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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.
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.
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.