Case Analysis - NY Psychotherapy via an Object Relations and Lacanian Viewpoint

(Names and details changed to protect the patient's privacy).

Jennifer is a 26-year-old NYC woman whose presenting problem was a persistent unhappiness and anxiety and an inability to form stable romantic relationships. After she looked for NYC therapists and found me, I have been seeing her for two months at a frequency of one session per week. She is very perceptive, friendly, and communicative and has a bachelor of fine arts degree in creative writing. She expresses herself very well and is well-spoken, although she has a slightly disheveled appearance. She shows a significant amount of self-doubt and anxiety and frequently expresses her desire to become more confident in herself and find a suitable career direction. She has previously been in therapy, at age twelve for about one year, two years in high school, and most recently for a few months with another therapist until the Covid pandemic started. The uncertainty of Covid and resulted schedule interruptions resulted in a rupture of her relationship with her therapist and she discontinued treatment because she didn’t feel the therapist was truly interested in her. Her parents divorced when she was nine but had been separated since she was an infant and have never been on good terms with each other. She has a brother, nine years older, who she describes as physically and mentally abusive during her childhood. However, she still cares for him and wishes their relationship would be better. Her father was a drug addict for most of his life and she describes him as a damaged narcissist who talks about himself incessantly and is not able to communicate with her in a health way. She describes having periodic episodes of obsessive compulsive disorder, which she believes helps her cope with distressing feelings. Her mother was physically present but often absent in a psychic or maternal sense. When the brother would be abusive or bullying her mother would say, “Ignore him.” In addition, her mother spent considerable attention to dealing with her father in their coparenting and post-divorce relationship. Jennifer describes her relationship with her mother as “very close” and says her mother is “her everything” - her confidante and best friend who is greatly supportive of her. I remember when I first heard her use the term “my mother is my everything” I thought to myself that it is a conspicuous choice of words and may be indicative of lack of separation and individuation from the mother. During the course of treatment I have noticed a decrease in Jennifer’s idealization of her mother into a more realistic and balanced view of her. One of Jennifer’s worries is that she wants to “do good in the world” by helping people but feels overwhelmed with the thought of choosing a career and doesn’t know where to begin. She often feels empty and has emotions that shift quickly. She experiences extreme sadness, anger, and anxiety at different times throughout the day and is often confused as to the cause of these emotions. Her romantic relationships are short and volatile, with the longest lasting only a few months. Often her relationships start out with a fast-paced progression into physical intimacy and sex but soon rapidly deteriorate until they inevitably end with an acrimonious breakup. She describes her feelings about her current boyfriend as wildly fluctuating and unstable. Sometimes she feels he is wonderful, caring, and intelligent and other times she feels he is awful, callous, and insensitive. She regrets her emotional outbursts with him and seems to realize that she can be verbally abusive when she feels that he isn’t treating her properly. In my work with her we have come to realize that she has an extreme fear of abandonment and describes the thought of him leaving as “terrifying and black.” Any disagreement between them, even on apparently trivial matters, seems to lead to an argument and theatrical yelling. She wishes that were not the case yet in the moment it just “seems to happen.” After severe arguments with him she will often get drunk or smoke marijuana, and she describes this as “numbing herself into oblivion.” Despite these volcanic arguments with him and the general volatility of the relationship she manages to stay in her job at the restaurant and arrive on time. She considers the job to be one of the aspects of her life that is the most stable, and she is grateful for it. Sometimes she will eat to the point of stomach upset and she’s not sure exactly why.

From an object relations view, faults in the patient’s early relations with her mother resulted in defective internal objects (psychic structures) that interfere with her ability to function as an adult. Note that I will refer to the “mother” for descriptive purposes as the common and customary primary caregiver, but the concepts apply to whatever gender identity the caregiver identifies as. Jennifer’s character structure exhibits characteristics of borderline pathology, including primitive defenses such as splitting, projective identification, idealization, and grandiosity, which ward off intense conflicts involving dependency on other objects (particularly with her boyfriend) and protect against her feelings of excessive aggression in response to perceived threats to herself and also the looming threat of the loss of love of her boyfriend. It is apparent that this is a repetition compulsion, as Freud would say.

Sometimes Jennifer will say hurtful things to me in the sessions. Rather than take the statements at face value I understand that, in Kleinian terms, she is the baby who is acting aggressively towards the breast. It is her way of communicating her frustration and anger towards me, and I have worked to help her find words for the underlying feelings that drive her outbursts. I believe she is expressing to me the powerful vestiges of what she had to endure as a child, the pain of neglect, the fear of abandonment by her primary object. I am impressed by Klein, who invented words for these primitive interactions and feelings. I have occasionally felt the effects of the patient’s projective identification, perhaps an induced countertransference, and am aware of feeling attacked and devalued. I appreciate that I have read about the intense reactions that frequently occur in analysts who are treating borderline patients, as this provided me with an awareness in the sessions of what was happening between us. Her projection created an induced reaction in me, the object, and I became aware of my countertransferential feelings of irritation, anger, and a helplessness to ease her distress.

Jennifer’s early childhood experiences with her primary object (mother) can be viewed in Lacanian terms. Lacan writes about, “jouissance,” or pleasure-in-pain that an infant experiences because its drives predominate in the absence of a yet-to-be-developed regulating ego. Eating to the point where it becomes greatly uncomfortable, a destructive appetite, if you will. Jouissance represents a destabilizing action against one’s self, an action that can be repeated throughout adulthood — a repetition of precisely what the drive seeks. It can be compared to the way an infant may cling to the mother’s breast, yet other times after nursing appears to do anything it can to distance itself from the breast. Or when a small child that is being held throws a fit when the caregiver won’t put them down. As Lacan points out with the concept of the objet petit a, the patient’s borderline characteristics may reflect a failure the in developmental relation between existence and language that occurs when an infant begins to acquire symbolic capacity in its mind as a result of the mother’s speaking to it. Here, the transformation of the mind by language enables the infant’s embryonic sense of self to develop as well as facilitating its slow transformation into a socialized human being. Lacan’s object petit a is the counterintuitive notion that during the transition from infant to adult that an internal object emerges from the lack of jouissance, a vague unconscious awareness of the primal fusion with the mother. It can be considered a part of one’s self that one is separated from, a ghost of the primordial and excessive jouissance we were once immersed in, that is “cut away” from the body by the acquisition of language and the symbolism that language enables. With this patient I am paying particular attention to the way in which she expresses herself and her feelings through language in the hopes that offering her my interpretations can impart some symbolic structure to her psychic world and her understanding of it. Lacan’s emphasis on language is important: borderline patients often grow up in families where the family could not accept what the child was seeing or saying, the child in essence become separated from their own language, their own ability to create symbols and links in their mind. Psychoanalysis provides the patient with a means to find the language that symbolizes parts of their minds that were shattered, malformed, or even unformed, and in this way helps the patient to gather and stabilize their self experience and allows them to better relate to themselves, others, and the world they live in.