Unit 19 Object oriented programme

Unit 19 Object oriented programme

The Object-Oriented Question: A Contribution to Treatment Technique B. D. Margolis, Ph.D.
Introductory Observations
The object-oriented question is a technical device favored in the treatment of the preoedipal patient (Spotnitz, 1969, 1976). It is, to all appearances, relatively uncomplicated, and seems to play a largely protective role in safeguarding the patient's fragile ego from experiencing more tension that it can tolerate. If, in the process, it helps resolve resistance and fosters the development of the narcissistic transferences, these appear at first glance to be serendipitous spinoffs of the analyst's ego-sheltering approach. It is the purpose of this paper, however, to demonstrate the contrary, namely, that the object-oriented question occupies a central position and exerts an influence disproportionate to its apparent simplicity on every aspect of the treatment process. What is an object-oriented question? It is a question calculated to direct the patient's attention away from his own ego and toward objects or events external to himself. What is the man's name? What was the movie about? Would I behave like that? The analyst asks this type of question because of the emotional state of the narcissistic patient. The latter is arrested in the narcissistic phase of development where self and object are not as yet completely separated and the one is often confused with the other. The ego of such a person is unstable, shifting in outline, unsure of its functions, and insecure in relation to the external world. Consequently, questions about himself or, as we say, ego-orinted questions, are bound to be experienced - 187 -

by such an individual as confusing or even assaultive. We therefore use object-oriented questions, with which he will feel comfortable, since they deal with external matters. Before proceeding, let us review the reasons for asking questions of any kind. The preoedipal patient is unable, because of his narcissistic defensive pattern, to express the full range of his positive and negative feelings. The analyst's interventions in treating such a patient are communications aimed at helping him hatch out of his emotional shell by responding with communications of his own. The analyst's intervention usually take the form of questions. This is not true, of course, when working with an oedipal patient. In that case, a declarative statement, i.e., an interpretation, tells the patient what the analyst knows about him. The patient finds this helpful because his ego is mature enough to use the insight provided to recognize his resistance and discard it. The immature ego of the preoedipal patient, however, is unable to cope with the bald facts and connections exposed by an interpretation. A declarative statement spelling out his dynamics is experienced by him as confusing and threatening. It sets off in him impulses toward aggressive action, arouses his anxiety as to his ability to control them and activates characterological resistance patterns. A question, on the other hand, is a communication with an open-ended request for whatever the patient is capable of giving at the time. The preoedipal patient may resist, if he so desires, by not answering at all. He may respond as briefly as his emotional capacity permits, and then draw down a curtain of resistance. He may engage in an investigative dialogue, powered by the analyst's questions and affording the patient the opportunity to expand his capacity for emotional communication. To safeguard the patient's fragile psychic economy and protect him from any sense of emotional invasion throughout the course of these interchanges, the questions are usually object-oriented, i.e., they are directed toward matters external to the patient's ego. In actually, there is no such entity as the pure object-oriented question. The patient's ego, whether brittle or robust, is impacted by the question, cognitively and emotionally. The ego's functions are involved in receiving it, processing it, and reacting to it. The more regressed the patient and the more fragile his ego, the greater the impact even of an object-oriented question. For the withdrawn patient, the most cautiously framed question, focused on an object most distant from the patient's self, is neverthless experienced as an irruption into the private precincts of his self and as an intrusion into - 188 -

his jealously guarded, self-imposed isolation. The object-oriented question, then, does not exist in a pure form. It is “objective,” i.e., focused on matters extenal to the self and sparing of pressure upon it, only relative to the impact of the blunter ego-oriented question. It is neverthless rewarding, in working with the preoedipal patient, to distinguish between the two types of question. Empirical findings (Meadow, 1970, 1974; Kalin, 1978; Lefkowitz, 1980) suggest that the object-orented question more successfully helps the patient engage in verbal communication. Uses in Therapy

