Brit J Psychotherapy - 2012 - Turp - CLINGING ON FOR DEAR LIFE ADHESIVE IDENTIFICATION AND EXPERIENCE IN THE

CLINGING ON FOR DEAR LIFE: ADHESIVE IDENTIFICATION
AND EXPERIENCE IN THE COUNTERTRANSFERENCE
Maggie Turp
abstract Certain states of mind in a patient are difficult to remain with and tend to
evoke defensive countertransference responses which, if enacted, obstruct therapeutic
progress. The state of mind discussed in this paper is ‘adhesive identification’, a term that
arose out of a conversation between Esther Bick and Donald Meltzer, when Bick said of
certain patients:‘They are sticky, they stick . . .’ The author presents an outline of ‘psychic
skin’ defences (Bick, 1968, 1986; Briggs, A., 2002; Briggs, S., 1998; Mitrani, 2001; Turp,
2003) followed by a more detailed account of ‘adhesive identification’ (Meltzer, 1975).
Cohen’s (2003) work on countertransference and integrity, based on her experiences in
a neonatal intensive care unit, is described. These resources are employed as a frame-
work for thinking about countertransference enactments arising in psychoanalytic psy-
chotherapy with an adult, adhesively attached patient. Extracts from a session with the
patient, ‘Janine’, are presented and discussed. In conclusion, the author returns to the
proposed links between integrity in the sense of thoughtfulness and respect and integrity
in the sense of the felt experience of being in one piece within a skin boundary.
Key words: adhesive identification, countertransference, psychic skin, psychotherapy,
psychoanalysis, integrity, hard to reach patients
Introduction
Adhesive identification is one of a number of defences against inadequate or
dysfunctional skin boundary functioning. The adhesively attached individual
clings tightly to another, looking to him or her to furnish some kind of func-
tioning sense of self. The individual clung to, in this case the therapist, may find
that the patient with the damaged skin boundary ‘gets under her skin’ in turn.
The psychotherapist’s sense of integration, of being in one piece within a skin
boundary, able to receive and think about the patient’s communications, may be
disturbed. The clinging behaviour, the constant attempts to remove any gap
between self and other, the refusal to acknowledge that the therapist has a mind
or skin of her own, threaten the capacity for objectivity and the maintenance of
an analytic attitude.
The link between the terms ‘integration’ and ‘integrity’ is evident in their
common derivation. The dictionary entry for ‘integrity’ furnishes us with two
linked meanings. The first refers to ‘the quality of being honest and having
strong moral principles’, the second to ‘the state of being whole and undivided’.
The work of Cohen, a child psychotherapist with a background in moral
philosophy, is grounded in these connections between the state of being ‘whole’
and the capacity to act with moral integrity:
MAGGIE TURP PhD CPsychol is a psychoanalytic psychotherapist and supervisor in

private practice and an honorary psychotherapist at the South London and Maudsley
NHS Foundation Trust. Her academic career has included lectureships at the University
of Reading and at Birkbeck College, London, where she also conducted infant observa-
tion seminars. She is a member of the Editorial Boards of the journals Psychodynamic
Practice and Infant Observation. Her publications include journal papers and Psychoso-
matic Health: The Body and the Word (Palgrave, 2001) and Hidden Self-Harm: Narratives
from Psychotherapy (Jessica Kingsley, 2003). Address for correspondence: 73 Torbay
Road, London NW6 7DU. [[email protected]]
© The author
British Journal of Psychotherapy © 2012 BAP and Blackwell Publishing Ltd, 9600
66 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA.
DOI: 10.1111/j.1752-0118.2011.01265.x
17520118, 2012, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1752-0118.2011.01265.x by UNIVERSIDADE ESTADUAL PAULISTA, Wiley Online Library on [01/05/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
MAGGIE TURP 67
My argument in what follows is that the capacity for the exercise of integrity rests
fundamentally on the integration of the personality. (Cohen, 2003, p. 69)
The context for the development of Cohen’s ideas is life (and death) in a
neonatal intensive care unit (NICU). Cohen describes defensive countertrans-
ference responses – her own and those of other members of staff – to the
plight of the prematurely born babies cared for in the unit. She draws out the
tension between a natural the desire to look away from helplessness, distress,
damage and dependency and the difficult but necessary work of not looking
away. To bear witness to what is disturbing and difficult, to resist the urge to
look away, is, in Cohen’s terms, an act of integrity, one that is possible only
insofar as the observer is able to hold him or herself together in the face of
distress.
Adhesively identified patients, like barely viable premature babies, look
to somebody else, in this case the psychotherapist, for survival. Without an
adequate sense of skin, their dependency is extreme. Typically, such patients
describe being unable to function in intimate relationships and feeling lost,
despairing and tormented by inner emptiness. They bring into the consulting
room a sense of a terrifying void with intimations of deadliness, whether
via suicide attempts or life-threatening deficits of self-care. In the case of pre-
mature babies, the condition of absolute dependency arises from their bio-
logical situation and tenuous hold on life. In the case of adhesively attached
patients, it arises from early damage or deficits that have resulted in distor-
tions of development. There are clear and striking differences. However, both
groups convey a sense of ‘exquisite fragility’ (Cohen, 2003) and endangered
survival.
The aim of this paper is two-fold. Firstly, I am interested in exploring further
how a ‘psychic skin’ conceptual framework can be of assistance in analytic work
with adult patients. This is a subject raised in this Journal by Hinshelwood
(1997). Hinshelwood drew attention to Bick’s attempt to reach a third layer
of experience in the unconscious, one associated with the primitive neonatal
struggle for skin containment. He argued that an understanding of the three
layers and the links between them can help guide and refine interpretive
choices. Hinshelwood described Bick’s ideas as ‘under-used’ (1997, p. 307). This
continues to be the situation with regard to analytic work with adult patients,
although reference to psychic skin defences is a frequent feature of descriptions
of analytic work with children (see, for example, Alvarez, 2002; Dollery, 2002;
Jackson & Nowers, 2002; Magagna, 2002; Rhode, 2002).
Secondly, I am interested in bringing Cohen’s work on integrity to the atten-
tion of a larger audience, in this case by demonstrating how it helped to make
sense of countertransference responses and enactments arising in psychoana-
lytic psychotherapy with an adhesively identified patient.The idea of integrity in
psychoanalytic work could also be described as ‘under used’ or under explored.
There is, of course, a considerable literature describing countertransference
effects whereby, as described by Betty Joseph, the psychotherapist is ‘nudged’
out of role (Feldman & Spillius, 1989). Cohen’s work is essentially concordant
68 BRITISH JOURNAL OF PSYCHOTHERAPY (2012) 28(2)
with this existing literature. In addition, and unusually, she locates the subject of
countertransference enactments within the broader philosophical discourse of
moral integrity.
Psychic Skin Defences

