A concrete representation of projective identification in art therapy with a DID patient

Projective Identification (PI) is a defense mechanism described by Melanie Klein. This mechanism, according to Klein, is “revealed in fantasies in which the subject inserts his or herself – in whole or in part – into the object in order to harm, possess or control it”. The main difference between projection and projective identification is that projection does not involve the object itself, whereas projective identification results in the object’s experience of being changed.

The therapist may assume an aspect of the client’s identity and the client will identify with the “other”, often an abusive other. Thus, the therapist vividly “knows” what it is or was like to be the client in her early relational context. The therapist’s affective experience is often intense and intolerable. Without the framework of PI it is difficult to maintain an empathic connection with one’s client. (Pearlman & Saakvitne, 1995, p. 104).

Projective Counteridentification (Grinberg 1990) is a term that relates to a specific response to the patient’s PI, which is not consciously perceived by the therapist. Consequently, he or she is ‘led’ passively to carry out the role that, actively though unconsciously, the patient has forced upon him. When this happens, the therapist will resort to every kind of rationalization to justify his or her attitude or disturbance. The therapist’s reaction is largely independent of his or her own conflicts and corresponds predominantly or exclusively with the intensity and quality of the patient’s PI.

Case study

I am describing an art therapy process with a DID patient with whom I have worked for the last ten years. 42 alters have been identified during therapy, out of which 15 have appeared in sessions. The presented vignette is a significant stage in our relationship and demonstrates, to my understanding, processes of PI and PCI as described in the theoretical part. The therapeutic model presented is of art in therapy in which the creative work is being done between sessions. The artistic result is then brought into session to be shared with the therapist. As such, it becomes a reflection and testimony of internal and external processes. The patient described in this paper brought both complete, and sometimes incomplete, artworks into sessions.

Picture 2	Picture 1

Picture no. 1 was brought to session about a year ago. It describes a sitting figure under a tree. The figure is framed with what seems to be a window and at first impression it looks like a picture within a picture. The patient titled the picture “together in this we are alone and alone in this we are together” (which is a quote from Bion). The picture, as she understood it, reflected the confusion in her sense of isolation and loneliness. When referred to the “we” in the title, she meant her relationship with all her alters as well as her relationship with me.
The main themes that were worked on when picture no.1 was presented were:

• The isolation the patient inflicted upon herself as a result of the emotional flooding and physical pain she experienced. At the same time she was aware of the fact that fewer and fewer people were ready to spend time with her because of her being emotionally flooded.
• One of the most important results that the patient developed, as a coping mechanism, was the technique of beading. She started to incorporate beads into her artwork, either as independent elements or as a part of a larger and more complicated piece of art. This kind of work required very limited movements, a lot of control in small motor skills and gentle handling of the material. There was a need for preplanning, consistency and perseverance. While being absorbed in beading, the patient succeeded in the prevention of self mutilation, could remain focused and concentrated physically, mentally and emotionally within defined and structured boundaries. The smaller and more structured her working space was, the more it enabled the patient to contain her emotions
• Parallel to the need for defined and structured boundaries in the creative process, it became clearer that the patient could be emotionally contained within the therapeutic relationship only when boundaries and framework were firm and tight. Different possibilities for communication with the therapist between sessions were gradually eliminated. (The patient was asked to call only in emergency situations, she was told that e-mails would be read, but not answered). I was aware of the fact that the strict boundaries and the clear definition of our relationship served not only the patient’s needs, but the impotence I felt toward her constant emotional demands as well. In retrospect, it became obvious that it was a stage in therapy where the patient experienced a non-sadistic “mothering” – her frustration, anger, and aggression were contained in very clear but soothing boundaries.

 

The materials, techniques, themes and images that appear in picture No. 1 were not new to us, only this time the patient managed to combine them all in one work.

I was left with the image of this picture until the day before the next session with the patient. During that day I accidentally bumped into Picture No. 2 while cleaning my studio. The patient had asked me to keep that picture for her four years ago, because she felt it was too difficult to keep it herself.

Picture No. 2

The alter who created this picture four years ago represented the introject of the abusive mother. The picture was done during a period of high symptomatology and remembering. It was the first hostile alter who was ready to be actively involved in therapy with me by the use of art materials. That alter used to appear in sessions only to express anger, and threat to put an end to therapy and to the life of the patient. (She was the one who was responsible for the self mutilation.) As therapy progressed, this alter felt more and more distressed and the conflict between the need to preserve the original abusive role and the new need to participate in therapy and have a safe place where her emotions were accepted, was clearer. It was then when she agreed to my suggestion to express her feelings through the use of the creative process.

