The destructive superego and depression

The context of this work was a specialist mental health service for people over the age of sixty-five in a unit including in-patient wards, a day hospital and out-patient services. In the interest of trying to respond to the diverse needs of patients, I explored longer gaps between sessions than the more usual practice of once-weekly therapy. This flexibility also enabled me to reduce the waiting time for patients to be taken on for therapy. For a few patients who were unwilling to make a commitment to weekly sessions, when I suggested they chose the timing of the next session some attended at monthly or longer intervals over a period of several years. This choice seemed to enable them to feel sufficiently held in a way they could manage and found helpful. Other patients like Mrs A found short term fortnightly sessions beneficial. The fortnightly sessions usually included a maximum of sixteen sessions which, with holiday breaks, covered a period of six to eight months. (For an extended discussion about this fortnightly model please see Terry, 2014).

Mrs A was a white woman in her late seventies who was referred to me by her consultant psychiatrist to see if therapy could be useful for her. Mrs A had a lifelong history of bouts of depression. Previously, in mid-life she had some therapy which she found helpful. Her psychiatrist was worried Mrs A was slipping into another episode of depression. In the following case study of short-term therapy with Mrs A I shall summarise and reflect upon the initial assessment meeting and each of the fifteen fortnightly sessions of the therapy, and include reflections on my counter- transference.

At the assessment meeting Mrs A described an unhappy life. She felt rejected by her mother and older brother. She felt close to her father but he was often absent because of his work. She married a man whom she found silent and withdrawn. He died early in the marriage leaving her with two young children. Mrs A continued working part-time in her chosen career until only a short time before I saw her. She suffered a great deal of pain from arthritis, and had concerns about increasing difficulties with her vision. She brought a dream which I interpreted as about her retirement and the loss of her work. Somewhat contemptuously she said 'Oh, it's all about retirement is it!'. During this meeting I found myself feeling I did not like her and did not want to take her on for therapy. But I felt it was unreasonable to refuse to work with her, and there was no-one else to whom I could refer her. I offered to see her once each fortnight for short-term therapy. At the first therapy session a fortnight later, Mrs A said she was surprised I offered to see her because she thought I was angry with her. I did not confirm or deny this observation which I found uncomfortably perspicacious. She then spoke about her career, describing her good professionalism in a way I felt was drawing a contrast with my poor performance.

At the second session Mrs A immediately berated me for keeping her waiting and for being so silent. With exasperation she said she'd been surrounded by silence since she was a child. Other criticisms followed. I felt dismayed. According to my watch I was on time, and I thought I had been pretty active. Later in the session I said I thought Mrs A felt she couldn't depend on me, that she had to be self-sufficient and hold herself together. Mrs A was visibly moved by this interpretation and asked me why, as she thought over her life, she kept blaming herself. She gave examples and said her daughter tells her that the kind of things she blames herself for don't matter. I said I agreed with her daughter. At the end of the session, with a sense of despair, she said 'I am my own worst enemy'.

I was troubled about my dislike of Mrs A. Reflecting on the assessment meeting and the first session I came to see Mrs A had projectively evoked a severe critic in me resulting in a hostile counter-transference. If, as a result of this counter-transference, I had referred her to another therapist I would have enacted that critical superego's denigration of her. When I could be curious about my reaction I became capable of being more reflective about my feelings towards Mrs A. Importantly, as Caper (1999) has pointed out, at first I had to struggle with my own superego which was so critical. Mrs A's experience of observing me, consciously and unconsciously, struggling with my superego may have brought some hope that if I could manage to disentangle myself from my superego then perhaps she could.

In the second session in relation to Mrs A's complaints about my keeping her waiting, I simply thought about the differences in our clocks. It did not occur to me I had kept her waiting for a fortnight in contrast to her previous experience of therapy which was probably weekly. I think such a thought was difficult for me to entertain because of a discomfort that however much I might try to justify the rationale for the fortnightly arrangement, it had aspects of an enactment of my feelings about not wanting to see her by spacing out the sessions. Later, my interpretation that she felt she had to hold herself together, brought a moment of closeness when she seemed to feel understood.

