferring a moral right to hate and to have feelings of revenge.  It serves as both protection from further hurt and re-experiencing unbearable vulnerability in current life, as a way of retaining a controlling tie to the int/ext object the person wishes to change, and is a possible stabilizing defence against disintegration.   This bondage to the object serves to ward off feelings of dependency, pain, loss and mourning, and the associated guilt for a person’s own destructive fantasies with possible fear of retaliation. The suppressed and unprocessed hatred manifests in preoccupying thought processes, is not directly expressed bodily, but maybe somatized, this is in contrast to the very physiological  arousal accompanying expressions of rage;  consideration of this difference begs a question of whether the overwhelming and destabilizing  feeling of ‘real’ experienced in rage is feared and therefore controlled by grievance? 
Clinically we encounter the patient’s need to maintain the bond to the inner spoiling or attacking aspect identified with the internal parent as a way of being in control, and so protected against any risk of this destabilizing vulnerability and dependency happening again outside the person’s omnipotence, (as Winnicott observed in describing one function of psychosis). Constant vigilance is substituted for relaxation and playing, this frequent feature where dynamics of perilous risk or revenge are defended against, accompanies a narrowed perception of reality which if relinquished, might reveal a world of others incongruent with the internal scenario to which such persons cling.  If the hatred and resentment are maintained at this unconscious level, the person has forfeited access to their aggressive energy with its creative potential.
Andre Green (1986) in his paper ‘The Dead Mother’ writes of the blank depression arising out of guilt and catastrophic loss associated with an experience of failure to keep the object (a very narcissistic mother with extreme need of mirroring from her child, or a depressed mother unable to enjoy her baby) alive, the patient now preserving a funereal attachment to a half alive internal object.  In his article on ‘Potential Space in Psychoanalysis’ Green describes the agonizing dilemma of the infant who looking in the mirror of the mother’s face and seeing nothing, thereafter remains in the grip of a ‘negative hallucination’, investment is in the non-existent object, in negative symbolization, similar to some borderline persons attachment to a bad internal object; the “most dreaded… interval between the loss of the bad object and its replacement by a good object………is experienced as dead time which the subject cannot survive. Hence the value for the patient of the negative therapeutic reaction, which ensures that the analyst will never be replaced, since the object which would succeed him might never appear or might only appear too late”. In clinical experience we may encounter a person’s attachment to the bad object, and this object’s perception of a horrendously unimaginably bad ‘self’, as preferable to non-existence, or to an existence (as a spontaneous being), that is unbearably threatening.
Kalsched (1996)who integrates Object relations theory with a Jungian approach writes of the above persistent pathological self-destructive attachments in terms of the Inner Self Care system, understood as an archetypal configuration deep within the psyche in which a severely traumatized individual is bonded to an inner daimon who is both protector and persecutor, keeping the person from risking new experiences and developing positive relationships with others in their life.  “The survival Self seems to be the form taken by the Self when its otherwise individuating energies have been diverted to an earlier developmental task, i.e. that of assuring the individual’s  survival.”  He describes how this distorted Caretaker dismembers experience (attacks on linking) and manifests as a disintegrative urge within the psyche, in order to preserve the personal spirit from re-experiencing unbearable trauma.  In his focus on the interpersonal aspect of the therapeutic process, he illustrates what he considers to be important treatment dynamics:  the analyst in allowing him/herself to be a transformational object, between two worlds: ‘in here and out there’, is both the object of desired illusion under sway of a necessary positive, even idealized, transference, and is also perceived to belong gradually more and more in the frustrating world of reality;  followed by the inevitable  necessary disillusionment with its accompanying protest and rage.  In Kalsched’s view holding the tension between the ‘real relationship’ with its concern and its boundaries, and the ‘illusory’ one, is essential to enable the patient to return to the essential polarities of the human condition, which have been escaped in omnipotent fantasy, when reality was intolerable.
The necessity of the therapist facing his/her own disillusionment in recognizing the limitations of what can be achieved with severely traumatized persons is an important part of the shared process.

It would seem that existential fears, annihilation anxiety, and primitive defences  against the return of ‘primitive agonies’, are central factors underpinning many instances of impasse, apart from cases where a kind of ‘secondary gain’ is uppermost in the grievance structured personality’s continuing search for vengeance.  Shame is another important element, with associated compulsive hiding of subjectivity.  Embodiment or its lack, inevitably linked to ego strength is a factor;  questions arise as to when does embodiment  warrant therapeutic assistance?  and when would this be counter productive? Does increased embodiment facilitate integration and an accompanying increase in agency?  I have found that too much bodywork a person may do independently when they are in a fragile emotional state, can be destabilizing without a relational container to modulate the process.  Perhaps this is an area where psychoanalytic practitioners could usefully exchange clinical experience with their more bodily centred colleagues?
Warren Colman, Training Analyst in  SAP: ‘Is the Analyst a Good Object?’
 in British  Journal of Psychotherapy  Vol 22 No 3 Spring 2006. [Forthcoming paper on inhibiting effect of analytic superego.]
Andre Green: ‘The Dead Mother’
‘Potential Space in Psychoanalysis’ in On Private Madness 1986. Repr. 1997 Karnac
Donald Kalsched:  The Inner World of Trauma:
                              Archetypal Defences of the Personal Spirit. 1996 Routledge.
Adam Limentani:  On Some Positive Aspects of the Negative Therapeutic Reaction.
       Int J.of  Psychoanalysis 1981Vol.62
Thomas H. Ogden: ‘The Concept of Internal Object Relations.’
1983 Int J.of  Psychoanalysis Vol.64
Herbert Rosenfeld:    Impasse & Interpretation. 1987 New Library of Psychoanalysis
John Steiner 1993:  Psychic Retreats. 
New Library of Psychoanalysis in assoc. with Inst of Psychoan London.
Jan Wiener:   Under the Volcano. Varieties of anger & their transformation..Journal of  SAP vol. 43 No 4 Oct 1998
D.W.Winnicott:          ‘Mind & its’ Relation to the Psyche-Soma’  1949
‘Primitive Stages of Emotional Development’ 1952
‘Aggression in Relation to Emotional Development’ 1950-55
‘Ego Integration’ 1962
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