Breakdown in communication: On finding the child in the analysis of an adult

SUMMARY

In this paper a patient is described in whom communication with parts of herself and with her objects, internal and external, had broken down. I suggest that her way of communicating was achieved by projective identification, as described by Klein (1946) and Bion (1962). The only way she could deal with and communicate her own very “bothered” feelings was to “put them” into the analyst. In this way she “bothered” the maternal or analytic mind in such a way as to make the analyst experience feeling like a “bothered” child.

I have tried to show how the analyst holds or contains these feelings, and to show the gradual establishment in the patient of a different way of communicating with the analyst and with the more primitive parts of herself.     

PARENTS AND THEIR CHILD AND THE ANALYST IN THE MIDDLE

The first part of this paper explains how the transgenerational mandate influences the mental activity of the child. When a child acts the denied suffering of the parental couple, the analyst risks being imprisoned by the transgenerational mandate. Frequently the analyst is unconsciously asked by the parents to cure without curing because the child's psychological birth, still in the making, threatens the defensive equilibrium of the parents. The analyst is thus caught between the parents and the child and must find his/her own way forward in order to free the child from the burden of the mandate. In the second part of the paper, an analysis of a 5-year-old child is presented. The author shows how a transgenerational mandate may hold a traumatic potential because it can impair heavily the child's capacity to think. The author also describes the way in which she works with the parents and how she manages the setting and the style of the interpretation. She insists in particular on the need to sustain the child's perceptions in order to gradually allow the child to take roots in his/her experiences and therefore develop his/her own identity.     

A Comparative Assessment of an Analysis of Envy: Commentary on Paper by Julie Gerhardt

This discussion is introduced with emphasis on the need for comparative psychoanalytic studies in our pluralistic psychoanalytic world and describes an approach to such an endeavor. A very brief comment on the extensive literature review is followed by a more detailed focus on the “analysis of envy,” which gradually changed into the analysis of the patient, as a person. The discussant's “empathic entry” into the analyst's mode of listening and responding was simultaneously also applied to the patient's experience, to see how well patient and analyst communicated with each other and whether or not the patient indicated that she felt understood or not. When she did not feel understood, the patient signaled this with an intensification of her envy into furious “envy attacks.” The analyst's “decoding interpretations” implied that the patient was causing her own problems and should not feel the way she did. The analyst discovered this later herself. Her discoveries in the fourth year of the analysis yielded notable changes both in her approach and in the patient's progress. Ultimately, the analyst allowed her subjectivity to enter the analysis and became better amalgamated with her chosen theory, leading to the changes in a progressively more fruitful analysis.     

Childless

This paper explores the complex interplay that unfolded between analyst and patient around their respective childlessness and aims to draw attention to the larger societal issues of imperative parenthood and the stigma of childlessness. As the analyst confronted her own internal conflicts about motherhood, children, and procreation as a woman living in a pronatalist society (one that encourages increasing birth-rates), she was treating a lesbian patient with a history of childhood relational trauma and sexual abuse who was undergoing fertility treatments. The patient’s experience with assisted reproductive technologies raised complicated questions and concerns within the analyst regarding their emotional impact on her patient and, more broadly, how they might reflect societal dissociation. Themes of trauma, loss, dissociation, and shifting self-states, which emerged during the fertility treatments and wove their way throughout the analysis, are discussed. In addition, the author describes the nature of the therapeutic action in this case.     

The development of a dream from concrete realization to symbolic story

This paper is based on material from an analysis with a girl who was four years old at the time she started analysis. I relate how we worked with her feeling of vacillating, between invading and being invaded by the object, and how she was finally able to let go of her omnipotent control to a higher degree than before. Inspired by Hanna Segal and Donald Winnicott, I trace our progress from; (1) a denial of separation; (2) the analysand establishes a certain sense of separation by creating her own “space”. Through splitting and projective identification, she rids herself of feeling dependent and helpless, feelings that she cannot bear to acknowledge. The analyst receives, contains and names these feelings; to a stage where (3) the relationship established through the agency of projective identification is dissolved, and makes way for an ability to experience dependence as well as a recognition of the analyst as a separate person whom the analysand needs and can use.     

The body of the analyst and the analytic setting: Reflections on the embodied setting and the symbiotic transference

In this paper the author questions whether the body of the analyst may be helpfully conceptualized as an embodied feature of the setting and suggests that this may be especially helpful for understanding patients who develop a symbiotic transference and for whom any variance in the analyst's body is felt to be profoundly destabilizing. In such cases the patient needs to relate to the body of the analyst concretely and exclusively as a setting ‘constant’ and its meaning for the patient may thus remain inaccessible to analysis for a long time. When the separateness of the body of the analyst reaches the patient's awareness because of changes in the analyst's appearance or bodily state, it then mobilizes primitive anxieties in the patient. It is only when the body of the analyst can become a dynamic variable between them (i.e. part of the process) that it can be used by the patient to further the exploration of their own mind.     

