Remarks on the Case of Pamela

This is a discussion of Robert Grossmark's paper: “The Case of Pamela.” It emphasizes the trauma in her early upbringing and uses her own words to describe the severe damage this did to both her physical and her emotional sense of existence. It touches on the crumbling of her ability to trust, the dysregulation of her physical and mental economy, the substitution of false self personnae for the endangered real self, and the inevitable enactments that occur in a treatment of this sort. Though recognizing the remarkable help that this treatment afforded her, it suggests that a further phase of explicit negative transference is being postponed and might be necessary for the full completion of this treatment.     

People are not cabbages: reflections on patient and analyst change

The author describes how her own internal change was a vital part of transformation between herself and two patients. She draws on Loewald's work as she discusses how change in her own internal relationship with her father was part of a lifelong emotional reorganization of Oedipal relations. She describes a process of mutual change whereby her and her patients' unconscious growth each stimulated the other. She suggests that the analyst's own emotional growth is a vital, not an incidental, part of psychoanalysis, as it brings new life to the work for patients as well as analysts themselves.     

SUPERVISION: A CONTAINERÆCONTAINED APPROACH

The authors illustrate an approach to the supervisory process as a learning experience for both supervisee and supervisor built on the containment of unconscious anxieties. It is argued that a core function of psychoanalytic supervision is to help contain the emotional turbulence and the unconscious anxieties arising and evolving in the two interacting domains of the analytic and the supervisory sessions. From this perspective, the analyst-patient interaction and that of the supervisee and supervisor can be understood as twin, tiered transformational arenas, the supervisory one being at the service of holding and grasping the roles the supervisee/analyst goes through as part of the analytic process. On the basis of detailed clinical material from a disturbed 7-year-old girl, the authors explore the interrelated issues and difficulties in containing anxieties and turbulence in both the analytic and the supervisory situation. When emotional containment is adequately handled, the supervision helps the understanding and development of the supervisee's use of his/her own personality as a treatment instrument, as advocated by Fleming and Benedek decades ago. The supervisory session thus furthers the resolution of clinical issues through symbol-formation, clinical sessions and supervision being twin domains for recording and understanding emotional evolution.     

A Single Intervention: A Visit to the Family

The following letter is reported unchanged except for disguised names. Concern with repairing disrupted relationships of adult members of a family with their own parents has been a matter of growing interest to a number of family therapists; Bowen (1), Boszormenyi-Nagy (2), and Framo (3), among others have stressed the importance of sending family members back to their families of origin. This report makes no effort to formulate the process in any particular theoretical framework (i.e., as reestablishing connectedness after an “emotional cut-off” or rebalancing a ledger of fairness, or whatever) but is intended only to illustrate the kind of outcome one may hope for in prescribing such a maneuver. It is offered simply as a clinical note. The letter needs little prefatory explication. Mr. Jack Newburgher had been a patient in psychoanalytic treatment for four years, with a quite successful outcome. On two occasions in the course of his therapy a joint session had been held with Mr. Newburgher and his wife, Muriel, when changes in his behavior had precipitated crises in the marital relationship. His therapy had terminated about two years before the visit referred to in the letter. Mr. Newburgher had called and asked for a joint consultation with Muriel about an acute family problem they were experiencing. Some — not all — of the background material was described, not nearly as coherently as it is reported in Muriel's letter, but in sufficient detail to make it plain that she was in distress about having to withdraw completely from her parents and that their family was in disarray as a consequence of her distress. The acuteness of the emotional disturbance, against a background of a lifelong adversary relationship between Muriel and her father and a history of ten years of illness on her fathers' part, suggested that the distress was the product of Muriel's anxiety and guilt over a decision to cut herself off completely from her parents. As a consequence, Muriel was urged to visit her family of origin, with the caveat that she might indeed discover them to be malignantly self-centered people indifferent to their effect on her and her family, but that she would at least have the gratification of having tried. The reference to “speaking French” was to the therapist having suggested that, on the other hand, she might find that her parents expressed their feelings in a different modality from her definitions of how feelings should be expressed, much as though their native tongue were French and she were insisting that they must speak to her in English.     

Thinking about and working with depressed mothers in the early months of their infant's life

This paper illustrates how my work has developed over the years and informed my thinking about, and work with, depressed mothers. It also describes the work of the Parent Infant Foundation in Sydney where pregnant women and mothers with infants and toddlers are seen in groups and individually through home visits. The relevance of the support of a peer group when doing such difficult work is described. The paper draws on a central theme: the depressed mother, returning to her own infant beginnings through pregnancy and birth, confronts a dead mother-dead infant dyad. Trauma from the mother's own infancy is seen to have created an internal, autistic, deadened, psychic space. It is argued that behind this deadness lies the primeval pain of abandonment and loss. The associated rage, previously repressed but now awakened by her alive infant and his powerful primitive demands, invade the mother's psyche. The internal deadness freezes her alive processes as mother to her baby. Unbearable pain is awakened - and she may be in terror and unable to move, or she may experience herself as drowning in something catastrophic. SUMMARY This paper illustrates how my work has developed over the     

