THE EMPTY SELF AND THE PERILS OF ATTACHMENT

Sheldon Bach
Carina Grossmark
Elizabeth Kandall

This article describes clinical work with patients who come to treat-
ment looking for help with chronic experiences of emptiness as well as
concomitant fears of relational impingement. We relate these difficul-
ties to distortions in the integration of basic developmental functions,
and we suggest a point of view including tangible yet unobtrusive in-
terventions that we have found helpful. We discuss countertransfer-
ence issues raised by these patients as well as possible etiology.

My prison cell—my fortress. —Franz Kafka, Journals, 1917

Today you are you, that is truer than true. There is no one alive
who is youer than you. —Dr. Seuss, Happy Birthday to You!

DESCRIPTION OF PATIENTS

This paper is about working with those patients who feel chroni-
cally empty, depleted, and alone, but who, when they attempt to
relate to another person, become so anxious about being over-
whelmed and losing themselves that they are forced to retreat
once more into loneliness. They often have the experience that
something is “wrong” with them without knowing what it is; they
seem to lack a basic understanding of how to find or remain them-
selves while in the presence of others. When they talk about them-
selves, they say: “I feel empty,” “What I feel is not real,” “The expe-
rience doesn’t stay,” “What I do didn’t really happen,” “Once I
leave this place, I can’t remember what we said,” “I feel like every-
one knows how to relate except me, and I can’t ask,” “I don’t
know how to be with people without losing myself,” and so forth.
Psychoanalytic Review, 101(3), June 2014 © 2014 N.P.A.P.
322 BACH ET AL.

Unlike people on the autistic spectrum, these patients clearly

desire to relate to someone else, but they seem to have no clue as
to how to go about doing so, as if they lacked directions or had no
road map. Unfortunately, as they begin to try to connect, the po-
tential for shame increases; self-reflection makes them acutely
aware of all they feel missing in their self and they develop a kind
of allergy to connectedness.
Proceeding from the clinical level, we have been observing
the actual interventions that seem useful for these patients and
trying to formulate a way of thinking about them. We believe that
in the early months of normal development, the primary caretak-
er is engaged with the infant in a mutual orienting exchange that
creates and scaffolds a multitude of basic self and ego functions.
These functions entail a supporting object, expressed both through
the external support offered by the mother’s body (the way the
baby is carried, rocked, and gently held), as well as through the
mother’s emotional presence and attunement, reflected in her
smile, gaze, vocalizations, and provision of vital needs in response
to the infant’s gestures. The protection offered by this supporting
object is essential for the psyche to develop its own internalized
center of gravity. Without this center of gravity, the child has no
frame of reference to orient himself or herself, to measure time
or proximity, or to develop a stimulus barrier and a containing
function.
For the patients we are discussing, this early scaffolding or
provision of basic developmental functions has been distorted or
undeveloped, and they tend to report an early generalized experi-
ence of absence of a support object. Most importantly, the inte-
gration of these functions into a holistic, smoothly running self is
severely impaired, often because the caregiver cannot provide ad-
equate holding and containment because her own maternal func-
tions are split-off and not consistently accessible.
Just to give a simple example of what we are talking about:
With many of these patients we have found it important at times to
speak very slowly, distinctly, and evenly. The pacing of words is im-
portant. We believe that they have a defective stimulus barrier, ei-
ther because of unusual early sensitivities or because of less than
adequate environmental facilitation, or some combination of these
THe Empty self323

