Psychiatry

Interpersonal and Biological Processes

ISSN: 0033-2747 (Print) 1943-281X (Online) Journal homepage: http://www.tandfonline.com/loi/upsy20

Patients Who Hate

Glen O. Gabbard

To cite this article: Glen O. Gabbard (1989) Patients Who Hate, Psychiatry, 52:1, 96-106, DOI:
10.1080/00332747.1989.11024432

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 Patients Who Hate
Glen O. Gabbard

FEW experiences in the life of the mental health professional are more unpleas-
ant than being intensely hated by a patient he is trying to help. In most cases
the hatred is mitigated by periods where the patient sees the treater as more
helpful and less malevolent, a shift that makes the treatment process more
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tolerable. However, there are patients who hate relentlessly, presenting a chal-
lenge that taxes the therapist's emotional and intellectual resources to an ex-
traordinary degree.

Some 40 years ago Fritz Redl and David
Wineman attempted to create a therapeu-
tic environment to treat such patients.
Designed for delinquent adolescents, this
innovative Detroit program was known as
Pioneer House. They described their expe-
riences with this population in their 1951
book, Children Who Hate. In this land-
mark work they poignantly depicted how
the extraordinary aggression of these chil-
dren had eroded every significant relation-
ship they had attempted, and how as a
result nobody wanted them. Their fami-
lies had labeled them impossible to live
with. All conventional forms of therapeu-
tic intervention had been futile. They ar-
rived at the doorstep of Pioneer House as
a court of last resort.
Today the long-term psychoanalytic
hospital performs a similar function in the
treatment of refractory adult patients. Al-
though only a relatively small percentage
of the adult referrals to these centers have
the same degree of antisocial pathology
as the population described by Redl and
Wineman, they nevertheless resemble
those younger patients in that their most
striking overriding characteristic is their
intense hatred of those who seek to help
them. Moreover, like the delinquents of
four decades ago, their families cannot
tolerate living with them, and all previous
treatment efforts, including outpatient
psychotherapy, pharmacotherapy, electro-
convulsive therapy, and short-term hospi-
talizations, have been dismal failures.
This communication is the second in a
series of efforts to describe and to under-
stand the unique features of the treat-
ment-resistant borderline patients who
now populate the units of the long-term
psychoanalytic hospital. In a previous re-
port (Gabbard 1986), one segment of this
patient population, the so-called "special"
patient, was described. These patients
create extraordinarily intense counter-
transference reactions in treaters and
come to occupy a favored position in the
lives of their treaters. Although the "spe-
cial" patients may manifest transference
hate that repels some treaters, they also
inspire heroic rescue fantasies in other
treaters, who will go to any length to help
these patients (Burnham 1966). In con-
trast, the hateful borderline patients dis-
cussed here are much more uniformly

Glen 0. Gabbard, MD, is section chief, C. F. Menninger Memorial Hospital, and staff psychoanalyst, the
Menninger Foundation, Topeka, Kansas.
For helpful comments on previous drafts of this paper, the author is grateful to Stuart Averill, James
Grotstein, Thomas Ogden and John B. Sutherland.