In the 1960s and 1970s Esther Bick and colleagues elaborated an account of
psychic skin defences, on the basis of their detailed and extended observation of
very young infants. In common with defences associated with the paranoid–
schizoid position, psychic skin defences relate to primitive terrors with regard to
the survival of the self. In the case of psychic skin defences, however, the
unconscious fear is not of being destroyed by the return of one’s own projected
destructiveness but of falling apart, in Bick’s terminology ‘liquefying’ and
‘leaking away’, as a consequence of not feeling adequately held together within
a skin. Bick (1968) describes how the skin is not at first experienced as having
sufficient binding force to hold the parts of the personality together. The infant
is always on the brink of emotional catastrophe, of falling apart and leaking
away.
Like Hinshelwood (1997), Andrew Briggs (2002) suggests that Bick’s focus
on the infant’s struggle for survival draws our attention to an earlier site of
infant development than that visited by Klein. On the basis of her observations
and those of her students, Bick describes how at the beginning of life the
attentions of the mother are experienced as a skin. The parts of the personality,
gathered and held together by maternal care, are for an infant at this stage
indistinguishable from the parts of the body and bodily functions. Over time, the
mother’s capacity to ‘enskin’ the infant is introjected and this process gives rise
to three-dimensionality, to the notion of internal and external space. Only then
is there a basis for adaptive splitting and projection, as described by Klein
(1952).
A number of defences against failures of skin containment, whether resulting
from inadequate early provision or from later traumatic experience, have been
identified. Bick refers to the formation of a ‘second skin’ via ‘skin toughening’,
a ‘rhinoceros hide’ defence that wards off fears of disintegration by forming
a tough, impermeable barrier around the self. Where toughening becomes
entrenched, dependence on attachment figures is replaced by pseudo-
independence. The infant now seeks containment primarily through visual or
auditory fixation on inanimate objects, or through a focus on his own breathing
and vigorous movements.The consequences for communication and relatedness
are evident, as in Bick’s description (1968) of Alice at 6 months, a hyperactive and
aggressive little girl whose mother nicknamed her ‘the boxer’ on account of her
habit of pummelling people’s faces. In adulthood, toughening can become mani-
fest in symbolic forms, for example, in ‘verbal muscularity’, cynicism, or cold
calculating rationality.
An alternative to toughening is resignation. Here Bick’s account is less exten-
sive. However, this state of mind is elaborated by Stephen Briggs who uses the
term ‘skin porosity’. Here, the psychic skin is leaky and falling in holes. Ego
function is lacking to the extent that the individual feels subject to whatever
MAGGIE TURP 69
comes his or her way and, moreover, experiences this as the only possible way
to be. Porosity is characterized by diminished emotional and cognitive activity,
expressed in an unadventurous and incurious state of mind. Briggs argues that
such a stance of passivity and resignation has serious implications for all aspects
of development. A description of a ‘porous’ adult patient can be found in Turp
(2003).
Thirdly, Bick and Meltzer describe what they refer to as ‘adhesive identifica-
tion’. In an unconscious attempt to compensate for his or her own sense of
‘skinlessness’, a child or adult makes use of another’s skin through a process
of close clinging and over-identification. Objects are related to in a two-
dimensional way. Both Bick (1968, 1986) and Mitrani (2001) offer examples of
child and adult patients where this scenario is enacted: the sound of the voice
and the experience of the gaze are repeatedly elicited in the therapist and clung
to voraciously by the patient.
As these various psychic skin defences have the same unconscious aim, we
will not be surprised to observe them alternating in the same patient or appear-
ing in hybrid forms. Talking to a teenager recently, and receiving the not untyp-
ical ‘Yeah, yeah, whatever . . .’ response, I noted wryly the way in which it
combined both resignation and a tough pushing away of my attempts to com-
municate. In this paper, the focus is on adhesive identification. Nevertheless,
examples of toughening and porosity are also in evidence, both in the patient’s
material and in the countertransference phenomena described.
Bick noted that:
Until the containing functions have been introjected, the concept of a space within
the self cannot arise. Introjection, i.e. the construction of an object in an internal
space, is therefore impaired. (1968, p. 484)
Lacking a sense of a skin boundary and hence of an internal space within
either the self or the other, the individual cannot make use of the experience of
‘alpha function’ (Bion, 1962), whereby a projection is contained, processed
in the mind of the other and offered back in a detoxified state. Hence for an
individual with a damaged sense of ‘inside’, the experience of a container/
contained relationship is extremely elusive. In its absence, he or she is obliged to
rely on surface contacts, skin-to-skin experiences, various forms of ‘clinging on’
and ‘sticking to’ for a rudimentary sense of safety.
Adhesive Identification
In 1986, Bick wrote vividly about adhesive identification as experienced in her
work with an adult patient, Mary, who suffered from eczema and complained to
Bick that she was ‘spilling out’. Bick experienced Mary as relating to her in a
two-dimensional way, clinging voraciously to her voice or gaze and sometimes
parroting her phrases.
My patient ‘Janine’ likewise complained to me of ‘spilling out’ of being
‘without a skin’ and of not being able to ‘hold herself together’. In the early
years of therapy, she found changes in routine occasioned by my breaks over-
whelmingly difficult.Twice during summer breaks she suffered major depressive
breakdowns and returned to stay with her only close relatives, putting herself
entirely in their care. Once, she stopped eating during my absence so that when
I saw her on my return she was stick-thin. The repeated message was that my
going away endangered her very survival.
In the light of certain benign developments, summarized in the clinical
section of the paper, the question of ending therapy arose and at a certain
point we agreed upon a finish date. A difficult period ensued. In a sequence of
sessions, including the one to be described, Janine seemed ‘locked on’ to me,
tracking my every move while at the same time refusing to look at me. Similarly,
I had the sense of her devouring my words voraciously while at the same time
refusing to hear what I was saying.
Janine’s shift into a state of mind where she was stuck and seemingly unreach-
able threatened further progress and also the planned termination of the
therapy. Like my patient, I was faced with the prospect of ‘no light at the end of
the tunnel’ – a phrase that Janine had used in the past to describe her plight. At
one point during the session, I found myself thinking: ‘She is clinging on to me
for dear life. I hardly have room to breathe.’ Bick writes of Mary that:
The desperate clinging for survival was mounted in the face of an experience of
lacerating separation that would let her life leak away like a liquid substance. It
therefore seemed likely that identification and mimicry of my phrases was due to
her sticking on to my surface, and I came to think of it as an adhesive identification
rather than a projective one. (1986, p. 293)
Two of Bick’s contemporaries, Meltzer (1975) and Winnicott (1960), likewise