circumstances. Thus their ego does not possess an adequate

sound barrier, and they experience harsh, loud, or unclear speech
as an actual localized physical assault to which they respond pri-
marily on the psychophysical level, rather than on both the psy-
chophysical and symbolic levels. Of course, this is no more than
many caregivers instinctively realize, but some babies on either
extreme of the continuum may go beyond the caring capacity of
the average good-enough mother.
In a sense this view deconstructs the internalization of the
primary object into the internalization of various functions, which
we find useful because patients differ in the degree to which each
function is compromised and also because it helps us to think
about the various therapeutic maneuvers that might address par-
ticular defects of functioning. Sometimes these patients have as-
similated a function but only defectively, so that it exists but feels
split-off and only intermittently accessible, or as if it were unreal
and not legitimate to use.
Normally, the mother starts from wherever the child may be
and helps provide the child with a functional ability to make use
of his or her internal and external world. In cases where this has
not gone well enough, the child is left with lacunae in functioning
that can show up in any area of life. Alvarez (2012)has written
compellingly about child and adolescent work “at the very foun-
dation of human relatedness” (p. 6). These early levels of psychic
fabric are the areas we are trying to address in our treatment of
these adult patients.
For example, some people have difficulty using the treat-
ment because they cannot follow the basic rule, or it makes them
anxious to do so. Freud’s injunction to “say whatever goes through
your mind” makes little sense to someone who is not certain
where he or she is located in the world, is not sure of self bound-
aries, and has not attained the ability to observe himself or herself
reflectively. For the neurotic patient as described in Freud’s dream
book (1900), associations tend to spread horizontally, then even-
tually deepen and form a nexus connected to some object-related
desire. For these patients, associations tend to spread horizontal-
ly, but they often do not form a deeper object-related nexus be-
cause the connection to their primary object is defective.
324 BACH ET AL.

In addition, their conflicts tend to be not only about drive

versus defense, but often about the great existential dichotomies
of life, such as living or dying, being or doing, reality versus unre-
ality, and so forth. This produces binary, either-or dilemmas that
only become slowly resolved through a long process of oscillation
and mourning rather than by insight through verbal interpreta-
tions (Kris, 1984).
These patients can live in their subjectivity, but it often feels
like a swirling chaos that is not useful to them for self-direction. In
such cases the analyst functions in the zone of proximal develop-
ment (Vygotsky, 1978), helping the patient specifically to discover
what he or she wants to talk about today and how one goes about
doing that. The analyst positions himself or herself to facilitate
the patient’s ability to use the interaction and to enable the pa-
tient to make use of the analyst.
This process of locating safe places in the self and the other,
or of figuring out the geography of who is who and what is enough,
and of finding orienting experiences around a central place are
essential to the formation of an experience of process, so vital for
any therapy. Finding safe places and orienting experiences can
only take place in a relatively calm atmosphere, so the over-
whelmed patient must first be held for a long time until some ba-
sic stimulus barrier and container functions are modestly in place.
How these patients come to own their bodies, their minds,
and their treatments is a creative discovery, unique for each per-
son. Because these discoveries are happening at such an early
body and sensory level, the patient’s feelings about the analytic
environment and the analyst’s place in it become central.
The importance of affect, gaze, tone of voice, body posture,
and the analyst’s availability at a very concrete bodily level form the
core communications at the beginning, often more essential than
any symbolic interventions. We hope that some of these points will
become clearer as we move on to some clinical vignettes.
Case 1. When a middle-aged man arrived for his initial ses-
sion, he was unsure how to let his therapist know that he was
there. Instead of ringing the bell or turning the doorknob, he
tapped delicately and intermittently on the door for several min-
utes until his therapist went to investigate the sound. His initial
THe Empty self325

timid arrival was followed by subsequent arrivals in which he

brought a multitude of bags and gear that took over a great deal
of space. He found it difficult to negotiate the space between the
chairs in the consulting room, and remarked on slight changes in
the position of the chairs, especially changes in the distance be-
tween chairs. He was concerned about his legs extending too far
into the space where his therapist’s legs rested. Despite this ex-
treme sensitivity, he took the liberty of touching and moving
many objects in the room. This marked uncertainty about how
much space to take up was repeated in his personal relationships,
where he often felt either overwhelmed or unlimited. We later
learned that this difficulty in regulating himself was paralleled by
the dysregulation of basic functions such as the sleep/wake cycle,
temperature regulation, feeding and levels of stimulation and
quiescence, resulting in cycles of indulgence and abstinence.
Comment. These patients often have difficulties knowing their
own or other people’s boundaries or their geographical location
in time and space, and these difficulties are often expressed in
psychosomatic problems affecting the skin, the gastrointestinal
tract, or in eating disorders.
Case 2. A young woman with an eating disorder heard that
her therapist was going to be away for a week. She then went out
to buy herself a very warm sweater. It was clear that for her the
therapist had begun to provide the function of a skin ego, which
she was now trying to replace in a concrete way. Her financial re-
sources were minimal, and when she found a sweater that she
liked but that was much too tight, she bought it anyway with the
resolution to lose some weight so that it would fit her properly.
She found it perfectly reasonable to try to alter her own body to fit
the sweater; it was hard for her to imagine that the environment
might be able to provide her with a correctly fitting sweater. She
was, after all, not very certain about the size or shape of her own
body, which felt quite unstable. From what one could gather, it
seemed that her body experience was not that of a separate, up-
right, stand-alone unit but rather more amoeboid, like a deliques-
cent body that could change unpredictably from very small to very
large and that was difficult to regulate.
Comment. Normally, people walk around with a fairly clear
326 BACH ET AL.

