Machon Hasharon - English

Mark Roitman M.D.

Mark Roitman M.D.

 Psychiatrist, Psychotherapist, Sex Therapist, Hypnotherapist


Group Analysis (SAGE, London, Newbury Park and New Delhi), Vol. 22 (1989), 235-248


Dr. Mark Roitman


The term 'projective identification' (PI) was first conceptualized by Melanie Klein and since then there have been various attempts to find its relation to, and distinction from, other psychological concepts. Some writers have broadened the concept to include all interpersonal relations (Horwitz, 1983; Zinner and Shapiro, 1972; Malin and Grotstein, 1966); others see it as a pathological mechanism belonging to a specified area of emotional pathology (Kernberg, 1984; Meissner, 1984).


According to Klein (1946) the origins of PI are found in the death instinct. The infant, in the first months of life, experiences aggressive impulses and severe anxiety arising from this, and in order to relive these painful and undesirable feelings projects them on to the mother; but because of lack of differentiation between himself and the mother the infant continues to perceive them as his own and to identify with them.


Segal (1973), in her book on the work of Klein, describes PI as a phenomenon whereby the self projects its parts on to the object. This creates the impression of the object possessing those attributes projected on it. But as a result of a reintrojection of these attributes, the self continues to identify with these attributes and to experience them as his own.


Because the material that is projected returns to the subject, Kernberg (1984) and Meissner (1984) see PI as an unsuccessful projection, where the self unsuccessfully tries to relieve itself of undesirable impulses.


They explain the lack of success as resulting from incomplete ego boundaries between the self and object. Kernberg (1984) declared PI to be the main defence mechanism of psychotic patients and those with borderline personality organization.


According to him, PI is not found in patients with a neurotic personality organization, except in extremely regressive states. With neurotics, Kernberg believes projection takes place of PI. He sees projection as a more progressive defence mechanism whereby the self successfully projects the unwanted aspects on to the object and thereby disconnects and relieves itself of them.



Projective Identification as an Interpersonal Mechanism.


Horwitz (1983) wrote that after a person has projected bad and aggressive parts on to the next person, the projector begins to feel weak and vulnerable and to see that person as possessing bad and aggressive aspects.


This situation arouses anxiety of being hurt and avenged by the person on to whom the projection has been made. Horwitz wrote that from that moment the projector begins to maneuver in order to prevent being hurt.


In the part of this paper dealing with PI in groups, it will be shown that the person that projects often maneuvers the person or persons on to whom the projection has been made but in a way that he or she will indeed be hurt. Thus, the projector relives in a real situation the inner experience of being hurt. In other words, as soon as the projector sees the next person as possessing specific attributes, the projector adjusts his behavior towards that person according to the perception.


This description of real behavior of the projector towards the person upon whom the projection has been made brings us from the intrapsychic world of projector to the space of interpersonal relations. Let us see what happens to the person upon whom the projection has been made.

Horwitz (1983) wrote that those traits which are projected from one person to another, begin to affect the second person's behaviour. The second person, who is the target of the process, undergoes a change in emotional functioning as a result of an intrusion of emotional contents from the other person.


Many writers (Horwitz. 1983; Meissner. 1984; Segal. 1973; Bion, 1959) describe the process in terms of contents being 'put into' the other person.

Bion (1959) describes the process as an experience in which a person feels maneuvered into fantasies not his own. Grinberg et al. (1976) called this part of the process of PI - 'projective counteridentification'.


But how do emotional processes in one person cause emotional change in another and even affect that person's behavior?


The descriptions of breaking-through of undesirable mental contents from the psyche of one human being into the psyche of another, making the other behave according to those contents sounds perhaps mystical and unclear. It seems that some connecting links in those descriptions are missing. It is hard to understand how a person may behave according to characterisitics that in no way appertain to him.


It seems there is a very delicate play between the need of the projector on the one hand and the valence or tendency of the person who is the target of the projection to receive, express and to behave according to the traits that have been projected.


How does one person cause another to behave in a specific way even if this person is not inclined to this behaviour?


As has been stated previously, as soon as someone begins to perceive another as possessing specific traits or, in other words, projects specific traits on to the other, the projector also begins behaving towards that person according to his perception of the person and in an active way manipulates the person to behave according to this expectation.


This real behaviour of the projection is the essential link in the process of PI without which the whole process would not occur.


In fact, the process of PI can be seen as an interpersonal one in which the activation of characteristics of an individual takes place according to the internal need of another person who projects those characteristics upon that individual.


Dicks (1963) studied both the adaptive and pathological use of PI in marital couples. He claimed that PI is responsible for the strength of the bond in the couple. According to Dicks, a man or woman chooses a spouse by the other's readiness to be a container for his or her projections, either because the chooser is not comfortable with those aspects of him or herself or because he or she does not identify them as his or her own.


The man or woman will then try to manipulate the partner to behave according to those traits, in this way completing the chooser's personality. Dicks (1963) wrote that without this mutual involvement the marriage is incomplete and problematic.


In groups we see how one member, or the whole group, chooses another member most suited for the projection, who outside this group may behave in a way similar to expectations.


It seems from the above that interruption in the process of PI happens in acute psychotic states. In those states the projection does not find its way to the characteristics of another person on to whom the projection has been made. This kind of psychotic projection forms the phenomenon of delusion.


PI and object-relations Theory


The universality of the mechanism of PI; the discovery of the phenomenon in healthy relationships; a description of the parallel process between patient-therapist and therapist-supervisor, require us to take an additional look at object-relations theory and at the mechanism of PI as a part of the theory.


It is common in psychoanalytic literature to begin a discussion on object-relations theory by assuming that the infant project bad and murderous impulses on to the mother and then internalizes them again bound to the mother-object or part of it.


For methodological reasons and for better understanding of the mechanism of PI, let us assume that the process starts with the mother and other significant figures and not with the infant, even though the processes are parallel or happening at the same time.


The infant, even before birth, becomes an object of the parents' fantasies and projections. During the early years, when the child develops and is dependent upon them, the parents, by virtue of conscious and unconscious behaviour, bring about the development of those characteristics that they both consciously and unconsciously wish to see in their child.


The infant responds to the operant behaviour of the parents with his or her biological structures, wherein lies the potential for development of the whole range of human characteristics.


