From pilot fish to analyst: Finding a path between symbiotic and autistic defences

This paper presents the clinical case of a patient with autistic features. One of the main difficulties in his treatment was the particular rapid rhythm of his projections, introjections and re‐projections that constrained the analyst's capacity for reverie and hindered the use of effective projective identification processes. These alternating defensive constellations lead either to an expelling autistic barrier or to an engulfing symbiotic fusion. Their combination can be seen as the expression of a defence against an unintegrated and undifferentiated early experience of self that was in this way kept at bay to prevent it from invading his whole personality. Maintaining the symbiotic link, in which I kept included by staying partially fused to what was being projected and using my analytic function in a reduced way, helped to relate to what was in the patient's inside. Leaving this symbiotic link let my interpretations appear to ‘force’ their way through the autistic barrier. Yet as the process developed they allowed to show the patient how he ejected me and what was happening in his inside, behind his autistic barrier. So I found myself on the one hand accepting the symbiotic immobilization and on the other hand interpreting in a way that seemed forced to the patient, because it implied a breaking of the symbiotic position. The inordinate speed of projections and introjections could thus be interrupted, creating a space for awareness, reflection and transformation, and allowed the emergence of a connection between the patient's inside and outside. In the course of treatment I realized that this kind of dual defence system has been described by the late Argentinian analyst José Bleger. He assumes the existence of an early “agglutinated nucleus” that is held together by a psychic structure he calls the “glischro‐caric” position, in which projective identification cannot take place because there is no self/object differentiation. I have considered the rapid and fugitive use of projection and re‐introjection I met in my patient to be a manifestation of the dual defence system Bleger describes. Although he does not specifically mention this particular vicissitude of operative defences he does give hints about a rhythm in the patients’ projections and introjections.     

Reply to Commentaries by Dodi Goldman and Avgi Saketopoulou

In this newly fashioned dialogue that allows us three respondents to continue our first-round discussions, I treasure the opportunity of learning more about Farhi's and Milner's works through the lenses of Dodi Goldman and Avgi Saketopoulou. Both respondents bring additional important historical information to this virtual roundtable, giving me another chance of re-reading Farhi's text through these new perspectives. I think that Goldman's information about Milner's interest in the natural science contributes a great deal to my understanding of her amazing capacity to tolerate her patient's changing psychotic states. I also learn a lot from Saketopoulou's sensitive discussion of the patient's last phone call to Milner shortly before her death in which the patient informs Milner that she had failed her in similar ways as Winnicott had failed Milner. I suggest a slightly different reading of the word failure and propose that the patient's utterance was a sign of a renewed strength rather than a statement of utter disappointment. A discussion of the place of phantasy in the intra-uterine life of a baby is also included in my response.     

Nina Farhi: Leaning on an Annealed Identification: Commentary on Paper by Nina Farhi

In my response to Nina Farhi's paper, I begin my discussion with the concept of a placental space that Farhi develops to represent the psychotic's internal experience of living in a fusion with the Other. Farhi's new concept of an annealed identification provides a useful addition to the psychoanalytic literature to describe the living conditions of a psychotic who is severely entrenched in an unyielding maternal bond. Basing her conceptualizations on Milner's psychotic patient Susan, Farhi also focuses on Milner's discovery that no repressed unconscious existed for her patient Susan. I suggest in my response that Freud's nearly forgotten idea of primal repression and Lacan's idea of maternal jouissance would shed additional light onto the psychotic experience and expand Farhi's notion of an annealed identification with the maternal figure. In addition, I argue for an inclusion of the Third whose presence is so powerfully lacking in the case discussion and in the patient's life.     

A mismatch of meaning and intentionality between analyst and analysand

In this paper, I will consider a type of misunderstanding in the analytical dialogue and the possible unconscious motivations underlying this. I will also make reference to the patient's use of the analyst's words for the purpose of narcissistic enactment and will explore the extent of the analyst's involvement in this. The subjects of misunderstanding and narcissistic enactment will be dealt with in relation to a patient's way of processing certain interpretations at the beginning of analysis and the concealment of her way of processing the analyst's words. By contributing dreams and other significant material in the sessions, the patient gradually revealed her phantasies which enabled the analyst to uncover the possible factors which determined her particular attribution of meaning to the analyst's words and her retention of information about how she had initially construed his interpretations.     