Mrs A's subsequent question about why she kept blaming herself, was a significant shift from her blaming me about the time and so on. Perhaps her question was also an unconscious query about how I managed to free myself from a critical superego. She was clearly touched by my understanding of how hard it was to depend on me. In the interpretation I simply tried to describe my understanding of her experience of being with me. I tried not to deny her feeling that I could not be depended upon, which had some truth when I was feeling so critical of her. Caper (1999) describes this kind of interpretation as a 'holding' interpretation and Steiner (1993 ) an 'analyst- centred' interpretation, which mean describing the patient's experience of the therapist as a result of what the patient has projected, and at times evoked in the therapist.

At the third session Mrs A came saying she was feeling better. She said perhaps she was feeling better because of a change in medication; but later she said that when she found she was blaming herself in various ways she recalled I'd said those things didn't matter. I replied I agreed with her daughter. Then Mrs A went on to say 'as you said last time I am my own worst enemy'. I said I didn't think she was her own worst enemy, but I thought a part of her mind was her worst enemy. She was much surprised by this and several times asked me to explain what I meant. She brought a dream in which she was with her mother and brother. She was telling them off. (In the assessment meeting she described an unhappy childhood because of her mother and brother.) She walked away from them and was on a journey. She made her way to a railway station to buy tickets but discovered she had lost her handbag. Everyone was speaking in a language she couldn't understand. The ticket sellers were passive and did nothing to help her. I said it sounded like she was beginning to stand up to the worst enemy in her mind, which was represented by her mother and brother in the dream. I said it seemed I was like the ticket sellers who were so passive and unhelpful. She laughed heartily in agreement.

In this first part of this third session Mrs A confirmed, somewhat ambivalently, some benefit from the previous session, which I see resulted from my supporting her ego to stand up against blame from her superego. She then recalled I said she was her own worst enemy. Following my clarification that I did not think of her like that but differentiated between a worst enemy in her mind and herself, she brought a dream which confirmed her standing up to her worst enemy superego. Her depiction of me in the dream as a passive, unhelpful ticket seller unconsciously confirms my earlier, therapist-centred interpretation of how I was a therapist on whom she could not depend. This denigratory view of me had persisted despite her experience of feeling some benefit from the therapy, and suggests an envious quality in her superego trying to spoil the good she had felt from the therapy. Her laughter in agreement to my interpretation of the denigration signalled some insight, in the way humour often reflects a capacity to step back and observe oneself or others, and be amused at our follies and tragedies. In this way Mrs A revealed her capacity for insight.

Steyn (2016 ) describes patients like Mrs A as less disturbed because they are able to recognise projections when interpreted. By contrast Steyn describes more disturbed patients who use a 'more total form' of projective identification to rid themselves entirely of what is projected with the result that the projection feels 'foreign'(p.1097). Steyn sees less disturbed patients maintaining an 'as if' nature of the transference, which is lost for more disturbed patients who remain convinced of the reality of their projected experience.

At the latter part of the third session Mrs A brought a dream which reminded her of the loneliness she felt throughout her life. She had few friends. She was lonely as a child and recalled a photo of herself on her own. Then she remembered she was smiling in the photo. She said her father had taken the photo. (In the assessment she told me she felt close to her father but said he was often at work away from home.) I said she wasn't on her own because she was with her father. I talked about how the dreams revealed negative propaganda spread by this worst enemy in her mind, suggesting I was passive and useless to her and she might as well be on her own; whereas she had the thought the sessions with me were helpful to her, perhaps she was even enjoying them.

In the latter part of the third session Mrs A's associations show her pursuing the implications of her insight about the transference distortions in the dream. She was able to disentangle some of the distortions in the narrative of her past, she was not always miserable and alone and, in the transference, in the here-and-now I help her like her father when I show her pictures of herself with me. The interpretations supported her ego to assert realistic observations freed of the superego's spoiling propaganda.