idea of what size “package” they are relative to the world around
them, but for this woman that was not true. Some days, when
things had gone well, she would think of herself as much larger
than she actually was, and on less good days she imagined herself
as tiny and ineffective. She had not been consciously aware of
these Gulliverlike changes in body image until we began talking
about them, but over the years they slowly normalized, as did
many of the other components of her self-constancy.
All of these patients have profound difficulties in locating a
body image that feels more or less stable and persistent over time.
They also consistently have difficulty in experiencing and identify-
ing their desires and emotions, and find it particularly difficult to
distinguish which emotions feel “real,” as if they were theirs, and
which emotions feel “false,” as if they were other people’s feelings
or as if they were supposed to feel that way.
Case 3. A female college freshman bemoaned that she found
it hard to tell the difference between a feeling that seemed a
true reflection of her self and a feeling that was some passing
whim or a feeling of obligation resulting from pressure by some-
one else.
She was anxious about dating but uncertain that she could
truly know whom she wanted or liked. Thus she managed the anx-
iety of dating by insisting that she could tell at first sight whether
she could love or marry the man she was dating. She felt that love
at first sight would be so intense that it could not be denied—a
kind of pseudo-knowing that avoided the anxiety of uncertainty.
Comment. While this kind of preemptive knowledge may act
as a placeholder until more authentic knowledge is possible, it
often fails because it is so overwrought, constraining, and either-
or. It is a self-holding attempt to avoid the catastrophic anxiety of
knowing nothing at all and falling into a bottomless pit.
Many of these patients have had an early life history defined
by trauma and loss.
Case 4. One young woman had lost her mother at an early
age through an unexpected medical catastrophe. Her father saw
in her childhood face the unanswerable question, “Where is my
mother?” Looking at his daughter filled the father with grief. In-
stead of being able to meet his child’s questions with the contain-
THe Empty self327

ment she needed, he met them with the intrusion of his own over-
whelming affect. This left her not only alone, but further burdened
by her father’s needs and the complicated confusion of where her
mother was and what had happened.
Comment. Often these patients seem to have identified with
an early object that was depressed, that caused pain, or that was
missing entirely. Sometimes it seemed that their identification
was with the absence and deprivation itself and with the empti-
ness of painful longing. This was often accompanied by confusion
between self and object, a confusion that manifested most clearly
in the transference regression.
Case 5. In the transference regression one man asked: “That
breath you just took; was that you breathing for me?”
Another one asked: “Why do you have that picture there? Is
that meant to do something to me?”
Late in the treatment one woman asked her therapist: “How
do you remember those things? How can I remember without
someone there to hold my memory?”
She did remember that her mother was distraught and
couldn’t come to pick her up from school. She was alone and dis-
oriented and she didn’t know when mother would come and she
felt unable to ask anyone. At that time, about ten or eleven years
of age, she began to resort to destructive and self-soothing behav-
iors like stealing money and food and then overeating.
Comment. What we see here is how much these children need-
ed adult help to navigate in the world and how, because of lack
of such help and an intrusive overburdening with the parent’s
needs, they retreat from the relational world into a world of sub-
stances, inanimate objects, and erroneous cause and effect corre-
spondences.
Case 6. A young man struggled with feelings of being “stuck”
any time he needed to make a decision, especially regarding work
and relationships. When talking about his girlfriend, he says: “As
she gets closer to me I get more and more anxious, as if she will
finally take over completely and then I will disappear entirely. So
I try to stay away or maintain a certain distance from her, but as I
get more distant I begin to feel less and less certain that I’m really
there, that I really exist in the world.” . . . “I like the winter months
328 BACH ET AL.

