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Playing in Winnicott's Potential Space:

The Treatment of a Hypersexual Woman
a

Vitor Hugo Barreto , John Giugliano & Michael Berry

a

University College London, London, United Kingdom

Widener University, Chester, Pennsylvania

McGill University, London, United Kingdom

Published online: 09 Mar 2015.

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To cite this article: Vitor Hugo Barreto, John Giugliano & Michael Berry (2015) Playing in Winnicott's
Potential Space: The Treatment of a Hypersexual Woman, Sexual Addiction & Compulsivity: The
Journal of Treatment & Prevention, 22:1, 89-104, DOI: 10.1080/10720162.2014.979381
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Sexual Addiction & Compulsivity, 22:89104, 2015

Copyright Taylor & Francis Group, LLC
ISSN: 1072-0162 print / 1532-5318 online
DOI: 10.1080/10720162.2014.979381

CASE REPORT
Playing in Winnicotts Potential Space:
The Treatment of a Hypersexual Woman
VITOR HUGO BARRETO
University College London, London, United Kingdom

JOHN GIUGLIANO
Downloaded by [University College London] at 10:16 13 July 2015

Widener University, Chester, Pennsylvania

MICHAEL BERRY
McGill University, London, United Kingdom

This is a case of a Brazilian female who defended against unrecognized and contradictory internalized representations of self
and others that were affectively charged. These defenses led to identity diffusion and disturbed relationships. The patient existed in a
compromised space between the internal (fantasy) and external
(reality) to maintain psychological equilibrium. When the external
reality of aging and sexual desirability changed, the potential space
changed. When the use of part-object relations to sustain her fantasy of being wanted and desired became in jeopardy of collapsing
she became depressed and despondent. Treatment focused on the
integration of her split-off parts of self and object representations.
The distorted perceptions of self and other were the focus of treatment as they emerged in the transferential relationship with the
therapist. The successful understanding of the transference was a
significant ingredient for the analytic treatment.
This article is a psychoanalytic case study of an indigent 50-year-old Brazilian
woman who came to treatment 1 year ago asking to be hospitalized because
she could no longer endure her life. This article focuses on how to conceptualize, from an object relations perspective, a patient who continually used
sex to regulate her mood and self-esteem to the point that it destroyed her
relationships with herself, partners, and family. The treatment is discussed,
but space does not permit a comprehensive explanation of how to treat

Address correspondence to John Giugliano, Widener University, Chester, PA 19103.

E-mail: dr.johng@hotmail.com
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from a psychoanalytic perspective. Nonetheless this case will help therapists understand their role in the patients pattern of relationships and will
highlight the value of enduring the transference and counter-transference
experienced. The intent of the treatment is not symptom relief but concentrates on the developmental causes of the symptoms. It is believed that if
the cause of the problem is repaired then the symptoms will naturally remit.
This is the case of Sinfonea (not real name) who has been attending a local
primary health care unit for a year where Dr. Vitorugo Barreto practices as a
General Practitioner and Psychoanalyst. Dr. John Giugliano, a professor and
private practice psychotherapist from Philadelphia, Pennsylvania, assisted
with the write up of the case and the theoretical conceptualization. This
was a transcontinental collaboration complicated by different cultures and
languages but unified by a mutual theoretical framework. To maintain the
integrity of the case, the reader is asked to understand that direct quotes from
the patient are the analysts translations from Portuguese to English. Our best
efforts were made to consider the culturally constructed connotations. Also
to maintain the integrity of the object relations theory, the formulation was
written in the language of the theory.
First I would like to discuss some concepts intrinsic to this case. Object
relations theory includes many theorists who are not entirely in agreement
about how people develop. One distinctive premise that transcends all differences is the concept of an object. An object is a significant person, part
of a person, or symbol of one of these who is the target of ones feelings
or intentions. What the developing infant internalizes is particularly significant to this theory and to the treatment. The infant does not internalize the
image of the object but the relationship between the self and the object, in
the form of a self-image or self-representation interrelating with a real or
fantasized object image or object representation. This is the place of exploration in treatment to understand this early developmental process to discern
how and what the patient internalized in order to provide the patient with a
corrective experience via the therapeutic relationship.
Initially, the developing infant is only able to view others as partobjects such as a breast or a hand. It is only later in development that a child
is able to develop object constancy and internally hold on to and relate to
a whole object, a complete entity with autonomous feelings, needs, hopes,
strengths, weaknesses, etc.
The second distinctive principle object relations theorists believe is that
human nature is innately object-seeking, not pleasure-seeking. This was a
monumental abandonment of Freuds theory where humans are instinctively
driven by sex and aggression. The premise that human behavior is primarily driven by relationships with others is at the heart of object relations
treatment.
Margaret Mahler was a Hungarian-born pediatrician/psychiatrist, best
known for originating the Separation-Individuation theory of child

