Clinical I Resistance DB. Week 8

Clinical Social Work Joumal Vol. 19, No. 2, Summer 1991

A DEVELOPMENTAL APPROACH TO RESISTANCE

Sylvia Teitelbaum, MSW

ABSTRACT: Diagnosis, treatment and technical interventions are depen- dent on a theoretical interpretation of the behavior of a patient. The clinical material presented addresses an initial alternative assessment of resistances, not from a classical theoretical position of opposition to the analytic procedure, the defense ofthe neurosis and a safeguard against pain and danger, but behav- ior that expresses a developmental need and deficit in the patient that is ex- pressed in the treatment and relationship to the therapist.

The concept of resistance has been reviewed by many theorists, in- cluding Glover (1955), Greenson (1967), and Schafer (1973). Since the data on resistance is extensive, a brief overview is offered to give a background and summary.

Freud introduced the term resistance in "Studies in Hysteria" (Freud, 1893-1895) with the treatment of Fraulein Elisabeth von R. He hypothesized that pathogenic, incompatible, conflictual ideas were forced out of consciousness. Freud concluded that dissociation from con- sciousness or repression operated as the source of resistance in the ther- apeutic process. In "The Interpretation of Dreams" (Freud, 1900), Freud continued to develop his understanding of resistance particularly as it relates to censorship imposed by resistance in the dream process. In this work, the well known statement is made, "whatever interrupts the prog- ress of analytic work is a resistance" (Freud 1900, p. 517). Freud thought resistance was a serious impediment to the therapeutic process, and in his early writings, terminology such as "fought", "combated" and "enemy" reflects such a view. He later softens his view by saying that "resistances should not be one-sidedly condemned, as they include im- portant material from the patient's past" (Freud 1916-1917, p. 291).

Freud's seminal book. The Ego and Id (1923), presents the tri-part personality structure of ego, id and superego. This led to a revision of

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the earlier definition of resistances, as the process of dissociation from consciousness (repression), to a more sophisticated concept of conflict be- tween the agencies of the personality (i.e., id, ego, superego).

In most general terms, Freud's structural model viewed the analyst as the elucidator of the defenses which operated to keep from conscious- ness the conflicts between the agencies of the personality. Thus, classi- cal mechanisms of defense are intrapsychic and resistance stems from anxiety generated by the conflict laden sexual and aggressive impulses. These concepts highlight the core Freudian view of resistance.

Several theorists contributed to our understanding of resistance, some simply elaborating on Freud's basic theories, and others offering a new vision. W. Reich (1933) deepened the work of Freud by focusing on character resistances. He spoke of conflicts that became "frozen" in character features and he outlined techniques of doing character anal- ysis.

Anna Freud (1936) enlarges our understanding by formulating and developing several ego defenses, thereby strengthening the concept of "ego" analysis. Greenson further expands Freudian theory in The Tech- nique and Practice of Psychoanalysis (1967). Greenson, a master of tech- nique, gives numerous examples of how to deal with resistances and emphasizes the centrality of resistance analysis in psychoanalysis.

Freud's reconceptualization of resistance within the structural model developed the concept that, in addition to the id, the ego and superego had pathological features. This laid the groundwork for ego psychology.

Ego psychology, based on drive theory and the tri-part model, em- phasized an appreciation of the strength of the ego and the defenses instituted against not only conflict between the agencies of the person- ality, but against actual reality situations. Internal drives and their de- rivatives were no longer considered the only source of motivation.

Object relations theory, in its redefinition of the object, emphasizes the mutuality in the interaction between mother and child, independent of instinctual needs. If the child experiences (in actual reality and/or internal experience of the object) mother as insensitive, depriving and/ or malevolent, psychopathology will develop, leading to structural dam- age. Primitive defenses that distort and blur the outer reality are readily seen in the more primitive and damaged personality.

The primitive defense, splitting, used to cope with contradictory feelings towards the love object, is explored by Fairbaim (1945), Gun- trip (1971) and Kernberg (1975). The defensive posture to avoid anxiety and abandonment is seen in the conceptual development ofthe conform- ing self (Fairbaim, 1952) and false self (Winnicott, 1958). Masterson (1972) speaks to the false self defense used to avoid retaliatory abandon- ment by the mother. Grotstein (1987) explores resistances arising out of fears of being overwhelmed and consumed by the object.