argued for the existence of an inchoate infantile state associated with sensual,
skin-to-skin, orientation towards the containing object. This theme has also
been developed in France (Anzieu, 1989; Houzel & Rhode, 2006) and the USA
(Mitrani, 2001; Ogden, 1989). In the UK, Bick and Meltzer collaborated in
developing a unique understanding of adhesive identification. To continue the
story in Meltzer’s words:
So we coined this term adhesive identification and the more we thought about
it the more we began to notice that it played a part in lots of our patients’ lives and
in our own lives. This was particularly true in relation to values, the difficulty in
establishing internal values; that is an internal source of values. For instance, one
noticed in people who were very artistic and seemed to have a very good taste in
art and to be very knowledgeable, that very often they reported they knew very
well that there was something wrong because when they went to a gallery they
always looked at the title before they looked at the picture. They always wanted to
find out who it was had painted it before they looked at the picture, because they
wanted to know its value before they actually looked at it. This was in a sense a sort
of prototype of their attitude toward the world. They really wanted to know the
price of things because they had no basis internally for establishing their own
personal evaluation of it in terms of its meaningfulness to them. (1975, pp. 302–03)
During the early years of therapy, Janine would become very anxious and
upset when her friends did not hold the same opinion as her. She kept her
friendships strictly separate, dreading occasions when one friend might meet
MAGGIE TURP 71
another and she might find herself in the presence of conflicting opinions in the
same room. She felt, as she told me, that she did not have ‘a mind of her own’.
She allowed herself to be convinced by whichever opinion she encountered at
a particular time. A conflict of points of view exposed her underlying emptiness
and left her feeling ‘muddled, paralysed and confused’ (Meltzer, 1975).
A high level of social awareness and a talent for imitation often serve to
conceal difficulties of this nature and it is not unusual for adhesively identified
patients to function well in the work environment. Janine was successful and
well liked at work. However, successful ‘as if’ relating can be a burden as well as
a blessing. Marilynn Robinson in her novel Gilead eloquently explores a
dilemma of this kind. The main character, Jack, says of himself:
When I was a boy, people took me to be older than I was and often expected more
of me – more common sense, usually – than I could come up with at the time. I got
pretty good at pretending I understood more than I did, a skill which has served me
through life. (Robinson, 2006, p. 44)
The reader is by this time aware that Jack is a tormented young man. Over
the course of the novel he will become involved in crime, be estranged from his
family and ultimately commit suicide. His highly prized capacity to pretend,
to play a part, contributes substantially to his failure to find a way through his
difficulties.
In exploring a further dimension of adhesiveness, Meltzer writes about his
and Bick’s patients’ relationship to time:
We began to recognize that the two-dimensional patients had a very oscillating
relationship to time, that it went in one direction and then it went back. . . . It was
as if you didn’t really get older in any inevitable way, that aging was a kind of
accident due to poor planning, or negligence, or the aggression of other people.
(1975, p. 302)
Meltzer’s observations helped me to make sense of the emphasis Janine
placed on the fact that, as she told me: ‘Everyone takes me for much younger
than I am’ and her searching on internet dating sites for a partner at least 10
or 15 years younger than herself. At the same time, she would suddenly feel
panicky about the prospect of retirement, relating to it as something that was
upon her already or would suddenly be upon her, rather than something
foreseeable for which plans might be made.
Bick’s work is focused primarily on an adequate or inadequate sense of a skin
boundary in moment-to-moment interactions. Of equal importance, in my view,
is a sense of being ‘enskinned’ in time, an experience referred to by Winnicott
(1960) as ‘continuity of being’. Meanings evolve over time and each of our lives
has a time-line. Without a sense of inhabiting that time-line, of knowing where
we are in relation to it, we are subject to the invasion of meaninglessness and
‘the chaos monster’ (Britton, 2003). I have suggested elsewhere (Turp, 2003)
that a key aspect of psychic skin containment is the provision of a parental
‘narrative skin’, whereby the infant’s experience is ‘storied’ as the parents talk
him or her through the day, recounting his or her experiences backwards and
forwards. The provision of regularly recurring rituals and parental attunement
to the infant’s readiness for action or need for space complements the provision
of the verbal narrative. This short example is taken from an observation of
‘Esther’, age 7 months, and her mother ‘Helen’:
Helen speaks in a slightly more animated way. ‘You had a croissant for breakfast
and then a long, long sleep. It’s not a bad life, is it? Are you ready to wake up now?’
Esther smiles more widely and kicks her legs. Helen laughs and gives Esther a little
tickle in the chest. Esther becomes more enlivened and drums her legs up and
down on the cot. (Turp, 2003)
Provided the parental narrative is respectful of the child’s emotional truth,
he or she gradually gains a sense of being an ongoing person, located in time and
growing older as the years pass by. A central feature of a psychoanalytic per-
spective on narrative is the relationship of the story told to the truth and reality
of the inner world. Parental narratives may fall short in this regard. (’She
absolutely loves her little baby brother. She’s not in the least bit jealous!’)
Whether as a consequence of deficits or of distortions, an absence of an
adequately functioning narrative skin often finds expression in considerable
confusion about one’s age, stage of life and capacities. Sherly Williams (1999)
describes how a therapist, in the position of ‘outsider’, can render possible
an exploration of personal truth and the working through of distorted
self-narratives.
In relation to clinical work with patients where skin containment issues are
to the fore, Anzieu warns against ‘interpretive bombardment’ which can be felt
to strip the ego of its protective envelope. In similar vein, Ogden warns of the
danger of confusing narcissistic resistances with:
. . . last-ditch defences against catastrophic anxiety resulting from a situation where
the necessary development of and trust in a ‘rhythm of safety’ between mother and
infant has not taken place or has been interrupted. (1989, p. 130)
Some time into my long period of work with Janine, during which she attended
all but one or two of her booked sessions, a rhythm of safety did become
established and a greater proportion of interpretive work became possible.
However, the prospect of therapy ending provoked a resumption and exaggera-
tion of adhesive relating.
Mitrani (2001), drawing on the work of Sydney Klein (1980) and Tustin
(1992), describes how, in non-autistic patients, both children and adults, edges,
outlines and shapes of inanimate objects can serve to provide a sensation of
impermeability or tranquillity. In the session described later, Janine retreated
into a shell, refusing to make eye contact with me. At the same time, I found
myself speaking more than usual (an enactment in the countertransference that
would have been better avoided) and eventually felt that she was making a
certain kind of use of my voice, dwelling on its contours, rhythm and volume,
transforming it into an inanimate object that she could touch, feel and take into
her possession. This impression was amplified when Janine brought a digital
voice recorder with her into the next session, saying that she wished to take my
words home with her. It is evident here that adhesive identification is indeed an
autistic spectrum defence (as originally conceived by Bick and Meltzer), one of
MAGGIE TURP 73
Mitrani’s ‘extraordinary protections’ that may nevertheless come to the fore in