The basic function of the object-oriented question is to resolve resistance to communication. Its uses, toward that end, embrace a range of occasions extending from the solely protective to the most complex analyst-patient transactions. The protective role of the object-oriented question is fundamental to its employment in every aspect of the analysis. The ego of the preoedipal patient must be safe-guarded at all times from excessive frustration-tension, although the kind and extent of the protection vary with the phases of treatment and the maturational changes going on within the patient's ego. Some notion of the complexity of function of the object-oriented question may be gained by observing its operation in a “solely protective” role. Three occasions involving resistance come to mind. (1) At the beginning of analysis, when the patient remains self-absorbed and makes no contact with the analyst, the latter will ask a number of object-oriented questions. The protective purpose is to secure the patient from regressing into a deeply pathological state. (2) At the other extreme, when the preoedipal patient early in treatment exposes too much of his inner life in one session, it may lead to uncontrolled regressin or to other serious forms of resistance. Many a therapist has rued the glow of satisfaction with which he ended a session of unrestrained outpourings by the patient, when the latter returned the following session in a glum and uncooperative mood—if he returned at all. The experienced anlyst will resort in such self-revealing sessions to object-oriented questions as counter-measures, in order to limit the patient's output. (3) When the patient hallucinates, becomes hysterical, or displays other such emotional or psychotic features, the object-oriented question serves to anchor him to reality. In all these instances, the analyst uses the object-oriented question - 189 -

to resolve the patient's resistance to speaking productively. In pursuit of this goal, however, he pays heed to the perilous state of this patient's ego and his need for insulatin. The questions he asks are cautiously and “objectively” framed so that above all they protect the ego from undue stress. For example, with such questions as, What day was that? How do I feel when you describe these things? The patient's attention is directed away from himself. At the same time, however, that the object-oriented question is engaged in protecting the patient's ego, it is simultaneously performing a number of other important functions. (1) It helps the analyst model contact functioning for the patient, in furtherance of the development of the patient's capcity for communication (Margolis, 1983). (2) It fulfills an investigative function. The patient's way of dealing with the question enables the analyst to study his special forms of resistance. A: What was his name?

(mumble followed by a change of subject.)
The resistance entails avoidance of contact in the shape of flight from the topic, and gives the analyst some notion of the patient's characterological way of dealing with reality. Furthermore, the patient's remarks, if any, about the object are actually a projected image of the patient's own ego. A: How do I feel when you describe these things?

P: You're upset.
This is obviously how the patient himself feels. (3) It helps develop the narcissistic transference. The patient's answer in the last example furthers such development. We may conclude that the object-oriented question is at times “solely protective” only in the sense that its role on those occasions is governed by an urgent need to come to the aid of the patient's ego and to ensure the survival of the analysis. Coincidental with that operation, however, other interlocking treatment purposes are also served. These other purposes turn out to constitute the presiding elements in the treatment process. The object-oriented question, as indicated, is initimately associated with the resolution of resistance, the development of contact functioning, and the evolution of the narcissistic transference. As we shall se later on, it is also one of the main forms - 190 -

of communication in joining and mirroring the patint. And it provides opportunities for the patient to experience reactions of frustration and gratification, thus helping him to mobilize and express his concealed aggressive and libidinal feelings. Contradictory Aspects

An intriguing aspect of the object-oriented question is the contradictory roles it is capable of playing, and the manner in which the contrasting tendenceis turn out to be cooperating toward a common end. A good example is provided by the exploratory qeustions with which the analyst reflects the patient's efforts at making contact. P: Why don't you say something?

A: What shall I say?
P: Anything you want.
A: What might that be?
P: I see you're not going to budge.
A: Why not?
P: I'm too weak or too spaced out to get you to do it.
A: Am I that powerful that I can't be budged?
P: (with some asperity) Not if I could get my act together.
A: When is that going to be, ten years from now?
P: (angrily) No, damn you. I'm gonna give you a piece of my mind right now. It is clear that the analyst's questions are experienced as frustrating by the patient. The analyst is interested in observing what the patient does with the anger that the frustration generates in him. The narcissistic patient, employing the narcissistic defense, tends to attack himself when frustrated. Will he resist expressing his aggressive feelings this time again? If so, what form will his resistance take? One purpose, then, in using the object-oriented question is to provide an opportunity to study the patient's characteristic forms of resistance to the voicing of aggressive feelings. The patient in the example given above reacts first defensively, then aggressively. The analyst, for his part, has accomplished the dual aim of evoking a display of the patient's resistance for scrutiny and helping the patient mobilize and express his negative feelings toward the analyst. Dividends enough from one set of questions. We are by no means finished with them, however. Rereading the - 191 -