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Developments and refinements in the knowledge base and treat- ment goals had a profound impact on clinical practice and led to a wid- ening scope for psychoanalysis.

Freud declared that narcissistic neuroses "can scarcely be attacked with the technique that served us with the transference neurosis" (1917 [1916-1917], p. 423). The narcissistic patient has "no 'capacity for trans- ference"' (Ibid., p. 447) and therfore psychoanalysis is not possible.

Kohut (1971, 1977) expands the applicability of psychoanalysis, re- formulating many of its concepts and redefines resistance. Essentially, Kohut's concept of resistance develops from the belief that the therapeu- tic process has the potential to reactivate past trauma with the mater- nal love object's lack of empathy, attunement and affirmation. Resis- tances in therapy reflect a fear of retraumatization, of reinjury and disappointment. Hence, a patient may not acknowledge the value ofthe therapist in order to safeguard against disappointment and pain. Freud- ian theory's content of repression involves castration anxiety and the drives whereas the content of repression in Kohutian theory involves fragmented and split off aspects of the self in response to anxiety of annihilation (Greenberg, Mitchell 1983, p. 362)

This brief review of the literature of resistance highlights the vi- sions of humankind based on different theoretical perspectives. A range of: taming, gratifying and dealing with conflictual drives (drive theory); development of high level defenses in response to adaptation (ego psy- chology); freeing of the constraints of past relationships developed through identification and internalized object relations (object theory re- lations) to the establishment ofthe self as a source of initiative and self- worth (self psychology), dramatize the importance of how theory deter- mines the analysts's conception of resistance and goals of therapeutic activity.

My contention is that certain behaviors that are often dealt with as resistances in the therapy are manifestations and expressions of a devel- opmental need and deficit in the patient. The perception that crucial aspects of heretofore missing maternal functions will be represented in the analysis embraces an object relations theoretical position. Winni- cott's term, the "holding environment" (Winnicott 1965), is used to de- scribe certain aspects of the analytic process that provide the illusion of protection and safety. This metaphor suggests a caretaking maternal function of standing between the child and the outside world, which not only offers protection from the dangers from the outside, but also from the dangers of the child's intemal experiences.

Kohut states that the analysand reactivates in the analysis, in a self object transference, the needs of a self that have been thwarted in childhood (Kohut 1977). He speaks to the developmental need of having the experience of a caretaker who is attentive, empathically attuned and confirms the uniqueness of the child's evolving self. The maternal

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function of attunement is crucial in responding to the anxieties and fears of the young child. When attunement, the empathic affective hond hetween mother and child (experienced as a "holding environment") is not forthcoming, the child is frequently forced into premature matura- tion. The child "ceases to be child, for to have a childhood requires the presence of a holding environment" (Modell 1984, p. 90)

In other words, does the child receive "good enough" (Winnicott, 1960) protection and soothing in the face of the typical experiences, anx- ieties and fears of childhood? Simple examples: a fight in school with a friend, heing the object of a critical teacher, a physical injury resulting from a fall, a foolish and/or embarrassing occurrence, are some of the stereotypical experiences of childhood. Optimal maternal responses evoke an image of the concerned parent, offering cookies and milk, an enveloping hug and reassurances that the child continues to be worth- while, valued in the mother's eyes ("the gleam in the mother's eye", Kohut 1971, p. 116), and will remain intact despite the painful episode.

What if these parental responses are glaringly absent in the life of the child? Will the internal experience and response by the patient to this maternal deficit be expressed in any form in the analysis and, if so, how will it manifest itself?

The analytic view that the therapeutic setting itself contains ele- ments of mother-child relations is seen in the writings of Spitz (1956), Winnicott (1965), Balint (1968) and Modell (1984). Analytic technique fosters an idealized maternal experience. The analyst is non-judgemen- tal, constant and reliable, responsive primarily to the patient's needs and not his own, has an understanding of the patient's internal psychic reality and can frequently illuminate and clarify what is threatening and confusing. No special activity on the part of the analyst is needed, for these characteristics simply represent the basic therapeutic stance in psychoanalysis.

