THE REPULSIVE

CLIENT

Florence L i e b e r m a n & M a r y L. Gottesfeld

At one time or another all m e n t a l health professionals have contact with a repulsive client. He is encountered in social agencies, in hospital settings, and in private practice. This client h a s a history of rejection by professionals of all kinds who tend to see h i m as ineligible for insight therapy and resistant in general to psychotherapeutic intervention. He is usually diagnosed as a rigid character disorder, borderline or schizophrenic. He need not be socially or economically deprived. Of course, if he is, his difficulties are further compounded. Frequently he is a she, a middle-aged m o t h e r with severely disturbed children, or the client who used to be called the "schizophrenogenic mother," t h a t is, the evil mother who is the cause of all the difficulty and who h a s to be removed from the life of the i m p o r t a n t client--her child. This client m a y also be an individual of either sex who is dem a n d i n g , helpless, or hopeless a n d chronically u n h a p p y . The important a n d d o m i n a t i n g characteristic is the ability to generate rejection by therapists who are repulsed by their noxious presentations of themselves a n d who consciously or unconsciously consider t h e m untreatable. We suggest that such a j u d g m e n t is the result of the therapist's disability rather t h a n the client's inability to be helped. In this paper we will a t t e m p t to identify clients who fall into this group by defining their characteristics and p s y c h o d y n a m i c s a n d to offer approaches for relating to t h e m so that the help t h a t t h e y are seeking can be available to them. Essentially, the repulsive client is one who induces a powerful feeling of rejection a n d disgust in the therapist; this occurs in reaction to the need on the part of the client to repeat an early history of rejection because of the p h e n o m e n o n of the repetition compulsion. Overtly or covertly these are extremely d e m a n d i n g clients. M a n y make specific major or minor requests of the t h e r a p i s t a n d frequently tell the therapist what to do. Others, by their helplessness, are really

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d e m a n d i n g omnipotence from their therapist. Furthermore, an observing ego is not present in these clients. As a result t h e y h a v e no awareness of their neediness a n d their constant demands, a n d almost everything is experienced by t h e m as denial a n d rejection. Yet this pattern, fed by the repetition compulsion in an attempt to relieve and master the early rejection, causes t h e m to seek professional help repeatedly. Of course, the life histories of all of these clients contain serious emotional rejections. But to u n d e r s t a n d t h a t t h e y need to repeat these rejections over and over again in attempts at m a s t e r y and restitution does not explain w h y therapists in contact with t h e m f'md it so difficult to resist the pull to repeat the original rejection a n d disgust. The repulsive client has strong, overpowering infantile needs, manifested by clinging, discontent, constant demands, a n d querulousness. Though this neediness is usually obvious to the therapist, too often there is unconscious resistance to accepting a n d working with it, because the mechanisms underlying the d e m a n d i n g n e s s are less understood. Because of their unresolved feelings of helplessness, there is a regressive drive to become one again with the object or its substitute (therapist) through incorporation a n d swallowing up, a n d to obtain the omnipotence previously projected onto adults by the infant. They then act as if they are omnipotent and proceed to tell their therapists w h a t to do a n d defeat a n y intervention t h a t seems to t h e m directed to the needs of others. Thus no matter w h a t the therapist does he is swallowed up and becomes one with the client a n d feels his despair, hopelessness, a n d helplessness. This client is then dismissed as not amenable to help. Intervention is sometimes attempted for the "others" in his environment, for whom the help m a y have been originally sought, thereby circumventing, avoiding, and completely rejecting the repulsive client. But this rejection of the client becomes the defeat of the therapist, who is neither therapeutic to the client nor to his i m p o r t a n t undifferentiated other. When the client is not rejected, when an attempt is m a d e to meet his needs as they are symbolically communicated t h r o u g h his demands, he becomes able to incorporate a n d later introject traits of the good, feeding parent and move on to more satisfactory social and internal functioning. Three case examples follow.