The next stage in the process is when the infant projects these acquired characteristics on to new external objects with whom he or she comes into contact in the process of development.


Through the process of PI it is as though the child invites the objects to enter into interaction and he or she introjects the newly-created object relations.


This process of projection and reintrojection of object relations is a continuing lifelong process. It is clear that object relations that are internalized in early life present a basis and therefore colour all further interpersonal relations in the future.


It is important to emphasize that in the process of development of the parent-child unit, the parents project not only and not necessarily, the bad parts of themselves. If the parents project on to the child their good and beautiful qualities, their love, their aspirations for achievement of their ego ideal, the child can develop those positive traits which please his parents and are of value to society and to himself.


But if through PI the parents cause the child to develop and express traits and drives that they cannot consciously accept within themselves, traits such as dishonesty, hostility, suspicion, inflexibility, promiscuity and antisocial drives, even though they are using the same mechanism of PI it can be assumed that the child will develop a character disorder of some kind of severity.


Projection and Identification as Externalization of Internal Dyads.


During development, the child enters into interpersonal interactions with various objects: parents; siblings; relatives and others. The relations that are established are then internalized by the child in the form of dyads that are made up of aspects of himself and aspects of the other from those interpersonal systems.


The child integrates these dyads into his developing personality and afterwards projects these dyads on to new interpersonal situations.


It is acceptable to think of projection and PI as mechanisms meant to relieve a person of undesirable parts.


Another function of PI can be seen - that of cognitive, affective and behavioural processing of the external reality by the internal world of a person made up of his internal object relations. This processing is meant to protect an internal continuity on the one hand, and the existence of relations with the outside reality and its objects on the other. One can liken this process to the construction of an identikit of external objects according to the variety of the internal object and self images.


In meeting with external reality, one part or another of the personality can be externalized according to both the internal and environmental needs of a specific interpersonal situation at a specific moment. Thus it is known that the same people, in varying interpersonal situations, take on different roles - that is, they project certain parts of their personality on the external object and other parts they leave for themselves.


The role of identification in PI demands further clarification. Often when using the term PI, it is not clear who is the object of identification.


Let us assume that a person, on contact with external reality, externalizes internalized relationship units, units that are made up of two-part dyads. Each dyad is composed of an aspect of himself and an aspect of an internal object.


The person executes this externalization by projection on to another with whom he enters into relationship aspects, traits of his internal object, while remaining or identifying with an aspect of himself from this internalized dyadic interpersonal system.


Now, through his real behaviour towards that same person, the projector causes the other to take on, or identify with, aspects or traits of the projectors internal objects. Thus, for example, a worker may project aspects of a parent on to his boss and draw out reactions that resemble those of his parent while behaving as he did when a child. In other words, the worker identifies with the role of child from his internal dyad.


In another interpersonal situation the opposite may happen. In this instance, a person will project on another some aspect of himself from the same internalized dyad while remaining or identifying with the traits or aspects of the internalized object from this dyad.


By his or her behaviour he will try to bring the next person to take on or identify with his traits from this internal dyad. Thus, the same person, when in the position of boss, will behave towards a worker as his parent related to him as a child. The boss will try to manoeuvre the worker into behaviour similar to the boss's own as a child.


Thus we see that both the projector and the receiver of the projection identify though each one with a different part of an internal dyadic system that undergoes externalization in a real interpersonal situation.


PI in Individual Psychotherapy


All that has been said about PI can take place in a therapeutic situation between therapist and patient. As an example, let us take a patient who comes to therapy with a feeling of frustration with life and anger at himself for not having succeeded, this will be the first stage in the process.


In the second stage, because of the intensity and intimacy of the therapeutic situation and with the therapist as a target of the patient's projection, the patient begins to experience the therapist as frustrating, and begins to feel anger towards him - this is the projection part of the PI. Until now all that is happening belongs to the intrapsychic world of the patient.

In the third stage, the patient begins, verbally and non-verbally, to behave towards the therapist as if the therapist is the cause of the patient's frustration. The patient may threaten and humiliate the therapist, find contradictions and faults in his or her personality. In addition, the patient can sabotage the efforts of the therapist by not turning up, coming late, remaining silent, withholding information and complaining about the therapist or by suicidal behaviour. All this is real behaviour within the process.


In the fourth stage because of the intensity of the accusations and the sophisticated behaviour of the patient, the therapist begins to discover traits within himself, that have become activated by the patient. The therapist begins to feel guilty, helpless, afraid of being hurt; fears punishment, abandonment, and feels frustration and anger - feeling that are universal in the human being and certain to be found within the repertoire of the therapist.


In the fifth state, if the therapist is not aware that these feelings are aroused as a result of the internal problems of the patient - the very problems that brought the patient to therapy - and that the patient's behaviour is guided by the unconscious need to relive his internal situation in the therapeutic setting, the therapist may express anger in various ways. The therapist may make premature or condemning interpretations, or reject the patient by canceling sessions, taking a telephone call in the middle of a session or even by unsympathetic looks.


In the sixth state the patient experiences the genuine anger of the therapist; the patient feels justified in his or her accusations and blames the therapist further. The therapist then feels and behaves more and more as perceived by the patient. This process, if not brought to consciousness, escalates spirally and can end with the patient leaving therapy or with 'acting-out' of another kind.


In the ideal situation the therapist is able to use his feelings to understand the therapeutic situation better. The therapist can examine his or her own feelings to understand to which need of the patient he is complying and which dyadic system of the patient will be complemented if the therapist behaves according to those feelings.


Ogden (1979) draws attention to the use of PI as a tool in the service of the growth and development of the patient. He claims that the therapist should not only show the patient the parts the patient projects, but also react to the patient in a way other then he would expect, so that when the patient maneuvers the therapist into a punishing reaction, the therapist ought to react with moderation and in this way break the patient's vicious cycle of ineffective personal relations. Bion (1959) and Horwitz (1983) claim that the internalization of moderate aspects of the therapist precede change and growth in the patient.


PI in Groups


Now that we are aware of the ability of a person to activate traits while in interaction with others, to influence the behaviour and be influenced by the psychic processes of another, we can assess the complexity of behaviour in a group situation.


If we look at the group as a stage, it is possible to see how each participant will act out an internal drama and use the other participants as players in the act. These personal dramas will create an exciting play in the process of group therapy.