Finding the depressed object in the obsessional: a clinical study

In this paper the author explores the clinical significance of the presence of a depressed internal object in a patient with marked obsessional features, dominating the patient's internal world and restricting relations in external life. After discussing important aspects of the contribution of Freud and later writers to the study of obsessional neurosis, the author provides clinical material that shows the patient's tormented relationship to a feared depressed object that was manifested in the transference. Developing her argument, the author suggests that if the analyst does not fully grasp the primitive anxieties of the underlying state of mind she can be prone to enter into an aggressive enactment with the patient's sadistic superego. This kind of enactment may arouse excitement and triumph in the patient, but actually confirms his doubts and fears about the capacity of his object to contain him.     

The role of the analyst in the analytic cure during times of chronic crises

The role of the analyst in psychoanalytic treatment during periods of chronic crises is illustrated with material from two case studies. The first clinical vignette shows an analyst able to stay with fears evoked in the patient by the traumatic external reality, even as the analyst tried to explore with the patient an inner universe that handled this reality in unique ways. The second case study focuses on how the analyst's countertransference during this period of chronic crises, which she was experiencing along with the patient, made it difficult for her to contain the patient's fears and anxieties, because of the threat to her own existence, as well as to her identity as an analyst. In this second case the analyst, out of denial of the external situation, focused blindly on the patient's internal reality in order to counteract her own sense of passivity and helplessness in the confrontation with death and destruction. She clung to "classical" analysis by trying to analyze the patient's defenses, work them through, etc., thus making so-called analytic interpretations rather than staying with the patient's fear, as well as her own, and helping the patient more directly. A turning point came with the birth of the analyst's granddaughter; fear for the new arrival's safety made the analyst sharply aware that it is impossible to ignore external reality, that it must be given a place both in everyday life and in analysis. This awareness enabled the analyst to contain the patients' fears, which helped him feel more supported and facilitated change.     

Early trauma and narcissism—autism bipolarity1

The analyst makes a series of considerations taken a posteriori from the analysis of a small number of patients. These patients have saved themselves from an early narcissistic catastrophe by developing precocious mental processes, while affective relationships rudimentarily repeat the impact with the original trauma. Primitive defences, essentially denial and vertical splitting, dissociate the tear in the psyche and structure a narcissism–autism bipolarity, revealed in aspects of the character which oblige the patient to automatically repeat a single matrix of experience. In therapy, it is necessary to construct a rst time of the trauma, by pending and linking threads of the primary relationship and strengthening them in the analytic relationship. This reconstruction of the background, a screen to project what had originally been rejected, is the prerequisite for coming out, in deferred action, from the hold of the pathological identifications. The author dedicates particular attention to the undifferentiated background, the nature‐environment torn by the trauma, and to the need to reconstruct this fabric of experience in the analytical relationship, as a fundamental element to the recomposition of the dissociated nuclei. In the clinical case, the analyst describes in particular how the analyst's words encounter an unbridgeable gap, a failure in the capacity for representation when opening the autistic nucleus. Through a regression lasting for about a year, a patient was able to live the experience of primitive agonies and that of an unbearable helplessness and, at the same time, was able to feel how the analyst supported her sense of existence. Subsequently, the patient was able to give shape, through visual images, to deep states of being and start the process of metabolising and symbolising the trauma.     

On talking-as-dreaming

Many patients are unable to engage in waking-dreaming in the analytic setting in the form of free association or in any other form. The author has found that 'talking-as-dreaming' has served as a form of waking-dreaming in which such patients have been able to begin to dream formerly undreamable experience. Such talking is a loosely structured form of conversation between patient and analyst that is often marked by primary process thinking and apparent non sequiturs. Talking-as-dreaming superficially appears to be 'unanalytic' in that it may seem to consist 'merely' of talking about such topics as books, films, etymology, baseball, the taste of chocolate, the structure of light, and so on. When an analysis is 'a going concern,' talking-as-dreaming moves unobtrusively into and out of talking about dreaming. The author provides two detailed clinical examples of analytic work with patients who had very little capacity to dream in the analytic setting. In the first clinical example, talking-as-dreaming served as a form of thinking and relating in which the patient was able for the first time to dream her own (and, in a sense, her father's) formerly unthinkable, undreamable experience. The second clinical example involves the use of talking-as-dreaming as an emotional experience in which the formerly 'invisible' patient was able to begin to dream himself into existence. The analyst, while engaging with a patient in talking-as-dreaming, must remain keenly aware that it is critical that the difference in roles of patient and analyst be a continuously felt presence; that the therapeutic goals of analysis be firmly held in mind; and that the patient be given the opportunity to dream himself into existence (as opposed to being dreamt up by the analyst).     