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development. Her theory posits four stages of development starting with

the limited inability to differentiate oneself from the external object (usually
mother). Eventually people develop the capacity to physically separate
from the primary caregiver. Yet the more difficult task is to internally individuate or develop a coherent concept of a self that has its own identity,
will, and individuality. In addition the individual is able to self-govern and
self-regulate while being in a relationship with another person. According to
object relations theory, sexual hyperactivity can be understood as a failure
to differentiate between self and object.
Winnicott was an English pediatrician/psychiatrist who worked with
children who were trauma survivors. Winnicott introduced the notion of a
transitional space which is a space that lies between the subjective self
and external objective reality. This space opens up when the child begins
to recognize the gap between her needs and the fulfilment of those needs
(at first, by the primary caregiver). It is within this space that the true self
can develop a sense of a me: and a not-me (Winnicott, 1953). In such
a space, the patient would be able to redress developmental deficits and
gain the strength to proceed autonomously. In such a space, the patient can
re-enact, experience, and/or master deficits in early object relationships. The
healing occurs when a patient experiences what she needed to experience
early in her development. Therapeutically the patient has the opportunity to
find her true self at the intersection of the subjective with the objective in
the context of a safe relationship with the therapist.
Some clinicians may see Sinfonea as a sex addict while others may
not. The field of addictions may define her behaviors as acting out, selfmedicating, risk taking, self-injurious, and, repetitive despite the negative
circumstances. At the very least most would agree that her sexual behaviors
are problematic. However there is more than one way to view the same
symptoms and many roads can lead to the same destination. Psychoanalytic
theorists are more likely to view this behavior as a repetition compulsion.
The term repetition compulsion, which is not exclusive to object relations
theory, is a psychological phenomenon in which persons repeat, re-enact,
or re-live a traumatic situation over and over again by unconsciously putting
themselves in situations where the event is likely to happen again. The
emphasis is that the behaviors are unconsciously motivated due to early
developmental deficits. Object relation treatment focuses on repairing these
deficits via the therapeutic relationship. The therapist provides the holding
environment that the patient was missing because of an insufficient maternal
attunement. It is the therapeutic relationship that allows for this corrective
experience because a person develops within the context of relationships.
The process is slower than other treatments but once the patient can become
aware of the origins of the needs that motivate the behavior and proceeds
to master the developmental stages, the unconscious need to repeat the
behavior naturally dissipates.

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This case is about a middle-aged woman who was unable to internally

regulate her self-esteem (as opposed to external regulation by validation of
others), and had a fear of being alone. She used sex as a means of establishing transient contact with others in order to regulate her intolerable
anxiety or depression. In her mind, others existed as part-objects to regulate
affective discomfort. These part-objects functioned as transitional objects endowed with maternal functions, which were internalized and manifested as
a repetition compulsion that will persist until another type of relationship is
experienced.
This is the case of Sinfonea, who lives in a poor rural part of northern Brazil (all names used in this case are pseudonyms). She has less
than an elementary education, works as a domestic, is the wife of an
abusive alcoholic husband and is the mother of 3 children (a 26-year-old
daughter from her first marriage and 2 sons 20 and 22 years old from
her second marriage). She was primarily raised by her maternal grandmother; she is the middle child of five siblings (4 sisters and a younger
half-brother).

Biopsychosocial History and Considerations

Her maternal grandmother raised Sinfonea. Her mother lived in the same
rural town. Her father rejected her because he thought Sinfonea was the
daughter of her mothers stepfather. At age 7 she was forced to leave school
to work as a housemaid and sugar cane cutter.
Sinfonea reported that she perceived her mother to be sexually promiscuous. Her mother would bring numerous men around, each time leading
Sinfonea to believe he would be her new dad. The rumors about Sinfoneas
maternal step-grandfather being her biological father have never been resolved. It is also believed that her mother had an affair with one of her
son-in-laws.
Like her mother, Sinfonea feels that she also has been sexually promiscuous throughout her life and now at the age of 50 wants to explore her
sexual behaviors. Sinfonea had her first sexual experience at 12 years old.
She would sleep overnight at a neighbors home where she began playing
with a 7-year-old neighbor boys penis (Interestingly when Sinfonea talked
about these sexual episodes, she would do so in the present tense). After
that, sexuality became a stage on which she could play a different role,
one on which she could express her own sense of power. Sinfoneas sexual
drive and behaviors were an ongoing source of internal distress. Her religious
and social background, which she also internalized profoundly, transformed
the expression of her desire into a seesaw of self-blame and a sense of
completeness.
The cultural expectations and mores for women growing up during
Sinfoneas lifetime in rural Brazil were very traditional regarding gender

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roles. Girls were expected to be virgins until they married. The boys would
gladly sleep with the village girls but would not value them when it came to
selecting a wife. Even though Sinfonea did marry, she never felt deserving
of such status because of her sexual behavior.