Bion (1959) gave the phenomenon or PI the function of a corner stone in group behaviour. According to Bion (1959) each participant contributes his PI to the reservoir of the group mentality. Bion called these conditions basic assumptions.


Grinberg et al. (1976) write that each member in the group will exert pressure on the group in order to build on it his family constellation. The member will try to cause others to play certain roles while keeping some roles for himself.


In another article Grinberg (1979) writes that it is important to remember that every role in the group is a result of PI. Besides the special tendency of each participant to take on a specific role such as, for example, leader, follower, yielder, or scapegoat, the participant behaviour and approach will also depend on the others, whose PI will determine the role and the timing of its appearance.


Horwitz (1983) describes three group scenarios in which PI has a central function. The first of these is role suction. He writes that essential functions exist in the group and it is as though the group chooses or nominates the candidates most suitable for these specific roles. The word 'suction' expresses graphically the force with which the group places a person in the required role.


The second scenario is the spokesperson. This is the phenomenon of accepting the role of leader by expressing the central topic of the group.


An alliance exists between the conflicts and characteristics of the member on the one hand, and the needs of the group on the other.


Groups discover very quickly who expresses anger easily, who feels comfortable with erotic contents, or who can express dependency.


A common error on the part of a beginner group therapist is lack of understanding of the behaviour of a group member as being not only a result of personal tendencies but also as bearing the heavy burden of the group.


The therapist may feel someone is very annoying and spoils the group and that if this member were to leave everything would be in order. In most cases dismissing this member from the group will result in another filling the same role.


The question arises then how to differentiate between expressions of a member as spokesperson and expressions as a member's own right. If, for example, a member expresses resistance and the group expects the therapist to deal with him, it is more than likely that the group, in fact, passively encourages the resistance. The inability of a group to deal with the domineering person, someone who is silent or a chronic complainer, shows that that member is expressing the feeling common to the whole group. When a member speaks for himself the group will inevitably leave that member and adopt other subjects.


The third scenario is scapegoating. By the use of PI group chooses a member who becomes the spokesperson for some pressing but also frightening and unbearable impulses of the group. The group then actively defends against, rejects, punishes, scorns and even sometimes throws out the member, if the therapist does not discern that the group, in a symbolic way, is punishing itself for its unwanted impulses that have been projected on to that member, the therapist may find himself participant to the cruel sacrificing of a victim.


PI and the Group Therapist


Every group needs a leader and chooses one from its ranks according to its needs or by activating certain traits with the existing leader, as in a therapy group.


The group may by PI give the therapist a tremendous amount of power, yet in another situation reduce him or her to helplessness.


The therapist should use those projections which give him or her positive authority, belief in his or her skill and ability to be effective in his work with the group. The therapist must be able to shake off and return to the group in the form of interpretation those projections which would make the therapist bad, hostile, helpless or omnipotent.


Kaplan (1982) warms of the danger of an uncritical use of PI by the group therapist. Thus, a therapist lacking in self-confidence may ignore this trait within himself and become critical and scornful of a group member who shows the same trait.


The following examples are presented in order to illustrate the role of PI in a group setting and its possible use as a therapeutic tool. All the examples are taken from a group which is being run at an out-patient clinic of a psychiatric hospital. The participants are aged between twenty-one and forty-four, and are diagnosed as having personality disorders of varying degrees of severity.


Example One


Helen, thirty-eight years old and single, is a technician in a large factory. She would come dressed garishly and arrive a few minutes late. Then, without regard to what was happening, or who was talking, would immediately begin telling how everyone at work was conspiring against her and none of the women working with her would talk to her. Everyone at work hated her and envied her for being so attractive, so well dressed, and for having the boss as a friend. It happened at her previous job too, it was the same with her sister and then again with her mother, it was the same everywhere; people were simply not good.


The group listened to Helen patiently, tried to give her advice, but to no avail. She gradually accused members of the group of not understanding her, of laughing at her and of being envious of her. 'How can they help me? Are they psychologists? I need an individual therapist'.


At this point the group became furious. Mary told her she did not know how to listen and that she was not the only one in the group. There were others who wanted to speak about their problems. This was enough for Helen. She took her bag, got up, and in anger cried out: 'I told you everyone hates me. I need an individual therapist'.

The example demonstrates how Helen externalized her internal object relations system of persecutory internal objects. These she projected on to the group and by her provocative behaviour caused an activation of those traits in the group. The group eventually assumed the role of hurting and rejecting Helen, in a sophisticated way, using Helen as a receptacle for its own projection of persecuted and irritating parts.


As long as Helen talked on endlessly and without better judgment, the group members, by their pointed and cunning questions, caused her to continue and get deeper into trouble, in this way she became the 'crazy' one in the group. It was helpful for everyone to become organized at the same time, to feel healthy and logical, while only Helen, the 'crazy' one, allowed herself to demand an individual therapist. When the group was rid of Helen, for a meeting or two, all this pseudo-organization broke down and the sanity disappeared until another member took on the role of a sick, miserable or 'crazy' person.


In our interventions we tended to react in a moderate, accepting manner to Helen's provocations. We protected her from becoming the scapegoat of the group. We continually made interpretations, both individual and to group as a whole, of the process of PI with emphasis on the balance between Helen's contribution and that of the group.


In the following sessions Helen was more relaxed and managed to relate to others without taking on her old role, in spite of the group's efforts to put her there. This clearly demanded of her maximum effort and concentration. We believe that her new behaviour could break the vicious cycle of pathological PI and that she would make new internalizations which would change her internal structures.


Example Two


This example shows the use of PI by the group where the therapist became the object of the group's projection and one of the group members was chosen as speaker of the group. During the session difficult issues arose concerning crossroads and ambivalence, every new problem more difficult than the one before.


Mary, the youngest in the group, said she did not know what she wanted to do with her life. Everything bored her. She did not want to be a clerk because she disliked office work. She wanted work with some mobility. Someone in the group suggested that she become a tourist guide, but this was not possible because of her religious background and because she did not travel on the Jewish Sabbath. She did not wish to be a nursery-school teacher because she did not like children. She had no patience for studying, and it bored her to be at home.


