Addressing and Confronting Bias and Prejudice

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capacity but lacks the second one. As a result, when faced

with disappointments, he gets very hurt and like any other

person who is frequently hurt, he gets angry. This anger

comes in the way of the mind's peaceful functioning in the

realms of both his relationships and vocation. Life gets

splintered and is lived in pieces. At times, the individual vents

his rage on self and others or tries to get rid of it by numbing

his mind (with the use of substances) or distracting himself by

impulsive gratifications. All in all, borderline personality

disorder is a very painful condition to have.’

• Narcissistic personality disorder. ‘The person with a

narcissistic personality disorder is someone who is

preoccupied with his own self. While it might come across as

such, this is hardly a matter of vanity. The fact is that the

person secretly feels quite worried about his own self and

carries a profound vulnerability to shame. Having been raised

on praise without much love and affection, such a person has

become dependent upon admiration. This is what he

constantly seeks. He feels perpetually compelled to improve

his talents, polish his image, and “sell” himself to others.

Now, all this takes a lot of effort, and energy. It is truly

tiresome. Besides it has the painful consequence of his

becoming unable to pay attention to others and also not

feeling really loved by anybody; he feels that people like him

only because of what he has accomplished not for who he is.

He feels alone in this world. While socially successful and

admired by others, the narcissistic person lives in a private

world of self-doubt, inferiority and insatiable longing for

genuine love and acceptance.’

This manner of telling the patient's diagnosis to him should

put to rest the prevalent notion that patients misunderstand

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 41

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diagnostic terminology and are narcissistically injured by it.

In holding onto this old-fashioned idea, one is liable to

overlook that the interviewer's cryptic attitude, fudging, and

uncomfortable avoidance can also have alienating and adverse

effects on the patient.

Following the discussion of the nature of the patient's

problem, the focus should shift to issues of its treatment. The

interviewer should now inform the patient of what he thinks is

the ideal treatment for the patient's malady, explaining,

especially if asked, the reasons for this recommendation. The

patient should also be informed, especially if things are

unclear, of alternate approaches to treating the condition

involved, and encouraged to ask questions about anything that

seems unclear Questions raised by the patient should be

answered factually, and the interviewer should not derail or

mystify the patient by ‘interpreting’ the reasons behind such

questions. For instance, the patient may ask why the

frequency of two to three times a week is needed for dynamic

psychotherapy. Or, he might ask about the difference between

psychoanalysis and psychotherapy. Subtle controversies in

the field notwithstanding, it is possible to answer such

questions in a simple, straightforward way. Regarding

frequency, one might say the following : ‘t h e pro b lems we

are dealing with here are deep and solving them requires the

sort of access to your inner world that can only be provided

by such frequency.’ One might explain the difference

between psychoanalysis and psychotherapy not only in terms

of frequency of visits and the use of couch but, to a certain

extent, in terms of the nature of the patient's activity (i.e., free

association) and the therapist's ‘quieter’ stance vis-à-vis the

patient's report of his thoughts, feelings, fantasies, and

dreams. In the end, it is the therapist's straightforward and

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 42

suicidal crises. Retrieved from http://ebookcentral.proquest.com

collaborative manner in dealing with the patient's questions

that counts.

CONCLUDING REMARKS

In this chapter, I have attempted to offer an account of what

constitutes a thorough initial assessment of a potential patient

for psy-chodynamic psychotherapy. I have divided my

comments into the categories of (i) forming early

impressions, (ii) assessing psy-chopathology, (iii) assessing

psychological mindedness and other ego functions, and (iv)

assessing the patient's motivation and realities that might

impact upon the feasibility of proper treatment.

I have described how pooling the four sets of data helps

choose a treatment modality and then described the process of

making recommendations to the patient, answering his

questions, and, through all this, beginning to set the ground

rules for treatment being undertaken.

Conducting these tasks is hardly restricted to gathering

objective information; the therapist's subjective experience

plays a key role throughout the evaluation process. Indeed,

vigilance towards early ‘countertransference’ yields all sorts

of useful clinical data, as I have already shown in this chapter.

What I wish to underscore now is that while the arousal of

strong feelings in the therapist does not necessarily preclude

his taking the patient into on-going treatment, circumstances

where this might be the case do exist. Intense discomfort with

a patient based upon cultural differences and/or the nature of

psychopathology at hand might, at times, not be ‘containable’

by the therapist's work ego. Instead of becoming unduly

valiant, it might then be preferable not to take the patient into

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 43

suicidal crises. Retrieved from http://ebookcentral.proquest.com

treatment. Politics, the last taboo in the clinical field, can also

contribute to insurmountable difficulties. Finally, there is the

issue of the therapist's competence to treat a particular patient.

While all sorts of professional and legal checks and balances

exist in order to assure this, ultimately the assessment of one's

competence rests upon a honest self-scrutiny and fearless soul

searching.

This brings up the fact that in-depth psychotherapy constitutes

an intrapsychic and interpersonal journey that is unpredictable

and, at times, dark and mysterious. Two people undertaking

such a trip together need to establish and maintain clear limits

and boundaries to prevent themselves from getting derailed.