96 PSYCHIATRY, Vol. 52, February 1989

 PATIENTS WHO HATE
hateful in their relationships with trea-
Lens, 80 that they rarely have found thera-
pists who can tolerate their aggression
long enough to mount a sustained treat-
ment effort. Rather than instilling heroic
rescue fantasies in their treaters, they are
more likely to evoke countertransference
hate (Winnicott 1949; Poggi and Ganza-
rain .1083). Sutherland (1083) has suc-
cinctly described this phenomenon as fol-
lows: "They create in the outer world a
replica of the inner world, i.e., a world full
of hate" (p. 528).
An organized destructiveness is a prime
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feature of these refractory inpatients. They
seem bent on destroying the staff who at-
tempt to help them. Indeed, they common-
ly erode the morale of the hospital staff
involved in their treatment. Prior to the
referral for long-term hospitalization, they
have typically made a shambles of briefer
treatment efforts. These patients clearly
meet Kernberg's 1984 narrowed criterion
of the negative therapeutic reaction, in
that they deteriorate consistently in the
face of the perception that a treater is func-
tioning as a good object who is determined
to help the patient.
The patients here defined represent a
subcategory of borderline personality dis-
order. Narcissistic, antisocial, depressive,
and psychotic features are also commonly
found in these patients. The overt behav-
ioral manifestations may differ signifi-
cantly across this spectrum of patients.
Some of the prominent behavioral charac-
teristics of the hateful patient population
include self-mutilation, suicide attempts,
bingeing and purging, substance abuse,
perversions, frequent angry outbursts
and, much less frequently, physical as-
saultiveness. Other investigators (Colson
et a1. 1986; Allen et a1. 1986) have devel-
oped statistically based profiles of long-
term patients who are particularly diffi-
cult to treat. The most difficult patients
were categorized as "pan symptomatic:' in
that they manifested a wide range of prob-
lematic symptoms. Many of the hateful
patients described here present similar
patterns of complex and multiple symp-
tomatic presentations.
PSYCHIATRY, Vol. 52, February 1989
THE SELF IN THE HATEFUL PATIENT
Common to all hateful patients is an in-
sufficiently developed self, characterized
by split self-representations pathological-
ly attached to primitive internal object-
representations. It follows from this
premise that the principal focus of hospi-
tal treatment, as well as the psychother-
apy process, must be the self, particularly
the self in relation to its internal objects
as they are manifested through the trans-
ference-countertransference paradigms
that develop in the hospital.
Few concepts in contemporary psycho-
analytic discourse are more controversial
than the self, and clinicians who utilize
the term as a conceptual focus must first
clarify their usage of the term. The con-
troversy has been summarized in numer-
ous recent contributions to the literature
(e.g., Kernberg 1982; Range1l1982; McIn-
tosh 1986; Meissner 1986). In brief, much
of the confusion stems from Freud's am-
biguous usage of Ich and Strachey's sub-
sequent translation of I ch as "ego:' Hart-
mann's (1950) suggestion that it is the
self, rather than the ego, that relates to
objects resulted in further ambiguity.
Hartmann's attempt to clarify the distinc-
tion between self and ego led to another
major controversy regarding the self: Is
the self an intrapsychic representation of
the individual or a source of action and/or
agency in its own right (Meissner 1986)?
Numerous authors (Guntrip 1969, 1971;
Schafer 1976; Sutherland 1983; Meissner
1986) have emphasized that the structural
theory and the model of the self as an in-
trapsychic representation put forth by
Hartmann and by Jacobson (1964) pro-
vide little basis for a concept of the self
that includes subjective experience and
personal agency.
Adding to the furor is Kohut's (1971,
1977, 1984) development of an entire psy-
chology of the self with its own theory
and its own theoretically informed tech-
nique. Kohut's self is an overarching holis-
tic structure that has its own separate line
of development apart from object related-
ness and from the components of the tri-
97