work with ‘ordinary’, i.e. non-autistic, patients (Mitrani, 2001).
Psychoanalysis and Integrity

My aim in this part of the paper is to explore potential countertransference
responses to the extreme survival anxieties implicit in a defence of adhesive
identification and to consider their implications for practice, drawing on
Cohen’s work. Cohen describes a number of work roles in relation to nursing
staff, doctors and parents in the NICU. Above all, she is concerned to be the one
person in the busy unit who makes it her responsibility to tune into the prema-
ture infant’s emotional experience and ‘speak for the baby’. In the service of
that aim, Cohen regularly spends time sitting next to an incubator and observ-
ing, trying to stay with what she is seeing and build a picture of the baby’s
experiential world.
In Chapter 5, entitled ‘Integrity’, Cohen describes her struggles to make sense
of the difficulties she experiences in remaining attentive to an infant she is
observing – baby ‘Ewan’ who has been born 16 weeks early. At the age of 4
weeks, Ewan develops meningitis and starts fitting:
I observed for a few more minutes then could not bear it any more. I looked around
the unit, taking time off. I felt very distractible and longed for some mothers to
arrive on the unit. (Cohen, 2003, p. 13)
A few days later, Ewan’s parents are told there is a high probability that their
son will be blind. At this point, his mother feels that she cannot bear to look at
Ewan and says that she does not want to visit him any more. Discussing this
situation, Cohen writes:
The babies’ experience is so hard for us to imagine, and it is so much easier not to
imagine it, because it is often painful, but if we dismantle our ability to think, this
affects the way we treat each other and our patients. (ibid., p. 7)
Cohen discusses how the effort not to look away, to try to imagine and
articulate the babies’ experience, militates against the natural desire to protect
oneself from psychic pain. It is easier to become busy and distract oneself, either
mentally or with physical activity:
It is easy for me to fill my time with other things. It is easier to talk to mothers,
fathers, or staff, however traumatic this may be, than to sit and watch a baby. (ibid.,
p. 20)
Defensive countertransference responses to situations that are hard to bear