best, because you can feel the cold all over and then you know
that you’re alive!”
Later he asked plaintively: “Can you help me get over this?
Do you know what to do?”
This man, who experienced his inner life as an icy tundra,
lonely and depleted, grew up in a cold, isolated area in England.
Two years before he was born his mother had delivered a stillborn
child, and she was reported to have been depressed and anxious
ever since then. He remembers her as constantly gone, busy and
traveling to other towns as part of her job, while he felt alone. His
memory is of himself waiting, constantly lonely and waiting and
never quite sure about the time when his mother would return.
However, this image of a mother he can never grasp alternates
with another image of a mother who is maddeningly impinging,
primarily ridden by her own anxieties. He also kept an image in
mind of his father working as a contractor, aloft on a scaffold,
competent and even heroic but unreachable, as he was unwilling
to teach his son anything of what he was doing because “it was too
unpredictable and too dangerous.”
The boy began to masturbate at an early age and it was clear
that compulsive masturbation, vigorous ice-skating, and shivering
in freezing weather were a few of the many prosthetic activities
that he used to keep the sense of himself alive. We also began to
understand that his preference to withdraw from interactions
with people and even his girlfriend were not a true preference for
being alone, but rather an uneasy choice between two poles of an-
nihilation: interacting with his girlfriend while running the dan-
ger of being engulfed by her needs, or feeling safe in a state of
isolation and emptiness while constantly struggling to feel alive.
Comment. These patients have often experienced a very lone-
ly childhood, and they struggle to retain their feeling of being
alive by incessant masturbation, by endless viewing of pornogra-
phy, by fine cutting, flagellation, or by other masochistic activities
that make them the subject of intense actions or emotions. It is as
if they were saying: Do anything you want to me so that I can feel
something and know in my body that I am alive.
In other patients this same feeling manifests itself in acts of
sadism in which the fading and dissolving self feels empowered by
THe Empty self329

torturing and murdering others in order to invigorate itself. The

developmental sequence seems to be that first the fading self tries
to establish an idealized other, a dictator or godlike figure to which
it can masochistically submit in order to solidify itself. Should this
fail, it regresses to sadistic and wildly omnipotent proclamations
that it needs no one at all and can do anything it wants without
limitations (Bach, 1994; Bach & Schwartz, 1972).
These patients are vulnerable both externally and internally.
Externally, the early maternal environment has not provided
them with an adequate protective shield so that they can resist
impingements, but internally they have not yet sufficiently appro-
priated their drives and made them their own, so they are also
vulnerable to uncontrolled instincts. They often live in a world
that is immediate and concrete, without a sense of past and future
and with the fear that they will be swallowed up and taken over.
“Managing” at every moment and in every interaction is a huge,
immediate task for them, as is the precarious job of preserving
their self.
Case 7. One patient commented: “I start feeling an obligation
to the other person. I always get sucked in. I need to let people
help me without letting them control me and without pushing
them away.” When describing her ability to recognize only the
voice of others while her own ceases to exist, she stated: “I could
only see what Jim wanted. I allow others to be too strong-voiced in
my head. I let my mother guide me in terms of schooling—what
to expect, what I should be doing. I let my friends choose me; I
even let my husband choose me. It is not in my nature to choose
or seek something, not even to decide who I am in love with . . . I
am always giving in or giving up.”
She described the ways in which her desire to meet people
becomes threatening because she feels like a “blank slate that can
be written all over by other people’s wishes.” Under these circum-
stances she withdraws in order to regain contact with herself, at
the expense of losing the other. She once reported: “When he
told me what to do I felt I had to refuse him.”
Comment. Of course such tendencies have implications for
therapeutic technique and management, which we shall explore
later. But here is a similar example from a different patient.
330 BACH ET AL.

Case 8. A young man recounted his difficulties visiting muse-

ums, and the shame he felt that his pace and rhythm were so dif-
ferent from everyone else’s. He explained that other people
would stop to look at each painting and slowly work their way
through the gallery, but that he felt obliged to rush through the
exhibit out of fear that if he became absorbed in a painting he
might be swallowed up by the experience and lose his own sense
of himself in the process. He preferred to go to galleries when
they were empty, so that he could be alone, move at his own pace,
and not be coerced by other people’s rhythms.
He felt coerced by other people’s opinions as well, and he
was particularly careful not to be swept up by general admiration
for writers such as Shakespeare or masterpieces such as the Mona
Lisa, fearing that if he agreed with the general opinion he would
lose his own sense of existence and intellectual independence.