This forms the topic of the next chapter.

Notes

1. Two comments need to be added here. One is in the nature

of acknowl edgment and the other involves a clarification.

The first pertains to the fact that the idea of conducting the

initial evaluation on consecutive days (instead of weekly

appointments) was suggested to me by my good friend,

Philadelphia-based psychoanalyst Albert Kaplan, some fifteen

years ago. Having found the practice extremely useful, I have

stuck with it and, of course, remain thankful to Dr. Kaplan.

The second point I want to make pertains to patients arriving

for a consultation from out of town. To them, I generally

recommend two sessions of one and a half hour length,

separated by a hour interval, in the same day. This avoids the

necessity of an overnight stay in town and therefore saves the

patient extra expense. Occasionally, however, more time than

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 44

suicidal crises. Retrieved from http://ebookcentral.proquest.com

this might be needed and an overnight stay in a nearby hotel

becomes inevitable.

2. The clinical material offered in this chapter and indeed

throughout this book makes use of fictitious names. I have

opted to use names instead of the conventional initials which

appear too ‘dry’ and, frankly, not quite human to me. I have

also made great effort to disguise the identi ties of the

individuals involved without the sacrifice of clinical accura

cy.

3. Highly pertinent in this context is the observation made by

Professor A.K. Agarwal of Lucknow, India, that the

customary mental status ex amination is useful with

psychiatric inpatients but has little applicabili ty to

non-psychotic, outpatient populations (Rajnish Mago,

personal communication, October 9, 2007).

4. Attempts at distinguishing neurotic (‘oedipal’) from

borderline (‘pre- oedipal’) character organizations must be

tempered by the fact that the two frequently overlap and

coexist. They might be condensed into each other or one

might serve as a defense against the emergence of the other.

Oedipal wishes are often associated with preoedipal fears

(e.g., separation and loss) and preoedipal object hunger

frequentlytakes on a triangular and sexualized flavor. Oedipal

drive derivatives can camouflage unresolved symbiotic

longings and a preoedipal babylike pleading can be a

regressive refuge from the guilt and anxiety of oedipal

competitiveness. All in all, there is much fluidity between

what are generally regarded as categorically neurotic and

borderline organizations.

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 45

suicidal crises. Retrieved from http://ebookcentral.proquest.com

5. A curious note to the literature on

psychological-mindedness was added by Werman (1979) who

noted that this capacity is not only evi dent in the ability for

self observation but also in one's view of the ex ternal world.

Exploration of the latter aspect however is often neglect ed.

Werman observed that the inability to accept random

occurrences and intolerance of ambiguity in the external

world are often the out ward manifestation of poor

psychological-mindedness. The ability to believe in chance

and to tolerate uncertainty are consequences of the

development of secondary process thinking and may be

regarded as a specialized aspects of reality-testing.

6. A simple and short question about the role of animals in the

patient's life, asked during the initial evaluation, can often

reveal clinically sig nificant information.

7. This emphasis upon the therapist's activities does not

eliminate the fact that the patient also assesses the therapist

during the initial evaluation. Such assessment, I believe,

consists of the patient's looking for the qualities of affinity,

empathy, kindness, patience, knowledge, and com petence.

The patient wishes to be understood and feel that the thera

pist can help him.

8. Such luxury of ethics is generally out of the reach of

trainees who are assigned cases and have little say in selecting

patients. The availability of supervision, however, provides a

balancing reassurance in this con text. Greater responsibility

rests with psychotherapists who, while oth erwise

experienced, might not be competent to treat this or that type

of patient for a variety of reasons.

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 46

suicidal crises. Retrieved from http://ebookcentral.proquest.com

2. BOUNDARIES

I never, or almost never, occupy the middle of my cage; my

whole being surges towards the bars

André Paul Guillaume Gide (1869-1951)

As human enterprises, dynamic psychotherapy and

psychoanalysis are intensely paradoxical at their base. On the

one hand, they are grounded in theoretical formulations

regarding development, mental functioning, psychopathology

and technique. On the other hand, they involve a deep and

sustained emotional relationship between two individuals. It

is this central paradox that dictates that, in the conduct of

these treatments, deliberateness and spontaneity, knowledge

and surprise, and discipline and freedom co-exist in a gestalt

of harmony. (For more on this matter, see Parsons, 2001.)

Clearly, such a complex ‘game’ cannot be played without an

agreed-upon guidelines and framework. The concept of

‘boundaries’ enters the discourse at this point.

In this chapter I will elucidate this concept in some detail. I

will categorize the plethora of notions that pervade this realm

into boundaries of three types: intrapersonal (intrapsychic),

personal, and interpersonal. This centripetal movement of

discourse will bring up the concept of ‘optimal distance’

(Bouvet, 1955; Balint, 1959; Mahler et al., 1975; Akhtar,

1992b), its potential overlap with ‘interpersonal boundaries’,

and the cultural variations and psy-chopathology of

boundaries and distance. Following this, I will address the

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 47

suicidal crises. Retrieved from http://ebookcentral.proquest.com

various types of boundary violations and also note waysto

prevent such mishaps and to deal with their socio-clinical

after-math.