I. The Demanding, Repulsive Client

Mrs. X was a short, plump woman with a loud, harsh voice and a demanding manner. She was married to a small, quiet man who worked all his life as an elevator operator. He tended to be self-deprecating, completely dominated

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by his wife, h a d no friends of his own, a n d indicated t h a t he did not know how to talk to other men. Mrs. X frequently belittled a n d ridiculed her husband and on a few occasions hit him publicly. Mrs. X came from a poor Jewish f a m i l y a n d w a s the oldest child of four and the only girl. Her father was a grocery clerk who worked long hours but still found it difficult to adequately s u p p o r t the family. Her mother was extremely negligent, and would lie in bed m o s t of the day. The children usually went to school without breakfast. I t w a s the father who was responsible for seeing that the family at least h a d dinner. He died when Mrs. X was 15. Shortly thereafter, the two y o u n g e r children were removed from the home by court order because of neglect a n d placed in a residential t r e a t m e n t center. Mrs. X and her future h u s b a n d both lived in the s a m e neighborhood. She became involved with him shortly after her father's death. Initially they lived with her m o t h e r who had remarried, a n d when they h a d their own a p a r t m e n t it was in her mother's building. Before m a r r i a g e Mrs. X k n e w t h a t her husband w a s sterile. When she conceived by artificial insemination, her family seemed to k n o w t h a t the child was not h e r h u s b a n d ' s , despite her secrecy. Consequently her anticipation of the joy a n d respect of her f a m i l y for finally becoming p r e g n a n t was denied to her. The d a u g h t e r ' s first two years were uneventful according to mother who was v a g u e in describing and r e m e m b e r i n g w h a t h a d h a p p e n e d . At age two mother perceived t h a t the child was obstinate a n d Mrs. X would yell, scream, and even beat the child. By the time her d a u g h t e r was three years old she sought help from a variety of clinics a n d h a d also tried a therapeutic nursery school. H e r complaint was her inability to h a n d l e her daughter, who was insolent a n d impossible to control. E a c h facility t h a t she w e n t referred her to another, where she could be "helped better." The little girl was, in fact, obnoxious, hyperactive, a n d had very little impulse control. T h e school often called the m o t h e r in regarding the child's behavior, a n d n e i g h b o r s complained t h a t she hit their children. Mother was e m b a r r a s s e d b y all of this a n d felt deserted by everyone. By the time of her fourth referral her child w a s eight, and her behavior w a s much worse. Mrs. X's worker became painfully a w a r e of her client's u n p l e a s a n t n e s s and her own strong negative reaction to it. Dealing with her was therefore a great strain because the therapist was c o n s t a n t l y on g u a r d a g a i n s t herself. Though the client tried to m a s k her a n g e r b y sweetness a n d ingratiation, her hostility to everyone was obvious. For example, Mrs. X telephoned one d a y to cancel her appointment, giving a very frivolous r e a s o n for not coming a n d refusing to consider keeping her a p p o i n t m e n t . T h e following week she was loudly a n g r y a n d indignant with her t h e r a p i s t for questioning her excuse, adding, "You don't care at all about me if you c a n ' t u n d e r s t a n d w h y I couldn't come." Though t h e therapist pointed out t h a t it w a s precisely t h a t she did care t h a t made her question the cancellation, Mrs. X w a s h a r d l y mollified a n d continued her bitter complaint. Her need to feel rejected, her lack of a n observing ego, a n d her inability to be logical or r e a s o n a b l e resisted a n y a t t e m p t s b y her therapist to be supportive and to meet Mrs. X's need for mothering. In addition, though Mrs. X would ask for advice a b o u t h a n d l i n g her child, she usually did the opposite. Mrs. X w a s referred to a mother's group with the hope t h a t if she were accepted b y her peers she might feel less attacked a n d become available for help. However, she continued her individual contacts with her individual therapist a t the same time. In discussing a n d p r e p a r i n g her for the group, the therapist learned t h a t Mrs. X felt she would be rejected a n d a n o t h e r preferred