partite structural theory. This concept of
the self has been criticized for being exces-
sively abstruse and ill-defined (Waller-
stein 1985; Meissner 1986), for vacillating
from "a subordinate content of narcissism
to a sometimes superordinate determi-
nant of mental disorders" (Havens 1986,
p. 365), for being artificially separated
from classical structural theory (Rangell
1982; Meissner 1986) and from the vicissi-
tudes of object relations (Kernberg 1984),
for being reductionistic in its formula-
tions about pathogenesis (Stein 1979;
Curtis 1985), and for being too "experi-
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ence-near" in its implications for tech-
nique (Curtis 1985).
Finally, one further source of debate has
arisen from the direct observation of in-
fants. From this vantage point, Stern
(1985) has addressed the need for a sys-
tematic understanding of the self as a
subjective and personal agent of activity
and initiative. His observational studies
have convinced him that the subjective
sense of the self is the primary organizing
principle of the infant, and he postulates
four different aspects of the self experi-
ence that are linked to a developmental
timetable.
It is most useful in understanding the
hate-filled patients herein discussed to
formulate the self as a central organizing
principle that involves both subjective ex-
perience and a sense of personal agency
and activity. Kohut's concept of the self is
consonant with this notion, but his em-
phasis on the holistic aspects of the self
tends to neglect the importance of self-
representations and their corresponding
object-representations. Moreover, the for-
mulation I am suggesting does not view
the self as existing apart from the ego, as
Kohut suggests, but rather it is imbedded
in the ego and is the end product of the
integration of the many self-representa-
tions, which are of course linked to vari-
ous object-representations (Kernberg
1982).
Sutherland (1983) notes that a basic fea-
ture of the self is its active initiating role
with the environment. The self strives to-
ward relatedness and unity, but in its
98
GLEN O. GABBARD
quest it encounters frustration from the
objects in its environment. Affects such
as anger associated with this frustration
result in splits within the self that form
subselves or self-representations that are
kept apart from one another because of
their incompatibility. The consequence of
the splitting of the self is that a perpetual
strain is created. This strain appears to be
responsible for the pressure to integrate
the split-off subselves into a holistic unity.
Ogden (1986) describes the same phenom-
enon as the development of suborganiza-
tions of the ego, some of which are as-
sociated with self-representations and
others of which are associated with ob-
ject-representations. Grotstein (1981) has
reached similar conclusions, noting that
the splits in the self really denote separate
subpersonality organizations. Each of
these split self-representations is mingled
with complementary object-representa-
tions. Rinsley (1977) formulates this phe-
nomenon as part-object-relations units,
which consist of an aspect of the self and
an aspect of an internal object, linked by
an affect.
For my purposes here, the terms self-
representation and subself will be used
synonymously and interchangeably to re-
fer to those split-off aspects of the self
that remain unintegrated in the hateful
patients described and which move in the
direction of integration into a more holis-
tic self as a result of effective treatment.
The search for a conceptual understand-
ing of the self in the hateful patient must
begin with the recognition that an inte-
gration of the self-representations into a
self has not yet been achieved. A develop-
mental arrest has occurred prior to the in-
tegration process. In Winnicott's sense
(1960), there has been a failure of the hold-
ing environment. The infant has encoun-
tered frustration in his efforts to elicit the
"good-enough mothering" that he seeks,
and splits occur that maintain good self-
representations separate from bad self-
representations, along with their corre-
sponding object-representations. To avoid
the implication that mothers are always
to blame for the problems in their chil-
PSYCHIATRY, Vol. 52, February 1989
 PATIENTS WHO HATE
dren, it is important to clarify that fail-
ures in the holding environment may have
other causes, including constitutional and
genetic factors in the infant that make her
difficult to mother, or a poor match be-
tween the temperament of the mother and
the temperament of the infant (Ogden
1986).
One consequence of the early division of
the self into subselves is that there is no
subjective "I" in the primitive hateful pa-
tient. Subjective experience is fragmented
by competing, unintegrated subselves. As
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Ogden has persuasively argued, this expe-
rience of "I-ness" or subjectivity is an
achievement of the so-called depressive
position (Klein 1946), and the patient who
is arrested at the paranoid-schizoid posi-
tion must tolerate an unfortunate state of
affairs in which the self exists predomi-
nantly as an object. Ogden notes:
Although Klein did not explicitly address the
question of subjectivity, it seems implicit in
Klein's clinical and theoretical accounts that
in the paranoid-schizoid position, there is no
interpreting subject mediating between per-
ception of danger and response to it. The fact
that this is a psychology without a subject is
the basic paradox of the paranoid-schizoid po-
sition. Psychological experience of the type
being described exists in itself, but not for a
self. [1986, p. 45]
Ogden's formulation of the role of sub-
jectivity in the paranoid-schizoid position
is critical to an understanding of the ori-
gins of hate. Since the patient arrested at
this level of development does not experi-
ence herself as master of her own fate, i.e.,
an active personal agent who shapes the
course of her life, she tends to feel like an
object vulnerable to repeated victimiza-
tion by others around her. One source of
hate, then, is the perception that others
are abusing her and not providing her
with what she needs from the environ-
ment. Whether or not the parental figures
in reality have been inadequate, the pa-
tient perceives them as withholding and
abusing; and they are certainly the origi-
nal targets of the hate. The infant's frus-
tration in the face of perceived parental
PSYCHIATRY, Vol. 52, February 1989
failure can explain the infant's need to
hate the parents without invoking the
Kleinian death instinct (Fairbairn 1944).
The infant's hateful feelings toward the
mother provide a powerful threat to his
ability to maintain a positive view of the
mother as his caretaker and feeder.
Hence, the splitting of the self into a
hating self-representation and a loving
self-representation preserves the good re-
lationship with the mother at a safe dis-
tance from the hateful feelings. However,
splitting also preserves and protects at a
safe distance the infant's need to hate
(Ogden 1986). The ability to hate without
experiencing panic stemming from the
fear that the love object will be destroyed
is a necessary developmental achieve-
ment; if loving feelings are not split off at
this point, the infant's development may
be compromised.
As a consequence of the failure of inte-
gration of the subselves, the hateful pa-
tient establishes a dominant part-object
relationship that involves a hating self-
representation and a hated object-repre-
sentation. The hating subself achieves a
prominence, then, that may make it ap-
pear as the individual's overarching iden-
tity. A subself that is yearning to love and
to be loved becomes sequestered or buried
beneath this contemptuous fac;ade and
provides no assistance in tempering or
balancing the hate with love in the pa-
tient's interpersonal relations. This ar-
rangement of a dominant hating self-
representation and a secret loving self-rep-
resentation further differentiates these
patients from the "special" patients (Gab-
bard 1986; Burnham 1966). In the latter,
the loving aspects of the patient's self are
not sequestered but rather are visible and
involved in creating splits within the hos-
pital environment wherein some staff
members are advocates for the patient
and others reject the patient as hateful. A
more uniform countertransference reac-
tion is produced by the hateful patient,
one in which treaters feel devalued, unap-
preciated, and hated. Many will simply
disengage from the patient. They may al-
so react with murderous rage toward the
99

