H. The ongoing process of treatment
1. Attention to the details of precipitants, to the original condition and to the repetitions of "loss" and depression that occur during the course of treatment. This may be frank object loss with oral conflicts, and/or "losses" associated with conflicts of the anal or phallic stages (Brenner, 1991). In each episode, highlight and enlarge the idea of "loss", moving toward the narcissistic injury involved. This injury is frequently in the area of loss of the (narcissistic) feelings of security, safety, being loved or valued, helped with certain activities, being in control, being successful, competent, or given or having achieved a certain social status. So look for eg. Exactly what has been lost, and how does that make you feel.
Asch (1980)"In our therapeutic work with such patients, the analytic task is to reconstruct gradually the specific hidden by the abstraction; to uncover the object the patient has chosen fate to screen; to trace out the genetic origins of the object he has chosen as his executioner."(p.55)
2. Identify the various ego states; specify, elaborate, eg. through fantasy, through memories of past similar experiences. Search specifically for derivatives, in the present and in the past, of primary narcissistic experience (feelings of "well-being" (Joffe and Sandler, 1965), of security, safety, being loved, valued, cared about, helped). Interpret the defenses involved in the patient's inability or unwillingness to get comfort from these states.
3. Be quite active. Do not let negative ego states of, eg. withdrawal, guilt, being abandoned, being persecuted, to develop too long or too far before intervening with reality, eg. your existence, a superego interpretation, your attentive presence, an indication of safety (Jacobson, 1971). The patient's regressions can be quite quick and profound and are not, by themselves, analytically useful. In fact, they can be more demoralizing and result in further spirals of hopelessness. helplessness, self-blame. On the other hand, do not "talk too long, too rapidly, and too emphatically; that is, never to give too much or too little." (Jacobson, 1971)
Another way of thinking about this is to remember that you are standing in for the "conditional introject" (Kligman, 1988). The person who gets seriously depressed needs the actual presence, from time to time, of the "other" to re-establish a stable, safe, loved inner object environment, ie. a loving ego ideal introject.
4. Identify any examples, in the present and in the past, of the patient's, justifiable-to-himself, aggression. This is a useful affect (because of its strength, directedness and somatic, muscular concomitants) around which to organize experience. As long as being aware of its existence does not lead to more guilt, the awareness of it gives the patient a feeling of initiative, power and mastery of at least a bit of his situation. That is, it supplies a bit of self-generated narcissistic satisfaction.
In the latter stages of the depression, the patient can be usefully made aware of his own tendency to (aggressively) abandon the disappointing object, a concept which is completely outside his conscious experience early on. This tendency should be tracked throughout the patient's life, because it becomes part of the self-knowledge that can lessen the tendency toward depression in the future.
Expressing anger to another person, especially the "lost", disappointing object is a separate issue. When the patient finally does this, competently, in a controlled way, and without fear or guilt, it means they are nearing the end of the depression. However, early on, expressing anger to the object can make things worse because they still very much need the object for the original narcissistic reasons. Expressing anger early on is often out-of-control (and so demoralizing), desperately (impotently) trying to get the object to comply with the patient's increasingly regressed demands for love, etc. (Rado, 1928). This usually results in more rejection by the object, more abandonment of the object by the patient, and a deeper rung to the depressive spiral.
5. Make use of every example of the development of depressive reactions to experiences in the analysis, eg. week-end separations, holiday separations, experiences of not feeling understood or loved or valued or cared about in the right way. In the context of the therapeutic alliance, this recognition of current affects and ideas then becomes part of the route into the re-affectualization of similar experiences in the past.
6. Interpret the patient's devotion to conventional methods of achieving narcissistic satisfaction. eg. "I must have a deep intimate relationship, with a life partner, to be happy." Clearly, conventional methods suit certain personality and constitutional types more than others, and real, healthy people are capable of getting real satisfaction from the most varied sources and activities. People who are disposed toward depression need particularly to develop sustaining, satisfying sublimations. Sublimations, which are less personal, less object-dependent, may be less likely to disappoint.
7. The analyst may need to actively support the patient's attempts to develop narcissistically satisfying sublimations, including achievements and participation in cultural and/or natural activities (Jacobson, 1971, Joffe and Sandler, 1965). Because of the patient's readiness to be disappointed, and their concentration on getting narcissistic satisfaction from their primary object (conditional introject), the patient may interpret their turning toward other sources of satisfaction as disloyalty to the object leading to (causing) the object's withdrawal of attention and love. A sustaining interest by the analyst in other sources of satisfaction for the patient can be internalized by the patient (the analytic introject) and added to the ego ideal introject, eventually modifying the ego ideal.
Similarly, the analyst may need to actively interpret the patient's acquiescence to the patient's superego's view of things. This may even go so far that the analyst would have to momentarily "stand up for" the patient's "right to exist" in an actual aggressive stand against the superego. (Jacobson, 1971) This involves a sudden intrusion of reality into what the analyst considers is a dangerous emotional and cognitive regression. It may, of course, deprive the patient of a more deeply held masochistic aim and, therefore, satisfaction, which will emerge in the aftermath of the analyst's activity and will, thus, become available for interpretation, then or later.
8. Issues specific to each underlying character type. These have to do with the different nuances in the transferences and in the countertransferences, different experiences of and uses of affects in general and the various affects in particular, and the degree of masochism and sadism present.