Schafer (1983), states that "the concept of resistance tends to pre- commit the analyst to an undesirable combative or adversarial view of the analytic relationship" (p. 163). The negative and aggressive conno- tations of some of our psychoanalytic language is readily seen in the literature. Reich's (1933) militaristic terminology (armor), Greenson's (1965) strategies of confrontation, adjectives of "hiding" and "avoiding" and Freud's (1912b) adversorial metaphors are just a few examples.

Schafer (1983) recommends that the analyst should approach what is "traditionally called resistance in an affirmative manner, that is, to approach it not as resisting or opposing, but as puzzling or intelligible behavior that requires understanding" (p. 168).

Most importantly, any given behavior is an expression of a myriad of dynamic issues and functions. The same behavior can be seen as re- sistance stemming from conflict derivatives or, as an expression of in-

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fantile longings and developmental gaps in maternal child empathic bonding.

Resistant behavior can be considered a positive indication of a de- sirable expression of negative transference that has been rigidly re- pressed (Loewenstein, 1957); resistant characteristics can be seen as an integrative value in coping (Stone, 1973) and/or an expression of self- assertion and autonomy (Blanck/Blanck, 1974)

The following vingettes demonstrate some of these issues. Sabrina, a single, strikingly beautiful fashion model from the midwest, came to treatment at the age of 25. A bright, reportedly gifted woman who en- gaged with some success in art and acting, presented herself in an in- tensely frenetic manner. Speaking rapidly with strong affect, she would frequently jump up from her chair, dramatically shift her posture or facial expression, which seemed reminiscent of posturing in front of the camera. Her presenting difficulities centered around her career which, according to her, was ebbing away after extraordinary success at an earlier age. She expressed confusion as to her future goals and concern over a series of dead end relationships with men where she was usually abused and abandoned. Sabrina spoke of her prior drug involvement and anorexia. All this material was presented with great intensity and drama, creating an aura of almost palpable anxiety as she filled the room with words, feelings and physical movements, without any mo- ments of silences and calm.

In the second session, Sabrina informed me that she was currently working with four other individuals. She had regular sessions with a maharishi, a teacher of Hindu mystical knowledge, an astrologer, a phrenologist, and a cognitive therapist. Sabrina said she needed these people, they gave her direction and advise, had the "answers," and with- out them she would feel terrified, unsafe and confused. Coming to psy- choanalysis was the recommendation of a friend who thought she could get additional understanding and help from a different perspective. Added to this seemingly cluttered world, Sabrina attended many classes in art, music, dance, drama, yoga and pottery.

A classical theoretical position would posit that Sabrina's involve- ment with four other therapists/advisors would dilute, if not make im- possible, a viable therapeutic connection with me. Indeed, Sabrina evi- denced a myriad of resistant behavior ranging from lateness to sessions, inappropriateness of affect, excessive movements (something being dis- charged in movement instead of words) and acting out (near verbatim reports of our sessions were shared with others), fostering a dilution of feelings and transferential reactions in our therapy (Greenson, 1967).

Of course, all this is resistant behavior; however, I choose not to interpret it and approach it as a piece of behavior that requires under- standing (Schafer, 1983). Additionally, I made the assessment that this

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desperate, needy frantic young woman would be unable to give up her involvement with these advisors. I found Sabrina exciting and challeng- ing and thus decided to begin therapy, albeit in a position of the fifth advisor/therapist in her busy world.

During the course of treatment, we explored the history that made some of her behavior intelligible. Sabrina's mother seemed a shadowy figure, supposedly preoccupied with the developing, training and main- taining of her daughter's great beauty. The patient was required to have a "perfect" appearance at all times. Her world was beauty shows, con- tests, and modeling lessons. At the completion of high school, Sabrina relocated to New York, by herself, under contract with a top modeling agency.

In contrast to her mother, Sabrina's father loomed in counterpoint with profound intensity and power. He was a commandant of a military school and imposed the same set of rigid rules on the house. Sabrina recalled countless examples of being unfairly accused. Apparently the father had an explosive, uncontrollable temper and both real and imag- inery infractions of behavior were dealt with by punishments that ranged from being locked in a closet for six hours to strap beating.