patient. Occasional glimpses of the loving
and vulnerable subself may be enough
to sustain the staff in their ongoing ef-
forts to reach the patient and to prevent
them from writing off the patient as
untreatable.
Ms. A was a 22-year-old woman who
was admittod to the hospital after years of
battling with her parents. Her opposi-
tionalism had grown to the point where
she refused to eat and had rejected all ef-
forts to engage in any therapeutic pro-
cess. For the first 2 months of her hospi-
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talization, she sat through every group
meeting with a haughty disdain that
alienated the other patients and the staff
as well. When she spoke, she made it clear
that nothing in the treatment environ-
ment was of any use to her. She denied
having any problems that required psy-
chiatric intervention, and she justified her
being in the hospital by saying that she
had nowhere else to go. She repeatedly en-
gaged staff members in struggles involv-
ing eating. When the staff expressed con-
cern that she was not taking in enough
nutrition so that her brain would receive
sufficient glucose to function well, she re-
sponded with contemptuous verbal bar-
rages, devaluing the staff and their exper-
tise. She maintained that she was the only
one who knew what her nutritional needs
were and that in fact she could function
perfectly well on two or three Cokes a day.
When staff or patients offered any kind of
support or confrontation in group meet-
ings, she responded with such extraordi-
nary rage that other patients gave up try-
ing to relate to her. After 2 months, a
breakthrough occurred when she made
the following comment: "I know I've been
obnoxious to everyone. But I'm so afraid
that none of you will like me that 1 reject
you before you can reject me:'
The glimpse of the split-off subself pro-
vided by this brief comment in the group
meeting was meaningful both for the staff
and for Ms. A herself. She frequently re-
called it as a turning point in her treat-
ment in which she had risked showing an-
other side of herself, and she was aware
that it enabled others to reach out to her
100
GLEN O. GABBARD
and to develop a treatment alliance with
her. Kohut's (1972) formulation of narcis-
sistic rage is useful in understanding this
patient, in that she inflicts on others the
narcissistic injury she fears will be inflict-
ed on her.
The split self-representations may also
account for the frellueuL feeling of these
patients that "something is missing:' As
Ogden (1986) stresses, a part object-rela-
tionship by definition is incomplete; it is
reflecting only one aspect of the self and
one internal object. The yearning for relat-
edness is often experienced by these pa-
tients as a yearning for completeness.
Again, this object-seeking activity, how-
ever contaminated with hate, may provide
a bridge to treatment relationships that
make the treatment of these patients ulti-
mately manageable. One of the most
striking features of these patients is their
persistence in seeking help despite repeat-
ed disappointments.
RESISTANCE TO TREATMENT
The frequency with which the hateful
patient receives the label of negative ther-
apeutic reaction reflects how tenaciously
the hating self-representation and the
hated object-representation resist at-
tempts to modify them. This resistance to
treatment is manifested by a re-creation
of the hate-filled internal world in the hos-
pital environment. A common source of
frustration in the staff working with these
patients is the perception that the patient
is more invested in perpetuating her world
of hate than in taking steps to change it.
The hateful patient's extraordinary at-
tachment to her world of contempt and
bitterness performs multiple functions.
1) A defense against envy. The role of
envy is critical in understanding the nega-
tive therapeutic reaction (Klein 1957). The
efforts of the hateful patient to obtain
what he needs from figures in the environ-
ment is massively compromised by the
patient's envy. If a treater is tolerant of
the patient's hate and is able to offer help
in the form of understanding and some
PSYCHIATRY, Vol. 52, February 1989
 PATIENTS WHO HATE