interchange, it strikes us that the frustrating stimuli cannot of themselves explain the progression that takes place in the patient's reactions, from self-attack to open expression of aggressive feelings. Another factor must be at work here. And it is to be found in the patient's narcissistic legacy. On a deeper level consistent with that legacy, the analyst's questions are experienced by the patient syntonically, as a form of feeding. They are evidence to the patient of the analyst's interest in him. The analyst wants to know more about him and is going to some lengths to find out. The patient reacts to this with a feeling of gratification and a release of tension. Under normal circumstances, one would expect the patient to express his relief through pleasurable reactions. He would laugh or make friendly remarks to the analyst. The infant when fed reacts with loss of tension, gurgles, smiles, falls asleep. But her the circumstances are not normal. Frustrating experiences in the patient's early life have led to the development of distorted patterns of discharge. The narcissistic defense in particular, which interdicted the release of aggression toward the mother, resulted in the accumulation of much tension in the patient. When he now experiences the analyst as feeding and caring for him, the release of tension often takes the form of expression of rage toward the analyst. His reaction is reminiscent of the child who embraces with angry reproaches the mother returning from an overly extended shopping trip. We thus have a merging in the object-oriented question of the two contrasting tendencies of frustration and gratification. In order for the patient to reexperience in the transference the traumatic events of his early years, he needs first to feel the lash of frustration provided by the object-oriented question. On a deeper level, in the context of feeding provided by the same question, the patient is granted the sequential therapeutic experience of frustration followed by openly declared aggression toward the analyst, who stands for mother. Between these two steps, resistance appears and is resolved. The scenario goes as follows: The analyst intervenes with an object-oriented question. The patient feels simulataneously frustrated and gratified. He experiences the frustrating question as the analyst's expression of interest in him, hence, as a form of feeding. Frustration leads to aggression, which the patient at first resists by attacking himself. The gratification inherent in the question, however, enables the patients to give up his resistance with safety and express aggressive feelings toward the analyst. The frustrating object-oriented question thus acts upon the patient as an emotional feeding which ultimately leads to the release of aggression. - 192 -

Interestingly enough, it is the libidinal drive, which was originally responsible for erecting the narcissistic defense, that is now used, after the patient's experience of need-gratification, to dismantle the defense. Moreover, with the change from self-attack to the release of rage at the analyst, a memorable maturational event has taken place, marking the patient's arrival at object transference. The object-oriented question emerges on all counts as a richly endowed instrument, which provides occasions for the contradictions and the syntheses necessary to further the patient's emotional growth. Aid to Maturation

We are now aware that, far from merely serving as a device to preserve the pateint's fragile ego, the object-oriented question fulfills a wide ranging therapeutic function. It is possible to follow the development of the narcissistic transference and the patient's maturational growth by studying the object-oriented questions directed to him as therapy proceeds. The more regressed the patient, the simpler the question. As he progresses maturationally, the object-oriented questions become more complex and directional. In the beginning phase, the quetions might be: What's his name? How old is he? They are directed at helping the patient extricate himself from his self-absorbed state. The patient's one-word answer acknowledges the existence, however indistinct, of an other. Further along, the questions become less innocent, as they begin to sensitize the patient to the attitudes and feelings of objects. What did he have in mind when he said that? How did he feel when he heard it? The building of the narcissistic transference, which has already dimly begun in these early exchanges, moves ahead with authority in the next phase, when the analyst is introduced as object. How do I feel about that? Would I react that way? Up to this point, the questions deal with matters external to the patient, which help him describe his own feelings by means of projection. Now the analyst begins to use object-oriented questions to alert the patient as to what feelings appropriate to a situation may have been repressed by him. Why does he think he can treat you so badly? Does that make me feel angry? And a step beyond that, How come I have to get angry for you? The last question approaches the sphere of the ego-oriented question, Why didn't you get angry? As can be seen, the object-oriented question, in its range from the elementary - 193 -