9 My discussion of technical matters, however, will not be

restricted to this aspect of boundaries. I will also describe the

measures needed to set up a clear and firm therapeutic frame

from the outset and to safeguard it from major encroachments

by transference and countertransference distortions.

INTRAPSYCHIC, PERSONAL AND

INTERPERSONAL BOUNDARIES

The term ‘boundaries’ is used in psychoanalytic literature in

three different ways: (i) intrapsychic boundaries, (ii) personal

boundaries, and (iii) interpersonal boundaries. Each of these

categories has its developmental origins, phenomenological

subtleties, cultural and pathological variants, and implications

for technique. However, these concepts overlap each other

and the following elucidation of them in separate sections is a

transparent artifice in the service of didactic clarity.

Intrapsychic Boundaries

Although Freud's (1900) early topographic model (dividing

the mind into conscious, preconscious and unconscious

systems) and later structural model (with entities like id, ego

and superego) both implied separation barriers within the

mind itself, the term ‘boundaries’ was not used by him. It

appeared, with a prefix, as ‘ego boundaries’ for the first time

in a paper by Tausk (1918). Later it was popularized by

Federn (1952) who described ‘inner ego boundaries ‘as

barriers that separate the ego from other mental structures.

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 48

suicidal crises. Retrieved from http://ebookcentral.proquest.com

Klein's (1935, 1940) and Fairbairn's (1952) models of

en-dopsychic structure also contained splits, schisms, and

sequestered schemas within the mind.

With Hartmann's (1950) differentiation between ‘ego’ and

‘self’ and Jacobson's (1964) refinement of ‘self’ as

‘self-representation’, the concept of boundaries came to be

understood somewhat differently. Jacobson (1964) proposed

that the initial intrapsychic structure is a fused self-object

representation that evolves through primary libidinal

identifications with the mother. Gradually, differentiation

between self- and object-representations begins. The

propensity for their defensive re-fusion exists and is

intensified by the presence of too much aggression within a

psychic economy: this can lay the foundation of a psychotic

core. Under loving cir cumstances, the self- and

object-representation differentiation continues and is followed

by the synthesis of ‘good’ and ‘bad’ self-representations into

a composite self-representation and of ‘good’ and ‘bad’

object-representations into a composite internal object

representation. These intrapsychic clusters are the

metapsychological counterparts of identity formation

(Kernberg, 1975, 1976). Here Erikson's (1950, 1956) work is

pertinent. Besides emphasizing the synthesis of sequestered

ego (self) fragments, Erikson underscored the importance of

bringing together the past, present, and (wished-for) future

views of the self; temporal continuity and continuity amidst

change was seen by him as the hallmark of healthy identity.

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 49

suicidal crises. Retrieved from http://ebookcentral.proquest.com

Personal Boundaries

The boundaries of the self as a distinct organism have been

described from various perspectives. Freud's (1895)

Reizchutz or ‘protective shield’ is perhaps the earliest concept

in this realm. Under this rubric, Freud proposed the existence

of a threshold of a stimulation by the external environment,

the exceeding of which becomes psychologically traumatic.

Later authors (Mahler, 1958; Khan, 1963; Gediman, 1971;

Esman, 1983) expanded Freud's views to include the

regulation of internal stimuli also among the functions of this

structure; Rapaport's (1951) term ‘stimulus barrier’ thus

became synonymous with Freud's (1895) protective shield.

The origins of such a barrier were traced to mother-infant

interactions whereby the mother regulates the stimulation her

infant has to face. This maternal function is gradually

internalized by the child who then develops self-regulatory

capacity with regards to the tolerable amounts of excitement,

activity, and stimulation.

Tausk's (1918) ‘ego boundaries’ and Federn's (1952) ‘external

ego boundaries that separate ego from the external reality’ are

also important concepts in this regard. These authors,

however, did not regard such boundaries as static and rigid.

Their ‘soft’ notions were gradually replaced, as Gabbard and

Lester (1995) note in their comprehensive review of the topic,

by reified concepts. Reich's (1933) description of ‘character

armor’, Bick's (1958) ‘skin around the ego’ and Anzieu's

(1990) ‘psychic envelopes’ are among the most prominent

illustrations of this tendency. The psychiatric ‘necessity’ of

distinguishing between psychotic and non-psychotic

conditions, both in the form of their flagrant ‘state’ and their

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 50

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sub terranean ‘trait’ (Frosch, 1988a, 1988b) further

consolidated the view that neat demarcations between self and

non-self were possible and even desirable. Winnicott's (1953)

delineation of the ‘intermediate area of experience’ and

Searles’ (1960) views about man's relationship with his

non-human environment are prominent exceptions to this

rigid me-not-me separation.

Interpersonal Boundaries

Psychoanalysts studying developmental processes (e.g.