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Case Description
It was a Wednesday morning. I was consulting, as usual, at a busy primary
care unit. This is a free health center run by government funds to serve the
less fortunate. On this particular Wednesday, Sinfonea had such an appointment. Her initial complaints were: I am not normal, nobody understands
me. I am really close to going crazy. Could you please lock me up somewhere and leave me there for a while? She went on to describe how her
alcoholic husband has been mistreating her for a long time. She talked about
how she felt despised by her mother, father, brothers, and sisters, and even
by her own children. My mom used to hold a knife to my neck Sinfonea
said: I feel there is no place in this world for me. I should not have been
born. I suggested that she alone could find her place in this world and
understand her suffering. If she agreed, she could come to see me two times
a week, giving her a safe environment to explore and understand her pain.
During the first months of therapy, Sinfonea presented as profoundly
submissive. Sinfonea regarded herself as someone who was easily hurt and
who felt constantly invaded by other peoples comments and actions. At one
point she said: Everybody wants to walk over me. I sometimes ask God five
hundred times: Why was I born, why was I born? My life is dedicated to
crying. Her narrative depicted her as defenseless against her husband. She
reported suffering emotional abuse and living with the continual threat of
physical assaults. In rages of drunken jealousy, her husband would accuse
her of having other sexual partners. He would also hide her more provocative
undergarments, insisting she might wear them in the presence of other men.
When he drank heavily he would become verbally and physically abusive
(often culminating in aggressive rough sex that she enjoyed). Each morning,
her husband would declare his love for her and promise that the previous
nights aggression would not be repeated. She would then give in to his
sexual desires and fantasies; however, she was disgusted by his alcohol
breath and lack of personal hygiene.
When asked to identify when her sexual behavior became problematic,
Sinfonea related two key moments of her life. Just after Sinfoneas first child
was born, her first husband, her true love ended the marriage and left
her and their daughter. Sinfonea blames the loss of her first husband to
her jealous behaviors and feelings. Feeling abandoned, Sinfonea became
profoundly sexual, and anxious about her ability to care for her child alone.
She recalled having fantasies that her inadequacies would lead to the childs
death.

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Sinfonea returned to her family until she married her current husband.
Shortly after beginning her new life with her current husband, Sinfonea
recalled an increasing fear of being left alone. It was at this point that the
repetitive sexual behaviors began.
She expressed feeling anxious about her husbands health. She was
afraid that he would fall ill due to his drinking. She went on to say: I can
say that I am afraid of losing him, not because I like him, but because of
sex. I cannot do without sex. How would Sinfonea be able to cope with
the abandonment and being alone without being able to readily medicate
herself with sex?
Asked to describe the kind of person she wanted to be, she imagined
herself as independent, in equilibrium and able to defend herself from others.
She knew, however, that this was an improbability. I have no letters, I am
illiterate. My husband calls me a jackass, he says I am stupid! She knew that
with so few skills and no formal education, the prospect of being able to
be self-supporting and independent was minimal. Like many women in her
circumstances, Sinfonea felt her only hope was to find someone to take care
of her.
As the sessions continued, her self-esteem and confidence improved
and she was able to talk about many intimacy issues. However her sadness
and loneliness remained a dominant theme throughout our conversations.
Eventually, antidepressants were prescribed and within a month, Sinfonea
reported a decrease in suicidal ideation and an increase in confidence and
motivation. Albeit, the focus of our sessions was on the same repertoire of
issues, Sinfonea reported physiological and emotional improvement due to
the medication.
Alongside this functional improvement, our sessions began to focus on
marital discord over sex. Her husband often told her that he owned her, and
she sometimes believed he was right. She went on asking herself: When am
I going to leave him? Sinfonea confessed that even in the beginning of the
current relationship, she felt a strong desire to have sex with other people.
She was currently feeling the same yearnings. It is a desire that is within
me, but I am afraid of leaving my husband and not finding somebody who
desires me. I am in my fifties already. At this moment, Sinfonea changed
the direction of her talk and spoke about the love she still felt for her first
husband, the father of her daughter.
Sinfonea would often visit her mother on weekends to enjoy sex with
her mothers neighbor. When her husband discovered some phone messages from this man it resulted in an argument that ended with her husband
raping her. Despite the increasing severity of her husbands threats of violence, Sinfonea gradually replaced her complaints about him and shifted
her focus to discuss her escalating sexual desires. She became preoccupied
with obsessive sexual thoughts and desires. She shared her sexual fantasies
about the men she met on the bus and on the streets. She would arrive