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to her. This perception was based upon the reality t h a t Mrs. X k n e w of another w o m a n who wished to enter the group. In discussing the referral with the group therapist, Mrs. X's therapist insisted t h a t her client h a d priority and shared her a s s e s s m e n t of the importance of her being accepted. From the beginning, group and individual t r e a t m e n t were considered as a combined m e t h o d of helping one individual; this w a s to be facilitated by shared u n d e r s t a n d i n g a n d open communication between the therapists. The group leader informed Mrs. X of the d e m a n d by her individual t h e r a p i s t t h a t she be considered first for the group, well a w a r e t h a t this would symbolize love and u n d e r s t a n d i n g to her. The group, which h a d been carefully prepared for a difficult new m e m b e r , was interested and accepting with her. Mrs. X told the group t h a t the problem was t h a t her d a u g h t e r wanted to be the center of attention. As they listened to her a n d allowed her to be the center of attention, she began to wonder if she h a d contributed to her child's difficulty because she always w a n t e d perfection. As she revealed the inconsistencies in her handling of her child, the group t a u g h t her w h a t y o u n g children need, a n d t h a t children need different kinds of help from mothers a n d fathers. T h e n she was able to tell t h e m t h a t only her father helped her, t h a t he h a d told her everything, even a b o u t menstruation. A turning point occurred with a crisis w h e n Mrs. X's d a u g h t e r w a s threatened with suspension from school. The client asked her t h e r a p i s t to attend the hearing, which she did, despite an inconvenient time a n d location. At the hearing, the expected occurred a g a i n a n d Mrs. X was a t t a c k e d b y a guidance teacher who b e g a n by reading a confidential psychiatric report on Mrs. X which was highly critical of her. The t h e r a p i s t intervened a n d h a d the reading stopped. Further, she complained about such t r e a t m e n t for a mother whom she declared was a good mother, who w a s t r y i n g h a r d to do the best she could. When Mrs. X s h a r e d this experience with the group, t h e y suffered with her, expressed anger, a n d supported her feelings. T h e group t h e r a p i s t spoke sympathetically of h o w frightening a n d upsetting this m u s t h a v e been to her. For the first time in all of these years of treatment, she cried. Mrs. X w a s now more open. She could s a y t h a t her life h a d c h a n g e d from the m o m e n t she entered the group, because of the feeling a n d dedication of the group t h e r a p i s t a n d the members of the group. She spoke glowingly of her individual t h e r a p i s t w h o m she frequently said was helping her. She reported improvement in relations with her h u s b a n d , t h a t t h e y were now a couple and the child no longer c a m e between them. In her individual sessions, as she b e g a n s e p a r a t i n g from her child, she beg a n to talk a b o u t her own early experiences a n d her feeling of deprivation. She began to look a t herself with some objectivity to see where she h a d contributed to her difficulties. As she identified with her worker as being maternal and giving, her child's b e h a v i o r showed i m p r o v e m e n t , her school performance w a s often praised, a n d she d e m o n s t r a t e d greater independence. Even Mrs. X's a p p e a r a n c e changed. She became more feminine and talked in the group of how women should look. I n turn, she w a s admired for her skill in fixing her hair. As she felt gratified a n d accepted (fed) emotionally, she was able to grow a n d accept the setting of limits. She b e c a m e active in striving more for her f a m i l y as well as herself. She wanted to m o v e from the public housing project, but realized t h a t this could not be done with her husband's modest salary. She admitted to a long-held ambition to be a beautician. Her t h e r a p i s t assisted her in obtaining a small loan to a t t e n d school which she successfully completed. When she was employed, she repaid the loan and the family was able to move to better housing.

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Discussion
We understood from Mrs. X's h i s t o r y t h a t h e r e a r l y m a t e r n a l deprivation left her i m m a t u r e a n d t h a t her entire life h a d conspired to recreate this early u n f o r t u n a t e s i t u a t i o n a n d c a u s e d all m e a n i n g f u l adults to be cast in the role of her rejecting m o t h e r , a n d t h u s confirm her repulsive perception of herself. In reality, she w a s treated cont e m p t u o u s l y b y everyone with w h o m she h a d c o n t a c t because of her d e m a n d i n g a n d a n g r y m a n n e r a n d her poor a n d u n e d u c a t e d status. It was the a r e n a of group t h e r a p y t h a t provided t h e first emotional t u r n i n g point in this case. W h e n the i n d i v i d u a l t h e r a p i s t argued with the group t h e r a p i s t t h a t Mrs. X h a d p r i o r i t y to enter the group, the t h e r a p i s t s understood the symbolic m e a n i n g of this, t h a t she w a s " f i r s t " to the mother-therapist. The group t h e r a p i s t t h e n comm u n i c a t e d to the client t h a t her i n d i v i d u a l t h e r a p i s t h a d d e m a n d e d priority for her to enter the group. T h i s provided a positive m o t h e r i n g experience, p e r m i t t i n g incorporation of the good m o t h e r who m a d e her feel good (loved) versus her own b a d m o t h e r who m a d e her feel bad (not loved). This new experience was the b a s i s for t h e emotional growth n e c e s s a r y for her to move b e y o n d her i n f a n t i l e fixation. Of course, this o p p o r t u n i t y to incorporate t h e good m o t h e r w a s repeated m a n y times with both therapists; d r a m a t i c a l l y in t h e i n c i d e n t at the school h e a r i n g . The group t h e r a p y was a v a l u a b l e adjunct. U n d e r t h e g u i d a n c e of the group t h e r a p i s t Mrs. X was t a u g h t how to get a l o n g with peers a n d from her peers she was t a u g h t m a n y simple t h i n g s a b o u t childr e a r i n g t h a t she h a d never observed or been t a u g h t ; t h i s w a s ego-enh a n c i n g . Experiences in w h i c h i m p o r t a n t others s a w a n d t r e a t e d her positively helped to correct her perception of herself.