‘It’s silly these doors don’t open’: a six-year-old girl emerges from a chronic state of emotional withdrawal

This clinical paper explores the way in which the first two years of a long-term psychotherapy helped six-year-old Anna to lessen her retreat into a chronic withdrawn emotional state. Over the course of the first year she would occasionally pick up the fridge from the doll’s house and try to open the doors, but because the fridge was actually a block of wood the doors could not open. In treatment, this inquiry came to represent the difficulties of engaging and making contact with a baby who found it very hard to feed. The author describes how, as Anna entered into a therapeutic relationship, it slowly became clear that there was an inner world jam-packed with persecutory anxieties and a family history of unmourned loss and trauma. Through fear Anna slammed the doors to her mind – to knowing herself – and by not feeding, Anna starved herself of opportunities for mental growth. It took some time for her to state, “it’s silly these doors don’t open, they should”. In the discussion of this clinical material the author draws on the work of Francis Tustin, Alessandra Piontelli and Marguerite Reid to consider the link between intergenerational and prenatal trauma and subsequent emotional disturbance in the child.     

BORGES, IMMORTALITY AND THE CIRCULAR RUINS

The author explores ideas surrounding immortality and death focusing on the interplay between their development in two stories by Borges ('The circular ruins' and 'The immortal') and their manifestation in a patient. With the help of Borges's stories, the author addresses the desperate necessity experienced by some individuals to search for immortality. This is not just an expression of the universal wish to live forever but, at a deeper level, arises from the impossibility of bearing the mental pain of experiencing ordinary human vulnerability and loss - death being the ultimate expression of such vulnerability. It is suggested that the relentless pursuit of immortality in such individuals expresses an omnipotent phantasy of ridding the self of the emotional pain and fear that arises through being alive. It leads to a denial of the emotional significance of passage of time, of separation and sexual differences. In actuality, the individual's state of not feeling approximates to a complete loss of human identity and emotional death, with no place for any meaningful others. The individual him/herself becomes a 'mere image', living in a delusional world peopled by him/herself and his/ her projections, and ending up trapped inside the circular ruins he/she has generated. The horror experienced at the stark awareness of the individual's emotional death and the wish to re-establish contact with the good internal objects that have been attacked sets in motion the long process of searching for the recovery of a sense of temporality (that would still include the wish for immortality) and, with it, a sense of identity.     

Discussion of Dr Hinz's contribution

The author places herself in the position of the analyst to 'listen' to a session reported by her German colleague, Dr Hinz; her interpretation of the material presented gives greater importance to the striving of the analysand to have his 'productions' appreciated than the analyst's interpretation of the negative transference aspects attributed to the same material.     

The effectiveness of therapeutic assessment with an adult client: a single-case study using a time-series design

This article presents the therapeutic assessment (TA; Finn, 2007) of a traumatized young woman named Claire. Claire reported feeling debilitated by academic demands and the expectations of her parents, and was finding it nearly impossible to progress in her studies. She was also finding it difficult to develop and sustain intimate relationships. The emotional aspects of close relationships were extremely difficult for her and she routinely blamed herself for her struggles in this arena. The assessor utilized the TA model for adults, with the exception of not including an optional intervention session. The steps of TA, particularly the extended inquiry and the discussion of test findings along the way, cultivated a supportive and empathic atmosphere with Claire. By employing the single-case time-series experimental design used in previous TA studies (e.g., Smith, Handler, & Nash, 2010; Smith, Wolf, Handler, & Nash, 2009), the authors demonstrated that Claire experienced statistically significant improvement correlated with the onset of TA. Results indicated that participation in TA coincided with a positive shift in the trajectory of her reported symptoms and with recognizing the affection she held for others in her life. This case illustrates the successful application of case-based time-series methodology in the evaluation of an adult TA. The potential implications for future study are discussed.     

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.     

Don’t tell me I’m normal: inpatient psychotherapy of a severely abused patient at the Cassel Hospital

This paper is a case study of a patient with severe personality disorder undergoing treatment at the Cassel Hospital. It looks at a phase of her individual psychoanalytic psychotherapy and how that sits within an institutional model of treatment that can be understood as applied psychoanalysis, in which Tom Main’s concept of a ‘culture of enquiry’ aims to observe and bring together splitting and projective processes operating at all levels of the organisation. The patient, who had been sexually abused and then suffered a prolonged suicidal breakdown, exerted intense pressure on the institution through her experience of herself as both a victim of abuse and a participant in it. A working through is described, in which different parts of the patient that had been projected into different parts of the institution are brought together, and her primitive demand for a two-person world gives way to an acceptance of triangulation. Themes from her individual sessions are enacted in the milieu-based treatment, and conversely struggles in the patient community appear in her sessions. It is from drawing these parts of the patient together as a whole institution that the treatment derives its power and effectiveness.     