Countertransference revisited

A female patient of mine recounts her week. I listen with interest, waiting for her to arrive at particular conclusions. She has suffered a great deal and still does, but prefers not to dwell on it. My interest turns into patience as she continues to talk but circumvents her discontent. She is adroit at avoidance, but easily offended when I point such things out. "I'd better wait" I think. I grow more aware that I must encourage her digressions. I feel frustrated. Getting further and further away, she skirts the issue with supple grace, then strays off into tangentiality. I forget her point and lose my focus, then get down on myself. The opportunity is soon gone. I glance at the clock as her monologue drones on into banality. I grow more uninterested and distant. There is a subtle irritation to her voice; a whiney indecisive ring begins to pervade my consciousness. I home in on her mouth with aversion, watching apprehensively as this disgusting hole flaps tirelessly but says nothing. It looks carnivorous, voracious. Now she is unattractive, something I have noticed before. I forget who my next patient is. I think about the meal I will prepare for my wife this evening, then glance at the time once more. Then I am struck: Why am I looking at the clock? So soon? The session has just begun. I catch myself. What is going on in me, between us? I am detached, but why? Is she too feeling unattuned, disconnected? I am failing my patient. What is her experience of me? I lamentingly confess that I do not feel I have been listening to her, and wonder what has gone wrong between us. I ask her if she has noticed. We talk about our feelings, our impact on one another, why we had lost our sense of connection, what it means to us. I instantly feel more involved, rejuvenated, and she continues, this time with me present. Her mouth is no longer odious, but sincere and articulate. She is attractive and tender; I suddenly feel empathy and warmth toward her. We are now very close. I am moved. Time flies, the session is soon over; we do not want it to end.     

THE THOUGHT SPACE OF GOD: THE HAUNTING BELOW THE I‐THOU RELATION

This essay attempts a phenomenological analysis of Descartes' statement, ‘my perception of God is prior to my perception of myself,’ and Buber's claim that God ‘is also the mystery of the self‐evident, nearer to me than my I.’ I radicalize the implications of Descartes' and Buber's claims by drawing on the thought of Husserl and Levinas, and couching the analysis in terms of Merleau‐Ponty's experiential notions of haunting and reversibility. This forces us to interrogate the subjective space in which we think God qua recognize the other, and shows us a kind of necessity that underlies the I‐Thou relation. My conclusion leaves us in a place of powerless subjective inwardness and awe.     

Incognito or not? the patient's subjective experience of the analyst's private life

This paper examines the meaning for the patient of the analyst's personal life and personality which are ostensibly banished from the consulting room. The therapist has a not‐always‐so‐secret “secret life”; that the patient is supposed to “not know”; about. Yet, more or less unconscious perceptions, impressions, and fantasies about extratherapeutic aspects of the analyst are omnipresent and significantly color the psychoanalytic enterprise.

Moreover the analyst as a person generally plays a critical and underacknowledged role in the patient's experience of the endeavor. Constructing multiple overlapping images of the analyst and of the analytic relationship, the patient discovers himself or herself in the matrix of these relationships with various images of the analytic other. The analysand is motivated to make sense of the analyst as wholly as possible, the better to place into context the analyst's interventions. The patient's resulting view of the analyst's subjective experience acts as a lens that filters and subtly alters the meaning of the analyst's communications.

I illustrate these points by relating my work with a patient whose dreams uncannily picked up on a (consciously) unknown aspect of my private life—my having a handicapped son. The treatment thereafter centered on the patient's identification with my child (as someone “disabled") and on the meaning of her having dreamt something so personal about her therapist.     

Rights,Duties and the Separateness of Persons

Let the fact of the separateness of persons be that we are separate individuals, each with his or her own life to lead. This is to be distinguished from the doctrine of the separateness of persons: the claim that the fact of our separateness is especially deep and important, morally speaking. In this paper, I argue that we ought to reject this doctrine. I focus most of my attention on the suggestion that the separateness of persons best explains the importance we attach to moral rights. After criticizing Nozick's use of the doctrine, I formulate an alternative account of the significance of rights. I then show how proponents of the doctrine of separateness have no principled way of distinguishing between egoism and moral libertarianism. I suggest that rejecting the doctrine of our separateness for the reasons I propose ensures that we need have no fear of having to embrace consequentialism as a result.     

