The psychoanalysis of a patient with ulcerative colitis. The impact of fantasy, affect, and the intensity of drives on the outcome of treatment.

In this paper the clinical case of a patient with ulcerative colitis is described, to illustrate how the vicissitudes of affects and fantasies, and the intensity of drives can set limits to the capacity for change in psychoanalysis. Drive intensity at all zonal levels is discussed. The author describes two unconscious fantasies which fuelled the resistance to progress, because of their inevitable links with traumatic and disavowed affects, and with libidinal and aggressive drives. The first fantasy described is that of the narcissistic impasse, in which the patient could not orchestrate an optimal distance with the object, who always seemed too perilously near or far. The second fantasy, giving rise to the first, is that of the Faustian bargain, according to which the patient repeated an infantile disposition to effect a trade-off with a needed but elusive ideal object, resulting in pathological splitting, a loss of a sense of ownership of the Psyche and the Soma, and eventual somatic vulnerability.