Then Debbie raised the problem of where to spend Passover. Her father was critically ill and she knew this would be his last Passover, but she disliked him, just as her children did. On the other hand she could go to her late husband's kibbutz where there was someone whom she really cared for. He, too, was very ill and he had asked her to be with him for Passover. Her children were also fond of him.


All during the session the group ignored the interventions of the therapists, the members gave advice to one another. Usually the advice given contradicts. In this case, half of the group advised Debbie to go to her father while the other half said she should go to her friend.


Toward the end Alex, who had been silent the whole session, said: 'I have a problem. I have to do my yearly military service in a week's time. I feel I can't do it. What should I do? I would like to do the service on my own terms. I'm in a special unit, I have been through the wars. I would like to do my service without guard duty and only in July or August. I would like my officer to be considerate of my wishes. But I wouldn't like to lower my medical profile. I wouldn't like to just be in the Civil Guard, I was always part of the action. I'm not prepared to sit around with a broom (1) in my hands. So what do you say, Doctor? There are only two-and-a-half minutes left. Can you gibe me a letter of recommendation?'


This is an example of how the group when in regressive, ambivalent state, struggling with violent and sadistic internal objects, succeeded by using Alex - as speaker - to project on the therapist the role of helpless and desperate parent unable to help and to protect, cruel and punitive and ready to avenge the hurt inflicted upon him. Mary also joined in the attack with Alex: 'Just a moment, I don't understand, are you or aren't you giving Alex a letter?'


Thus, in a moment, the therapist was manipulated into a situation in which whatever would be done would not be good. In a situation such as this, it is important that the therapist will be able to stay with the experience of despair, ambivalence and anger that have been aroused. It is important that he does not give in to feelings of despair and then abuse his authority by insulting or hurting one of the group members.


It seems that Alex, after attacking the therapist, was taken aback. On the one hand he was afraid of destroying the therapist as the father-figure, on the other, of the therapist's vengeance. But when Alex saw that the therapist did not take the role that he had assigned to him, he smiled and asked in a relaxed and playful tone: 'So what do you say, will we have a government or not? It really bothers me whether or not the government will hold out'. To this the therapist answered, with a smile: "Maybe you are asking, Alex, whether we, the therapists, will hold out'.


Example Three


This demonstrates how the group use of PI can activate the therapist's conflicts and how this can delay the solution of the group's conflicts.


Danny was referred to the group two months after it had started. In a short interview with me, before joining the group, he told me he had been referred to the clinic a few days earlier because of anxiety attacks which disturbed him in his position as manager at work. In the meantime he was feeling better.


On his first meeting with the group, he introduced himself by his first name and said that that would be all for the time being. He was silent for a number of sessions and when asked, said he was usually quiet and did not like talking.


At the end of the sixth meeting, he waited until all participants had left and then asked me if it was necessary to continue taking medication. The therapeutic contract stated that there would be no referring to the therapist before or after the meetings and that no one would be given individual sessions.


I was trapped in a situation where I did not know whether Danny was taking medication, nor could I determine whether in fact he needed it at all. I told him he should raise the question in the group. Although I said this, I was not sure how I could conduct a psychiatric examination within the group or give a recommendation about medication as I do with my individual patients.


During the next ten sessions, Danny sat silent except for short skeptical comments here and there and a sarcastic smile. When questioned, he replied: 'I asked the doctor a question and I'm waiting for a reply. I have patience'.


In spite of his silence, I found myself more and more preoccupied with Danny. I felt guilty and unworthy as a group therapist with Danny not speaking, and as a doctor for not knowing whether or not my patient is taking medication, or whether his symptoms had disappeared. According to his behaviour in the group, I saw that he did not need medication, but how could I say this if he did not ask me? I was angry with Danny for hiding the fact that he received medication and at myself for not asking him. I found myself fantasizing that I give him a punch.


The matter reached a climax during the twentieth session. Four minutes before the end of the meeting, Danny began talking: 'Today I feel much better than when I first arrived. I do exercises every morning and evening. I'm no longer afraid to leave the house. I'm not sure what helped me, whether it was the group, the tablets or simply a matter of time. I would like to know from Dr. Roitman whether to continue taking the tablets or not?'


There was silence in the room. All eyes were on me. I felt like a toreador in the ring when the bull attacks and there is no possibility of escape. There were only two alternatives: to kill the bull or to climb onto his horns. The tension was probably more than Rita, one of the participants, could bear: 'But you already told us outside that you no longer are taking medication'. 'Shh, it's not important' - the group tried to quieten Rita. I almost had to pinch myself in order not to burst out in haste. I said we would continue talking next time.


The attack was so intense that, immediately the group left the room, both the co-therapist and the recorder turned on me: 'Why didn't you answer him? He simply asked whether or not he should take medication?'


It took me a long time before I could rid myself of the heavy feelings that I had from this session. With time I began to understand that Danny, through an unconscious process, had been chosen by the group as being the most appropriate to express the regressive need of the group: to be understood without words, as an infant by the mother and when not understood or satisfied, to scream with rage. I understood that the need of the group at that moment was to project on me traits of being the bad mother. Through active manipulation the group put me in this role and then accused me. My feelings of guilt about my omission concerning the medication made it easy for the accusations of the group to connect with my own internal accusing and punishing objects causing me feelings of anger and guilt.




It is possible to see PI not only as a limited defence mechanism symptomatic of one or another pathology, but also as a variety of psychological processes, intrapsychic, interpersonal, group and social that may be either adaptive or pathological, depending on the situation.


Diagnosis, bringing them to consciousness in therapy groups will enable participants to recognize these processes when they take place in interpersonal and social situations in their lives. This will help them to avoid being hurt and hurting others, the problem responsible, to large extent, for the suffering that brought them to therapy.




Appreciation is expressed to Rona Strauss, PsSW, for her help in translating the manuscript and to my colleagues for their suggestions and criticism.

1 'Broom' is slang for an old model of long gun used by the Civil Guard.