degree of kindness, the patient may envy the helpers defended the patient against
these qualities since he feels that they are the painful awareness of her envy.
so lacking in himself. He may then hate 2) Protection of the good self and the
the staff member all the more as a result good object. The preservation of the domi-
of this envy. Kernberg shares this view: nant self-representation as hateful pro-
tects and insulates the good internal self-
As a therapist persists in helping the patient and object-representations in their se-
in the fnce of obvious lack of response or even questered sanctuary imbedded in the ego.
worsening of the patient's condition, the pa- Here they are safe from the contaminat-
tient's envy and resentment of the therapist's ing influences of aggression. Sutherland
commitment and dedication may reinforce his
guilt over mistreating the therapist (who, in (1983) notes that a negative therapeutic
contrast to the patient's other experiences, reaction is often related to a subself hid-
does not respond to hatred with hatred) and den in a fortress, making it inaccessible to
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thus his need to escape from guilt. [1984, p. therapeutic interventions and unavailable
242] for integration with other subselves.
The case of Ms. B also demonstrates
Because of such envy, the patient ap- this second source of treatment resis-
pears to spoil and destroy the therapist's tance. She systematically destroyed all at-
interpretations, his concern, and even the tempts by the staff to establish a thera-
holding environment that the therapeutic peutic alliance. Such attacks on linking
relationships of the hospital provide. symbolically represent a primitive attack
Ms. B was an intelligent professional on the representation of the breast (Bion
woman in her early 30s, who was chroni- 1959; Grotstein 1981). The staff working
cally depressed and severely suicidal and with Ms. B felt an extraordinary lack of
who had battled narcotics addiction for gratification because she consistently bit
years. Numerous attempts at outpatient the hand that was attempting to feed her.
psychotherapy and brief hospitalization Grotstein (1981) stresses that the attack
had failed. She came to the hospital con- against linkages is pervasive. Not only
vinced that this treatment effort was as does the patient attack any linkage to
hopeless as the previous ones. When a good objects in the environment but simi-
staff member would make positive com- larly she attacks internal linkages be-
ments to her about her courage and perse- tween good and bad self-representations
verance in the face of her despair about and between good and bad object-repre-
the hopelessness of life, she would laugh sentations. Linkages threaten the split-
derisively and let the staff member know ting process, which is serving a powerful
that he could not possibly understand defensive function in these patients-
what it was like to suffer the way that she namely, to protect the endangered loving
was suffering. Her tendency to spoil any- subself and loved object-representation
thing good or helpful was compellingly from being destroyed by the enormous ha-
captured in her comment: "Why should I tred. The attacks on linkage to the help-
get out of bed and participate in treat- ing object in the hospital environment
ment? Life is not worth living. There is no preserve the attachment to the hated in-
point to it. You get up in the morning, you ternal object. These patients often have a
eat breakfast, and then all day you make history of involvement in sadomasochis-
shit inside you:' Her metaphor also ap- tic relationships since those constella-
plied to how she spoiled the nurturance tions are the only variety of externally
that the hospital staff provided for her. available linkages that do not threaten
The repeated degradation of help into the internal arrangement of self- and ob-
"shit" preserved her hateful dominant self- ject-representations.
representation in connection with a hated 3) The fulfillment of revenge fantasies.
and contemptible object-representation. The systematic defeating of treaters
Moreover, the devaluation of the help and through the hateful rejection of their help