ETIOLOGY

Clinically, what we have generally observed is an absent and emo-

tionally depleted mother (or father) who turns to the baby only
on the basis of her (or his) own needs for comfort and reassur-
ance. This parent leaves the child bereft and devitalized by her
absence and her lack of relatedness and responsiveness, or else
entirely flooded by the mother’s own unbearable needs and af-
fects. What we have observed are mothers who look at their babies
but do not see them, who listen to the child but cannot hear him
or her, and who touch the baby only for concrete technical rea-
sons, like bringing the baby to bed, or changing diapers, or out of
their own need for reassurance and comfort.
When these babies become adults, later experiences that
might objectively seem satisfying are often felt by them to be dis-
appointing, unsatisfactory, and unreal. One reason is that any
experience of satisfaction feels foreign and suspect as it distanc-
es them from the familiar internalized depriving or absent ob-
ject. The only self that seems to feel real is the self that was expe-
rientially stamped in through the early years of pain—the self
that is identified with emptiness and longing for the absent
mother.
THe Empty self331

There are many possible ways of conceptualizing the situa-

tion in which these patients find themselves, and each point of
view brings certain insights. For example, they are often seen as
having inadequately or defectively internalized a primary object,
or as having lost a primary object that they are struggling to re-
find. This viewpoint generally proposes the finding or refinding
of the object and its relation to the self in the transference, and
points to the developmental and defensive obstructions to this
process. Another point of view emphasizes conflicts between in-
ternalized objects and attacks on the good object, or defenses that
evacuate important feelings and de-link the relationship with in-
ternal objects. This viewpoint is very helpful in returning to the
patient his or her disavowed experience, but we felt that with the
particular set of patients we are describing, verbal interpretations
of disavowed experience did not always get at some of the deeper
issues that beset them.
It is primarily the study of the transference and countertrans-
ference in the analytic setting that informs us about what has
transpired in our patients’ early experience. These are patients
who seem to have had a primary object that could not relate and
respond to the infant’s needs from the start, in contrast to Green’s
(2001) dead mother, who was at first sufficiently connected and
emotionally available but was subsequently lost. In Winnicott’s
(1965) words, “the etiology of these patients’ illness goes back
[to] and involves a distortion at the time of absolute dependence”
(p. 54).
Research suggests that even at the earliest times an infant at-
tempts to find cause and effect in his or her world. This need to
know the world and one’s place in it is the foundation of process.
When cause and effect is found in the early connection with the
caregiver, the child feels alive. If the experience of cause and ef-
fect is precarious, then the feeling of a smooth process of alive-
ness is lost. When the links between moments of experience are
missing, then the person’s experience is no longer smoothly ana-
logue but becomes digital, with moments that are “on” and mo-
ments that are “off.” These “off” moments may be experienced as
emptiness or anxiety, and they usually cover a profound fear of
falling, annihilation, and death of the self (Bach, 2008).
332 BACH ET AL.

This disruption of links may be caused by external attacks or

negligence, by internal attacks on linking, or by developmental
disruptions. Often all of these causes are present and interactive.
The child lives in constant danger of emptiness and loss of self.
In treatment we teach experientially about the development
of process and the continued existence between binary/digital
moments. Although we may point this out in words, it is our own
continuous connection, bodily vitality, and intimate attention to
the patient’s predicament that carries the most weight. These are
precisely the qualities that were lacking in the early maternal care
of our patients. They describe having parents who were missing
through death, emotional absence, addiction, or intermittent
withdrawal, or parents so narcissistically preoccupied that the
child felt their interest to be intrusive, mechanical, and appropri-
ating. Even worse, very often their parents provided these inter-
mittent reinforcements in impossible-to-predict alternation. The
children felt like they were playing a pinball machine: They never
knew what would come up. We know that this type of random re-
inforcement schedule is the hardest to deal with and the most
difficult from which to free oneself.
We also know that match is very important in determining
how parents and infants respond to each other. As Ellman (2012)
has repeatedly emphasized, high endogenous-drive infants who
find “normal” amounts of stimulation aversive may disappoint
their mothers; low endogenous-drive children may need more
than normal stimulation and both may exceed the mother’s abili-
ties to respond adequately without feeling narcissistically wound-
ed by this strain on their mothering capacities. Infants who are
trained to respond primarily to their mother’s needs rather than
to their own needs may already be heading down the pathway to
false-self formation.
If these patients are able to relate a narrative history, or if
one develops through reconstruction, it is often a history of lone-
ly and precocious ego development of the “wise baby” type (Fe-
renczi, 1949). The toddler, confronted by an unstable and unpre-
dictable environment, is forced to grow up prematurely and
become a little psychiatrist in order to manage the “crazy” adults
in his or her environment. These are children who tend to speak
THe Empty self333