Attention and Narration to Micro-Moment Registrations of Embodied Dialogue in the Clinical Interaction: How Are We Doing?

ABSTRACT

This article offers a comparison between two different strategies for clinical attention. The author compares his lens shaped by a musical metaphor of “polyrhythmic patterning” on embodied registrations which he describes as “fluidity” in contrast to a lens of structures or categories of experience. He then contrasts this lens to that offered by Lewis which she describes with the metaphor of an “imaginary camera” with which she creates “snapshots” as representations of unbearable (and often unformulated) trauma shaped by the patient's narrative and her own trauma history. Acknowledging the exquisite connection between analyst and patient, the author uses 2 clinical moments to further illustrate the benefits of each metaphoric lens for possible analytic work.     

Losing a training analyst for ethical violations: A candidate's perspective

The author presents her experience as the analysand of a training analyst who was investigated and expelled for ethical violations with another patient, including sexual-boundary violations, during her analytic training. While boundary violations by training analysts are not uncommon, the particular trauma experienced by 'bystanders' such as candidates and supervisees is not discussed in the literature, nor the response of institutes to the educational problems that are generated. The author illustrates the complications for candidates that arise from the dual roles of training analyst as educator and analyst when he or she faces investigation or censure, including isolation and secrecy, which promote various splits in the candidate, analytic dyad and group, as well as loyalty conflicts. The discussion covers three phases of the author's experience as a candidate-analysand, namely the period encompassing the institute's ethics investigation, the announcement of findings to her and to the institute as a group, and the ensuing individual and group dynamics generated by her analyst's expulsion from the institute and revocation of his medical license. Theoretical perspectives are utilized to understand the group regression, including contamination and contagion fears, which occurred in the wake of the training analyst's expulsion, and the impact of these processes on the candidate, including the pressure to function as a 'container' for projections of the group. Implications and recommendations for candidates and institutes are made for dealing helpfully with trainees who are affected by the process of dealing with a training analyst's ethical violations. Short-term and longer-term outcomes of the experience are considered.     

Nameless Desire: Alexithymia and the Anorexic Patient

In this article, the author attempts to provide a psychoanalytic understanding of the anorexic patient who is disconnected from her affective experience and is considered to be alexithymic. Through her restrictive food ritual, this type of patient may organize her internal states by repeatedly creating an illusion of what it is that she needs and desires. The author asserts that the task of the therapist working with the anorexic patient with alexithymia is to be aware of his own sensation-based reverie as lived within the intersubjective arena. This will enable the therapist to assist the patient in building an affective vocabulary to accurately identify, differentiate, and label the internal signals of her body. It is suggested that the subjective emotional experience of the patient will continue to be reorganized, expanded, and enriched as the therapist and patient mutually influence one another in this unique relational matrix. A clinical vignette is provided to illustrate intersubjective treatment interventions with a difficult-to-reach anorexic patient.     

Tactics and empathy: Defences against projective identification

In this paper the author argues that interpretations made when the analyst has not done the emotional work of recognising and bearing what kind of object she has become in the patient's psychic reality will be experienced as empty tactics – even lies – rather than interpretations of integrity. However, interpreting from a position of bearing the truth of the patient's perception will be technically difficult and indicate turmoil as the analyst struggles to take in the patient's view of her. If the analyst avoids integrating her own picture of herself with the patient's picture (despite giving voice to the patient's picture) the split inside the analyst will be felt and intensify the patient's need to split. Vignettes demonstrate how the analyst, believing she is trying to understand, may become a projective‐identification‐refusing object and the issue of the analyst's disclosure of her countertransference is examined. Ultimately, the author argues, a capacity to receive and bear projective identification requires empathy with both patient and analyst‐as‐patient's object, engaged in a process about which both are ambivalent.     