At the fourth session Mrs A spoke again about her loneliness. She went to a meeting of a group for older women. She described the women in a way I found amusing and laughed with her. I became uncomfortable because I realised I was joining in mocking the women. I said I felt she was ridiculing the women and was reminded of Groucho Marx who said any club that would have him as a member he wouldn't want to join. She laughed. At the next, fifth session she came back saying she'd been thinking about what I said about ridiculing the women and Groucho Marx. She said she recognised these things in herself and did not like them. During this session I reminded her we were now nearly half way through the therapy and confirmed the ending date.

In the fourth session, encouraged by Mrs A's reflectiveness I risked an explicit interpretation of her envious denigration. This is an example of what Caper (1999 ) describes as a 'containing' interpretation which can be made when the patient can manage recognising the therapist's separateness and freedom to have a different view. Steiner (1993) describes these interpretations as 'patient-centred interpretations' when the therapist can make interpretations which help the patient understand their contribution to their difficulties and when they are therefore able to retrieve projections. I approached the interpretation in an indirect way by interpreting her transference relationship to the older women in the group, sometimes described as an 'extras-transference' interpretation. Extra-transference interpretations are frowned upon in some psychoanalytic circles, but in his seminal paper on effective interpretations Strachey (1934) acknowledged the usefulness of extra-transference interpretations. Intuitively I included some humour about Groucho Marx. With hindsight I think I was apprehensive about interpreting the envy in her mockery of the group, especially because she might hear the interpretation as a condemnation of her from my superego.

The joke helped her step back and, in the laughter, observe herself like Groucho Marx. Mrs A showed how she held the sessions in mind and reflected on them between the sessions. She was able to mull over the interpretation and reach a painful recognition of her envy. The ownership of her envy was a breakthrough because instead of internally feeling the victim of an envious superego, and externally of other people when her envy was projectively attributed to them, her ego was taking responsibility for its envy.

Much later, after the therapy with Mrs A was concluded I came to understand more about the source of my initial dislike of her. I recalled that in the first therapy session she said she was surprised I offered to see her for therapy. She thought I was angry with her when she asked me in the assessment session about the difference between a psychiatrist and a psychologist. When she gave this explanation I realised I had forgotten her asking the question. I think the question very likely provoked difficult feelings in me about the differences between the two professions of psychology and psychiatry. I have a lower position in that pecking order. The question stirred uncomfortable feelings of envy. My discomfort reflected my own superego's disapproval of such feelings. Her question and my reaction were repressed, but I was left with a strong disapproval of Mrs A. Reflecting on how my superego was evoked in the counter-transference freed me of its influence, and enabled me to engage constructively in the therapy with Mrs A to reach an understanding of how troubled she was by her superego. But I failed to understand the source of my disapproval because of the strength of my superego's condemnation of envy. I was thus prevented from recognising Mrs A's early unconscious communication specifically about her struggles with her envy and her superego's condemnation of it. Only with hindsight could I see she had projectively communicated about her envy and her superego's disapproval of it by evoking my envy and my superego's disapproval of it. My dislike of her was an enactment of my superego's condemnation of myself and my envy.

Steyn (2016) has written eloquently of our struggle as therapists to bear what patients find loathsome about themselves when this means trying to bear loathsome aspects of ourselves, which are evoked in the counter-transference through projective identification. In a searching case study of her own difficulties, Steyn describes defences against projective identifications. For example when apparently making an analyst-centred interpretation a therapist might say 'You feel I am angry with you…' in such a way as to imply the patient is mistaken. The therapist may be denying the truth of the patient's experience because what has been evoked in the therapist felt unacceptable. As I have indicated, I believe an aspect of these difficulties is that what is included in the projected feelings is a superego condemnation of the feelings. The projection evokes condemnation from the therapist's superego about similar feelings in the counter-transference. So as therapists we can come to feel we shouldn't have those feelings. It can then be hard to maintain an attitude of curiosity about our feelings, and explore the possible communicative aspects of the counter-transference feelings including the sense of condemnation.

At the sixth session Mrs A brought a dream which was about her retirement. Discussing the dream she became sad. For the first time she acknowledged how much her work meant to her and how much she missed it. She then spoke of a relative who was 'jealous' of her success at work.