early, draw pictures that are very advanced for their age, and who
impress by their ability to converse with adults, whom they may
prefer to their peers. They may perform well in school and be
creative and bright. But this development may prematurely force
them into self-objectivity, self-reflexivity, and self-assessment, by-
passing a childhood period of dwelling in their own subjectivity
and learning to own their feelings while being protected by the
environment. This type of precocious ego development has often
been associated with a false self (Winnicott, 1965) or later feelings
of unreality, depersonalization, and meaninglessness (Auerbach
& Blatt, 1996; Bach, 1994; Ferenczi, 1949).
If, as is more usual, they are unable to narrate a continuous
life history and have only a fragmentary grasp on their life or, as
sometimes happens, they have a somewhat continuous narrative
but feel as if they had heard about it from someone else and not
lived it themselves, then the narrative will be pieced together and
filled in through reconstruction and reliving in the transference
over the course of the analysis.
We feel it of utmost importance to understand and be clini-
cally sensitive to what it is that allows someone to own his or her
experience and feel that it belongs to him or her, rather than to
experience the narrative as an impingement coming from the
outside or forced upon him or her. With these patients, this prin-
ciple guides our technique of being unobtrusive but expectant,
alive but not overwhelming, available but not insistent.

CLINICAL TECHNIQUE

Because the patients we are describing feel so easily swayed and

overshadowed by the presence of another, we particularly empha-
size the importance of a nonintrusive therapist and environment.
While most nonpsychotic patients easily distinguish self from oth-
er, these patients are hypersensitive to that distinction and are
yearning for  experiences that will help them find and authenti-
cate the self. So, what is ideal for them, at least at first, is an inter-
action that is mostly all about them and does not present the ther-
apist as a separate, omniscient person.
This is easier said than done, as they are adept at discovering
334 BACH ET AL.

or projecting what they think the therapist wants from them and
then wordlessly conforming to it just as a chameleon changes its
body color to blend into the environment. Particularly when the
therapist inserts himself or herself into the treatment as a sepa-
rate object from the beginning, then the patient often falls into a
compliant false-self transference because he or she desperately
needs the object but cannot be himself or herself in its presence.
It has been our experience that if we can remain sufficiently
present but not intrusive, the patient will relate to us as a support-
ive environment rather than as another person and will be able to
use this support to find and strengthen his or her own self, rather
than trying to comply with what he or she perceives as our expec-
tations, which the patient is trained to read better than his or her
own. Because any living person terrifies these patients, we try to
operate on a functional rather than a personal level, as a supplier
of time and space rather than an adversarial other. Of course this
approach derives from Winnicott’s facilitating environment and
Kohut’s self-object transferences, to name only a few influences,
but it might not necessarily lead to a full-scale analysis. We feel
that we can quite effectively help these patients without necessar-
ily plumbing the psychic depths. In fact, we believe that restoring
or revitalizing the early developmental functions may be seen as a
prerequisite for the success of later analyses with the same or a
different analyst.
Here is another ordinary example of what we mean. When
patients who are having trouble in a business or social relation-
ship finally manage to express something of what they actually
want to do, we may suggest that they put their thoughts down on
a piece of paper so that when they go to have the meeting or
make the phone call, they can see what it was that they wanted to
say. They need evidence of what they talked about in the session,
evidence, as it were, that they actually existed for a time, if only in
the session, evidence that they once owned these thoughts.
Many of these patients appear to be very “concrete,” a con-
creteness that often seems to mirror the lack of connection be-
tween what Freud (1915) called the “word presentation” and the
“thing presentation,” or between the symbol for the thing and the
thing itself, or between the word and the feeling. But sometimes
THe Empty self335