IL The "Schizophrenogenic" Mother

Mrs. Y was a college graduate and both she and her husband were professionals. She came from a middle-class family and her father was an artist and an intellectual. He was a reserved and withdrawn man who was emotional only in his work; her mother was narcissistic, selfish, and self-centered. She was always intensely involved with her own mother and as a child suffered from separation problems when she entered school. Mrs. Y had three psychotic episodes which occurred when there was emotional separation from her mother: when she was in college, after her marriage, and when her husband's job caused the family to move to another city. She was seen with her schizophrenic son, age 21, who appeared to be close to a psychotic break and was asking for hospitalization which his mother wished to prevent because this would have been his third. In the preceding month she had been told by her son's psychiatrist that she had made her son ill and that he was schizophrenic. In addition, at a family therapy session at the family agency they were attending, she was castigated by the social workers leading the session, called a "schizophrenogenic" mother and the

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cause of the entire family's problems. She had had three other experiences with therapists, all of which terminated when they refused to see her. In the present contact, she began by making a series of demands, telling the new therapist what to do to prevent her son's hospitalization. However, there was gross emotional deterioration in him and he was hospitalized. Mrs. Y was intelligent, educated, and able to express herself forcefully and articulately. She made numerous telephone calls to her therapist, often with impossible requests (e.g., "My son is on the roof, what should I do?" or "My husband is walking the streets at night. Should I lock him out?"). Her therapist was also told what to tell hospital personnel, husband, and son, because Mrs. Y perceived that none of these listened to her. Her therapist always listened respectfully, and thanked her for her advice. She was requested to be sure to continue to offer suggestions that could help her situation. Though she was encouraged to call whenever she felt it necessary, she was asked to call at certain times to be sure her therapist would be free to speak to her. As Mrs. Y found that her calls for help were listened to seriously, she was able to decrease them to a reasonable number, from two per day to once a month within a year's time. Actually Mrs. Y's advice and requests in reference to how the family should be helped often fell into the "demanding" or "show me that you care" category. For example, when she asked for advice about her son's old psychiatric medication, she was informed t hat the therapist was not a physician and did not know. However, her request was first listened to and the client felt the emotional acceptance which was symbolically communicated by respectful attention to her demands. At other times, her advice clarified the family's needs. For example, Mrs. Y's insistence that the family be treated together, her objection to the arbitrary separation insisted upon by other therapists, was correct. Since psychosis was a family problem, all members were "fused." The sicker the individuals in the family, the more they were merged. The stated "patient," the young son, was still deeply involved with his parents and affected by the family disequilibrium. It was only as they became stronger t hat they were more differentiated and somewhat separate. By seeing them together, by understanding the mother's request and the family's need, the therapist functioned as an executive ego and was able to assist the family through periods of stress and into a period of relative reintegration and growth.

Discussion
In Mrs. Y's case, t h e r e p e t i t i o n c o m p u l s i o n w a s to r e p e a t t h e e a r l y experience o f fusion, w h e r e she r e m a i n e d fixated. H e r d e m a n d s , angrily s t a t e d b e c a u s e o f t he a n t i c i p a t e d rejection, were for t h e t h e r a p i s t to allow e m o t i o n a l m er ge r, as in t h e e a r l y m o t h e r - i n f a n t r e l a t i o n s h i p . T h u s she w oul d w a n t t h e t h e r a p i s t to be o n e w i t h h e r a n d h e r f a m i l y . H er d e m a n d s on t h e t h e r a p i s t ' s t i m e v i a t e l e p h o n e calls, r e q u e s t s for advice, e x t r a a p p o i n t m e n t s , a n d s e n d i n g letters for t h e t h e r a p i s t to read, were all in or der to regress to t h e e a r l y u n d i f f e r e n t i a t e d m o t h e r child r e l a t i o n s h i p . It w a s onl y b y n o t t u r n i n g h e r a w a y t h a t she w as a m e n a b l e to t h e r a p e u t i c i n t e r v e n t i o n , for b y b e i n g l i s t e n e d to she w a s t h e n able to listen to t he t h e r a p i s t .