to the complex, acts as accessory to the development of the narcissistic transference and as gauge of the patient's maturational growth. In furtherance of these objectives, the object-oriented question constantly explores what next maturational step the patient is prepared to take and provides him with the proper opening to take it. In the elementary phase, when the analyst asks, What's his name?, he is trying to ascertain whether the patient can gainfully absorb a judicious morsel or two of nourishment. The patient's one-word response signals an acceptance of gratification and betokens a small advance toward wider emotional horizons. After the patient begins to make contact with the analyst under his own impetus, more complicated object-oriented questions explore his readiness to venture into more expansive communication. Question and answer help resolve resistance and foster the development of the narcissistic transference, the elaboration of progressive communication, and the growth of object relations. Relationship to Narcissistic Transference and Object World

Two basic tasks of the object-oriented question are: development of the narcissistic transference and educating the patient to the shape of reality and how to deal with it. We have already seen that well nigh all uses of the object-oriented question, in whatever context, indirectly further the development of the narcissistic transference. However, the object-oriented question can also directly pursue the same task. As the patient speaks, the analyst, serving as object, will often call attention to himself with object-oriented questions. Do I approve of that? How do I feel about that? What would my advice be? Shall I speak to him for you? What shall I say? How would I handle that? The questions draw the patient's projections onto the analyst and thereby help the narcissistic transference unfold (Margolis, 1979, 1981). The second basic task of the object-oriented question, which involves educating the patient to the shape of reality and how to deal with it, takes two forms. The one more intimately associated with emotional growth concerns helping the patient focus more precisely in making his needs known. - 194 -

P: I wish you'd help me.
A: With what?
P: How to get along with people.
A: What people?
P: Men (women).
A: What's the problem?
P: I'm hostile and drive them away with nasty remarks.
A: What help shall I give you?
P: Help me become friendlier toward men (women).
The difference between the patient's first statement and last represents a focusing of his expression of need. Another version may have the patient complaining, People don't like me. The analyst responds with, Who are these people? How do they show it? Does they include me? The patient gradually moves from the nebulous, characteristic of the narcissistic state, to the specific, paralleling the progress of the young child from generalized yelling to the explicit verbalizing of need, I'm hungry. As Ferenczi (1919) states: “The tendency to pass from the general to the more and more particular dominates the whole of psychoanalysis” (p. 184). The patient is literally being educated to feel and verbalize. The second educational use of the object-oriented question concerns itself with teaching the patient how to cope with reality situations. The emotional immaturity of the narcissistic patient often renders him inept in his dealings with reality. It becomes necessary, in order to ensure his survival as well as to help him continue in treatment, to teach him how to handle difficulties in his everyday life. With the aid of the object-oriented question, he is led to examine the difficulties realistically and to evaluate in advance the outcome of actions he may be contemplating. How will that help? Why isn't that a good idea? Why is that the wrong thing to do at this point? Is that appropriate behavior? What's the best way to go about getting the job (passing the exam, getting him to listen to you)? What could one say to convince him? How will he react if you attack him? If you reason with him? The analyst can give the patient outright information and advice on all these matters. They would, in all likelihood, however, fail in their purpose because the narcissistic patient is not emotionally ready to receive the information and advice. The object-oriented question, on the other hand, allows for this by exploring the patient s readiness and letting him declare whether or not he is prepared to deal with the matter. Moreover, the only way the patient himself can divine - 195 -

whether he is emotionally in the position to absorb this information is by talking and communicating his feelings and understanding to the analyst. In short, his acquisition of the ability to understand and deal with reality grows with his increasing capacity to express his thoughts and feelings to the analyst concerning the object world. It is clear now why the object-oriented question is a principal modality, the engine, as it were, of the analytic process. In general, by the answers it elicits from the patient it establishes what his maturational level is and his state of readiness to advance beyond that. It then provides him with the wherewithal to make the advance. While doing that, it progresses from the quite elementary to great emotional complexity, as it engages the evolving feelings of the patient and fosters the growth of the narcissistic transference. The Relevant Question