In this sixth session Mrs A's dream about retirement echoed the first dream she brought at the assessment session. In contrast to her difficulty in considering her feelings about retirement at that time, Mrs A was able to be in touch with her sadness about the loss of her work. The loss, signalled by the dreams, was probably linked to what her psychiatrist feared would be another episode of depression. Mrs A's denigration of herself and her achievements had its source in an envious superego. The denigration protected her from envy projected into others, as though there was little about her to be envied. When she was able to own her projected envy she was able to realistically appraise her success and the value of her career. The withdrawal of the projections of envy into others meant, when such figures were re-introjected into her superego, the superego would be thereby weakened. Owning her envy meant her ego was stronger and less vulnerable to being dominated by the superego. Consequently she was in a better position to maintain realistic appraisals of herself and others.

In recognising her relative's 'jealousy' Mrs A appreciated how enviable her work had been, and she was able to feel sadness about its loss. Her envious superego's relentless criticisms about her work protected her from the depressive pain of losing a career in which she had been successful and from which she derived much satisfaction. Mrs A's denigration of her work illustrates how the envious superego's denigration enabled her to try to overcome the pain of loss and mourning, but at the same time this meant she was then vulnerable to becoming depressed.

I assumed Mrs A use of the word jealousy to describe her cousin's envy, reflected a popular usage, in which envy and jealousy are sometimes confused and used interchangeably. On reflection, perhaps Mrs A intuited how her cousin was jealous of Mrs A's love of her work as well as envious of the good work Mrs A had achieved, and wanted to spoil Mrs A's relationship with her work. Usually jealousy refers to a triangular relationship in which one person is aggrieved about the loss of the loved one to another. The joining of envy and jealousy can be seen to have spoiling, even murderous consequences when jealousy leads to murder of either or both the loved one and the other who has displaced the jealous person.

Mrs A's dream about the loss of her work in the sixth session was probably triggered in the transference by my reminder in the previous session about the ending date of therapy, we were then half way through. I didn't interpret the dream in terms of the transference relationship but stayed with the sad feelings which she was able to feel when she did not denigrate what or who was lost. Her sadness indicated a depressive move into mourning instead of becoming depressed. There was much to mourn, the loss of her career, the ageing of her body, ultimately the loss of her own life, and in the here-and-now, the ending of the therapeutic relationship.

At the seventh session Mrs A described how she had been to a family wedding. It had been some time since she had seen the people who were present. She was shocked to see how much her relatives had aged. I interpreted the shock of recognising her own ageing, and that time was running out in her life and in the therapy. She spoke of difficulties getting on with anything or knowing just what she wants to do with the time that is remaining. In a rather wistful way, she wondered why she couldn't get on with things. I said, 'Well, we could spend time thinking about it, but perhaps that's the kind of rumination which has to be stopped so you can get on with things'. Later, I said perhaps if she really took seriously that time was running out, she might know what she wants to do in the time that is left. She replied that as she tries to think of what she wants to do her mind goes blank, she has no idea. Towards the end of the session, she said she found herself thinking of her longing to travel. I said, 'Well, what are you waiting for!' She laughed.

At the eighth session Mrs A spoke about her experience of raising her children, and her son's and daughter's families and successes. She said she'd noticed how much she is drawn back to thinking about the past, and is inclined to criticise herself for not doing better. I said that this takes her away from the present and enjoying what she has achieved. I confirmed the dates for the Christmas break which was in a month's time. At the ninth session, the penultimate one before the break, she was in a lighter, playful mood. She described feeling 'euphoric' because in her garden which she loved, she'd noticed a robin who accompanied her when she was gardening. The robin kept an eye on her. Later, she talked about a minor traffic scrape which occurred when parking her car, and she added with a laugh, 'But I'm not beating myself up about it'. I said I thought she was managing the 'worst enemy' in a better way, not dominated by it. She agreed, but added 'not completely'. In the tenth and final session before the break, Mrs A talked of difficulty in asking her daughter for help, and later finding herself singing when the daughter was helping her with some clearing up. She spoke of her enduring arthritic pain and worries about her declining mobility. Towards the end of the session she talked of how unsupported she felt by her husband because he didn't talk to her.