are not limited to becoming distracted and feeling a strong urge to look away.
Doctors in the NICU have to perform procedures on the babies, such as insert-
ing lines into their tiny veins, which the babies clearly find painful, so much so
that they quickly learn to squirm away when a doctor approaches. Cohen
observes doctors continuing cheerfully with their work, sometimes whistling,
sometimes blaming the baby for difficulties with the procedures or making
flippant or cruel comments:
John was writhing as she held his arm and screamed when the needle went in.
Another SHO came and said: ‘Oh, Jane, can’t you get it in?’ She said she could not,
went on trying and then gave up. She looked at the baby and said: ‘You horrible
little thing’. The two of them pored over him – Jane was whistling softly to the
music. I began to feel quite sick. . . . Anthony set to; at one point he moved
in rhythm with the music. He relentlessly continued while John writhed and
screamed. (ibid., p. 63)
In discussing this situation, Cohen describes how doctors get into what she
calls a ‘rubbery, indifferent or cruel state of mind where these things do not
matter – they simply have no meaning’. Suffering is ignored or minimized as
though it were of no importance and hence did not need to be taken on board
(ibid., p. 90). Summarizing the defences she has described, Cohen concludes:
We may undermine our own perceptions, look the other way, fall asleep or just stay
away. If we succumb to this temptation, we may act with negligence or cruelty. My
job is to help people recognize these states of minds in themselves and so to help
them not to be run by them. (ibid., p. 158)
My aim in presenting and thinking about the following session is to identify
such reactions where they occur and consider my efforts, not always successful,
‘not to be run by them’.
Psychoanalytic Psychotherapy with Janine

I present below extracts from one particular psychotherapy session with Janine,
taking place towards the end of a therapy that extended over many years. I am
not in a position to disclose biographical details relating to Janine but hope
to succeed in conveying and considering what Williams (2002) refers to as the
‘texture’ of this particular session.
As is true of many of our patients, Janine’s start in life was unpropitious and
her childhood experience more than usually difficult. Meltzer writes of certain
mother–infant situations:
When these infants got anxious, their mothers got anxious too and then the infant
got more anxious and a spiral of anxiety tended to develop which ended with the
infant going into a state of some sort of quivering, a kind of disintegrated, disor-
ganized state that was not even screaming, not a tantrum, just something one would
have to describe as disorganized. (1975, p. 295)
Janine’s mother had mental health problems. Her father travelled with his
work and was often absent. Our work together established in Janine’s mind and
mine the understanding that she had frequently been subject to experiences of
this nature. A lot of our early work could be described under the heading
of establishing the ‘rhythm of safety’ described by Ogden.There were periods of
progress and significant setbacks, particularly around breaks. At times, Janine
struggled with suicidal ideation, sometimes phoning the Samaritans on a daily
basis. She had periods of not eating, becoming strikingly and worryingly thin
and frail. At these times, in particular, in the face of what seemed to be perverse
and wilful self-neglect, I struggled with feelings of frustration and exasperation,
MAGGIE TURP 75
sometimes expressed in concrete somatic impulses, such as wanting to cry out,

throw up my hands or tear at my hair. These experiences seemed to relate to
Janine’s periods of being ‘beside herself’ and descending into anguish and
despair. Although or perhaps because Janine’s masochistic behaviour provoked
me and got under my skin, it succeeded in unconsciously communicating some-
thing of the horror and misery of living within her own damaged skin boundary.
The situation after some years of work was that Janine had been promoted,
had a good relationship with her work team and was highly regarded. For the
first time, she had established and was maintaining a loving relationship with a
live-in partner – something she had always wanted but had felt was out of reach.
This relationship was not without its problems and was frequently called into
question; nevertheless it had survived for more than two years. It was Janine’s
first long-term sexual relationship and stood in marked contrast to an earlier
relationship, near the beginning of therapy, when she had clung tenaciously to
an idealized version of the archetypically handsome man she had met, stub-
bornly disregarding his all too obvious evasions and deceptions. Of equal sig-
nificance were changes in Janine’s relationship with me. She was no longer the
baby who could not tolerate being put down. She no longer fell to pieces in my
absence. Instead, she was able to speak about her fearful ‘wobbly’ feelings in the
run-up to my departure and to tell me on my return that she had missed me but
had nevertheless managed to keep me in mind. In the light of these develop-
ments, the question of ending therapy arose. It would not be appropriate here
to describe the lengthy trajectory of the ending process. Suffice to say that the
favourable developments noted above and Janine’s expressed wish ‘not to be in
therapy for ever’ eventually outweighed both her and my doubts and misgivings
and an end date was agreed. At the time of the session that follows, there are ten
months remaining before the end date that has been negotiated. Our normal
pattern at this point is to meet twice a week. However, I have been obliged to
cancel the second appointment of the previous week, hence there has been a
longer than usual gap between appointments.
Janine comes in, sits down and looks into her lap, not making eye contact with me.
I am reminded of the ‘looking away’ that characterized so many sessions in the
early years, when Janine was unable to make eye contact with me until the time
came to say ‘goodbye’ as she left the room. We discovered at that time that Janine
could not bear to look at me for fear of seeing in my face that I had a separate
mind, a perspective on her situation that was other than her own. She was even-
tually able to acknowledge that, paradoxically, unless I had a mind of my own I
would not be able to be of any use to her. I feel nonplussed as I register that we
seem to be back in a place I thought we had left far behind.
Eventually, without looking at me, Janine speaks, saying that she was thinking
on the way to the appointment that she was not going to get what she needed today.
I hear her comment as accusatory and feel a flash of anger in the face of her
foregone conclusion. This quickly turns into contempt. I find myself almost laugh-
ing inside at the nonsense of it all. ‘Why bother?’ asks an internal voice. Janine tells
me how disappointing it is, when she needs something so desperately, to know in
advance that it’s going to be one of the times when she doesn’t get it.
At a certain point, my state of mind shifts from despairing to harsh and

