Envy: I Want ALL That You Are (Part 2 of 2 )

Treating Primitive Envy in Patients with Severe Personality Disorders

This is Part 5 of a 12-Part Series: The Hardest Things in Psychotherapy

Why It is Envy So Hard to Treat?

One of the paradoxes of treating primitive envy is that improvement often makes things worse. As therapy begins to help, envy can intensify.

In patients with severe personality disorders, improvement often triggers envy. This creates a self-defeating cycle where psychotherapy success actually worsens functioning. This can be demoralizing for both therapist and patient.

There are three treatment approaches that can help:

1. Supportive-Expressive Approach
2. Transference-Focused Psychotherapy
3. Mentalization-based Treatment.

1. Supportive-Expressive Approaches

This approach is for patients with severe personality disorders who cannot access specialized treatments or where transference interpretation of envy is just not possible.



One approach is to:

• Validate how hard it is to receive help (no interpretations)
• Build ego strength and frustration tolerance, and
• Use psychoeducation

“For some people, when therapy starts to work, something inside of them resists change. Does that make sense?” This can be a helpful explanation for patients.

2. Transference-Focused Psychotherapy (TFP)

Transference interpretation can address primitive envy directly.

The key work is consistent interpretation of the envious attacks when they emerge in the transference. This is always to be viewed as a defense against the unbearable experience of depending on a good therapist.

Call this out in real time:



“Since our last few session, I noticed, after we appeared to discover something important, you have come into our next session feeling that our work is pointless or useless.”



What’s most important for the therapist is accepting and surviving the devaluing attack without retaliation. Not being destroyed by the devaluation is itself is part of the cure.Subscribe

Not being destroyed by the devaluation is itself is part of the cure.

By being envious, the patient also destroys the good progress of the work. Doing so enables the patient to avoid the pain of needing and the fear of losing the therapist.

Patients with severe envy often need to discover that their attacks do not destroy the therapist, the relationship, or the work. Surviving the attack becomes part of the treatment itself.

3. Mentalization-Based Treatment (MBT)

The purpose of a Mentalization-Based Treatment (MBT) approach is to explore—when envy is present—how the capacity to mentalize the therapist is lost.

This involves:

• Slowing down and returning to the moment the rupture in the alliance first appeared.
• With curiosity, exploring what the patient imagined the therapist was feeling during the attack. Ask the patient to describe what they think the therapist was intending.
• Avoid the direct confrontation of envy. Instead, work towards restoring the patient’s ability to reflect on what they were feeling and where the feelings came from.

Common Considerations for these Treatment Approaches

1. Monitor you own countertransference without a direct expression of your feelings. Primitive envy can make therapist feel bored, hopeless, aggressive or angry.
2. Avoid premature praise or optimism. This will make an envious patient feel worse.
3. Highlight how the patient’s progress can paradoxically activate the envious attack and understate the patient’s progress.
4. Distinguish envy from aggression driven by deprivation. Many aggressive attacks on the therapist are protests against real or perceived therapeutic failures—problem in the alliance. These devaluing attacks may be ameliorated when the therapist acknowledges real errors or mistakes. In other words? Note all attacks are envious. This distinction will help to determine your approach

Don’t Be Too Optimistic.

Klein’s framework holds that helping patients develop the ability to tolerate the ambivalence of love and hate, and experience some gratitude simultaneously with envy — is the therapeutic aim.

Group Therapy As Adjunct.

In some patients with a severe personality disorders, group therapy can surface envious dynamics in ways that are more workable than the dyadic setting. This is because peers can sometimes confront what the therapist cannot without activating persecutory transferences.

Realistic Prognosis

Primitive envy is among the hardest things to treat.

The goal is rarely to eliminate envy. More often, it is helping patients tolerate gratitude, dependency, and growth without needing to destroy them.

Robert E. Feinstein, MD

Professor of Clinical Psychiatry, Zucker School of Medicine at Hofstra/Northwell

Psychiatrist, Psychoanalyst, Educator, and Supervisor Contact: Feinster@RobFeinsteinMD.com

Owner & Founder Empathian LLC ( An Online Mental Health Education Company)

Empathian.com | Add me on LinkedIn