PSYCHIATRY, Vol. 52, February 1989 101


has a symbolic meaning of revenge
against the patient's parents. The patient
derives enormous gratification from this
fantasy of paying back the parents for
their perceived neglect and abuse. These
patients are akin to those described by
Kohut (1972) as suffering from chronic
narcissistic rage. The narcissistic insults
they received in childhood are perceived
as so devastating that their lives are
characterized by the ruthless pursuit of
revenge against parental surrogates in the
environment.
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4) The preservation of identity. The
sense of identity connected with the hate-
ful self-representation, rudimentary as it
may be, may be far preferable to no identi-
ty at all. Klein (1946) first recognized that
fear of annihilation is one of the earliest
and most fundamental anxieties. Even
though there is no integrated or whole
sense of self in these patients, they never-
theless experience a form of annihilation
anxiety when the predominant self-repre-
sentation is threatened by the infiltration
of more loving aspects of other subselves.
The threat is often voiced by these
patients as a fear that they will no long-
er exist. Hence, the hateful self-repre-
sentation defends against annihilation
anxiety.
5) The preservation of meaning. Side by
side with the fear of annihilation may be
an equally disturbing concern - that one
will continue to exist but will do so in a
state of total meaninglessness. Grotstein
has eloquently described this dreaded
state:
The domain, not of meaninglessness per se,
but of all too meaningful meaninglessness, a
nothingness, an insignificance, a failure to
matter to oneself or to others, a failure to find
meaning in oneself or the world that is so pain-
ful that meaning dissolves, and a pain beyond
words-beyond meaning-results. [1987, p. 66]
Hating and evoking hatred in others has
been the raison d'etre of these patients.
This pattern of interaction, then, has
served as an organizing principle that
fends off a catastrophic sense of despair,
102
GLEN O. GABBARD
such as that so compellingly depicted in
the plays of Samuel Beckett. l
6) The avoidance of separation anxiety.
A negative relationship is better than
none at all. The paradoxical quality of this
function is clear - the very behavior that
drives others away may unconsciously
serve the function of preserving connect-
edness. These patients often feel that
without hatred, there is no sense of a rela-
tionship with another person. This fanta-
sy was active in Mr. C, a 24-year-old man
who came to the hospital with a mixture
of antisocial and self-destructive behavior
problems. Every Friday around 5 p.m.,
when his hospital doctor, Dr. D, was pre-
paring to go home for the weekend, Mr. C
would create a crisis on the hospital unit.
The nursing staff would call Dr. D to the
unit to see him, and Mr. C would assail
him with threats of suicide and elopement
from the hospital. When Dr. D would at-
tempt to disengage from Mr. C, the pa-
tient would accuse him of not caring and
of being more concerned about going
home to his family. Mr. C would frequent-
ly be so provocative that he would evoke
angry responses from Dr. D, who would
then feel guilty the rest of the weekend.
The doctor's subjective experience was
that Mr. C had "gotten under my skin;'
and he could not rid himself of thoughts
about the patient. He found himself wor-
rying that Mr. C would hurt himself, and
he would think back to their last inter-
change and regret the fact that he had
allowed himself to be provoked to anger.
It eventually dawned on Dr. D that these
crises on Friday afternoon fulfilled an im-
portant psychological need for Mr. C.
They established connectedness on the
verge of a 2-day separation from his doc-
tor. Dr. D's experience of the patient's hav-
ing gotten under his skin was a concreti-
zation of the patient's fantasy that he
placed a part of himself in Dr. D so that
his doctor would carry him with him
lIn this regard, it is interesting to note that as a
young man Beckett was analyzed by Bion, the first
analyst to fully grasp the importance of the fear of
meaninglessness (Grotstein 1987).
PSYCHIATRY, Vol. 52, February 1989
 PATIENTS WHO HATE