Mahler, 1958, 1971, 1972; Mahler et al., 1975; Winnicott,

1967, 1969, 1971; Tyson, 2005, 2006; Parens, 1979, 2006)

invariably posit a view of boundaries as evolving from a ‘dual

unity’ or ‘symbiosis’ or ‘merger experiences’ between two

persons-i.e. mother and child.

10 Their models thus lay down the prototype for the

interpersonal blurring of boundaries which, during adult life,

can be accentuated by pathology or, in moderation,

capitalized by the developmental-ly advanced capacities of

mutuality (Bergman, 1980), collaborative work, love, sexual

excitement (Kernberg, 1977, 1995) and friendship. Marital

relationships especially test the resilience of the core self and

flexibility of its outer boundaries.

This brings up the related issue of boundary-permeability, to

which is relevant the work of Landis (1970) and Hartmann

(1991), who described ‘permeable’ or ‘impermeable’ or ‘thin’

and ‘thick’ boundaries, respectively, as a broad way of

organizing clusters of personality traits. Those with ‘thin’

boundaries displayed suggestibility, weakness of identity, and

inconsistent defenses and behaviors. Those with ‘thick’

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 51

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boundaries had stable identity and consistent behavior; they

were also firm and assertive in interpersonal transactions.

While constitutional factors did play a role here, the

‘thickness’ of boundaries showed a correlation with strong

identification with the same-sex parent. It was also noted that

if boundaries become ‘too thick’, rigidity and smugness

results and if they become ‘too thin’ intense vulnerability to

narcissistic injury and shame follows.

In sum, the term ‘boundaries’ seems to have intrapsychic

referents (keeping mental contents or structures apart),

personal referents (differentiating self from non-self), and

interpersonal referents (regulating the impact of interacting

with others). This last-mentioned emphasis upon the concept

of boundaries is especially evi dent in the psychoanalytically

informed literature on marital and family therapy (Sholevar,

1985, 1995) and, in an even broader way, in the

psychoanalytically informed writings on ethnic conflict

resolution (Volkan, 1988, 1997). Finally, it should be noted

that the psy-chotherapeutic (or psychoanalytic) situation-with

its fixed length of sessions, predictable rhythm of

appointments and payments, relative anonymity of the

therapist, abstinence, and neutrality-is a highly special set-up

of interpersonal boundaries. It is a context that requires firm

limits on the one hand, and, on the other, being subject to

intersubjective processes like empathy and projective

identification allows subtle and transitory mergers of two

minds. The work that goes on in this situation tests all

boundaries regardless of their being intrapsychic, personal, or

interpersonal.

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 52

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THE RELATED CONCEPT OF OPTIMAL

DISTANCE

The term ‘optimal distance’ was introduced into

psychoanalytic literature by Bouvet (1958). In a paper titled

‘Technical variation and the concept of distance’, he defined

‘distance’ as ‘the gap that separates the way in which a

subject expresses his instinctual drives from how he would

express them if the process of “handling” or “managing”

these expressions did not intervene’ (p. 211). Bouvet went on

to explain that this ‘managing’ represents an aspect of the ego

defense, and ‘draws attention to the exterior aspect of the

ego's activity, while “defense” characterizes more particularly

its internal aspect’ (p. 211).

A peculiar tension seems to exist in this definition. On the one

hand, by regarding the gap between two manners of drive

discharge as its cardinal characteristic, Bouvet posits an

intrapsychic definition of the word ‘distance’. On the other

hand, by focusing on ‘managing’ or the ‘exterior’ aspect

rather than on ‘defense’ or the ‘internal’ aspect of the ego's

activity, Bouvet leans toward an interpersonal definition of

distance. This stance is more apparent in the following

passage from the same paper.

The distance that a patient will take from his analyst varies

constantly during the analysis, but in general it tends to

diminish as the analysis progresses, until it disappears. It is

this point which I call the rapprocher (which signifies in

French ‘drawing close’, but progressively). Once attained,

this partial rapprocher can be jeopardized by other conflicts,

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 53

suicidal crises. Retrieved from http://ebookcentral.proquest.com

but appears to be more easily reestablished, and to lead finally

to a more general rapprocher. (pp. 211-212)

The same intrapsychic-interpersonal tension in the definition

of ‘distance’ is evident in the writings of Mahler (1971;

Mahler et al., 1975). She begins her view of ‘distance’ as

being within the largely interpersonal mother-child matrix but

ends up with an internalized capacity for establishing optimal

distance-in other words, with an ego-attribute. ‘Optimal

distance’ for her is ‘a position between mother and child that

best allows the infant to develop those faculties which he

needs in order to grow, that is, to individuate’ (Mahler et al.,

1975, p. 291). This distance varies from one phase of

development to the other. In the symbiotic phase, the optimal

distance is pretty much zero. In differentiation phase, it

reaches its zenith. In the rapprochement sub-phase (from

eighteen to twenty-four months) no distance appears

satisfactory as there is intense conflict between progressive

drives for self-expression and separation on the one hand, and

regressive wishes for closeness and merger on the other. Only

after this phase is traversed with the help of a tolerant and

loving mother does the capacity for self and object constancy

appear. The ability to maintain optimal distance from

love-objects now develops. This definition is an obviously

interpersonal one.

