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Section 5
Transference Therapy

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Denial
In the patients we are considering, denial may manifest itself as simple disregard for a sector of the patient's subjective experience or a sector of his external world. When pressed, the patient can acknowledge his awareness of the sector which has been denied, but cannot integrate it with the rest of his emotional experience. It is relatively easy to diagnose the operation of denial because of the glaring loss of reality-testing that it brings about. The patient acts as if he were completely unaware of a quite urgent, pressing aspect of his reality.

One patient, who had to meet a deadline for a thesis upon which his graduation and the possibility of a job depended, simply dropped the subject of the thesis in the psychotherapy sessions during the last two weeks before the deadline. He had discussed with his psychotherapist his fear of and anger toward the members of the committee in charge of examining his paper, and his denial here served the purpose, primarily, of protecting him against his paranoid fears of being discriminated against, and from those teachers whom he supposed wished to humiliate him in public. The therapist repeatedly confronted the patient with his lack of concern about finishing the paper and with his lack of effort to complete it. While interpreting the unconscious implications of this neglect, the therapist explored and confronted the patient with the many ways in which he was preventing himself from completing the paper in reality.

Denial can take quite complex forms in the transference, such as the defensive denial of reality aspects of the therapeutic situation in order to gratify transference needs.

One patient, in an attempt to overcome her anger about the analyst's unwillingness to respond to her seductive efforts, developed fantasies about the analyst's hidden intentions to seduce her as soon as she expressed her wishes for sexual intimacy with him in a submissive, defenseless way. At one point this fantasy changed to the fantasy that she was actually enjoying being raped by her father and by the analyst, and at one time intense anxiety developed in her, with a strong conviction that the analyst was actually her father, that he would sadistically rape her, and that this would bring about disaster. Out of the several implications of this transference development, the need to deny the reality of the analyst's lack of response to her sexual overtures, and her anger about this, seemed to predominate. The analyst pointed out to her that in one part of her she knew very well that the analyst was not her father, that he was not going to rape her, and that as frightening as these fantasies were, they still permitted her to deny her anger at the analyst for not responding to her sexual demands. The oedipal implications were excluded, for the time being, from his comment. The patient relaxed almost immediately and at this point the analyst commented on her reluctance to enter into an intimate relationship with her fiancé because of the fear that her unrealistic angry demands on him would stand in the way of her sexual enjoyment, and because her projection onto her fiancé of her own anger would turn the actual intimacy into a threat of sadistic rape for her. This opened the road to further insight about her denial of aggressive impulses as well as of reality.

This last example illustrates what the consistent working through of the pathological defenses which predominate in borderline patients attempts to accomplish. The working through of these defenses increases reality-testing and brings about ego strengthening, rather than inducing further regression. This example also illustrates the partial nature of the transference interpretation and the deflection of the transference outside the therapeutic relationship.

At times the patient especially needs to deny the positive aspects of the transference, because of his fear that the expression of positive feelings will bring him dangerously close to the therapist. The patient fears that such excessive closeness will free his aggression in the transference as well as the (projected) aggression of the therapist toward him. Schlesinger (34), in illustrating this particular use of denial, has suggested that denial in the area of positive transference reaction should be respected because it may actually permit the patient to keep himself at an optimal distance from the therapist.

Omnipotence and Devaluation
These two, intimately linked defensive operations of omnipotence and devaluation refer to the patient's identification with an overidealized self- and object-representation, with the primitiye form of ego-ideal, as a protection against threatening needs and involvement with others. Such "self-idealization" usually implies magical fantasies of omnipotence, the conviction that he, the patient, will eventually receive all the gratification that he is entitled to, and that he cannot be touched by frustrations, illness, death, or the passage of time. A corollary of this fantasy is the devaluation of other people, the patient's conviction of his superiority over them, including the therapist. The projection of that magical omnipotence onto the therapist, and the patient's feeling magically united with or submissive to that omnipotent therapist, are other forms which this defensive operation can take.

This defensive operation is actually related to the primitive idealization mentioned above. The fractionating of the defensive operations which are characteristic of borderline patients into completely separate forms may clarify their functioning but it does necessarily oversimplify the issue. There are complex intertwinings of all these defensive operations, and they present themselves in various combinations.

A patient with severe obesity and feelings of intense insecurity in social interactions eventually became aware of her deep conviction that she had the right to eat whatever she wanted and to expect that whatever her external form, she would still be admired, pampered, and loved. She paid only lip service to the acknowledgement that her obesity might reduce her capability to attract men, and became very angry with the therapist when the reality of this consideration was stressed. The patient began psychotherapy with the assumption that she could come for her appointment with the therapist at any time, take home the magazines in his waiting room, and need not care at all about leaving cigarette ashes all over the furniture. When the implication of all this behavior was first pointed out to her, she smiled approvingly of the therapist's "perceptiveness," but no change occurred. It was only after the therapist made very clear to her that there were definite limits to what he would tolerate, that she became quite angry, expressing more openly the derogatory thoughts about the therapist that complemented her own feelings of greatness. The conscious experience of this patient was that of social insecurity and feelings of inferiority. Her underlying feelings of omnipotence remained unconscious for a long time.
- Kernberg, Otto, Borderline Conditions and Pathological Narcissism, Aronson Inc.: London, 1986.

Personal Reflection Exercise #1
The preceding section contained information about borderline personality disorder: denial and omnipotence. Write two case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Peer-Reviewed Journal Article References:
Carsky, M. (2020). How treatment arrangements enhance transference analysis in transference-focused psychotherapy. Psychoanalytic Psychology, 37(4), 335–343.

Liebke, L., Koppe, G., Bungert, M., Thome, J., Hauschild, S., Defiebre, N., Izurieta Hidalgo, N. A., Schmahl, C., Bohus, M., & Lis, S. (2018). Difficulties with being socially accepted: An experimental study in borderline personality disorder. Journal of Abnormal Psychology, 127(7), 670–682. 

Stern, B. L., Diamond, D., & Yeomans, F. E. (2017). Transference-focused psychotherapy (TFP) for narcissistic personality: Engaging patients in the early treatment process. Psychoanalytic Psychology, 34(4), 381–396.

Tmej, A., Fischer-Kern, M., Doering, S., Hörz-Sagstetter, S., Rentrop, M., & Buchheim, A. (2021). Borderline patients before and after one year of transference-focused psychotherapy (TFP): A detailed analysis of change of attachment representations. Psychoanalytic Psychology, 38(1), 12–21.

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