‘A Way Out’ and A Way In: Reply to Commentary

I express my appreciation for Michal Rieck's thoughtful and fully felt reading of my paper. I underline her points that the regression that an unobtrusive yet fully engaged analyst can allow, is not solely a phenomenon in work with more disturbed patients, and that the essence of this position is to be without separateness. I outline a process of the “flow of enactive engagement,” which fosters a narrative unfolding of the field of the treatment. I suggest that the flow of enactive engagement is a contemporary mutual form of enacted free association and that Rieck is correct in saying that from my perspective psychoanalytic cure need not involve the analyst's interpretation. The mutual enactment itself can be the interpretation.     

PROBLEMS OF INTERNALIZATION: A BUTTON IS A BUTTON IS—NOT

Analysts hope to help the patient internalize a relationship with the analyst that contrasts with the original archaic object relation. In this paper, the author describes particular difficulties in working with a patient whose defenses and anxieties were bulimic, her movement toward internalization inevitably undone. Several issues are considered: how does the nonsymbolizing patient come to internalize the analyst's understanding, and when this does not hold, what is the nature of the patient's subsequent methods of dispersal? When the patient can maintain connection to the analyst as a good object, even fleetingly, in the depressive position, the possibility of internalization and symbolic communication is increased.     

The Strangeness of Passing: Commentary on Paper by Christopher Bonovitz

Christopher Bonovitz gives us a rich landscape of the theoretical, historical, and relational aspects of his work with his mixed-race patient. In my response I explore what seems missing: a stronger sense of the patient as a person, more of her own history in her family, more of the clinical back and forth with her therapist, a sense of what is being played out in the transference, and particularly what “passing” is for her. I show how his choices about how to think about her story and how to tell it are oversaturated with awareness of identity and race at the expense of the basic human relationship. In the face of such racial anxiety, there is a pull to rely too strongly on countertransference as a way to gain privileged access to knowledge about the other. I attribute many of these problems to the inescapable power of race in our culture. Furthermore, I address the themes of hatred, silence, secrecy and transgression as they relate to the history of transgenerational trauma for this patient and invite our broadening our awareness about how they play out in the therapeutic process. We are faced with the difficult, yet the essential task of holding and living out the patient's anger and outrage at the racial hatred that has been endured.     

Reply to Commentaries

Questions of historical context resonate with an Independent view of the importance of history. The historical backgrounds of North American and British psychoanalysis are relevant. Some American analysts may be seen as belonging to the Independent tradition, and the relation between Independent analysis in Britain and Relational analysis in America needs further consideration. I ask how far Relational analysis is taking on an institutional identity, and link this to Poland's discussion of “outsiderness.” Responding to Bass's and Berman's comments on my clinical examples I discuss why I sometimes do think analysts need to ascribe meaning to a patient's material. In other instances an analyst will invite the patient more into the process by which meaning evolves between them. To move freely between these positions is central to my view of clinical technique. I express doubts about analysts asking patients for their emotional reaction to an analyst's interventions. This risks being intrusive, and may tend to keep the exchange at the conscious level of a patient's mind. The analytic relationship is an interpersonal one between real people, but the analyst needs also to remain symbolically available as an object of unconscious fantasy and projection.     

Tribute to Ellen Noonan

This story was written after the conclusion of a period of therapy with a patient who had experienced severe childhood trauma. It was one of those occasions when it didn't feel right to even enquire about the possibility of publishing a paper on the basis of our work together. The priority was to avoid any intervention that might constitute an intrusion into an individual who had already been too much intruded upon. Having come to that conclusion, I found myself writing this short story. The events described are entirely different from those described by my patient. However, the story captures part of the emotional truth of the patient's situation and state of mind and, in this sense, constitutes a reworking of the material that emerged in therapy.     

The countertransference impact of autistic defence in an otherwise neurotic patient

This paper investigates the question of why, in the psychoanalytic psychotherapy of a patient with encapsulated autistic pathology, the steady maintenance of a therapeutically neutral stance can be especially difficult. Transference and countertransference vicissitudes are examined. The author notices that the patient's intolerance of ‘opposites’ (cf. Tustin, 1986), combined with extreme antipathy to having that intolerance noticed, can elicit corresponding, and potentially destabilizing, countertransference reactions. These reactions comprise an unstable tension between co‐existing pressures towards fusion with, or expulsion of, the patient, their co‐existence under further pressure to remain unnoticed. Until perceived, this state of affairs risks collusion with the pressure either to merge with or to expel the patient, and compromises the capacity to notice the detail of the transference process and even to notice co‐existent positive and negative transference images. Detailed clinical illustration is given, including a session where it was difficult to notice the patient's experience of a couple as a combined object. The author finds these observations of bipolar countertransference tensions illuminated by Green's concepts of positive and negative narcissism and of the disobjectalizing function, and specifically accounted for by Ribas's theory of autism as radical drive defusion.     