In other writings, however, Mahler takes a more intrapsychic

perspective referring to the distance ‘between the self and the

object world’ (1975, p. 193). That she means internalized

objects here is confirmed by the very next sentence, which

refers to the

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 54

suicidal crises. Retrieved from http://ebookcentral.proquest.com

oscillation between longing to merge with the good object

representation, with the erstwhile (in one's fantasy at least)

blissful union with the symbiotic mother and the defense

against re-engulfment by her (which causes loss of

autonomous self identity). (1975, p. 193)

The symbiotic and practicing phase described by Mahler

(1965, 1971; Mahler et al., 1975) have a close correspondence

with Balint's

(1959) ‘ocnophilia’ and ‘philobatism’, respectively. The

ocnophilic world consists of objects separated by horrid

spaces and the philo-batic world of friendly expanses dotted

with unpredictable objects. The ocnophil lives from object to

object, cutting short his travels through empty spaces. The

philobat lives in cordial spaces, avoiding contact with

dangerous objects. The ocnophil is a homebody, the philobat

an eternal vagabond. Balint traced the ocnophilic tendency to

the early tactile contact with mother and the philobatic bent to

the latter separation-tolerant, visual contact with the mother.

His acknowledgment that the two tendencies always co-exist

parallels Mahler's (1972) recognition of ‘man's eternal

struggle against both fusion and isolation’ (p. 130).

One thing is clear. All three authors dealing with distance

(Bou-vet, Mahler and Balint) imply that it is a Janus-faced

concept with both intrapsychic and interpersonal referents.

One way out of this paradox is to use the concept only in one

particular context at a time. Thus in describing an individual's

character, ‘optimal distance’ is best used in its intrapsychic

sense i.e. as an ego-capacity. And, in describing the

individual's relationships, therapeutic or otherwise, the term is

best used in its interpersonal sense. However, this does not

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 55

suicidal crises. Retrieved from http://ebookcentral.proquest.com

seem entirely satisfactory since both intrapsychic and

interpersonal dimensions are active in all circumstances at the

same time. This is most clear in the course of development

when the intrapersonal is on the way to becoming

intrapsychic and that, in turn, is tried out in the interpersonal

realm. The best way out of this conundrum is, I believe, to

accept the paradox and to regard the dialectical tension

between the two perspectives (intrapsychic and interpersonal)

as being inherent to the concept. Finally, it should be added

that the vicissitudes of the Oedipus complex also contribute to

the capacity to maintain optimal distance. Exclusion from

parental sexuality and acceptance of generational boundaries

are cardinal achievements of this phase (Freud, 1924).

However, this does not imply complete sensual and

aggressive disjunction between generations.

Putting everything together, it appears that at the preoedipal

level, optimal distance refers to a psychic position that

permits intimacy with others without loss of autonomy and

separateness without painful aloneness. At the oedipal level,

optimal distance can be viewed as the capacity to renounce

primary oedipal objects in a way that (on the aggressive side)

permits individual autonomy without sacrifice of traditional

continuity and (on the libidinal side) establishment of the

incest barrier without total obliteration of aim-inhibited,

cross-generational eroticism.

This makes it abundantly clear that the ‘interpersonal

boundaries’ and ‘optimal distance’ are, in some ways,

conceptual twins. Both refer to the ego's modulation of

relationship between self and others. Both are

developmentally derived, though might also have some

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 56

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constitutional substrate. Both are, to a greater or lesser extent,

products of modal child-rearing, hence culture-bound.

CULTURAL VARIATIONS

The clarity, firmness, and permeability of boundaries are

governed not only by constitutional and psychological factors,

but by the cul-ture-at-large as well. While it is easy to see

how child-rearing patterns in one or the other society might

uphold this or that degree of psychic separateness and

autonomy as being desirable, the fact that psychically

extraneous variables (e.g. density of population, means of

communication and travel) and one's large group's history,

literature, and mythology can also affect personal and

interpersonal boundaries often comes as a surprise to mental

health practitioners. Take, for instance, intrapsychic

boundaries, especially those keeping the conscious secondary

process mental contents separate from the primary process

material of the unconscious. Comparing a group of poets and

artists with a group of bankers and surgeons on this parameter

alone would readily reveal that the optimal

conscious-unconscious separation differs greatly between

them. The former have much greater access to their

unconscious goings-on and are more comfortable with the

seemingly inexplicable messages from the vaults of their

psyche. Modal prototypes of intrapsychic boundaries clearly

differ in these groups.