mocking. Am I becoming ‘rubbery and indifferent’ as described by Cohen?
Even at the time, it is not lost on me that the situation is well on its way to
becoming a self-fulfilling prophecy. Of course, when I am in this state of mind
Janine is unlikely to ‘get what she needs’, not least because I am not in a fit
state of mind to be of help. So, from the very start of the session, I am struggling
with countertransference responses of blaming and hatred, taking the form of
mocking thoughts and a cruel desire to punish Janine, who seems to throw my
efforts back in my face before I have even spoken. My feelings are perhaps
similar to Janine’s. In her adhesive state, she blames and hates me for allowing
the therapy to end and attacks me accordingly.
I collect myself and try to find a point of connection with Janine. I say that she has
had to wait longer than usual for this appointment and I wonder whether that has
anything to do with the way she has come in today. She says she thinks it has made
a difference . . . It’s been ages since she saw me, and then I’m going away at Easter
and then there is my break in the summer. She does not mention the date in
December when we have agreed to bring the therapy to a close but I find it is very
much on my mind. I say she really is fed up with me today. She is feeling resentful
of me on two counts, on the one hand for being away and on the other for not being
of any use to her when I am in situ. I add that I wonder whether our recent
agreement to bring the therapy to a close at the end of the year is also playing a
part in her dissatisfaction.
She looks up and glares at me briefly, then returns her gaze to her lap and sits in
silence, her shoulders braced, furious and unreachable. I feel suddenly helpless. It
seems that, whatever I do, I am bound to fall short. I just want to be done with the
session, to be anywhere but here. Naturally, I have anticipated setbacks as the end
date approached. However, Janine’s sudden regression has taken me by surprise.
At this point, I am almost overwhelmed by an urge to look away from
Janine’s despairing and disturbed state of mind and remove myself to some
other arena. Having realized this, my capacity to think is somewhat restored.
I return in my mind to Janine’s original comment that ‘she is not going to get
what she needs.’ I find myself considering the implicit assumption that I should
somehow supply Janine at regular intervals with ‘what she needs’. In this version
of events, whether or not she thrives or even survives depends entirely on me.
Am I colluding with the idea that I bear sole responsibility?
After a long silence, Janine says that the situation at work is very fragile again,
but that’s not really the problem. The problem is that she feels so depressed and
anxious all the time. Of course, other people at work worry about being made
redundant as well, but for her it’s not really about the money. It’s her need for work
to help hold her together, to keep her from plummeting. She needs her familiar
group of colleagues and the structure of work. Of course, the money would be a
problem as well but that’s not the main thing.
I ask her whether she is saying she thinks for other people the only problem
would be of a financial nature?
In retrospect, I regret this question. I seem to indirectly suggest that Janine’s
problems are much the same as those of others, thereby minimizing her pain
MAGGIE TURP 77
and insulating myself from her suffering. In particular, I fail to register the
significance of the reference to ‘redundancy’. In reality, one could say that I am
the person being made ‘redundant’ since I will lose Janine as a (paying) patient
and hence a part of my employment. But, in her mind, she is the ‘redundant’
one. She is painfully aware that I do not need her in the way that, just at the
moment, she feels she needs me. She experiences me as indifferent and rejecting
and wonders whether, for me at least, it is ‘really about the money’.
Janine says: ‘Well, no,’ but qualifies this by again emphasizing the difference
between herself and other people. She tells me that Anthony sometimes says he
understands, that she is not the only person to feel the way she does, but actually
he doesn’t understand at all. He thinks he gets it but in fact he doesn’t and she finds
it very frustrating! I say she is telling me it is the same with everyone she is close
to. She doesn’t feel properly understood by anybody, including me.
Janine is still looking down into her lap and I comment that she is finding it very
difficult to look at me today. She says that she too has noticed she is not looking at
me today. I say that, in view of what she has said about Anthony, I wonder whether
she is afraid she might look at me and see another person who thinks she does
understand her, but whose understanding is of no use to her because it is less than
perfect.
This interpretation, although reasonable enough, sidesteps the central feature

of the situation, namely the fraught and desperate state of mind in which Janine
finds herself. It is, perhaps, an expression of my need to restore order and a
semblance of normality in the session. I am aware of feeling shaken and under-
mined by Janine’s attacks on me and the therapy. Perhaps I myself feel in
danger of being undone, of ‘leaking away’? To defend against this, I diminish the
magnitude of the crisis. Had I not enacted this countertransference response,
Janine might have told me more about her thoughts on not being able to look
at me and what followed might have been different.
Janine sits in silence for a long time, then says coldly: ‘The thought comes to mind
that I shan’t get what I need.’
I say that she doesn’t seem minded to try for something herself today, but seems
stuck in a passive place, hoping I will come and find her, intuit what she needs and
provide it for her. She responds by saying with great feeling that this is the case.
Can’t I see that she didn’t get nearly enough feeds when she was little? If only I
could see that and give her enough feeds now, maybe she would begin to feel she
had taken enough in to keep herself from drowning in a sea of despair. She weeps
for a long time. Now, I feel truly moved by her distress. Eventually I say: ‘I can see
how unhappy you are’. The atmosphere in the room becomes less fraught and we
allow some minutes to pass in silence.
As her tears fade away, Janine’s downcast face takes on a grim expression. She
again complains bitterly that, for the most part, I do not offer her anything that
really helps. I say: ‘You want me to feed you, even as you look away from me and
tell me I am no use to you.’
I am disappointed that the easing of Janine’s hostility has so quickly evapo-