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for therapy dressed up, usually with a low neckline, and wearing perfume.
She fantasized about living somewhere very far away, where nobody knew
her. Where she would then behave as her real self, dress in sexy clothes
like the younger girls, and feel desired by all men. She would drink beer
every day to unleash her libido and become, in her words, a pervert. These
sexually charged narratives would often result in regression where she became childlike, defenseless, and dependent. She would seek guidance, answers, and reassurance. She would question her fantasies and herself and
ask, Where does this perversion come from? Do I have a mental illness?
To me this questioning seemed like an attempt to maintain a childlike dependence on me. Again she was looking to me for answers, guidance, or
maybe absolution. The answers, if given, would have comforted but not freed
her.
In most of the sessions, Sinfonea would talk about how grateful she felt
for the treatment I was providing. She used a saying common in Portuguese,
God is in heaven and you are on Earth. This reflected her view of me
as superior or more powerful, similar to other men she had in her life.
Sometimes Sinfonea would slip and call me pastor instead of doctor, and
she would catch it and correct herself. Maybe she fantasized that I would be
the man who would protect and save her.
She began to realize how often she was drawn to men who would hurt
her. She said her first husband was the only man she ever really loved and
claimed to still love him. She compared him to her current husband, claiming
that she loved her first husband despite his physical impairment (a small
penis) and as for her second husband all she liked about him was his penis.
Her first husband made her feel very comfortable in bed, just as her pastor
did in the therapy sessions (she then corrected this to doctor, a possible
projection to defend herself against her erotic transference).
In one of our sessions, after seeking an assurance that she was allowed to speak about anything, she asked to see my penis. I answered
that, while she could definitely talk about her desires, the relationship we
were building was of a different nature. This setting of boundaries seemed
to resonate with Sinfonea. This simple intervention along with further exploration gave Sinfonea pause to discern between sexual and non-sexual
relationships and how to draw boundaries. Thereafter, without being aware
of it, she described a few occasions in which she set limits on her sexual
behaviors.
As Sinfonea revealed more about her sexual intensity, she recalled a
time when she was 18 years old and attended a family party. She reports
that the husband of her sister, Amanda, got her drunk and raped her. He
then threatened her with further harm if she mentioned the assault to anyone.
Years later she told her mother and Amanda about this violation; at first they
did not believe her and ultimately blamed her for provoking the attack. She
recalled how she used to sleep in the same bed with Amanda and brother-

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in-law and fantasized about having sex with him. She also admitted that she
currently has rape fantasies about her husband disrespecting her and forcing
to have intercourse even when she was not feeling well.
As Sinfonea began to delve further into her sexual history, her earliest
memory was when she was 12 years old. She recalled how she would
molest the 7-year-old neighbor boy by playing with his penis. She would
go to sleepovers at her mothers friends house, and would attack the boy
during the night. On one occasion she manipulated the boy and thought she
felt him penetrate her. She even believed that she lost her virginity (though
she later discovered that nothing had happened). Her first real intercourse
happened when she was 15, with the father of her daughter: From then on
I never stopped wanting sex. Since then she had sex with many men and
most often initiated the encounters. She even recalled betraying her sister
Leticia by sleeping with her husband, who upon discovering this, never
spoke to her again. I was shameless at that time of my life. My mom had
the same problem, she told me. Because of Sinfoneas sexual improprieties
her family became very upset with her and grew more distant. Sinfonea felt
helpless and alone.
Sinfoneas accounts alternated between her intense sexual life and her
childhood relationship with her mother. For the sake of clarity, the two
themes will be described separately. Sinfonea presented herself as a highly
active sexual participant. She described an intensely vigorous sexual life
with her first husband. She also spoke about the first time she cheated on
her husband was with his nephew, with whom she had numerous sexual encounters. She was also having sex with a neighbor during that time.
She perceived that most of these men where just using her and hurting
her feelings. She did not take responsibility nor aware of how she might
be using them. Sinfonea felt deserving of her husbands aggression toward her. This was her punishment for her uncontrollable sexual desires
and behaviors. In these accounts, she constantly vacillated from being victimized to that of being a shameless pervert. She struggled to understand
and defend her position while fluctuating with an accompanying seesaw of
feelings.
Over time, Sinfonea explored more about her relationship with her
mother. She described how she never felt loved by her mother. She felt that
her mother treated her siblings much better, especially her sister, Leticia.
Her grandmother would often defend Sinfonea from her mothers attacks.
But after the betrayal of Leticia her grandma was displeased and rejected
Sinfonea. Her grandmother died before the two could reconcile, something
Sinfonea deeply regretted.
When Sinfonea was born, her father did not believe she was his daughter; rather she was the offspring of her mothers stepfather. This suspicion was so strong that he abandoned her mother, after which Sinfonea
was placed in the care of her grandmother. She began to understand why

