When patients probe the analyst: Manifestations of patient testing and its complexity – An in-depth exploration of case examples of extant research

Abstract

Patients probe the analyst with the goal of challenging pathogenic adaptations to early experiences. As the core concept of control mastery theory (CMT), testing is contextualized within psychoanalytic theory. The current work examines 29 articles illustrating therapies performed or analyzed using the CMT approach for the occurrence of testing, which takes place through interaction, self-presentation, narratives, or the use of the setting. The various manifestations of testing and their potential meanings are described. An in-depth analysis of selected testing examples is performed to compare tests within patients and across studies. The results show that patients differ in their testing strategies, shift testing strategy during the process of treatment, combine tests, and test multiple conflictual themes within a single test. Therefore, the importance of applying a case-specific approach, based on a thorough understanding of a patient, becomes evident. Recommendations concerning psychoanalytic technique, including the role of interpretation, as illustrated in case vignettes, are introduced.

Key words:

• control mastery theory
• object relations
• transference
• case studies
• psychoanalytic research

Notes

1 In this manuscript we use analyst and therapist interchangeably to address both professions. In citations, the authors’ original term is employed.

2 Distinguishing them from daydreams, unconscious phantasies according to Klein (1959, p. 250) “are an activity of the mind that occurs on deep unconscious levels and accompanies every impulse experienced by the infant,” as for example hallucinating being fed and loved; however, it also includes hallucinations producing feelings of being deprived and persecuted.

3 Ferenczi (1949) had already postulated that the child introjects the adult’s sense of guilt when he brought back the reality of traumatic experience in his theory of psychopathology, after Freud had rejected his own trauma theory in favor of his seduction theory. Freud contributed to the concept of guilt in his essay “Mourning and melancholia” (1917) and developed the concept of borrowed guilt in “The ego and the id” (1923).

4 Gazzillo and colleagues (2019a) aim to make tests more easily identifiable by proposing to apply the concept of compliance and noncompliance to the pathogenic belief rather than to the expected reaction of the clinician.

5 Weiss (1993) claims that dreams do not necessarily have a wish-fulfillment component but have an adaptive function and can be considered as important messages that dreamers send to themselves.

6 Nonetheless, analysts may be seduced into allying with a strict superego.

7 Winnicott (1969) considers this an accomplishment that is not always achieved in normal development and it may thus become a task for patients who have not yet achieved it. Therapists facilitate the ability of patients to achieve the capacity to use an object. This entails enabling the patient to view an object as independently existing, rather than to simply relate to it as “a bundle of projections” (p. 712) under the omnipotent control of the child.

8 This should not be confused with Bacal’s (1998) “optimal responsiveness.” In fact, CMT is more consistent with the view of Kohut (1984), who stresses the empathic understanding of the patients’ experience and the attunement to their needs, while aiming for optimal frustration, in opposition to optimal responsiveness. CMT theorists and Kohut both ascribe an importance to gaining insight and understanding via the therapeutic relationship.

Additional information

Notes on contributors

Alexandra Nicole Novak

Alexandra Nicole Novak, MS, is a second-year doctoral candidate at the University of Klagenfurt, Austria. This doctoral program focuses on psychotherapy and psychoanalysis, for which she has completed all required coursework. In addition, she has concluded two years of preliminary training in psychotherapy at a private institution and worked at an inpatient facility. She is currently training as a psychoanalyst at an Austrian institution affiliated to the IFPS.

Jonas Luedemann

Jonas Luedemann, MSc, was a university assistant at the University of Klagenfurt, Austria where he taught and performed research for the Department of Clinical Psychology.

Sylke Andreas

Sylke Andreas, DrPhil, is professor and head of the Department of Clinical Psychology at the University of Klagenfurt, Austria as well as director of research of the university's outpatient clinic and psychotherapeutic research & teaching center. She has been awarded her approbation as a psychological psychotherapist at the Lou Andreas-Salomé Institute (DPG) Göttingen and at the APH Hamburg, Germany. Currently she is a member of an Austrian psychoanalytic association accredited by the IFPS and training as supervisor for mentalization-based treatment.