Confirming the ending date and the imminence of a holiday break in these latter sessions galvanised Mrs A's thinking about making the most of the time left in the therapy and in her life. Quinodoz (2010) has written about how older people can get stuck in deadly grooves as a defence against recognising advancing time and the approach of the end of life, as though going round and round in circles can prolong life and avoid death. I felt encouraged by the story of the robin who accompanied Mrs A in her garden because I understood it as a reference to myself in the transference. I had become a helpful internal object with whom she was becoming identified in observing her mind, especially how her envious superego can attack her. In the last session before the holiday, the anticipation of my abandonment of her stirred denigration of me. In the transference I was felt to be like her silent husband whom she lost early in her married life. She was again vulnerable to an envious superego's denigration to try to alleviate the pain of loss.

After the Christmas break Mrs A was unable to resume therapy on the eleventh session because of heavy snowfalls. This meant it was six weeks before I saw her again at the twelfth session. She said Christmas had been difficult, but unlike previous Christmases she didn't get depressed. She noticed she was drawn to critically going over the past, but often succeeded in stopping herself doing so and was able to get on with other things. She made plans to visit an art gallery with a friend and to have a short holiday abroad with her daughter.

In this twelfth session I was encouraged to hear Mrs A had not become depressed. It was evident she was maintaining an identification with an observing ego, noticing herself being attacked by the superego, and thereby better able to withstand the attacks which otherwise could have led to depression.

At the thirteenth session, which was the third last session, Mrs A came saying she still had problems about 'no motivation'. She talked in a despairing way about the problems of ageing, particularly her struggle with arthritis and mobility. She described wishing she would simply not wake up in the morning. She found herself thinking there was no point in continuing her daily exercises even though she knew she felt better after she did them. I said it seemed to me it wasn't so much an absence of something called motivation, but more the presence of a destructive force in her mind which undermines her and tries to persuade her she'd be better off dead.

In this thirteenth session as we neared the ending of the therapy, there was a regressive return to the beginning, as though nothing had been achieved, which Freud (1937) recognised as a plea not to end the therapy. For Mrs A this included a resurgence of an envious superego which tried to promote despair and erase any hope. She was not actively suicidal. Her passive death wishes were aspects of internal envious attacks.

At the fourteenth, penultimate session, she talked of better contact with her daughter who had again been helping her clear things out, and who surprised her by giving her a big hug. She brought a dream in which she was in a large house which was like the building in which she had worked. She was sorting and clearing things out. She said there were many rooms, some of which she could no longer enter, and she felt she was too old and there were things she could no longer do.

In this fourteenth session, there was some recovery as she felt supported by her daughter in the clearing out work and by myself in the transference. The dream confirmed the clearing out work continuing in her mind, and that she was more able to face what was and was not possible for her at that stage of her life and the therapy. She was not depressed but was mourning the end of her career, her life and the therapy.

At the fifteenth, final session, Mrs A brought some flowers. She said they were not the flowers she had hoped to bring. The poor weather prevented her from going out to get the ones she had in mind, which she specially liked because they were 'simply themselves, no frills or decorations'. She brought a dream in which a young girl was lying in a rowing boat out at sea, and thinking with resignation that she was dying. She looked up and saw a huge liner which had come to rescue her. Mrs A then talked of how much she'd appreciated and benefitted from the therapy. She had recently joined a large organisation linked with her religion which would give her access to a range of clubs and activities. She spoke of feeling there was more she could pursue. She mentioned her interest in reading reviews of books she has read. She was often struck by the reviewers' insights and returned to the texts to think about those insights. She looked forward to having the opportunity, through the clubs, of being able to discuss such things with others.

- Extract from: A Clinician's Guide to Understanding and Using Psychoanalysis in Practice, Edn. 1, by Paul Terry, Copyright © 2023 by Routledge. Reproduced by permission of Taylor & Francis Group 9781032334455.  

Original source of publication: Terry, P. (2014). Not too late: Fortnightly short term dynamic therapy with older people. Psychodynamic Practice, 20,4, 362-72.  

Watch Paul Terry and Esther Ramsay-Jones in conversation about the book.