A psychically autonomous and separate self is also not

universal. Such a structure is the end-product, or at least the

desired end-product, of the childhood

separation-individuation process (Mahler et al., 1975) and its

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 57

suicidal crises. Retrieved from http://ebookcentral.proquest.com

re-working during adolescence (Blos, 1967) in the Western

Anglo-Saxon culture. To regard this developmental trajectory

as ubiquitous to human experience betrays psychoanalytic

colonialism. Careful observation of mother-child inter actions

in India and Japan, experience of treatment of children and

adolescents from those cultures, and reconstructions in the

analyses of adults living there (Carstairs, 1957; Roland, 1998;

Kakar, 1985; Freeman, 1998; Bonovitz, 1998) have revealed

that the clearly demarcated ‘psychoanalytic self’ is not the

modal psychic structure. Instead of an individualized self, the

prevalent psychic organization is one of ‘familial self’

(Roland, 1988). Such a self is characterized by intense

emotional connectedness and reciprocity with others and

draws its narcissistic sustenance from ‘strong identification

with the reputation and honor of the family and other groups’

(p. 8). Its modes of cognition and relating are highly

context-bound and differ from the individualistic and

autonomous self typically seen in the West, especially North

America.

The degree to which an individual's self remains permeable to

influence from others, especially one's elders, also varies from

culture to culture. Writing of Indian patients, for instance,

Kakar (1985) states that

the relational orientation is still the ‘natural’ way of viewing

the self and the world. Thus it is not uncommon for family

members, who often (and significantly!) accompany the

patient for the first interview, to complain about the patient's

autonomy as one of the symptoms of his disorder. (p. 446)

The emphasis in such cultures is upon inter-dependence and

not upon autonomy. Friendships are deep. People take all

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 58

suicidal crises. Retrieved from http://ebookcentral.proquest.com

sorts of relatives into account while making important life

decisions. ‘Infantile objects are relinquished very gradually

and this process does not take place to the degree necessary in

cultures where the child is being prepared to live an adult life

that is independent of the extended family’ (Bonovitz, 1998,

p. 182). Not surprisingly, the view of what is ‘optimal

distance’ between two individuals (and their psyches) also

varies in these cultures. This effects what is felt to be the

normal frequency of contact between relatives and friends, the

extent of intimacy in relationships, and even the amount of

physical contact between people.

All four variables mentioned above (i.e. the porous versus

closed nature of intrapsychic boundaries, individual versus

familial self, relational versus autonomous orientation and

average-expectable optimal distance) impact upon the

conduct of cross-cultural psychotherapy and psychoanalysis.

Overlooking this can lead to assumptions and interventions

that result in hurting the patient and/or creating falsehood in

the therapeutic alliance.

PSYCHOPATHOLOGY

Psychopathology often involves disturbances of boundaries.

In fact, the more severe the psychopathology, the greater is

the disturbance of boundaries. This applies to all three realms

(i.e., intrapsy-chic, personal, and interpersonal) of boundaries.

A few examples should suffice to illustrate this proposition.

Intrapsychic boundaries between various psychic structures

(e.g., between id and ego, between ego and superego, and

between ego and ego-ideal) are affected in a number of ways

by psy-chopathology. Schizophrenic psychoses, for instance,

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 59

suicidal crises. Retrieved from http://ebookcentral.proquest.com

involve a diminished demarcation between id and ego. The

primary process begins to alter thinking; wishes and dreads of

the inner world come to dominate the ego's perception of

external reality. Another situation where collapse of

intrapsychic boundaries is evident is narcissistic and

hypomanic character pathology. The usual gap between ego

and ego-ideal closes in these conditions resulting in confusion

between real and wishful self-perceptions; boastfulness,

cockiness, and irreverence are the behavioral counterparts of

this. Yet another situation is the fusion between a harsh

superego and the ego, leading to the syndrome of ‘messianic

sadism’ (Akhtar, 2007) where malignant prejudice and cruelty

towards others becomes morally sanctified.

In contrast to such intrapsychic boundary dissolutions are

states characterized by the cropping up of abnormal barriers

between clusters of mental content. The syndrome of identity

diffusion (Kernberg, 1975, 1984; Akhtar, 1984) that underlies

severe personality disorders and the defensive separation of

self-representations in ‘dissociative character’ (Brenner,

1994, 2001) are prime examples of this type of intrapsychic

boundary proliferation. Contradictory self-states, including

those representing different eras of life, exist in sequestered

form without being synthesized into a composite whole.

On the outer rind of personality, the boundaries that separate

self from non-self also show alterations in states of

psychopatholo-gy. In psychoses and ‘psychotic characters’

(Frosch 1988a, 1988b; Volkan & Akhtar, 1997; Akhtar,

1997), blurring of such demarcations is a central feature. In

the ‘as-if’ personality (Deutsch, 1942), the permeability of

personal boundaries is greatly increased resulting in rapid

identifications with others which are ‘lost’ with a comparable

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 60

suicidal crises. Retrieved from http://ebookcentral.proquest.com

ease. The exact opposite is true of bull-headed narcissistic and

paranoid characters who refuse to be influenced by anyone, or

of those with Asperger syndrome (Wing, 1981) who remain

peculiarly disconnected and cold in their interactions.

This brings up the psychopathology of ‘optimal distance’.