References:Bion, W.R. (1959), Experiences In Groups. New York; Basic Books. Dicks, H. (1963), 'Object Relations and Marital Studies', British Journal of Medical Psychology 36: 125-9. Grinberg, L., Gear, M.C. and Liendo, E.C. (1976), 'Group Dynamics According to a Semiotic Model Based on Projective Identification and Counteridentification', in L.R. Wolberg, et al. (eds) Group Therapy, pp 167-79, New York: Stratton Intercontinental. Grinberg, L. (1979) 'Countertransference and Projective Counter-identification', in L. Epstein et al, (eds) Countertransference, Vol. 8, pp 169-91 New-York: Jason Aronson. Horwitz, L. (1983) 'Projective Identification in Dyads and Groups', International Journal of Group Psychotherapy 33(3): 259-79. Kaplan, R. E. (1982) 'The Dynamics of Injury in Encounter Groups: Power, Splitting and the Mismanagement of Resistance', International Journal of Group Psychotherapy 32: 163-80. Kernberg, O. (1984) 'The Influence of Projective Identification on Counter-Transference', Presentation at the First Conference of the Sigmund Freud Center of the Hebrew University of Jerusalem. 'Projection, Identification and Projective Identification', 27-29 May, Jerusalem, Israel. Klein, M. (1946) 'Notes on Some Schizoid Mechanisms', in M.M. Klein (ed.), development and Psychoanalysis. London: Hogarth Press. Malin, A. and Grotstein, J.S. (1966) 'Projective Identification in the Therapeutic Process', International Journal of Psycho-Analysis 47:26-31. Meissner. W.W., (1984) 'Projection and Projective Identification'. Presentation at the First Conference of the Sigmund Freud Center of the Hebrew University of Jerusalem. 'Projection, Identification and Projective Identification', 27-29 May, Jerusalem, Israel. Ogden, T.H. (1979) 'On Projective Identification', International Journal of Psycho-Analysis, 60:357-73. Segal, H., (1973) Introduction to the Work of Melanie Klein. New York: Basic Books. Zinner, J. and Shapiro, R. (1972) 'Projective Identification as a Mode of Perception and Behavior in Families of Adolescents', international Journal of Psycho-Analysis 53:523-30.


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(A lecture given at an International Conference on Sex Therapy and Rehabilitation - 1998)


Dr. Mark Roitman


The case I will present now is interesting because of diagnostic and treatment challenges that arouse during a total of eight months (30 sessions) of therapy.


Michael is a 50 years old man. With his childish face, shy smile, and thick black hair, he looks much younger than his age. He lives with his elderly parents and a younger sister.


His mother was hospitalized in a psychiatric hospital about 30 years ago and diagnosed both as Heibephrenic Schizophrenia and Reactive Depression, which means that we don't have her exact psychiatric diagnosis.


His younger sister was hospitalized several times in different psychiatric hospitals. She is diagnosed as Chronic Schizophrenic. Michael describes her as very shy, unable to contact with people or leave home alone. However at home she cleans and cooks compulsively.


Michael's father is a retired clerk and Michael describes him as a very nervous and a "heavy customer character" suspicious man. The family leads a very isolated life style, with no one ever entering their home.


Michael himself developed as a shy suspicious boy with very few friends. He used to study for long hours and had good grades, especially in mathematics. He graduated high school and entered an engineering school.


During a reserve service at the army, in the age of 20, he had his first psychotic breakdown and was hospitalized. During 13 years between 1967 till 1980 he was hospitalized in four psychiatric hospitals for at least eight times. The clinical pictures as described in the release letters - vary from catatonic, paranoid, to depressive states. And the diagnosis varies from Hebephrenic Schizophrenia to Reactive Depression, which means that the diagnosis is unclear.


During the hospitalizations and between them, he expressed paranoid thought against his father and against his physicians. He made two serious suicidal attempts by trying to hang himself and tried to cut his penis.


Despite the hospitalizations he managed accomplish his BA in mathematics with excellence. He tried several jobs but was fired after a short time because of slowness and mistakes he made. His longest job (3 years) was as a receptionist in a public outpatient clinic.


After his last hospitalization, in 1980 he never worked again, and lived on social security pension. During his hospitalization and till his arrival to our clinic he received different doses of antipsychotic, antiparkinsonic and antidepressant medications. At the time of his first visit he received Clorpromasin 100gr / day.


All of these years he used to get up late and to get his breakfast in bed, served by his sister. His only duty at home was to take his sister for walks and to the doctor. Once a week they went together to a coffee shop or to MacDonald's. Every once in a while Michael would visit his married university friend. Most of his time at home he used to watch television or to read newspapers.


His sexual life consisted of masturbation about twice a week. He always masturbated by standing in the bathroom and soaping his genitals. He never masturbated in a lying position in bed because of the fear to be overheard by other members of his family, especially by his sister, for whom he believed it would be disastrous because of her shyness and fear of any expression of sexuality.


His only experience with a woman was a single unsuccessful visit to a prostitute in the Red Lights district during his visit to Amsterdam, many years ago.


On his first visit to the clinic, he looked well groomed, a little bit shy and childish. He was a little bit anxious, and had difficulty to listen patiently. His pattern was to cut me in the middle of the sentence when sensitive topics were touched. When hearing my Russian accent he started telling old Soviet jokes and slogans.


However there were no signs of psychotic or mood disorders. His judgment was not impaired and he seemed well informed about political, social and financial matters.


However there was something strange in him. He looked like a person from another historical epoch. His reason for coming to the clinic was his wish to learn to function sexually. His plan was to find a woman friend through a matching agency and he wanted to gain some experience before entering a real relationship.


He expressed fear and suspicion of women by stating that all women want the same thing, namely to marry him and then get hold of his money and possessions.


The first stage of the treatment included meeting the surrogate outside the clinic, developing social skills, keeping a conversation, functioning as a partner in a restaurant and during a visit to a museum.


He formed a good, although in some ways childish relationship with the surrogate. The next stage was a very slow work on "Sensate Focus". Michael advanced enthusiastically, he watched with interest video materials, asked many questions.


In the sessions with the surrogate he performed well sensual massage but mostly enjoyed being taken care of, caressed, massaged, and washed. Both Michael and the surrogate reported a pleasurable atmosphere, good humor and spontaneous erections.


The next stage was mutual masturbation. Michael learned well to excite and masturbate his partner, but was unable to reach an orgasm except in a standing position when his genitals were soaped.


After a few disappointments in reaching orgasm in positions other than that, he started having problem achieving erections. It was impossible to teach him to put a condom because a condom would slide off his soaped penis. He was reluctant to masturbate differently at home and reported reduction in desire to do it at all.


