This is a simplistic but commonplace explanation of what happens both in the hospital community and in psychotherapy. Both transference and countertransference can be powerful forces in our work with patients who utilize splitting as a primary mechanism of defense.
What Do These Patients Need?
Splitting patients need a psychiatrist who is a constant, continuing, empathic force in their lives; someone who can listen and handle being the target of intense rage and idealization while concurrently defining limits and boundaries with firmness and candor. These patients need someone who can provide them with the necessary experience of being understood and accepted, and who will not be overwhelmed by their needs, fears and anxieties.
On the surface, meeting these needs does not seem difficult, were it not for the existence of that powerful force known as countertransference. "Countertransference" is used here to mean both the therapist's transference reactions to the patient's transference, e.g., products of one's own personal history and unresolved conflicts, and also those reactions that are natural human responses to both idealization and anger.
We all enjoy being admired and respected and are tempted to believe in this veneration. Similarly, the cry of a screaming child touches the heart of a feeling person, and hatred directed with fierce intensity sears the soul of the most hardy. But the intensity of countertransference reactions that surface during therapeutic work with a patient whose primary mechanism of defense is splitting can be surprising and frightening to even the most experienced therapists.
Psychiatrists in training frequently ask: "How can I deal with these countertransference reactions?" with the expressed hope that in some way they can be analyzed or swept away. However, the therapeutic situation requires that we move forward with our work re-gardless of our countertransference feelings. Otherwise, while waiting for our reactions to abate, the patient may make a suicide attempt, elope from the hospital or engage in some other dangerous and impulsive behavior.
Understanding and analyzing our own developmental history helps to mute, utilize and control our affects and responses. However, appreciating our own past histories will not eliminate our emotional responses, nor would we want it to.
Since we cannot escape the impulse to recoil or be overly protective, how do we proceed? This process of going forward therapeutically conjures up images for me of watching my first autopsy. As an eager pre-med student I very much wanted to see an autopsy. A medical student working in pathology made it possible, but as I stood outside the door of the lab I was suddenly drained of all my energy and medical curiosity. About to consider slipping away, the firm pressure of my friend's hand pushed me through the swinging doors. There I was, feeling swamped with the realities of illness, disease, and death, and asking myself, "Was this truly where I wanted to spend the rest of my professional life?"
What helped me to get past those feelings? It was the same thing that gets us past all of the very real tragedies that we see and feel in our work. I pushed the feelings aside and began to immerse myself in understanding the puzzles that the autopsy presented. What was the disease process? Where did it begin? What pathology did it produce? How could it have been prevented?