While agoraphobia, claustrophobia, and difficulties in

adjusting to a marital relationship are often the result of

conflicts over optimal distance, it is in the setting of severe

personality disorders that distance related problems become

most evident. For individuals with these conditions,

involvement with others stirs up a characteristic ‘need-fear

dilemma’ (Burnham et al., 1969): to be intimate is to risk

engulfment and to be apart is to court aloneness. This can lead

to various compromise solutions. The borderline continues to

go back and forth (Akhtar, 1990; Gunderson, 1985; Melges &

Swartz, 1989). The narcissist can sustain allegiances longer

and shows such oscillations in ‘slow motion’ (Adler, 1981;

Kernberg, 1970). The paranoid bristles at any change in

distance initiated by others, preferring the ‘reliability’ of his

fear of being betrayed (Blum, 1981). The schizoid opts for

withdrawal on the surface while maintaining an intense

imaginative tie to his objects (Akhtar, 1987; Fairbairn, 1952;

Guntrip, 1969). The anti-social and the hypomanic, though

internally uncommitted, develop swift intimacy with others.

In essence, all severe personality disorders show impairment

of the capacity to maintain optimal distance. Their problems

are gross, however. More subtle anxieties in this realm,

accompanied by fantasies of ‘tethers, orbits, and invisible

fences’ (Akhtar, 1992b) surrounding one, can exist in less

disturbed individuals. These are often discernible only during

the work of in-depth psychotherapy or psychoanalysis.

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 61

suicidal crises. Retrieved from http://ebookcentral.proquest.com

BOUNDARY VIOLATIONS

Though transgressions of the therapeutic frame occurred from

the earliest days of psychoanalysis and psychodynamic

therapy

, the term ‘boundary violations’ itself gained popularity

only after the seminal book by Gabbard and Lester (1995).

According to them, ‘boundary violations’ refer to egregious

enactments on the therapist's part that are harmful to the

patient. While such acts can emanate from predatory and

psychopathic tendencies on the therapist's part, most times

their occurrence is a matter of psychody-namic ‘co-creation’

by the patient and the therapist.

12 In other words, it is the unchecked interplay of transference

and counter-transference that leads to boundary violations.

Gabbard and Lester (1995) emphasize that behaviors

constituting ‘boundary violations’ differ from those subsumed

under the term ‘boundary crossings’. There are four

distinctions between them:

• ‘Boundary crossings’ involve a transient blurring of the

selves of patient and therapist and the resulting proneness to

enactment is caught ‘mid-way’ by the therapist. He then

reflects upon what was about to happen and uses that

knowledge for the advancement of therapy. In contrast,

‘boundary violations’ are characterized by a loss of

self-reflection on the therapist's part. Consequently, such

behaviors destroy the viability of treatment.

• ‘Boundary crossings’ are enactments that are discussed

by both therapist and patient whereas ‘boundary violations’

are typically placed outside of the context of therapy. It is as

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 62

suicidal crises. Retrieved from http://ebookcentral.proquest.com

if those behaviors (e.g. hand-holding, kissing) had nothing to

do with the treatment that is being carried on.

• ‘Boundary crossings’ are generally responded to by the

therapist and patient by reflection and attempts to understand

what just took place. ‘Boundary violations’, in contrast, are

unresponsive to the therapist's own efforts to understand and

control them. There is also an aura of secrecy about such acts.

• ‘Boundary violations’, in contrast to ‘boundary

crossings’, are exploitative of the patient and are harmful to

the treatment pro cess. There is a profound neglect of the

patient's interests on the therapist's part. At times, there might

even be a deliberate at tempt to manipulate and hurt the

patient.

Subtle overlaps between the two concepts notwithstanding,

this view of ‘boundary violation’ prepares one to observe,

record, and reflect upon their occurrence in a variety of

realms as the treatment process unfolds.

Sexual Boundary Violations

In the course of intensive psychotherapy, one frequently

encounters ‘erotic’ (Freud, 1915) and ‘erotized’ (Blum, 1973;

Akhtar, 1994, 1996) transferences. The former emanates from

unresolved oedipal longings and is generally subtle in

expression. The latter arises from oral hunger, carries more

explicit sexual demands, and has a coercive nature. The

therapist dealing with the former begins to feel enthusiasm

towards the patient. The therapist dealing with the latter feels

burdened and manipulated. Paradoxically, then, the patient

who is less stridently demanding of sexual involvement with

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 63

suicidal crises. Retrieved from http://ebookcentral.proquest.com

the therapist gives rise to a more ‘real’ erotic

counter-resonance in the therapist. The risk of the therapist

developing a ‘love-sickness’ (Twemlow & Gabbard, 1989;

Gabbard & Lester, 1995) is great under such circumstances.

A number of other variables contribute to the therapist finding

himself on the ‘slippery slope’ of countertransference acting

out. The most common scenarios causing this are the

following:

• The therapist of an abused female patient might be under

the sway of ‘disidentification with the aggressor’ (Gabbard,

1997) whereby he might disavow any (transference)

connection with the patient's abusers and try to be at the

utmost kind and indulgent towards her. Consequently he

might make heroic efforts to ‘help’ the patient and, in the

process, transgress boundaries (e.g. by hugging and kissing

the patient).