throughout the weekend. The fantasy
that he continued to torment his doctor
during their separation felt like a triumph
over the limits of the relationship (Gab-
bard 1982; Heimann 1955). In contrast to
the positive attachment to the treater in-
herent in a therapeutic alliance, this con-
nectedness to Dr. D posed no threat to the
internal hating self-representation since,
via projective identification, Dr. D was
now the carrier of the hated object-
representation.
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TREATMENT CONSIDERATIONS
The foregoing conceptual framework
permits a brief and schematic discussion
of some general treatment considerations.
An approach to psychoanalytically in-
formed hospital treatment based on trans-
ference-countertransference has been de-
scribed elsewhere (Gabbard 1986). In
brief, the internal object relations of the
patient are recreated in the hospital envi-
ronment, i.e., in the patient's relationships
with key figures on the treatment staff.
Via projective identification, treaters find
themselves assuming the role of one or
more of the patient's object-representa-
tions and/or the patient's self-representa-
tions. Systematic processing of such
projective identification both in staff
meetings and in meetings with the pa-
tient are critically important if these pa-
tients are to be effectively treated.
The overall goal in the treatment of the
hateful patient is, of course, to integrate
the split-off subselves or self-representa-
tions into a holistic self that feels a strong
sense of subjectivity and personal agency.
From a Kleinian perspective, this shift in-
volves a transition from the paranoid-
schizoid position to the depressive posi-
tion (Klein 1946). The patient is likely to
resist this integrative effort with a tenaci-
ty that is awesome to behold. The man-
agement of the countertransference hate
produced by such patients often serves as
the fulcrum around which the treatment
fails or succeeds. Denial of the hatred may
subtly or not so subtly undermine the
PSYCHIATRY, Vol. 52, February 1989
- - - - - - - . - -.... ~ ---" -------- -."~--~-----. --
treatment (Searles 1967; Winnicott 1949;
Poggi and Ganzarain 1983). The treaters
cannot be expected to avoid having the
same reactions that everyone else has had
to the hateful patient. Kernberg, in a dis-
cussion of treatment stalemates in charac-
terologically disordered patients, cautions .
that "the therapist may be tempted to col-
lude with splitting mechanisms in the pa-
tient as one way of preserving his own
good feelings about the patient in the face
of his generally unrelenting aggression"
(1984, p. 247). Members of the treatment
staff may assume an artificially friendly
and superficial demeanor to avoid the bit-
ter taste of aggression in themselves and
in the patient. If treaters present them-
selves as all-good, unconditionally loving
objects, they will simply promote further
splitting, i.e., internalization of a part-ob-
ject instead of an ambivalently experi-
enced whole object. A more likely develop-
ment, however, is that the patient's
intense envy will abort any internal-
ization process. At the other extreme,
staff members may repeatedly and ruth-
lessly confront the patient with his or
her demandingness, greed, and lack of
gratitude.
The integrative goal in the treatment of
these patients requires a balanced ap-
proach where glimpses of the loving as-
pects of the buried self-representations
must be actively sought out and used to
temper the intense hatred of the predomi-
nant self-representation. The psychother-
apist of these patients must make a con-
certed effort to present both aspects of
the patient as part of the same person.
The treatment staff in the hospital can
assist the psychotherapist by similarly re-
fusing to collude with the splitting pat-
tern. A unified presentation of both sides
of the patient may eventually help him to
embrace both sides as parts of a compre-
hensive whole. For example, staff mem-
bers may point out that the "good" as-
pects of the patient displayed yesterday
are part of the same person who is demon-
strating "bad" qualities today. A success-
ful integration of these disparate aspects
of the self may present the patient with a
103
------------ --------------"---