The object-oriented question is effective only when relevant. Its purpose is to resolve resistance in such a way as to safeguard the patient's fragile ego by directing his attention to external matters. This is not the same as distraction for distraction's sake. Following is an instructive illustration of the latter. A patient who has just come to treatment begins to pour forth a great deal of distressing material about his early life experiences. The analyst, realizing that this excessive self-exposure will surely activate serious resistance later on, decides to step in with an object-oriented question. The patient, proceeding with his long narrative, says: P: So my mother punished me by shutting me in a closet.

A: Were the trains running on schedule this morning?
P: Aren't you listening to me?
Although this bit of dialogue may strike the reader as ludicrous, student therapists have been known to bring even more bizarre interventions to their supervisors. What is lacking in our sample question is organicity. The question is not organically associated with the patient's thoughts of the moment. Small wonder that his reaction is one of suspicion that the analyst is not listening. In order to slow him down or shift his attention from himself to an external matter, the analyst needs to ask a question which bears upon the topic the patient is currently occupied - 196 -

with, eliciting concrete details about it. How big was the closet? Was there light in the closet? The principle of organicity applies to all levels of object-oriented question. The self-absorbed patient who makes no contact in the opening phase of treatment is asked simple questions related to the subject he is talking about. What's his name? When was that? Later on, more complicated questions will still address themselves to matters uppermost in the patient's mind. What would I have done if that had happened to me? What is my opinion on the subject? In every instance where object-oriented questions are employed, from the beginning of treatment to its termination, the purpose remains unchanged, to resolve resistance to communication. In order to succeed in this, the question must be organically connected with the patient's current concern, so that he perceives it as relevant and validates it with an appropriate response. In sum, the complex therapeutic process provides the object-oriented question with the opportunity to affect a multi-dimensional universe and to serve as an active principle in every area of treatment. It is a visible presence in the interventions that promote the growth of the narcissistic transference, that deploy the induced countertrans-ference feelings in the resolution of resistance (cf. Margolis, 1978) and that put the joining techniques into effect. A single question or series of questions will often accomplish all of these simultaneously and lead to progressive communication and maturational growth. References

Ferenczi, S. (1919), On the technique of psychoanalysis. In Further Contributions to the Theory and Technique of Psychoanalysis. London: Hogarth Press, 1950. Kalin, E.B. (1978), A study of the relative effectiveness of two types of interventions at the beginning of psychoanalytic treatment with adolescent drug abusers. PhD dissertation. Lefkowitz, S. (1980), Pathological verbalizations of process and reactive schizophrenics as a function of object- and ego-oriented questions and interviewer's style. PhD dissertation. Margolis, B.D. (1978), Narcissistic countertransference: emotional availability and case management. Mod. Psychoanal., 3: 133-151. [→] Margolis, B.D. (1979), Narcissistic transference: the product of overlapping self and object fields. Mod. Psychoanal., 4: 131-140. [→] Margolis, B.D. (1981), Narcissistic transference: further considerations, Mod. Psychoanal., 6: 171-182. [→] Margolis, B.D. (1983), The contact function of the ego: its role in the therapy of the narcissistic patient. Psychoanal. Rev., 70: 69-81. [→] - 197 -

Meadow, P.W. (1970), The relative effectiveness of two educational techniques used in the extinction of maladaptive responses which block learning. Dissertation Abstracts International, 31: 1-97. Meadow, P.W. (1974), Research method for investigating the effectiveness of psychoanalytic technique. Psychoanal. Rev., 61: 79-94 [→] Spotnitz, H. (1969), Modern Psychoanalysis of the Schizophrenic Patient. New York: Grune & Stratton. Spotnitz, H. (1976), Psychotherapy of Preoedipal Conditions. New York: Jason Aronson. - 198 -