Thick- and thin-skinned organisations and enactment in borderline and narcissistic disorders

In this paper the author argues that enactment is any mutual
action within the patient/analyst relationship that arises in the context of
difficulties in countertransference work. Such enactment is common during the
treatment of borderline and narcissistic disorders. In order to delineate
different forms of enactment, which in his view may be either to the detriment
or to the benefit of the analytic process, the author describes a patient who
was identified primarily with a sadistic mother and who threatened the analyst
with a knife during treatment. Three levels of enactment involving
countertransference responses are described of which two, namely a collusive
countertransference and a defensive countertransference, were detrimental to
the analytic process. The third level of enactment was beneficial but only
because the intervention by the analyst was independent of the analytic process
and yet in response to it. The author uses Rosenfeld’s distinction between
thin- skinned and thick-skinned narcissists to illustrate how enactment is most
likely when a patient moves between thick-skinned and thin-skinned narcissistic
positions. Nevertheless the move between thin and thick-skinned positions
presents an opportunity for effective interpretation, allowing progress in
treatment.