even the reality of the thing itself is in question: Is it their own

thing, thought, feeling or is it a thing that belongs not to them
but to someone else? We have mentioned that because of internal
or external attacks and developmental disruptions they often find
themselves without the links between moments of experience, so
that the smooth process of aliveness is missing and they feel in
constant danger of losing themselves.
Speaking of this dilemma, a patient once said: “If I verbalize
the emotion, it is gone. I cannot even remember what I said. I
don’t end up with anything in front of me.” Sometimes this gap
between the feeling and the verbalization can be linked up by
finding some onomatopoeic way to connect them, as we often do
with children; some word like an emoticon that contains the emo-
tion: that was sc-a-ry! That was so b-i-g ! It seems significant that
onomatopoeia derives from the Greek: I make the name.
These patients have been impinged upon in an early and
traumatic way. This impingement, an early experience of the oth-
er’s demands and expectations and the use of the child to fulfill
these needs is traumatic because it eclipses the child’s ability to
know his or her own experience. In these cases the child has made
the terrible, impossible choice of knowing the other’s experience
at the expense of his or her own in order to maintain connection
to the other.
Therefore we must treat each feeling and thought as provi-
sional until its authenticity has been established, and when we are
sure it is authentic because the patient has definitively labeled it
as such, we try to link, concretize, and expand it because it is this
owned thought or feeling that will fill up the emptiness. It has got
to bear the stamp: Made in my own mind by me.
Fundamentally, our technique revolves around these con-
cepts. The execution is similar to what one might do with young
children, for example, speaking slowly, distinctly and comforting-
ly; joining words to feelings with onomatopoia, gestures, and ex-
pression; having patients write down their thoughts and feelings
so as not to lose them; and helping them figure out on a very
concrete level how they want to use the session and what they
want to say, and so forth.
Case 9. When one patient seemed to be concerned about how
336 BACH ET AL.

much physical space he was taking up in the therapy room, the

therapist remarked: “It is very difficult to know where to put one’s
legs.” The therapist was careful not to single the patient out and
embarrass him, but to present the difficulty as part of the human
condition. This is in keeping with our desire to operate on a func-
tional rather than a personal level and to rely on proximal devel-
opment occurring in the presence of the therapist. It also tries to
deal with the terrible shame that these patients often feel, a shame
well known to child therapists who manage it through the indirec-
tion of play therapy, where the shame can be displaced onto the
animal or doll.
Comment. Far from feeling patronized or talked down to, our
patients seem grateful that someone has finally understood what
they need in order to be helped, and that the therapist is willing
to assist them in addressing it. Here is an example of an exchange
employing standard technique informed by this point of view:
Case 10. Another patient had great difficulty in distinguish-
ing between authentic feelings and passing fantasies. He was very
upset at having fallen far behind in his work, but could not bring
himself to complete it even though he kept thinking “I owe it to
them—they pay me for this.” The therapist suggested further ex-
plorations that eventually led to his description of being out of
touch with the job and longing to feel in the swing of things. With
this awareness, the work no longer carried the feeling of some-
thing outside of himself that someone else wanted him to do. It
could now possibly be something that he also wanted to do. This
allowed him to move toward the work without feeling he had to
lose himself to satisfy the other, and without the usual resentment
associated with that subjugation. This delicate sorting process of
discovering whose feeling is being felt and from which direction
the pull is coming is the central work necessary to help patients
locate themselves and access their capacity for agency.
In the following session the patient had this to say about it: “I
enjoyed when you found my self for me. You turned the responsi-
bility from something I had to do into my wanting to because you
gave me a chance to connect to it, a responsibility I could own as
opposed to having it own me, so it turned the perspective around.
And I think that’s my goal here with you, a perspective. And I
THe Empty self337

think we were onto something today when we were talking about

my experience—it’s something that’s yours and ours together.”
Comment. We want to note again that this low-level, concrete,
specific way of working with these patients does not in any way
preclude a later, more traditional way of working analytically with
internal and external attacks on linking or developmental trau-
mas. It is just that we have found that there is at least one class of
patients for whom words at the beginning have very little mean-
ing and who need our specific help to be able to move from the
psychophysical level to the symbolic realm before the classical in-
terventions become useful.