rated. After a few minutes, having recovered a more kindly feeling towards
Janine, I continue.
I say I can see she is in quite a fix and can find no relief from the situation
she feels herself to be in. She has told me in advance that nothing I offer will be
of any use, so she feels without hope. Although she has no hope, that doesn’t
protect her from her bitter disappointment about the unsatisfactory nature of
my offerings.
At this, still without looking at me, she says despondently that I have lost her
now. It has all become far too intellectual and – just as she thought – she will have
to leave without getting what she needs.
This final intervention on my part was, I believe, potentially fruitful. At this

point, however, Janine perhaps feels too bruised by those aspects of the coun-
tertransference that I have failed to contain to be able to make use of more
helpful interventions.
Countertransference is, of course, not only something to be managed but also
a privileged source of information about the patient’s inner world, as first
expounded by Heimann (1950). I have no doubt that the responses stirred up in
me during the session described resonate with those experienced by Janine
during infancy and childhood. She too has experienced feelings of uselessness,
hopelessness and fury at the impossibility of the situation in which she finds
herself. She too has been treated with the cruelty and indifference she stirs up
in me. Janine described in earlier sessions how her family would either mock her
for her attempts to contain her anxiety – for example, through rocking back and
forth or banging her head against the headboard of her bed – or otherwise
ignore her and carry on as though nothing were amiss.
Such situations stand as striking examples of the reversal of the container/
contained relationship described by Gianna Williams (1999), where parents are
frightened and frightening and project anxiety rather than containing it. Janine
has responded to taunting and indifference by looking away, as she now looks
away from me, as Cohen looks away from the damaged premature babies whose
survival is in question, and as I look away, when the pressures become too great,
from my patient’s neediness, fury and distress. In this state of mind, my capacity
to recognize and respond to the true state of Janine’s inner world is inevitably
compromised.
The element of narrative skin disturbance is also apparent. Just as the narra-
tive of our work together, including our journey towards an ending, is disrupted
by the above session, so has Janine’s narrative been terribly disrupted on many
occasions.As a young child, when she needed her mother to soothe and reassure
her, she found herself instead soothing and reassuring her mother. Later, just
when her schooling was going along in an orderly and satisfactory way, events
would transpire that required yet another change of school and her world would
once again be turned upside down.
Following such a session, the possibility of thinking in supervision about what
has transpired is of crucial importance. Indeed, my supervisor’s capacity to
think with me about what transpired and what it might signify has been crucial
both to the clinical work with Janine and the writing of this paper. In a recent
publication, Leader drew attention to the way in which supervision is not simply
a matter of accumulating and transmitting knowledge: ‘. . . but rather confronts
MAGGIE TURP 79
both supervisee and supervisor with significant questions about their own posi-
tion and self-image’ (2010, p. 228).
Concluding Comments
It is widely acknowledged that, in order to be able to make therapeutic use of
the countertransference, to identify within it the specific quality of patients’
remembered and unremembered experience, we need as far as possible to avoid
becoming caught up in enactments. Janine’s psychic skin boundaries were in a
poor state of repair. That the patient with damaged psychic skin boundaries can
get under the therapist’s skin is evident from the cited session: on such occa-
sions, the integrity and hence the therapeutic capacity of the practitioner are
liable to be undermined.
We all aspire to work with integrity yet seldom pause to consider in detail
what is involved, or to note the specific phenomena associated with the endan-
germent or loss of integrity. In exploring these matters, I have drawn on
Margaret Cohen’s writing on integrity and presented a clinical encounter
that formed part of a long period of psychoanalytic psychotherapy with an
adhesively identified patient. Detailed consideration of the transference/
countertransference dynamics and their interrelationship with my fluctuating
capacity to work with integrity has, I hope, demonstrated the value of close
observation and reflection in this area. In presenting this material, I have
endeavoured to underline the ongoing significance of a sensed skin boundary
around the self, both for the patient and the practitioner. I have suggested that
when that boundary is compromised, as, for example, when a practitioner feels
stifled by and intruded upon by an adhesively identified patient, thoughtfulness
is undermined and reactive responses become a real and present danger.
Moving on from the specific set context described above, I will conclude by
underlining the readily available link between the clinical illustration provided
and everyday life and language. When people reflect back on times when they
were caught up in strikingly reactive behaviour, they are apt to comment that
they were ‘falling apart’, ‘unravelling’, ‘in pieces’ or ‘beside themselves’. Thus
they allude to the phenomenon of not feeling properly ‘enskinned’, to the
experience of not being properly located within a boundary around the self,
either because the boundary has been shattered (‘in pieces’) or because they
have not been able to remain inside it (‘beside myself’). The frequent occur-
rence of such phenomena and the expressive turns of phrase associated with
them suggest that the potential of a ‘psychic skin’ conceptual framework for
understanding human behaviour, both within and outside the consulting room,
has yet to be fully explored.
References
Alvarez, A. (2002) Failures to link: attacks or defects, disintegration or unintegration?
In: Briggs, A. (ed.), Surviving Space, pp. 240–4, London: Karnac.
Anzieu, D. (1989) The Skin Ego, Turner, C. (transl.). New Haven, CT: Yale University
Press.
Bick, E. (1968) The experience of the skin in early object relations. International Journal
of Psychoanalysis 49: 484–6.
Bick, E. (1986) Further considerations on the function of the skin in early object
relations. British Journal of Psychotherapy 2: 292–9.
Bion, W.R. (1962) Learning from Experience. London: Heinemann.
Briggs, A. (ed.) (2002) Surviving Space: Papers on Infant Observation. London: Karnac.
Briggs, S. (1998) The contribution of infant observation to an understanding of feeding
difficulties in infancy. Infant Observation 1: 44–59.
Britton, R. (2003) Sex, Death and the Superego. London: Karnac.
Cohen, M. (2003) Sent Before My Time. London: Karnac.
Dollery, J. (2002) Secondary skin and culture: Reflections on some aspects of teaching
traveller children. In: Briggs, A. (ed.), Surviving Space, pp. 172–87. London: Karnac.
Feldman, M. & Spillius, E.B. (eds) (1989) Psychic Equilibrium and Psychic Change:
Selected Papers of Betty Joseph, London: Routledge.
Heimann, P. (1950) On countertransference. International Journal of Psychoanalysis 31:
81–4.
Hinshelwood, R.D. (1997) Catastrophe, objects and representation: Three levels of
interpretation. British Journal of Psychotherapy 13: 307–17.
Houzel, D. & Rhode, M. (eds) (2006) Invisible Boundaries: Psychosis and Autism in
Children and Adolescents. London: Karnac.
Jackson, J. & Nowers, E. (2002) The skin in early object relations revisited. In: Briggs, A.
(ed.), Surviving Space, pp. 208–25. London: Karnac.
Klein, M. (1952) Notes on some schizoid mechanisms. In: Klein, M., Heimann, P., Isaacs,
S. and Riviere, J. (eds), Developments in Psycho-Analysis, pp. 292–320. London:
Hogarth.
Klein, S. (1980) Autistic phenomena in neurotic patients. International Journal of
Psychoanalysis 61: 395–402.
Leader, D. (2010) Some thoughts on supervision. British Journal of Psychotherapy 26:
228–41.
Magagna, J. (2002) Mrs. Bick’s contribution to the understanding of severe feeding
difficulties and pervasive refusal. In: Briggs, A. (ed.), Surviving Space, pp. 135–56.
London: Karnac.
Meltzer, D. (1975) Adhesive identification. Contemporary Psychoanalysis 11: 289–310.
Mitrani, J.L. (2001) Ordinary People and Extra-ordinary Protections: A Post-Kleinian
Approach to the Treatment of Primitive Mental States. Hove: Brunner Routledge.
Ogden, T. (1989) On the concept of an autistic–contiguous position. International Journal
of Psychoanalysis 70: 127–40.
Rhode, M. (2002) Whom does the skin belong to? Trauma, communication and sense of
self. In: Briggs, A. (ed.), Surviving Space, pp. 226–39. London: Karnac.
Robinson, M. (2006) Gilead. London: Virago.
Turp, M.D. (2003) Hidden Self-harm: Narratives from Psychotherapy. London: Jessica
Kingsley.
Tustin, F. (1992) Autistic states in children. Revised edition. London: Routledge.
Williams, G. (2002) Internal Landscapes and Foreign Bodies. London: Karnac.
Williams, G. (1999) On different introjective processes and the hypothesis of an ‘omega
function’. Psychoanalytic Inquiry 19: 243–53.
Williams, S. (1999) The therapist as outsider: The truth of the stranger. British Journal of
Psychotherapy 16: 3–15.
Winnicott, D.W. (1960) The theory of the parent–infant relationship. In: The Matura-
tional Processes and the Facilitating Environment, pp. 37–55. London: Hogarth, 1965.