The children, which included two younger brothers, lived in terror of this apparently tyrannical and sadistic man. The patient probably received the least amount of corporal punishments as her father seemed to favor his daughter; however, his supposed seductiveness created addi- tional anxiety. Sabrina remembers receiving no protection from the mercurial reactions of her father. Apparently her mother would either side with her husband and/or deliberately remove herself from the situ- ation.

In my view, a central dynamic in Sabrina's rapacious acquisition of five different advisors/therapists in her life was a desperate attempt to find soothing and protection. Her world resonated with profound dan- gers from the outside and intense feelings of being overwhelmed, fright- ened and confused. During the first stage of treatment, I focused on Sabrina's yearnings to find someone to help her feel comforted and safe. Not surprisingly, approximately six months after treatment with me had begun, Sabrina terminated her contact with her advisors. The ther- apeutic process was giving her the frame, the grounding and a sense of safety. As ego consolidation proceeded, she could give up her frantic search for the idealized protector outside of our therapy. Needless to say, there were other dynamics operating; however, this issue had centrality in the first stages of treatment.

Another clinical example is presented in the following vingette. David, a married surgeon from a European immigrant family, entered treatment at the age of 45. He appeared utterly confident and spoke articulately and insightfully about his presenting problem. He sus-

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pected that an intensification of his chronic state of mild depression was triggered by the retirement and relocation of the medical director in the hospital in which he worked. David had warm and loving feelings to- wards this man and greatly felt the loss of his presence. Apparently David's skills and talents were recognized as he acquired a position of power in the hospital at a fairly young age. Indeed, it was not hard to see David "taking charge" and being very authoritative, if not some- what dictatorial, in his role.

David told me, or rather informed me, that there were conditions that had to be agreed on before he would start therapy. The combination of being an avid reader and his wife being in psychoanalysis, gave David a general understanding of psychoanalysis. David's conditions were that I was to discuss, teach and educate him about the body of knowledge of psychoanalysis, including all and any techniques that I was to employ. Secondly, under no circumstances would he lie on the couch. He said that Freud employed this technique only to avoid the tedium of face to face contact. David concluded the use of the couch was a "morally reprehensible gimmick used by analysts to have power."

Aside from the obvious transference implications, resistent behav- ior seemed apparent. I was asked to collude with the patient (Langs, 1975) in his defense of intellectualization and in a colleague like fash- ion, expound theory. David's rigidity indicated his need to hold his feel- ing in check (Greenson, 1967) and his refusal to lie on the couch altered the frame of the analysis, preventing the opportunity to enhance regres- sion and free association. Indeed, free association, as a basic technique, would be seriously compromised. Not only was the patient determining the content of the sessions, he appeared to be reversing the role of pa- tient/therapist.

Since I assessed that David would not pursue treatment if I re- quired that he revise his conditions immediately, I decided to agree with his terms, with the proviso that we renegotiate these issues in two months. Indeed, he saw treatment as a last and not very desirable last resort since his attempts at mind control, exercise, extensive reading and positive thinking were to no avail in lifting his depression. He was also opposed to medications. Thus David started treatment on this du- bious note.

During the course of treatment, David's history began to shed light on the intensity and rigidity of his demands. His mother was a forceful, opinionated woman who allowed no latitude or compromise in her atti- tudes of child rearing. According to the patient, he was told he was toi- let trained at 9 months of age. David remembers having to complete his meals in the entirety, or be required to eat the cold leftovers in the next meal. His mother apparently overreacted to any or all infractions of be- havior and David remembers being grounded for one month for being

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five minutes late for a curfew. David recalled repeated admonitions from his mother (whom he referred to as "Dragon Lady"), that he "bet- ter not turn out to be a failure like his father." His home felt joyless and oppressive as he had the constant feeling of "walking on eggs," waiting for the axe to fall.