Picture No. 2 is acrylic on canvas with twisted wires and sharp cuts. It was a horrible testimony to the level of anger, pain, victimization and self mutilation the patient could expose at that point. The host personality felt she could not keep that picture and asked me to keep it for her.

When I saw that picture 4 years later, the day after a session, I remembered picture no.1. I felt an urge to confront the patient with the picture because of the huge contrast between those two pictures, in order to demonstrate her progress in therapy. I, therefore, left picture no. 2 exposed for the session the day after.

I found the patient standing at the door, crying and trembling. For the most part of the hour she cried, screamed and complained about the fact that I acted without getting her permission, forced her to see the picture when she was not ready for it, and breached her trust in me. Her extreme reaction resulted in a complete paralysis and she called it “shock therapy”.

The patient could not identify with my perception of her progress as it was reflected in those two pictures. It was important to the host personality to emphasize that the alter who created picture No.2 still felt the same amount of rage and anger, and that not much changed during those four years in her self image. She talked a lot about how ashamed she felt in her exposure to the picture in front of me.

Other issues mentioned in that session related to an attempt to understand the changes that had occurred between that big canvas picture and the small beaded one. Concrete dimensions as size, space, art materials and techniques, as well as the different alters involved in the work and their ability to cooperate, were noted. By the end of that process the patient was able to see and accept the fact that she had reached a point where she could express her feelings in a very delicate and complicated way that did not require hiding the picture.

Where is the PI?

During all the years of her therapy, the patient asked me to keep some of her artwork for her in my studio. Those pieces were always exposed because they hung on the walls with the pictures of my other patients. In contrast to previous occasions it was the first time the patient asked me to hide it for her. This specific act started the concrete process of PI. The patient was exposed to all the memories, pain, aggression and threat that were stored in that hostile alter, who until then did not express those feelings through art. As dissociation did not work as well for the host personality any more, she could not contain those feelings and “transferred” them to me. It can also be assumed that the patient unconsciously wanted me to experience some of what she experienced as if she said: “look at me and at what’s in me, Let’s see how you deal with it…” By transferring the picture to me, the patient also expressed her readiness for a dialogue with the hostile alter who represented her inner abusive part. This dialogue became possible only after giving the therapist the aggressive and hostile role. My conscious response at that time was of acceptance and containment. I felt no problem with keeping and hiding the picture. In retrospect, I understand the projective counteridentification  as described by Grinberg (1990). After a 4 year “amnesia” I understood that my reaction was a little more than fulfilling the patient’s request. I assumed that it was too difficult for me to have that picture and I might even have felt victimized when I was exposed to it. Dissociation was a good solution on my part, which enabled me to keep picture No. 2 for the patient without feeling what and whom it represented. My unexpected encounter with the picture created in me an intuitive need to have the patient see those two pictures together, without checking whose need it was, who had to be comforted by demonstrating progress, whether it was an attempt to return the horrible image to the patient or to replace it with a “nicer” one.

Throughout the whole process with the patient I was unsure of who the therapy leader was, who knew better. Was the patient strong enough to be responsible for what she was going through? Was my task reduced to joining her in support and reassurance? When would I be needed for leading, actively structuring situations rather than giving in to her demands? I experienced most of our sessions as coping with a flood of pain, anxiety, rage, guilt, shame as well as with the patient’s perceptiveness to my own reactions and her emotional neediness. I found myself struggling for my own space. It is clear to me that I was not ready to become a victim in order to enable the patient to get rid of her victimization. At the same time I understood that in order to be efficient in the therapeutic situation I had to be able to help in the containment and processing of the traumatic experiences and their results. The act of exposing the picture and having the patient face it was probably an act of defiance on my part. As if to tell her: “look at where you were 4 years ago. I believe you in your pain and suffering, but look at the progress”.

We should not forget that picture no.2 was created by a hostile alter that up until that time was not ready to participate in therapy. It took 6 years of therapy to get her trust to the point that she was ready to be involved in the creative process. Giving up the rights to be the only one who kept her secrets and sharing them with me was an act of trust that the patient was not ready to accept and contain before going through 4 years of processing, as described here. Coping with anger, rage and aggression evolved into coping with pain, loss and grief through the building of boundaries, trust and confidence in our relationship.

Summary

This paper demonstrated a process in which transference, projective identification and projective counteridentification occurred at the emotional level and had their representation at a concrete level. The patient – the victim – transferred to me her pain and suffering by asking me to hide her picture no. 2 for her. For 4 years I became “the victim” and kept her secret. I, as much as the patient, used dissociation as a defense mechanism and did not remember that I had that picture.

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