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her mother did not show her any love or affection and was constantly
beating her. Her mother blamed Sinfonea for the breakup of her marriage.
She was beginning to realize how she was shaped by her own history and
in particular the circumstances surrounding her birth.
When she was seven, her mother took her back, but the reunion did not
last long. She was often farmed out to other families to work as a housemaid,
coming home only on weekends. Nevertheless, she felt secure around her
mother, despite all her other contradictory feelings. The same seemed true
of Sinfoneas husband; her conflicting feelings seemed to be responsible for
a kind of attachment from which she could not release herself.
Sinfoneas relationship with the penis seemed an important theme to
be investigated further. It was clear that she was worried about losing her
husbands penis. Sometimes she would say: I like his penis, I do not like
his person. She began her sexual life by actively manipulating a boys
penis and fell in love with a man who had a small penis. She described how
whenever she felt desire for a man, she wanted to see his penis and would
often request to do so. If she did not ask to see his penis, she would obsess
about it forever.
Outside therapy, she took up new leisure interests and began to explore
opportunities to improve her education. However, she continued to struggle
with her marriage and generally felt helpless to do anything about this.
Sinfonea slowly showed signs of improvement in overall functioning. She
was more confident about her ability to take care of herself and operate more
independently. Previously she would complain about not being able to read
the names or numbers on the front of buses, and would be accompanied
to sessions by her youngest son. Now she would take the bus to the health
unit by herself.

Case Conceptualization
Object relations derives its principles of human motivation from the need for
early relationships and consequently sees the primary goal of psychoanalytic
treatment as the modification of object relationships that have grown out of
these early relationships. Each object relations theory has a different view
of critical factors in the development and pathology. In light of the diverse
object relations theorists, this formulation will draw primarily from Donald
Winnicott and Margaret Mahler.
Over time Sinfonea developed sufficient despair and depressive symptoms to enable her to present for treatment. Likely, by virtue of her advancing
chronological age with its accompanying loss of sexual desirability, an internal crisis arose in which previous intrapsychic compromises no longer
worked for her, necessitating a new solution and enabling her to finally
advance in developmental age.

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Sinfoneas overwhelming sadness and anxiety when faced with the possibility of losing her husband (penis) or her sex appeal (her power over the
penis) unmasked her lack of internal regulation of self-esteem and an intense
fear of abandonment. With her fragile ego, she uses sexual encounters to
validate her worth and satisfy her need to merge with others, even though
this only provides transient gratification (Giugliano, 2003).
She relates to her partners as part-objects because of her incapacity to
reach a place of object constancy (Mahler, 1971). Sinfonea struggles with
the developmental tasks of the late practicing and early rapprochement subphase of Mahlers Separation Individuation process. This may be because the
abuse she reported experiencing interfered with the developmental process
(Giugliano, 2012). She defensively warded off fears of object loss and to a
lesser extent, loss of the love of the object. Sinfonea was prematurely cut off
from maternal responses and her dependency needs were met with shame
and guilt. Sinfonea experienced prolonged separations from her mother, permanent loss of her father, and a succession of supposed surrogate fathers
thus generating her lack of trust and fears of attachment and separation.
Her subsequent relationships in life consequently have taken on a transient,
shallow, indiscriminate and ungratifying pattern.
Even Sinfoneas relationship with her mother was characterized by a
succession of abandonments. In the absence of positive introjects, a holding, soothing self did not develop. Her mothers neglect or inappropriate
response to Sinfoneas needs left her with an incomplete sense of being
cared for. Consequently, feelings of terror, of utter aloneness, emptiness,
and helplessness emerged (Graham & Glickauf-Hughes, 1992). Without the
mothering from her maternal grandmother, however inadequate, Sinfonea
would be far more fragile. In an undifferentiated environment, her mother,
as the object of primary identification, was a source of unbearable frustration (Winnicott, 1960). Sinfoneas fragile ego is explained by her ambivalent
feelings towards this internalized object of cathexis (mother) that triggered
an internal sense of self-annihilation when faced with aggressiveness and
hatred. This is exemplified by Sinfoneas statement when we first met, My
mom used to hold a knife to my neck . . . I feel there is no place in this world
for me . . . I should not have been born. This internal object has remained
unmodified; hence Sinfonea expressed the same feelings towards her mother
throughout her life.
Sinfonea struggled in life to regain an object she never had, a father. By
defensively manipulating the part-object (the penis, in this case), Sinfonea
regresses to the safety and comfort of the Mahlers practicing sub-phase
where the world is her oysteran omnipotent place. She can powerfully
attract and play with any penis she wants/can get, in this omnipotent fantasy
object relationship. Accordingly, Sinfoneas sexual acting out represented an
attempt to regain control of the lost object. It was conceivable to preserve
her ego and to save the loved object through her sexual behavior (Klein,