At this stage he became suspicious of me and of the treatment. He expressed suspicion that our only goal was to rid him of his money. The surrogate that was new in the clinic and was eager to succeed, also turned with claims to me: You are the doctor. Is there no drug or injection that will give him a good erection? If you don't know any send him to another doctor". It was obvious that the whole process reached a crisis.



My consideration at this stage was as follows:


1) The physical examination at the beginning of treatment showed no medical problems.


2) Laboratory findings: Prolactin and total Testosterone levels were normal.


3) The patient masturbated and reached orgasms with no problem previous to the crisis.



4) The patient reached erection during the "Sensate Focus" state of the treatment.


5) There was a little possibility that the dose of 50 mg of Cloropromasin interfered with his erection and ejaculation.



6) It was dangerous to reduce farther his antipsychotic medication, especially when he became belligerent and suspicious.
At this point of treatment the surrogate had to cancel 3-4 sessions because of medical problems of her own, leaving Michael and me in doubts concerning the continuation of treatment.



The situation was ideal for acting out, and it didn't take long for Michael to act. He didn't appear for the session with me and cancelled the payment for his last appointment.


He arranged a visit to a private urologist, not the one connected with the clinic.



The laboratory tests showed slightly elevated levels of Prolactin and slightly lowed levels of Testosterone. (On the initial examination the levels were normal). The NPT test showed 5 erections during an 8 hours sleep lasting from 8 to 31 minutes. The tumescence was good, and the Rigidity - good at the base of the penis and weak at the distal end. The conclusion was - clear inefficiency of rigidity at the distal end of the penis. The Urologist prescribed Tesophalmed Forte (A combination of Yohimbin with Strichnine) and Xatral - a drug for the possible enlargement of Prostate Gland.


In the session that followed four weeks of disconnection Michael looked relaxed. He told me: "You see, I told you that my problem was physical and not psychological".


He was ready to go on with the surrogate therapy. Seeing Michael relaxed and in good spirit as he was, I decided to take the risk and take him completely off the Clorpromasine that has a potential of elevating prolactin levels. This same session I recommended him to quit taking Antihypertension drug that was prescribed to him by his family doctor since his blood pressure was normal during continuous measurements for several months.


The renewal of sessions with surrogate was very successful. Michael had good erections, learned to put a condom. Very soon he made penetration and achieved orgasm in different positions.


His spirit was high and one day he started a course in C++ - an advanced computer language. In a few months parallel to his progress with the surrogate he finished the course with excellence and began looking for a real job in programming.


After a few disappointments in the interviews he decided not to reveal his real life story and invented a cover story. It is now three months that he successfully works in a computer company with a very good salary.


Meanwhile his progress with the surrogate was amazing. He became familiar with the missionary position, woman on top position, woman on four position, sitting position. He even managed to orgasm twice with an interval of twenty minutes. The surrogate couldn't stop praising him. He had strong erections even before taking his pants off.


A question remained: was his success a result of the medication he received from the urologist or quitting Clorpromasine or the Antihypertension drug. Or was it a placebo effect or a function of advancement in surrogate therapy.


At this stage I decided to take him gradually off Tesopalmed Forte. He used to take two tablets daily morning and evening. Not wanting to destroy the placebo effect if it was one, I used the technique of disorientation originally used in hypnosis. I ordered him for a week to take off one pill in the evening every other day. The next week, to take off the pill in the morning every other day - at the days he took the pill in the evening. The week that followed, I advised him to stop taking the pill in the evening, and the next week - to stop taking the pill at all.


All those weeks his sexual function continued to improve. In the middle of the process of taking him off the drugs, when already sure of successful termination of the treatment, I asked Michael what were his plans after the termination. I was sure of receiving a mature and reasonable answer.


Instead Michael told me that all women want the same thing - to marry him and get hold of his money. He told me that he trusts no one. It is obvious that he can't leave his sister alone after his parent's death and no woman will agree to live together with his sister. His sister also will never agree to let him live with another woman.


His next passage was that the treatment is very expensive and he decided to stop it now. All reasoning trials, that he had only two - three sessions left and it made no sense to leave with medication while he can get rid of them completely, did not help.


In the last minutes I tried to explain to him that his investment in treatment was probably the best investment in his life. For the first time in 50 years he has a real job with a very good salary, for the first time he discovered himself as a virile man, able to satisfy a woman and enjoy sex himself. For the first time in 30 years he was off all the medications. All my explanations and pleads for no avail.


While he was already at the door I uttered: "You are a heavy customer", those same words that he used to describe his father. Michael hesitated, then smiled, turned around and said: "let's arrange an appointment". This was the second crisis in the treatment. The next session Michael told me that when I said: "You are a heavy customer" - he understood that he is suspicious as his father. "Not that my father is wrong, but I decided to give it a chance."




The case I presented here is interesting because of complexity of problems and challenges it posed upon the therapeutic team. We see here a chronic mental patient with severe psychopathology in the family, symbiotic relationships with his mentally ill sister, suspiciousness as a symptom, a character trait and family strategy, variety of medical problems and all this in one 50 years old virgin man.


We see in this presentation how surrogate sex therapy can be used as a powerful lever in rehabilitation process of an otherwise hopeless case.


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An essay in the Psychopathology 20:220-223 (1987)


D. Eizenberg, I. Modai, M. Roitman, E. Mendelson, H. Wijsenbeek

Abstract. The association between musical hallucinations, depression and acquired hearing loss is described in two elderly patients. Following the presentation of this underdiagnosed clinical phenomenon we propose that musical hallucinations should be addressed as a final outcome of several factors including both mental and physical components. This conceptual framework enhances our understanding and treatment of such phenomena.





Acquired hearing loss is increasingly encountered among the elderly. Musical hallucinations associated with acquired deafness and depression is an entity rarely described in the medical literature, and is considered an underdiagnosed phenomenon [1]. An association between hearing deficits and mental disorders in old age has generally been assumed but has been poorly substantiated in the psychiatric literature [2].


The contributory role of depression in the occurrence of musical hallucinations was described in two patients while in a state of nonpsychotic depression [3]. A recent survey showed evidence of an association between hearting loss and dysphoric states [2], thus elderly depressed patients are more susceptible for developing musical hallucinations.