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Mrs. Y w a s more di s t urbed t h a n Mrs. X, b e c a u s e h e r f i x a t i o n w a s on a m u c h earlier level (fusion r a t h e r t h a n i n c o r p o r a t i o n ) a n d she act u a l l y h a d h a d t hr ee p s y c h o t i c episodes, as h a d h e r son a n d h u s b a n d . B e c a u s e o f h e r ve r bal intelligence, h e r e m o t i o n a l p r i m i t i v e n e s s w a s not u n d e r s t o o d . She was oft en o v e r t l y rejected b y p r o f e s s i o n a l s , w h e r e a s Mrs. X was rejected in m o r e covert w a y s (referral elsewhere). Mrs. Y's r e l a t i o n s h i p s were all v e r y u n d i f f e r e n t i a t e d a n d i n v e s t e d with s t r o n g o v e r l a y s of t h e o r i g i n a l i m p o r t a n t one. S h e b e c a m e m o r e a t t a c h e d to he r t h e r a p i s t t h a n Mrs. X a n d s o u g h t h e r a d v i c e on all m a t t e r s , l ar ge a n d small. S h e could n o t d i s t i n g u i s h b e t w e e n l a r g e a n d s m a l l m a t t e r s - - t h e y were all l a r g e - - a n d so s h e felt compelled to t u r n to t h e t h e r a p i s t for help. B u t t h e r a p y c a n be a correct i ve experience b e c a u s e t he therapist, u n l i k e t h e p a t h o l o g i c a l m o t h e r , will enc o u r a g e s e p a r a t i o n w hen t he client is r e a d y .

III. The Helpless and Hopeless Repulsive Client

Mr. Z was a very short, colorless, timid, and apologetic-looking man, fifty years old. He came to the attention of a child guidance clinic because of the school difficulties of his nine-year-old daughter who also misbehaved at home. The child would not obey her mother and had frequent tantrums during which she would beat her father. He accepted this as well as his wife's complaints, and did nothing. It was Mrs. Z who applied to the clinic for help and who was an active participant in the treatment plan while Mr. Z tended to be on the periphery of the clinic, as he was on the periphery in all aspects of his life. He worked at a marginal job in the men's clothing industry, the same job obtained for him by his brother when he had come to America as an immigrant. Though he described himself as a good and responsible worker, and his boss as fatherly, he received no advancements and was one of the first employees laid off when the factory was retrenching. After that he had only sporadic and temporary work when his union sent him out for a job. Though he complained that he was always overlooked, he never saw that he could do anything about it. He was in fact always by-passed and even discriminated against. He had only the hope that he could keep going long enough to be eligible to receive a small union pension. The details of his early life were vague. It was known t hat he was the youngest of a large family, that his father had died when he was a small child and that because of family poverty he had gone to work at a young age. His older brother was described by him as dynamic, powerful, and successful. It was this brother who obtained his job for him, arranged his marriage, and who always told him what to do. His employer, his brother, his wife, and his therapist were all contaminated by Mr. Z's passivity and resignation. All felt helpless when with him, and hopeless that he could do anything worthwhile. To his therapist he was a boring client, the passive, ineffectual father and husband. By contrast, his wife was an active, gratifying client. She was seen by the same therapist and in response to therapy became even more active on her own behalf, obtained work to augment her husband's income, improved her appearance, and was able to change her child-rearing practices. She continued to despise and to treat her husband contemptuously. Mr. Z, on the other hand,