COUNTERTRANSFERENCE

Probably many analysts would agree that the most difficult part of
working with such patients lies in managing the countertransfer-
ence. Although some patients seem very modest, even timid, in
their hopes or needs at the outset, others silently or openly pro­
ject an intensity of demand that feels like being with a hungry
baby who is desperately crying to be fed but who is unable to feed.
Eventually, we too find ourselves in the same position of which
these patients complain: Either we feel swallowed up by them or
else we feel isolated, out of contact, despairing, and needy.
Our impression is that the mothers of these patients were ei-
ther “not there” or sometimes overwhelmingly present, but always
enrobed in their own narcissistic world and unavailable for use by
the child. Our patients have repeatedly characterized the atmo-
sphere of the dyad in terms such as: “She was there but not there,”
“There was no room for me,” or “She was absent in her presence.”
The child usually experienced this absence through a fog of pain-
ful affects such as longing, anger, and shame. This absent/pres-
ent mother became an accustomed and familiar “safe” haven, that
is, the child was imprinted with or made a primal connection to a
painful absent figure. Rather than making a pleasurable attach-
ment to a mother who felt alive and there, the child made a pain-
ful attachment to the image or the aura of an absent mother.
Thus, in later life, pleasure and the presence of a vital connection became
aversive, since pleasure was experienced as the loss of the familiar “safe
338 BACH ET AL.

haven” of the painful and absent or sometimes overwhelmingly present

mother.
In this way the analyst’s attempts at friendliness and useful
interventions are sometimes met by the patient’s “masochistic”
negative therapeutic reaction or refusal to be fed. This negativity,
together with the patient’s limited object constancy and dimin-
ished sense of continuity that leads to the forgetting of prior ses-
sions and the obliteration of work that had seemed productive,
often produces a countertransference of both anger and despair
in the analyst. Sometimes, pushed by the patient’s unconscious
needs, we find ourselves feeling or perhaps even becoming dis-
tant and distracted, very much like the patient’s mother must
have done.
At other times the patient’s deadness and detached affect
can pull the analyst into becoming the needy, forceful, “enliven-
ing” but interrupting parent who is both “invited” to play this role
and rejected for doing so. The analyst’s awareness of these states
of loneliness, deadness, and despair that may quickly shift into
feelings of being impinged upon are of utmost importance. It is
through living with our patients and in their world that we can
gently invite them to be curious about their struggles and to focus
on their internal experience.
In the process of trying to convert the patient’s attachment to
a painful negative object into an attachment to a pleasurable posi-
tive object, we find ourselves dealing with the patient’s fear of new
experiences and his or her loyalty to the empty and unfriendly
but very familiar mother of childhood. We feel that the counter-
transference reactions we have discussed are normal and unavoid-
able, a situation that makes it extremely helpful to have regular
consultations or some venue where it is possible to discuss these
feelings without embarrassment or anxiety.

SUMMARY AND CONCLUSIONS

We have learned that the ability to own one’s thoughts and feel-
ings precedes the ability to narrate and process them. At the be-
ginning of treatment with the patients we are describing, the work
is rarely about dialogue or interpretations, but almost always about
THe Empty self339

provision. To paraphrase Winnicott, the environmental provision

by the analyst is there to meet the patient’s needs within the realm
of the patient’s omnipotence. We have understood this to mean
within the realm of the patient’s ownership and the patient’s real-
ity. We are discussing a class of patients who have little sense of
ownership of their experience and thus little sense of its reality.
We have been trying from the ground up to find ways of respond-
ing to their sometimes silent sense of emptiness and unreality.
Phenomenologically, these patients live with gaps in their ex-
periential world: a gap between the body and the mind, between
the emotion and the symbolic word, between experience and the
sense of reality, and between the self and the other. While in some
philosophical sense these existential gaps exist for everyone, these
people acutely experience these gaps as absences or emptiness
and live in a world that is not analogue, continuous, and smoothly
flowing, but rather digital and punctuated by on/off moments
that reverberate with anxiety about death of the self.
We try to respond to this anxiety with an appreciation of their
terror, and to understand their desperate feeling that their only
alternatives seem to be moving closer and falling into the abyss of
other people, or moving away and falling out of the world. We try
to offer an immediate steadying hand to help them balance on a
very narrow margin until it grows wider in time. We try to offer
this help in ways that do not preclude the possibility of further
treatment of whatever variety.
While a good deal of what we are suggesting may seem obvi-
ous to many, we thought it worthwhile to speak directly about
these patients and at least to put on record an attitude and proce-
dure which some of our colleagues have no doubt already come
to on their own. We hope that this will elicit further comments
and discussion.

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