Surprisingly, there are possibly only two other case reports of such an association in the medical literature [4, 5]. We present two case histories of elderly depressed patients with musical hallucinations.


Case reports

Case No. 1


B. A., a 70-year-old patient, married and mother of a son, was referred to our clinic in an acute psychotic depression. She suffered from four recurrent depressive episodes in the last 30 years. At the time of admission to the hospital, B.A. complained about anxiety, depressive mood and voices speaking to and about her. In addition, she spoke about musical hallucinations, which appeared during the last 4 months concomitantly with the last depressive episode.


The musical hallucinations were of childhood songs, monotonous and extremely disturbing by their persistence and exacerbation during silent ambiance and at night. During the 4 months they progressed into hallucinations of two voices singing, a man sang love songs, which she remembered from her childhood in Hungary.


She was treated with haloperidol, 3mg/day, which affected a disappearance of the critical libretto. Central and peripheral brain atrophy was demonstrated by computerized tomography.


Case No. 2


A.M., a 65-year-old woman, married and mother of 2 children, was referred to the psychiatric outpatient clinic in a depressive state. She manifested depressive affect, inability to work, insomnia, decreased appetite, constipation and anaclitic anxiety. She had suffered 3 similar kinds of depressive episodes 4 years ago, and also attempted suicide by swallowing 20 capsules of Amytal Sodium 300 mg. At that time musical hallucinations first appeared in the form of melodies from radio programs. The songs disappeared concomitantly with remission and for 3 years she felt well. When the depression reappeared, the songs emerged again and she was able to vocalize them. She gained insight into this phenomenon by the reality feedback of her husband.


The course out of improvement of the depressive episode was inconsistent due to noncompliance problems. There were three remissions and exacerbations due to cessation of medication and therapeutic contact. Every exacerbation was accompanied by the reappearance of musical hallucinations.


The drug treatment included first amitriptyline, 150 mg/day, then a trial of chlomipramine. 150 mg/day, followed by doxepin, 100 mg/day. When dosage was reduced after 2 months to 75 mg/day of doxepin, there was a resultant clinical decline and concomitant reappearance of musical hallucinations and depression. This time the music was a combination of religious melodies from the radio. And a 'noise of woods'. The music and the noise increased when less external stimuli were available.


Recurrent electroencephalograms performed during her evaluation and treatment showed no epileptic activity. Computerized tomography illustrated slight atrophy in the parietal lobes. Audiometry revealed a borderline sensory neural decline of hearing in both ears.





Hallucinations occur in all sense modalities with auditory hallucination by far the most common [6]. Hallucination, among other perceptual disturbances, may be very hard to evaluate for there are few objective signs associated with them. This is one of the reasons why hallucinations are rarely of pathognomonic significance. The presence of other associated signs and symptoms is usually required to establish a specific diagnosis.


Common clinical practice suggests that the less formed the hallucinations the more likely they are due to biochemical of neurological causes, while the more formed, describable and prolonged hallucinations probably denote a functional psychiatric disorder [7].


Although hallucinations usually indicate a severe disruption in reality testing, auditory hallucinations may also occur in normal populations. Parish [cited in ref. 8] reported that approximately 12% of the normal population has experienced a hallucination in the waking state. Mott et al. [9] found in a control group of admissions to a medical ward 16 of 50 patients who reported experiencing an auditory hallucination at some time in their life [9].


In the medical literature there are a few case reports of patients identified by the clinical association of musical (formed complex) hallucinations and acquired hearing loss [1, 10, 11]. The hallmark of this group is the lack of psychopathology and advanced age.


The perceptual release theory of West [citied in ref. 3] hypothesized a disruption of the usual level of external sensory input necessary to inhibit the emergency of percepts of memory traces within the brain. Thus, previously recorded perceptions may by released into awareness and create hallucinations. One may conceptualize musical hallucinations as a net outcome measure of several components, which affect the normal 'balance' of sensory stimuli.


Regional brain atrophy disclosed by Computerized Tomography and a degree of hearing loss were found in both patients. These two findings are more prevalent among the elderly population and probably represent irreversible vulnerability of other components affecting perceptual processes to produce musical hallucination.


A significant relationship between hearing impairment and dysphoria was reported among an elderly population [2, 23]/ we recently described two patients with musical hallucinations while in a state of nonpsychotic depression [3]. One of them suffered from acquired deafness. But no such pathology was found in the other. Cessation of musical hallucinations occurred concomitantly in both patients with improvement of the affective state. The clinical course presented here by both patients supports the contributory role ascribed to depression.


Musical hallucinations are not unique to depression and/or acquired hearing loss. The effect exerted by drugs should always be considered.


A salicylate-induced musical hallucination in an elderly lady with otosclerosis [13] is a recent example of the clinical constellation of hearing loss and drug effect in an elderly patient. Our second patient described an increased intensity of her hallucinations during the first week of her second therapeutic trial with clomipramine. This could be attributed to the affective state of depression yet unimproved; on the other hand, the clinical phenomenon might represent transitory side effects of clomipramine.


It seems reasonable to address musical hallucinations as a final clinical outcome of several factors, some of which are organic (e.g. regional brain atrophy, drugs) and some of them functional (depression). A frequent diagnostic error arises if the physician seeks to make a diagnosis of organic or functional disease when in fact - both are present.


It has been suggested that formal musical hallucinations associated with deafness and/or depression are more common than generally appreciated [3]. One of the reasons given is that affected patients are reluctant to discuss their false perceptions lest people think them crazy [2]. We believe the phenomenon might exist among psychiatric patients as well who view their false perception as egodystonic.


Another reason might be the doctor's awareness. Our recognition of an additional two patients within the periods of 1 year attests to this fact. There is a tendency to ascribe all clinical manifestations to one or the other 'disorders' rather than to confront both simultaneously. Identification of contributory components, both mental and physical, will enhance our understanding and treatment of such phenomena.






1. Ross, E.D.; Joaman, P.D.; Bell, B.; Sabin, T.; Geschwind, N.; Musical hallucinations in deafness. J. Am, med, Ass. 231: 620-622 (1975).