Brit J Psychotherapy - 2012 - Turp - CLINGING ON FOR DEAR LIFE ADHESIVE IDENTIFICATION AND EXPERIENCE IN THE

Uploaded by

Copyright:

Available Formats

Brit J Psychotherapy - 2012 - Turp - CLINGING ON FOR DEAR LIFE ADHESIVE IDENTIFICATION AND EXPERIENCE IN THE

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Brit J Psychotherapy - 2012 - Turp - CLINGING ON FOR DEAR LIFE ADHESIVE IDENTIFICATION AND EXPERIENCE IN THE

Uploaded by

Copyright:

Available Formats

CLINGING ON FOR DEAR LIFE: ADHESIVE IDENTIFICATION

AND EXPERIENCE IN THE COUNTERTRANSFERENCE

MAGGIE TURP PhD CPsychol is a psychoanalytic psychotherapist and supervisor in

Psychic Skin Defences

Two of Bick’s contemporaries, Meltzer (1975) and Winnicott (1960), likewise

Mitrani’s ‘extraordinary protections’ that may nevertheless come to the fore in

Psychoanalysis and Integrity

Defensive countertransference responses to situations that are hard to bear

Psychoanalytic Psychotherapy with Janine

sometimes expressed in concrete somatic impulses, such as wanting to cry out,

At a certain point, my state of mind shifts from despairing to harsh and

This interpretation, although reasonable enough, sidesteps the central feature

I am disappointed that the easing of Janine’s hostility has so quickly evapo-

This final intervention on my part was, I believe, potentially fruitful. At this

You might also like