Response to Phillips,Hopkins, and Berman

Adam Phillips asks why we need to engage in professional policing. He exceeds my own professional comfort zone when he suggests that a great thing about psychoanalysis is that “it does not necessarily make people better.” I make a plea for a measure of professional idealism that takes account of the analyst's power. In her discussion, Linda Hopkins provides fascinating anecdotes that support my ideas about Masud Khan's analysis. Hopkins also argues for the value of idealization in therapeutic process, noting that I excessively emphasize its problematics. I agree with Hopkins's perspective and muse about why my paper reads otherwise. Emanuel Berman distinguishes institutional from individual idealizations and argues for the value of the latter while underscoring the difference between de-idealization and devaluation. I query the inevitably problematic nature of institutional idealizations.     

Working with psychosis: Part 3 – ‘Struggling to contain madness – losing and recovering a capacity to think’

This is the penultimate paper in a series about working with a patient suffering from a psychotic disorder. The paper describes the third year of the work in which ‘John’ had four breakdowns in a period of six months. Much of the time I was unable to think. I was sitting on the edge of my chair either worrying that John was breaking down again or trying to help him recover from a breakdown. My small office became a cramped prison cell in which I felt myself a witness to a disturbing dance into and out of madness. A turning point seemed to happen as I developed a way of thinking about John's breakdowns. I seemed then to become a less persecutory figure in John's mind and more someone to whom John could turn for help. We found a way of thinking and talking about an infant in John. John responded by finding a way of being in my office as though he was reclining in a hammock. His breakdowns ceased. He was able to share in common humanity's concerns following September 11. Finally, I discuss thoughts about containment particularly about the paternal role in containment, drawing on Robert Caper's elaboration of Bion's ideas about containing psychotic aspects of experience.     

The Archimedean point and eccentricity: Hannah Arendt's philosophy of Science and technology

In this contribution I discuss Hannah Arendt's philosophy of culture in three rounds. First I give an account of my view on Hannah Arendt's main work The Human Condition. In this frame of reference I distance myself from the importance attached to Hannah Arendt as a political philosopher and hold a warm plea for her as a philosopher of culture (I and II). Second I pay attention to her view on science and technology in their cultural meaning, expressed in the last chapter of The Human Condition. This part consists in a summary of her thoughts as I read them (III, IV, and V). After these two rounds I make some critical remarks on Hannah Arendt's interpretation of science and technology. The viewpoint of ‘eccentricity’ will be discussed as a frame of reference for her philosophy of culture (VI).     

Enactment as Therapeutic Hand Grenade: How Bursts of Emotional Honesty Can Get a Stuck Treatment Moving Again: Discussion of Holly Levenkron's Paper

In my discussion of Levenkron's article, I consider ways of understanding the patient's therapeutic progress that were not highlighted by the author. Adding my own criteria to Levenkron's definition of enactment, I suggest that what the author labels as enactment might be seen as a last-ditch but successful effort to get patient and analyst out of a stuck and painful place. I explore the interplay of confrontational and nonconfrontational interventions in contributing to cure, and I suggest placing a greater emphasis than did the author, on the intersubjective contexts out of which the patient's troublesome behaviors emerged.     

Embodied female experience through the lens of imagination

Abstract: In 1971, I made a film entitled Self Portrait of a Nude Model Turned Cinematographer in which I explore the objectifying ‘male’ gaze on my body in contrast to the subjective lived experience of my body. The film was a radical challenge to the gaze that objectifies woman – and thus imprisons her – which had hitherto dominated narrative cinema. Since the objectification of women has largely excluded us from the privileged phallogocentric discourses, in this paper I hope to bring into the psychoanalytic dialogue a woman's lived experience. I will approach this by exploring how remembering this film has become a personally transformative experience as I look back on it through the lens of postmodern and feminist discourses that have emerged since it was made. In addition, I will explore how this process of imaginatively looking back on an artistic creation to generate new discourses in the present is similar to the transformative process of analysis. Lastly, I will present a clinical example, where my embodied countertransference response to a patient's subjection to the objectifying male gaze opens space for a new discourse about her body to emerge.