PROSPERO'S PAPER

The writer proposes that the interplay between the hermeneutics of psychoanalysis and literature can illuminate understanding of the transference and countertransference at large in an analytic treatment. Writing about the work with a young woman who had been persistently sexually abused as a child and who developed anorexia in her adolescence so severe that her life was endangered both by the illness and by attempts at suicide, the author finds his reading of Shakespeare's The Tempest a powerful informant to the work. Interpreting the object relations represented by Prospero and Miranda and the process of their integration into new mental structures lends the analytic work an additional level of understanding, in particular in relation to the oedipal bond between patient and analyst. When the analyst is confronted by the imminence of his own death towards the end of the analysis, his reading of Prospero's relinquishment of his magical powers and his release of his daughter into sexual maturity and independence helps the patient to replace her destructive inner objects with more reparative and benign ones as she develops a capacity for concern and mourning.     

The body one has and the body one is: Understanding the transsexual’s need to be seen

The transsexual individual confronts the analyst with a disturbing otherness. How this otherness is understood, that is, how the analyst ‘looks’ at the patient through her distinctive theoretical lens impacts, in turn, on the patient’s experience and what transpires between them. In this paper the author outlines a developmental model rooted in attachment and object relations theory to provide one alternative way of ‘looking’ at some of these patients’ experiences in the clinical setting. It is suggested that in some cases of transsexuality the primary object(s) did not mirror and contain an early experience of incongruity between the given body and the subjective experience of gender: it remains unmentalized and disrupts self‐coherence leading to the pursuit of surgery that is anticipated to ‘guarantee’ relief from the incongruity. Through an account of work with a male to female (MtF) transsexual who underwent surgery during her five years of psychotherapy, the author explores how a focus on the transsexual’s experience of ‘being seen’, that is, of being taken in (or not) visually and mentally by the object in their state of incongruity, affords another window through which to approach the transsexual’s experience in the transference–countertransference dynamics.     

THE PATIENT'S OBJECTS IN THE ANALYST'S MIND

In every analysis, the analyst develops an internal relationship with the patient's objects—that is, the people in the patient's life and mind. Sometimes these figures can inhabit the analyst's mind as a source of data, but at other times, the analyst may feel preoccupied with or even invaded by them. The author presents two clinical cases: one in which the seeming absence of a good object in the patient's mind made the analyst hesitate to proceed with an analysis, and another in which the patient's preoccupation with a “bad” object was shared and mirrored by the analyst's own inner preoccupation with the object. The use and experience of these two objects by the analyst are discussed with particular attention to the countertransference.     

Los Degradados: Out,down, dead: Transmitted and inflicted trauma as encountered in the analysis of a 6‐year‐old girl1

The author presents the analysis of a precocious traumatized little girl, which reveals the ways in which historical trauma is transmitted and intrafamilial trauma is both disguised and represented. The play as it evolves is seen to simultaneously communicate what the child struggles with and to resolutely try to hide what has actually happened. Analyst and child together participate in play which utilizes displacement, enactment and interactive enactment, the latter play mode being the very hallmark of profound traumatic experience. Carlotta, the child, helps the analyst to follow her quest for meaning making even as the interaction between them adheres to and departs from the deepening pentimenti of traumatic experience, which needs to be unraveled and reconstructed in order that her own developmental progression can be rejoined. The analysis facilitates Carlotta's capacity to play in a more unfettered fashion and to assist her family's recovery as well.     

Poetics in the Clinical Encounter

Amidst a mounting impasse, a patient’s startling slip of the tongue opens this analyst to a crucial awareness of her affective experience so that she can begin to reenter her patient’s. The analyst’s openness to her own vulnerability serves to free both participants from collapse into a doer–done-to complementarity. The enactive communication expands the depth of their connection and dis-connection in the moment. Just as a poem says metaphorically what cannot be said in ordinary prose, the slip jolts both participants into more imaginative intersubjective ground that transcends a sense of time and potentiates clinical momentum.     

The Reconstruction of Psychic Trauma

The author discusses the difficulties that arose in the analysis of a female patient suffering from a delusional disorder, where traditional criteria of suitability for psychoanalytic treatment were initially lacking and had to be established as part of the process. The transference-countertransference interaction came to a deadlock, understood by the analyst as due to the patient’s pathological dyadic relating. She was lacking in her capacity of reflective functioning, and there was no potential space to foster a fruitful therapeutic dialogue between analyst and patient. The analyst adopted a bystander perspective as a vantage point from which to comment on the patient’s narrative, whereby she succeeded in gradually altering the dysfunctional dyadic exchange into an interaction where a triadic perspective was introduced as a means to making possible meaningful communication between patient and analyst. Substantial changes were achieved with this procedure as a point of departure. The case study highlights aspects of dyadic versus triadic functioning of the analytic pair, and serves to illustrate theoretical points pertaining to the ongoing debate between professionals on how the basic structural elements of the analytic relationship should be conceptualised.