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1935). At the same time the penis acquired a symbolic meaning of power,
which could be related to penis envy. A pervert, as she sometimes called
herself, will use part-objects (such as the penis) and eventually discard them,
not being fully able to build a true-self relationship.
Khan (1981) stated that perverts treat human objects as things, as
transitional objects to be used, idolized, dirtied, and then discarded. Khan
equated desiring an incomplete object/sex partner with a drug fix, used
to escape pain, rage, depression, or paralyzing apathy. In the process of
actualizing her needs, Sinfonea fails to truly involve herself because her sex
partner is not seen as a whole person with depth. Sinfonea repeatedly talked
about penises as if they had a life of their own, apart from the person to
whom they belonged. In this realm, the penis can be seen as a transitional
object that developed into a fetish object and retained this characteristic
throughout her adult sexual life (Giugliano, 2003).
Sinfoneas childhood was spent in a world of women, where male figures were present only as sexual partners. She would repeatedly recount
how her mother was believed to have had an affair with her son-in law,
the husband of the oldest child, Isabela, as well as with the current husband of her grandmother. Stories of her mothers intense and inexhaustible
sex life created for Sinfonea a boundariless environment, where she could
play with a childs penis during her latency period and have sexual encounters with her sisters boyfriends and any other man she desired. She also
used sex to validate her illusion of omnipotence and mastery. This supports
Winnicotts potential space phenomenon discussed earlier. It was in this
space where she played her games. The irresistible seducer becomes the
central defensive role using sex to validate the grandiose illusion that the representational world can be omnipotently and pleasurably manipulated and
controlled (Coen, 1996). The attempt to solve problems or control anxiety
through illusory means leaves Sinfonea doomed to repeat the action endlessly because using the sexually addictive behavior has no effect in reality
on the problem she is trying to solve. In reality the process increases reliance
on sexual acting out for magical solutions, to the exclusion of mastery over
the conflicts (Graham & Glickauf-Hughes, 1992).
Sinfonea used her sexuality in this space between her internal world
(fantasy) and her external world (reality). Winnicott (1971) defined this space
as an intermediate area of experience, a transitional space, where the child
will experience reality in an intermediate state between a babys inability
and his growing ability to recognize and accept reality (p. 3). At the same
time, this illusionary in between space offered an alternative to Sinfoneas
unbearable internal and external worlds. From the evidence of her repetition
compulsions it was clear that if allowed she would probably choose to
live in this transitional environment where she could use partial objects as
needed. Yet although Sinfoneas internal world remained unchanged, her
external world (i.e., aging, decreased desirability etc.) mandated conflict

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and demanded a developmental resolution. Given the many deficits in her