2. Eastwood, M.R.; Corbin, S.L.; Reed, M.; Nobbs, H.; Kedward, H.B.: Acquired hearing loss and psychiatric illness: an estimate of prevalence and co-morbidity in a geriatric setting. Br. J. Psychiat. 147:552-5556 (1985).

3. Aizenberg, D,; Schwarts, B.; Modai, I.: musical hallucinations, acquired deafness and depression. J. nerv. ment. Dis. 174:309-311 (1986).

4. Clovis, W.I.: They hear music (letter) Am. J. psychiat. 133: 1096 (1976).

5. Ross, E.D.: musical hallucinations in deafness revisited (letter). J. AM. Med. Ass 240:716- (1978).

6. American psychiatric Association: Diagnostic and statistical manual of mental disorders; 3rd ed. (American Psychiatric association, Washington, 1980).

7. Ludwig, A.M.: The perceptual sphere in principles of clinical psychiatry (Free press, New York 1980).

8. Junginger, J.; Frame, C.L.: Self report of the frequency and phenomenology of verbal hallucinations .J. Nerv. Ment. Dis. 173:149-155 (1985).

9. Mott, R.; Small, I.; Anderson, J.: Comparative study of hallucinations. Archs gen. Psychiat. 12:595-601 (1065).

10. Hammeke, T.A.; McQuillen, M.P.; Cohen, B.A.: musical hallucinations associated with acquired deafness. J. Neurol. Neurosurg. Psychiat. 46:570-572 (1983).

11. Miller, T.C.; Crosby, T.W: musical hallucinations in a deaf elderly patient, Neurol. 5:301-302 (1979).

12. Gilhome-Herbst, K.: Jumphry, C.: Hearing impairment and mental state in the elderly living at home. Br. Med, J. 281:903-905 (1980).

13. Allen, J.R.: Salicylate-induced musical perceptions (letter). New Engl. J. Med. 313: 642-643 (1095). D. Aizenberg, MD Geha Psychiatric Hospital Beilinson Medical Center Petah Tiqva 49100 (Israel)


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Monday, 12 August 2013 06:54

Sex surrogates


A report in the Jerusalem Post - Oct. 1997


Gloria Deutsch


Dr. Mark Roitman, a psychiatrist specializing in sex problems, was horrified when it was suggested to him that women who work as sexual surrogates were considered akin to prostitutes.


"Nothing could be farther from the truth," he maintains. "These women are all educated and come from the caring professions - teaching, nursing, and social work. Yes they do have sexual intercourse with the patient, but only in the final stage of treatment. And surrogate is a very effective treatment in the majority of cases of sexual dysfunction.


Surrogacy - when specially trained women teach men with sex problems to function correctly - was pioneered in the fifties by sexologists like Masters and Johnson and Hellen Kaplan in the United States, is by any standards a fairly revolutionary concept even today, and especially in a basically conservative society like our own. Sexual surrogate is nevertheless regarded as an essential part of behavioral treatment for problems like impotence and premature ejaculation.


Dr. Roitman, who has a private clinic in Kfar-Saba, has been a psychiatrist for twenty years and sees many patients suffering from anxieties and depression, but fully one third of his practice is devoted to sex problems.


Any woman wanting to become a surrogate has to go through vigorous psychological testing and extensive interviews to ensure that she is suitable.


"We prefer mature women, between the ages of twenty five and fifty, from a stable background", explains Dr. Roitman. "They have to be single to avoid family conflicts. We're not looking for great beauties, just the sort of woman the patient would be likely to meet in everyday life. If you saw them outside the clinic, you wouldn't look twice".


Candidates who want to be surrogates have to go through a special course as well as be tested psychologically to ensure they have the right motivation. Patients to be treated by surrogates also have to meet stringent criteria.


"Men of all ages come to me with their problems" says Dr. Roitman, "and if I feel they would benefit from a surrogate relationship, I recommend it to them. Besides men suffering from impotence and premature ejaculation, there are many disabled army veterans whose treatment is carried out in conjunction with the Ministry of Defense. All these patients suffer from low self-esteem and social awkwardness and have problems in finding partners if single. Another group are those suffering from recurrent depression and personality problems of all kinds, and even schizophrenia. In conventional settings they were never considered candidates for sexual therapy and rehabilitation but in the surrogate clinic the results with these men are good".


This raises the question of the surrogate having to be alone in intimate - very intimate - situations, with a man whose mental stability is, to put it mildly, questionable.

"All patients who enter surrogate programs get a thorough psychological evaluation to decide if they are suitable", says Dr. Roitman, reassuringly, "No drug users or HIV sufferers are accepted, and condoms are always used.


Sessions take place at the clinic in a small room with a double bed and a shower and last 90 minutes. The procedure used is one developed by Masters and Johnson called Sensate Focus Exercises. The patient learns at each session, to touch and be touched, progressively in different parts of the body.


Explains Dr, Roitman, "For the first time in his life, he learns to feel comfortable with the opposite sex and becomes acquainted with his own and his partner's body".


Every meeting of a patient with his surrogate, is preceded by a meeting of the patient with his therapist, but perhaps more importantly, the surrogate also meets with the therapist to plan the session thoroughly. The patient always knows what assignments are going to take place and the surrogate will work in the session strictly according to the plan she has received from the therapist.


The number of meetings depend on the particular problem and the pace of progress varies for each patient. Anything between twelve to fifteen meetings take place on average. The cost to the patient, other than those subsidized by the Ministry of Defense, is $ 220 for the surrogate, and around $ 100 for the preliminary meeting with the therapist. It is certainly not a cheap form of treatment but Dr. Roitman emphasizes that when the treatment is completed the patient has not only solved his sexual hang-ups but is functioning better on all fronts.


"Patients who were out of work have gone back to their jobs. They no longer need drugs to counter depression and socially they are rehabilitated. So although it is very expensive, it has a wide-ranging beneficial effect," he says.


In his private clinic, Dr. Roitman uses sex therapy videos to reinforce the lessons learned from the surrogacy sessions. These films, made by s husband and wife team of therapists form the United States, leave little to the imagination and it was mildly disconcerting to be given a demonstration, as though watching what, in any other context, would be considered pornography were a normal part of a serious interview about a fascinating subject.


Surrogacy may strike people as anything from 'not quite nice' to outrageous', but Dr. Roitman points out, it has a higher then 90% success.


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