sense of a historically continuous self and
a sense of personal subjectivity for the
first time. Movement into the depressive
position by necessity will entail a mourn-
ing process and considerable anxiety
about hurting the individuals the patient
has grown to love. These depressive anxie-
ties may precipitate frequent regressions
that demoralize the treaters.
The attitude of the treaters in the face
of discouraging developments plays a cru-
cial role in the treatment process. On the
one hand, the staff must maintain a cau-
Downloaded by [Australian Catholic University] at 17:35 16 August 2017
tious spirit of optimism about the poten-
tial treatability of these patients. They
must be thoroughly convinced that the in-
tegrative task is possible when positive
experiences in the environment predomi-
nate over negative experiences (Klein
1958). On the other hand, they must have
a healthy respect for the patient's resis-
tances to change and must empathize
with the patient's need to hate in light of
the multiple functions hatred performs.
The dominant hating self-representation
is passionately attached to the hated in-
ternal object-representation. Similarly,
the latter has an intense need for the for-
mer (Ogden 1983). Neither will give up its
partner without a massive struggle. A
shift toward integration will be experi-
enced as an annihilation. If the treater is
sensitive to this issue, he will refrain from
approaching the patient with an overzeal-
ous investment in changing her. Inexperi-
enced treaters rapidly learn that such an
attitude will be used as a weapon against
them by the hateful patient, who will se-
cretly gloat at her triumph over the trea-
ter's wish to change her. Hence, the appro-
priate attitude of the treatment staff
must veer between the Scylla of naive fu-
ror therapeuticus and the Charybdis of
cynical and nihilistic pessimism.
Above all, the hospital provides a hold-
ing environment for the patient (Stamm
1985). Like other significant figures in the
hateful patient's life, the treatment staff
will experience hate toward the patient.
However, in the optimal treatment milieu,
the staff members are not driven away.
Just as a good-enough mother steadfastly
104
GLEN O. GABBARD
returns again and again to minister to the
infant despite his affective storms, the
treatment staff return again and again to
process with the patient what has hap-
pened and to confirm that they have not
been destroyed. The persistence and dura-
bility of the treatment staff over a long
period of time is a critical factor in the
ultimate transformation of the patient's
self- and object-constellations. Only if the
external objects in the environment are
seen as durable and indestructible can the
patient risk letting go of the internal at-
tachment to the hated object-representa-
tion (Ogden 1986).
As both Ogden (1986) and Grotstein
(1981) emphasize, projective identifica-
tion (Klein 1946) is the principal method
by which internal objects are modified.
The hospital milieu and the psychothera-
peutic process that occurs in conjunction
with the hospital treatment provide active
arenas for projective identification and
subsequent modification of internal ob-
jects. As the hated object is tempered
with concern and caring from objects in
the external environment, the hating self-
representation will similarly be modified.
When the treatment of the hateful patient
is successful, the sequestered subself as-
sociated with love and positive feelings
comes out of hiding in response to the
presence of the persistent and durable
good (though imperfect) external objects
in the treatment environment. The case of
Ms. A reflected the beginning of this
process.
This process of modification and inte-
gration is a slow and painstaking ordeal
that requires extraordinary patience in
the treatment staff. Not only must the pa-
tient loosen the attachment to the inter-
nal hated object, but also he must learn to
trust the treaters without giving in to his
fear that they will be overwhelmed and
driven off by his hatred. Interpretation of
such anxiety, as well as concerns about
annihilation and separation, may be use-
ful and necessary. At other times the pa-
tient will present himself as completely
impervious to the impact of interpreta-
tions because he will perceive them as co-
PSYCHIATRY, Vol. 52, February 1989
 PATIENTS WHO HATE
ercive efforts to effect linkages that he is
resisting. As Searles (1986) notes, the
emotional atmosphere provided in the
treatment setting is often more important
than interpretation in the treatment of
such primitive patients. Moreover, inter-
pretations that are tinged with sadism are
a frequent countertransference develop-
ment. Hence, as a general rule, the inLer-
pretive role belongs more properly to the
psychotherapist, while the staff members
working in the milieu should attempt to
establish a good-enough holding environ-
Downloaded by [Australian Catholic University] at 17:35 16 August 2017
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