personal development, sex seemed to provide the only source of relief from
her depressive and anxious mood. So for as long as attainable she used
men, transient part-objects, to externally regulate internal affective needs for
comfort (Giugliano, 2003).
Sinfoneas relationship with her mother remained colored by the same
feelings of rejection. The triangulation of Sinfoneas early object relations
with her mother and her mothers partners (men who told her they were
her dad), are internalized lost objects: mothers love and mothers desired
objects. Even now when Sinfonea visits her mother, she still complains that
her mother never displayed love to her and sidelined her when her sisters
were present.
Sinfoneas sexuality appeared to be one of the few aspects of her life
where she could experience a momentary sense of pleasure and control.
In her first encounter as an adolescent with the 7-year-old boys penis, she
found an object to which she could relate differently, from a position of control, quite unlike the objects she had related to previously. (As an important
aside, it is not outside the realm of possibilities that Sinfoneas attachment to
sexualized part-objects [the penis] is a repetition-compulsion related to very
early incestuous sexual trauma that she might have repressed. She never
discloses or discovers an early history of childhood sexual abuse during the
treatment. Nonetheless, while still in late-latency or pre-pubescence [at age
12] she molests or plays with a 7-year-old boys penis. Surely, this was
traumatizing to a boy of such a young age. This play activity seems very
unusual for a girl, if she wasnt herself victimized in some virtually identical way. Whether or not this is so, only Sinfonea can unveil it.) Her sexual
desire functioned as a defense mechanism against the feeling of abandonment accompanied by a sense of revenge and the illusion of mastery over
what was once beyond her control. The repetitive characteristic of her behavior demonstrated how it had become the only way in which she could
experience closeness. Elmone, Lingg, and Schwartz (1996) discussed how a
traumatic experience can be reenacted repeatedly in an attempt to control
what was once uncontrollable.
Painfully negative and neglectful experiences are often repressed.
Nonetheless they often continue to exert dynamic influence on affect and
behavior in the form of an organizing unconscious fantasy (Arlow, 1969).
The impact of such unfathomable sentiment and longings on subsequent
choice of life partners is striking. Akhtar (2009) states, A girl who lacks
a father supportive of both her efficacy and her erotic strivings feels hurt;
the resulting anger can give rise to defensive idealization on the one hand
and helplessness and masochistic submission on the other (p. 15). Her repetition compulsion was selection of abusive men in hope of mastery and
control. But mastery does not always come easily. In her relationship with
her husband, Sinfonea alternated between submissive jealousies, born of a

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continuous fear of losing the object (penis), and being in control of her resentful husband. This led to a contradictory and conflicting position, where
she controlled the object (penis/husband), but constantly endangered this
control when in the presence of other men, as if she were testing the limits of the marital relationship and of herself. This experience also gave rise
to self-blame and punishment in the form of her husbands aggression and
alleged domination.

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Course of Treatment
Object relations theorists differ significantly but they have an underlying
commonality that human development and pathology are the consequence
of internalizing early interpersonal relationships. Therefore object relations
treatment concentrates on the manifestation of these internalizations in the
form of object relationships including the therapist. The intermediate space,
described by Winnicott (1971), plays a major role for the development of
transference. It is this space where Sinfonea can create and experience herself. From this small gap it was possible to build a relationship. Sinfoneas
transferential relationship was characterized by an intense idealization that
strengthened over the course of therapy. As a reaction to her narcissistic loss
of equilibrium, it served her to relate to an object as being complete and
all-powerful (you are perfect and I am part of you), while at the same time
allowing her to defend against the feelings of emptiness and despair she
encountered.
The submissive characteristics she predominantly presented at the beginning of her treatment demanded a caregiver. However as the transference
relationship gradually developed, her other self began to emerge. The possibility to play or experiment in a setting where the analyst survives the
patients drives without retaliation allows Sinfonea to experience herself as
whole. This laid the ground for the analytical process to continue.
She felt no difficulty talking spontaneously and seemed to value the
eye contact the sessions provided. While never demanded, this appeared to
be something she had not experienced often and was received with gratitude. During the early stages of her treatment, the transference was rarely
interpreted. When such interventions were attempted, they seemed to be
received as words without meaning, and were at the time incomprehensible to her. Jacobson (1954) suggests allowing the idealizing transference
in depressed patients to go on for extended periods without interpretation
because she believed such patients were attempting to recover their ability
to love through magical love of the analyst. To interpret too quickly is
to interfere with the patients need to use the analysts in a way that can
ultimately lead to a restorative function. Jacobsons primary contribution to
the technique was to show that the analytic treatment could be successful with severely depressed patients as long as the analyst is willing to be