• The therapist and patient might act out their repressed

oedipal fantasies. ‘The female patient may have harbored a

childhood fantasy that she was somehow taking care of her

depressed father in despair over an empty marriage. The

analyst, on the other hand, may be unconsciously rescuing his

depressed mother to heal the patient. Female patients who

have childhood suffered trauma may be particularly appealing

to the love-sick analyst who is intent upon rescue’ (Gabbard,

2006, p. 42).

• A male therapist might mistake his female patient's

desire for maternal tenderness and nurturance for sexual

advance and, in a state of personal vulnerability, succumb to

the temptations this causes in him.

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 64

suicidal crises. Retrieved from http://ebookcentral.proquest.com

Sexual boundary violations are more likely to occur if the

patient has been sexually abused as a child and is re-creating

a similar situation though, of course, with the hope that a

repetition of early trauma will not occur this time. The

likelihood of violations markedly increases if the therapist is

characterologically unable to handle erotic

countertransference or has become so due to romantic and

sexual deprivation in his current life (Gabbard & Lester,

1995; Celenza, 2007).

Narcissistic Boundary Violations

Though the therapist's misuse of the power difference in the

dyad does contribute to sexual boundary violations, there are

egregious behaviors where themes of domination, subjugation

and control occupy the center stage. Naming them

‘narcissistic boundary violations’, Levine (2005) underscores

the role of self-aggrandizement in them. Haughty disregard of

the patient's autonomy, taking over the daily conduct of his

life, advising him to marry this or divorce that person are all

manifestations of such violations. This may result from the

therapist acting out a particular countertransference

stimulated by the patient. More often, it emanates from the

therapist's narcissistic character pathology even if that is

brought into play, at a given time, by a patient's ‘seductions’.

CLINICAL VIGNETTE 6

Bill Silverberg had been in intensive treatment with a highly

charismatic therapist known for his stylish clothes and

expensive cars. The therapy floundered. Bill dropped out and,

a few years later, his therapist passed away. Six months later,

Bill entered into treatment with me.

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 65

suicidal crises. Retrieved from http://ebookcentral.proquest.com

A highly masochistic man with a tall and lanky frame, Bill

had a ‘father problem’. On the one hand, he despised his

father for constantly ridiculing him during his childhood. On

the other hand, he was dependent upon the old man's financial

largesse. Unable to make ends meet on his own, Bill received

a monthly stipend from his wealthy father. His treatment with

me was characterized by a powerful father transference in

which he attempted to both flatter and devalue me. Praising

me to great extent, he would defeat all interpretations by

turning them into trite witticisms. Gradually, however, I

learned that this sadomasochistic game was actually an

advance over his original tendency to be utterly subservient to

authority figures.

Now a memory from his previous treatment emerged. Bill

told me that once he was going to Napa Valley, California,

and mentioned it to his therapist. The latter responded by not

only giving him tips about the wineries to visit but by talking

about his own extensive (and expensive!) wine collection.

Bill brought back a bottle of wine to his therapist as a gift. It

was accepted without question. This soon became a pattern.

Bill would bring wine for his therapist who would take it

without any question or discussion. Then one day, Bill

brought a case of wine bottles for his therapist who gave him

his car keys and asked Bill to put it in the trunk of his car

before starting the session!

The enactment of narcissistic-masochistic (and homosexual)

transference-countertransference fantasies is clearly evident

here. What is disturbing though is not the patient's

‘seductions’ and submission but the therapist's nonchalance

and smug exploitation of his patient.

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 66

suicidal crises. Retrieved from http://ebookcentral.proquest.com

Cultural Boundary Violations

With the changing demography of patients and therapists

nationwide, the likelihood of the two partners in the clinical

dyad belonging to different ethnic, racial, religious, and

linguistic backgrounds has increased. With this, the potential

of ‘cultural boundary violations’ (Akhtar, 2007b) has grown

by leaps and bounds. These involve situations where the

therapist imposes his or her values regarding a wide range of

sociocultural matters upon the patient, causing the latter to

suffer unnecessary confusion and ia-trogenic conflict. For

example: How often should an adult offspring call his

out-of-town mother on the phone? Should premarital sex be a

necessary step before the decision to get engaged and

married?

‘Cultural boundary violations’ are also caused by the therapist

ignoring that such boundaries even exist. Treating immigrant

and racially different patients with no attention at all to their

cultural backgrounds constitutes a situation of this sort.

13 Pronouncing the name of an immigrant patient or of his

hometown in one's own way without asking the patient's

guidance about the correct way of saying them is a more

subtle form of ‘cultural boundary violations’ based upon a

colonial mentality. Insistence upon an illusory cultural

oneness is, in the end, more harmful than reassuring to the

patient.

Miscellaneous Boundary Violations

There are other transgressions, besides those mentioned

above, which can harm the patient. Prominent among such

Akhtar, S. (2009). Turning points in dynamic psychotherapy : initial assessment, boundaries, money, disruptions and 67

suicidal crises. Retrieved from http://ebookcentral.proquest.com