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did nothing. E v e r y t h i n g was too m u c h for h i m a n d he w a s a l w a y s overwhelmed. As a result, little was expected of him. I n effect his therapist was as helpless as he. The acceptance of the client's limitations, the lack of r e a s o n a b l e expectations, and the absence of well-defined goals were rationalized as " s t a y i n g where the client was." Secretly, the t h e r a p i s t really felt quite proud of the fact t h a t at least she s a w this hopeless m a n with w h o m few would work, a n d of the fact t h a t she was willi_ng to s t a y for evening a p p o i n t m e n t s . O f course, when Mr. Z would frequently call to cancel, she more easily accepted his reasons. After all, one could not expect too m u c h from him. Shortly before one of these evening a p p o i n t m e n t s , Mr. Z called to say t h a t he did not feel well a n d did not t h i n k he would m a k e it on time. He was quite obviously a s k i n g to be let off. But this time, the t h e r a p i s t told him to come a n d she would wait. Mr. Z whined at the b e g i n n i n g of this interview t h a t he was too tired, too ill to do a n y t h i n g . Furthermore, at this time he really felt ill. When he was offered tea, he accepted it a n d t h e n b e g a n to vomit. His t h e r a p i s t held the waste b a s k e t for him, a n d b e g a n to t h i n k about her noxious food. Before Mr. Z's next visit, his t h e r a p i s t s o u g h t consultation to better understand the d y n a m i c s of this hopeless client. T h e v o m i t i n g w a s understood as passive aggression a n d the only c o m m u n i c a t i o n a "helpless" child could m a k e in response to poor feeding a n d poor caring. At this n e x t visit, when Mr. Z a g a i n said he could not do a n y t h i n g about his d a u g h t e r ' s m i s b e h a v i o r with him, he w a s asked w h y e v e r y t h i n g was more difficult for h i m t h a n it was for other f a t h e r s who c a m e to the clinic. He responded t h a t he h a d h a d less t h a n a n y o n e else, a n y other f a t h e r s a n d everyone in his family. He talked with feeling a b o u t b e i n g y o u n g a n d confused when his father died. No one told him a n y t h i n g or helped h i m to do anything. He was sent to work, but not told how to be successful. When he w a s 13 he was even sent to a s t r a n g e city to work a m o n g strangers. He a l w a y s felt t h a t no one cared about him and he w a s a l w a y s afraid a n d a l w a y s u n h a p p y . He described h i m s e l f as being worn out early in life, a n d a hopeless failure in his eyes a n d everyone else's. Mr. Z w a s helped to review his early life f r o m a different v a n t a g e point. Instead of focusing on his inabilities, his abilities were s y m p a t h e t i c a l l y understood. He h a d in reality attempted to be reliable a n d dependable. Assistance was given to h i m with job difficulties, recreation, communication, a n d with his wife a n d daughter, but at the s a m e time r e a s o n a b l e expectations for his behavior were communicated to him. As he identified with his therapist as really interested a n d maternal, as he perceived a new self-worth through her eyes, he acted in a firmer yet more protective w a y with his child, no longer allowing h i m s e l f to be beaten. In the long run, Mr. Z became a hero. One day, his d a u g h t e r w a s accosted by a s t r a n g e r because of her provocative m a n n e r while in his presence. He chased this f r i g h t e n i n g stranger away, o b t a i n e d police support, a n d properly chastised his y o u n g d a u g h t e r for her behavior!

Discussion
U n d e r l y i n g Mr. Z ' s p a s s i v i t y , w h i n i n g , a n d h e l p l e s s n e s s w a s t h e a n g e r o f a c h i l d c a u g h t u p in e v e n t s b e y o n d h i s c o n t r o l . W h a t M r . Z rep e a t e d w a s a n e a r l i e r p e r i o d w h e n h e h a d b e e n u n a b l e to d o a n y t h i n g

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about his father's death, a n d w h e n he perceived he was ordered to do things without support and without u n d e r s t a n d i n g . Originally his anger was really the panic of a child c a u g h t in a c h a n g i n g a n d incomprehensible situation. There m a y also h a v e been guilt about his father's death, but this material was repressed. I n t h a t early situation, he h a d felt pushed around by o m n i p o t e n t forces (adults, brother, etc.). He never was able to communicate his distress, b u t the s i m m e r i n g unexpressed anxiety and anger resulted in an abject individual who rarely m a d e a n y overt d e m a n d s a n d was immobilized. In reality, Mr. Z defeated everyone, himself included, by doing n o t h i n g . When he was able to reflect u p o n his p a s t helplessness with the objective ego of a therapist who was willing to assist h i m to meet acceptable a n d reasonable goals, he did not feel as helpless a n d did not need to repeat the original helplessness; this p a t t e r n being a repetition compulsion reflecting an effort to m a s t e r t h e helplessness. Mr. Z did not bother his therapist with d e m a n d s n o r did he give advice. But in some ways his repulsiveness was more insidious. With such weak individuals, such babies, it is sometimes possible for a therapist to delude himself t h a t h e is really p r o v i d i n g the missing "mothering." However, m o t h e r i n g t h a t does n o t hold out expectations for growth and performance is smothering. Only w h e n the client is expected to grow and separate a n d is assisted in t h a t growth is he really mothered. T h e n he is helped to go from repeating an earlier t r a u m a to m a s t e r i n g it in life.