David's father is remembered as kindly and ineffectual, a brilliant and broken man who did not realize his dreams of becoming an architect and instead grinded out a barely adequate living as a shoe salesman. David's father seemed intimidated by his wife and could not offer David any protection from his overbearing mother. There was one important exception. Overruling his wife's protests, David's father initiated and maintained a weekly Saturday morning Father and Son time. David described with great tenderness the long intellectual discussions he had with his father, ranging from philosophy to politics. It became the high- light of his week to take a Saturday morning walk with his dad, escap- ing from the repeated humiliations and harping demands of his mother. He remembers feelings of peace, calm and safety with his dad at these times.

Of course, there are multiple ways to interpret David's initial de- mands made on the analyst. I focused on the formulation that David's need to have me engage in intellectual discourse was a means of at- tempting to recapture with the analyst the rare moments of comfort and safety he experienced in his childhood. Undoubtedly he could not feel safe or protected lying on the couch as it evoked terrors of humiliations and loss of control. His profound yearning for protection and safety be- came a major theme in the sessions. A year after David started analysis, he was able to lie on the couch. His need for intellectual discussions eventually dissolved during the course of treatment.

Another example is presented in the following case. Brad, an entre- preneur, was involved in a stormy divorce proceeding when he entered therapy at the age of 42. He described himself as a "workaholic," who skillfully developed a string of outlet stores in the northeast area. He was very proud of his accomplishments and felt that the impending di- vorce seemed "to pull the rug out" of his usual feelings of well being and confidence. His reaction of anxiety, uncertainty and mild depression seemed an enigma to him, as he felt that he did not particularly love his wife. However, he had no desire to end his marriage. The divorce was initiated by his wife, who apparently met another man, hut also ex- pressed dissatisfaction with Brad's remoteness and unavailability. The patient expressed anxiety in connection with his two children, partic- ularly his 6 year old, who he feared would begin to drift away from him because he moved out of the home.

Brad developed an immediate idealized transference to the analyst, extolling her ability to understand and be attuned to his feelings. He

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felt he never had these feelings before and therapy felt like a haven and respite from the pressures in his life. The sessions developed a charac- teristic rh5i;hm as Brad expounded, with the most exquisite detail, the seemingly most insignificant minutiae of his daily experiences. He ap- peared to feel I was eagerly awaiting this data as he punctuated his discourse with statement like, "I know you want to know.", and "I'm sure you want a follow-up of what I told you in yesterday's session." Often, when a patient is talking freely, there is a flow between the past and the present; however Brad was totally focused on the present with the presentation of seemingly trivia. Fixation in time, rigidities and focus on trivia or external events are often viewed as the more obvious clinical examples of resistance (Greenson, 1967).

Of course, the narcissistic implication of this behavior is apparent (Kohut, 1977). However, for the purposes of this discussion, I'll focus on the behavior that I felt expressed a gap in maternal empathic connec- tion.

The patient's history gradually emerged in the treatment, which made one aspect of looking at his behavior understandable. Brad was the younger of three children, bom in a middle class family. At the age of seven, he arrived from school to find his home in pandemonium,. His father, feeling ill, had come home early from work, and had died of a cerebral hemorrhage five minutes before Brad exited from the school bus. That momentous day changed Brad's entire life. Apparently the family lived above their means and no financial provisions were made in the event of his father's death. Unprepared and untrained, his mother had to immediately find employment, leaving Brad in the care of a twelve year old sister and fourteen year old brother. His brother was reportedly sadistic, heaping verbal and physical abuse on the patient. Brad remembers not wanting to burden his overworked mother with his problems, for fear that she would "drop dead" like his father. He would remember a feeling of almost wrenching anxiety as he would open the front door to be greeted by his brother. His sister seemed absent, always involved with many friends and activities. Brad's few attempts at re- ceiving soothing and protection from his mother seemed to be greeted with statements that expressed her sense of burden and hopelessness. Indeed, she had no time or energy to listen to his feelings, let alone his daily experiences. She rushed home from work, cooked, cleaned and went to bed.

As Brad spoke of those experiences, with intense feelings of pain, anguish and longing for the attention and safety from his mother he had before his father's death, a shift occurred in the content of the sessions. Minutia of his daily events no longer filled the session as he could now verbalize his longing for empathy, attunement and protection

There are deep and healing developmental implications for the pa-

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tient who can experience the analyst as someone who can understand and resonate with his inner feeling. Brad demonstrated an increasing capacity to tolerate the inevitable frustrations that occurred when I was unable to offer a perfect empathic response. This process aided structure building (Kohut, 1977).