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more flexible regarding the interpretation than classical technique allows in

psychoanalytic work (Summers, 2014).
Dealing with counter-transference through self-reflection and supervision was fundamental to determining the appropriate approach to this case.
Exposure to the patients repetitive sexual content was interesting, exciting,
boring, and annoying at different times. The vicissitudes of these feelings
were probably an important response to counter-transference analysis. It
was possible to identify crucial moments where the analysis of the countertransference prevented an enactment on my part. This played a major role
in shifting the content presented by the patient.
Analytically this case holds great interest, but the degree of care demanded by the patient was a concern. By making use of this countertransference, it was possible for Sinfonea to examine her dependency needs
as part of the conflict. Seduction was a customary mechanism for Sinfonea
to get her needs met. The presentation of sexual content, to some extent,
sounded as if Sinfonea wanted to seduce me, as she later revealed having
seduced a doctor before. When faced with no result of her indirect and unconscious seduction, Sinfonea directly addressed her desire to see my penis.
My refusal of her request allowed her the safety to reveal her most intimate
sexual encounters unifying the subjective fantasy with the objective reality
she had once believed to be separate.
Over time, the feeling of boredom came over me as Sinfoneas repertoire (resistance to leaving her husband and freeing herself from domestic
violence) became repetitive. It was as if she was asking me to do it for
her, to save her. Fairbairn described this moral defense. Because the child
is so dependent on the bad and frustrating object (in this case mother), she
absolves mother and blames herself instead, Im a bad girl. It is safer for
the child to believe that she is bad than blame the mother who has complete authority. If the child accepts herself as the bad object she increases
her chances of survival because she always has the opportunity to change.
Nonetheless if the child sees the all-powerful mother as the bad object, the
child is overwhelmed with a sense of doom. This leaves the child confused
with unconscious and undeserving guilt (Kernberg 2008). I became the frustrating but needed object. The feelings of anger were intimately related to
this situation, and represented a threat to the analytic relationship. Interpretations to resolve the unconscious guilt feelings brought an intensification of
Sinfoneas resistance of a negative therapeutic reaction. Because acceptance
would mean that she comes to terms with the libidinal attachment to bad,
ambivalently loved object, which is core of her internalized object relations
(Kernberg, 2008, p. 36).
Sinfoneas submissiveness and aggressiveness were important points of
identification that helped me to understand her and gauge my own capacity
to embrace the case. As the analytical process survived her unconscious
attack, Sinfonea gradually strengthened herself to denounce her husband

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with the aid of her family. Sinfonea got to experience herself as whole
within a relationship with me while she was increasingly able to see herself
independent from me.
As Sinfoneas need to externally regulate her self-esteem and mood diminished, her sexual acting out held less usefulness and therefore decreased.
She was referred to a local center that helps protect women from domestic
violence. She perused legal advice from public lawyers so she can further
protect herself from domestic violence. The more she individuated, the more
she became whole and the less helpless she felt. She left her husband. Sinfonea is in the early stages of repairing relationships with her mother and
siblings. Temporarily, Sinfonea moved back to her mothers home and is economically and emotionally supported by her daughters and sons. She was
referred to an adult educational program to get her diploma. She applied
and was accepted. She attends school, is looking for work and continues to
be seen for psychotherapy twice a week.

CONCLUSION
Through the therapeutic process Sinfonea was able to move toward object
constancy, through an integration of split-off, archaic, frozen-in-time, partobjects. The only sense of her pseudo-goodness from the beginning was a
(manically defensive) sexualized, powerful dominance over the good (little)
penis. What seemed to depress her was the sense of herself as small and
weak, and identified with the bad (abusive, powerful man/abusive mother)
object. Due to her identity as being the hated child product of incest, she both
experienced the self and the other (mother) as being bad. She experienced
little if any love from her mother, indeed mostly hatred. Her experience of
being lovable (good) came only from grandmother; whose own husband
was the alleged perpetrator of incest and Sinfoneas suspected biological
father. This made for great complications in her achieving object constancy.
She was left with disappointment and a sense of failure in self and primary
objects since she had such a dearth of early good enough primary love
objects with whom to identify. Sinfonea did not have an attuned primary
caregiver who could provide the potential space for Sinfonea to tease out
the subjective from objective and develop a sound sense of self.
Sinfonea existed in a compromised space between the internal (fantasy) and external (reality) to maintain psychological equilibrium. When
the external reality of aging and sexual desirability changed, the potential space changed, leaving Sinfonea depressed and despondent. Old coping
mechanisms no longer provided comfort. The use of part-object relations
to sustain her fantasy of being wanted and desired became in jeopardy of
collapse; leaving Sinfonea face to face with the early reality and future fears
of abandonment and attachment. Treatment focused on the integration of

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her split-off parts of self and object representations. From an object relations
standpoint, the treatment provided Sinfonea with an integration of the splits
in her affect and thinking. The distorted perceptions of self and other and
the associated affects were the focus of treatment as they emerged in the
relationship with the therapist (transference). The successful understanding
of the transference was a significant ingredient for the analytic treatment.

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