CONCLUSIONS
In this paper we have a t t e m p t e d to relate theoretical concepts to actual practice a n d to show how a particular constellation of early deprivation m a y result in certain clients acting repulsively a n d thus being deprived of a therapeutic experience. We believe this occurs with those clients who are extraordinarily regressed a n d emotionally imm a t u r e so t h a t their strong infantile need to be cared for is encapsulated. Unfortunately, they do not look like the babies t h e y are, alt h o u g h t h a t is h o w they are experienced by others who react with disgust a n d communicate t h a t they should "stop acting like a baby." The primitive need of these clients is for early mothering; the repetition compulsion locks t h e m into seeking it from all potential maternal surrogates; the force of their d e m a n d i n g n e s s causes t h e m to be unappealing a n d rejected a n d thus the initial t r a u m a is recreated. Therapists m u s t be prepared to be m a t e r n a l with such clients, for to do otherwise m e a n s t h a t the therapist will be victimized by their pathology a n d act in an antitherapeutic m a n n e r . Such clients will never be able to "grow up" until they have first been permitted to "grow on"

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the t h e r a p i s t a n d h a v e a benign experience to c o m p e n s a t e for the early n o x i o u s mothering. W h e n t h e s e clients tell you w h a t to do in addition to m a k i n g d e m a n d s , t h e y n e e d to be listened to r a t h e r t h a n ignored. It is no more humiliating for a t h e r a p i s t to take advice t h a n for a p a r e n t to listen and u n d e r s t a n d a n i n f a n t ' s cries. These clients are difficult to treat, not so m u c h b e c a u s e of complex, obscure p s y c h o d y n a m i c s , b u t b e c a u s e of their c o n s t a n t neediness a n d d e m a n d i n g n e s s . These are severely d i s t u r b e d clients a n d their needs a r e n o t only for the d a y t i m e a n d e a r l y e v e n i n g feedings but also for t h e 2 a.m. feeding, a n d initially o t h e r feedings on d e m a n d . It is this t h a t requires considerable m a t e r n a l w i l l i n g n e s s on the p a r t of the t h e r a p i s t a n d the ability to w i t h s t a n d c o n s i d e r a b l e strain. Because of this it is helpful for the t h e r a p i s t to h a v e s o m e support, either by supervision or consultation. We need to r e m e m b e r t h a t e a r l y morning feedings are often shared so t h a t t h e m o t h e r c a n g e t s o m e rest. In the case of Mrs. X the s h a r i n g of the case b e t w e e n t h e g r o u p a n d individual t h e r a p i s t s allowed for m u t u a l support. In t h e other c a s e s superv i s i o n m b o t h f o r m a l a n d i n f o r m a l - - o f the case a l l o w e d respite for the therapist. H o w e v e r , in order to successfully help s u c h clients, the first requirement is the ability to resist the initial rejection induced b y their repulsiveness. In time, w h e n t h e s e clients feel a c c e p t e d emotionally, t h e y feel gratified and then c a n g r o w a n d a c c e p t t h e setting of limits. This t h e n begins the delineation of their d i f f e r e n t i a t e d sense of self.

REFERENCES Lieberman, F., & Taylor, S. S. Combined group and individual treatment of a schizophrenic child. Social Casework, Feb. 1965. Lidz, T., Fleck, S., & Cornelison, A. R. Schizophrenia and the family. New York: International Universities Press, Inc., 1965. Spotnitz, H. Modern psychoanalysis of the schizophrenic patient. New York: Grune & Stratton, 1969.
Hunter College School of Social Work I29 East 79th Street New York, N. Y. 10021

Clinical Social Work Journal Vol. 1, No. 1, 1973