The purpose of the clinical vignettes was to demonstrate the acting out in the analysis, absent nurturing maternal functions in the mother infant relationship. I believe that initially, an analytic stance reflecting a resonance with these patients' self-experiences, fosters a therapeutic connection. In patients who suffer from an early absence of maternal functions, challenging questions or confrontations of apparent resistant behavior can, at best, increase defensiveness and be non-productive or, at worst, lead to a premature termination. These patients live in an internal world of unsafety and desperately hold onto their adaptive means of survival. They demonstrate a variety of personality compensa- tory facades. These can range from a pseudo independence and apparent confidence to a timorous, placating cooperative facade. They often share an excessive reaction to real and imagined criticisms and attacks. Fre- quently, interpretations of resistances by the analyst are experienced as just such an attack or criticism.

Stolorow and Lachmann assess that to interpret a defense as a de- velopmental arrest may make the analyst too benign but it is far more forgiveable than dismissing it solely as a aspect of the patient's patho- logical defenses (Stolorow & Lachmann, 1980).

Eissler's seminal paper on parameters (Eissler, 1953) speaks to the justification of an analyst adapting non-interpretative stances with the patient under particular circumstances

Modell (1984) speaks to the holding environment of the first phase of treatment and then to the consideration of shifting to a more classical position at later points in therapy. Gedo (1979, 1980) expounds on his belief that developing modalities or altering therapeutic stance should shift depending on phases of development that are seen in the therapy. Patients are never fixated in a single dynamic constellation as evi- denced by progressive and regressive trends seen in the course of a sin- gle session. Ongoing clinical assessments are required, albeit a very dif- ficult task, to assist us in determining which vision of the behaviors manifested is most useful in furthering the anal}^ic inquiry. The best we can do as analysts is to try particular interventions that follow from different formulations, assess their impact and be flexible to shift our technique in the face of the continual changing dynamics presented by the patient. Since behavior has multiple determinants which the an- alyst can assess in a variety of ways, our interventions are often best measured by the responses of the patient. Is the patient more defensive in reaction to the analyst's intervention? Is the patient enabled to initi- ate and continue free associations? Does the patient's response deepen

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our understanding and/or continue to work through dynamic issues? These are some of the questions that can indicate the efficacy of the analyst's intervention.

However, as the treatment develops, the shift to a more classical model may be indicated. Indeed, the so called confrontative intervention can foster a state of individuation and separation (Siverman, Lachmann and Milch, 1982). Developing this point further, a multi-model approach has its advocates in the psychoanalytic field. Fred Pine (Pine, 1989) re- fers to the psychology of drive, ego, object relations and self as sharing common assumptions and beliefs. Their combination illuminates human functioning and "require us to see psychoanalysis not only as a psychol- ogy of conflict, but also of repetition and development. . ." (Pine, p.595).

There are times when the dynamics or external events in a patient's life dictate introducing a parameter and therefore there is a need to shift one's analytic stance. This is often not acknowledged particularly by newly developing candidates in training who are fearful of being crit- icized for violating the classical rules of analysis. Sometimes these clini- cians veer in the direction of rigidity and blind obedience to their under- standing, often misunderstood, of neutrality, confronting defenses, centrality of interpretation as a technique, use of couch and an overall vision of the "tabula rasa" of the analji;ic role. The accusation that one is doing supportive treatment resonates as a powerful invective. Confu- sion abounds over the differences between the concepts of parameter, gratification of wishes and neutrality. This confusion can lead to anxi- ety, uncertainty and rigidity, often resulting in a combative, adversarial stance towards the patient's defensive verbal and behavioral expres- sions. A misinterpretation and simplification of Freud's definition, "what- ever interrupts the progress of analytic work is a resistance" (Freud, 1900), often thrusts the novice into a battlefield where success depends on defeat of the insidious defenses. This kind of antipathy augers poorly for therapeutic success in any theoretical framework. The inability to be open to a creative flexible approach to each patient can lead to a sterile and non-productive experience for both patient and analyst.

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