On Becoming One-Self: Reflections on the Concept of Integration as Seen Through a Case of Dissociative Identity Disorder

This paper explores the concept of “integration” as it relates to the development of self-awareness and the recognition that one exists as a self. It is argued that this awareness relies on a capacity for self-reflection which is intimately tied to the ability to locate oneself in time and in space. Through the presentation of a patient with Dissociative Identity Disorder, the author demonstrates how the development of the patient's consciousness of self progressed through the treatment and particularly, through the relationship between analyst and patient. In the case presented, the patient began treatment unaware of her dissociative structure. She was also unaware of the continuity of time, including the concepts of past, present, and future as they related to herself, and to the fact that she existed in a body that was subject to the basic laws of physics such as being able to be in only one place at one time. Through the development of a self-reflective capacity and a growing familiarity with the various aspects of herself, the patient began to develop a sense of herself as a continuous entity physically, psychologically and spiritually.     

‘I am not crying. I am rubbing my eyes’: Annie and the hollow object

This article explores the relationship between the development of severe eczema and asthma in an eight-year-old girl and her difficulties with experiencing psychic pain and conflict. The author focuses on the transference dynamics that preceded and surrounded the psychosomatic reaction in the session. The observations in this case may explain why patients, despite feeling taken over by intense physical sensations, can display flatness and superficiality of affect giving the appearance that they are emotionally ‘hollow’. The author proposes that these patients experience an emotional sense of emptiness in themselves and in their objects that is the result of a very early defence of dissociation caused by overwhelming anxieties of annihilation that are lived out in and through the body. The appearance of a psychosomatic symptom during the session can follow the emergence of sudden and intense raw hostile feelings towards the primary object, accompanied by a sense of danger and profound anxiety, as the hated object is also desperately needed for the subject’s own physical/emotional survival. The analyst can contribute to triggering these episodes by failing to contain the patient’s projections, which may lead to the patient feeling forced to re-introject unprocessed and unbearable ‘psycho-physical’ emotions. This article discusses the different degrees – and forms – of symbolic functioning in connection to this girl’s experience of her eczema and asthma and their manifestation in the transference relationship to the therapist.     

Consultation in adolescence: Hurried,terminable, interminable1

The physiological ambivalence displayed by adolescents towards dependence on adults is an obstacle, at least initially, to a course of psychotherapy. A consultation is often the only thing that can be offered to start with, and constitutes an essential stage even for those teenagers who go on to prove themselves able to benefi t from therapy or analysis. The way this fi rst meeting is handled is therefore crucial. The author investigates the diffi culties and paradoxes of this consultation, the particular nature of the ‘time’ of the consultation compared to that of therapy, and the different internal attitude this requires of the analyst. She thus identifi es two separate confi gurations‐a hurried consultation and an interminable consultation‐which can result when the consultation fails in its primary objectives. Both are connected with possible collusive elements in the professional linked to specifi c adolescent angst. The very detailed account of a consultation shows the ‘journey’ made by a 14 year‐old starting from her urgent request to be freed from a symptom experienced as an incomprehensible obstacle, to her gradual development of curiosity towards herself and towards her own mental and emotional make‐up, resulting in her acceptance of therapeutic treatment, which would initially have been impossible.     

The 'secret cocoon': fantasies about the private self in the absence of consensual reality

Clinical material is presented from an analysand whose defense of withdrawal to 'a private internal space' was mobilized when she became confused, within her relationships and within the transference, about whose understanding of a shared event was 'real.' Analysis of the defense as resistance revealed a disrupted sense of connection to others and to the analyst in the face of the difficulty in determining a consensual reality. This was accompanied by emotional withdrawal, with a complex fantasy of retreat to a protective inner hiding place, or cocoon. The phenomenology and functions of such withdrawals, the fantasies accompanying them, and the ways in which they changed during the analysis are discussed in this paper. For the patient described, the analysis of her shifting 'cocoon' states and of the fantasies connected with them eventually enabled her to access her creative 'private self' more freely and with less conflict.     

Infanticide and the Right to Life

Michael Tooley defends infanticide by analysing ' A has a right to X' as roughly synonymous with 'If A desires X , then others are under a prima facie obligation to refrain from actions that would deprive him [or her] of it.' An infant who cannot conceive of himself or herself as a continuing subject of experiences cannot desire to continue existing. Hence, on Tooley's analysis, killing the infant is not impermissible, for it does not go against any of the infant's desires. However, Tooley's argument in support of his analysis seems to justify, instead, a slightly more subtle analysis—namely, ' A has a right to X ' is roughly extensionally equivalent with 'Unless A expresses his or her desire that not- X , then others are under a prima facie obligation to refrain from actions that would deprive him or her of X .' But given this analysis, the infant's purported lack of any capacity to conceive of himself or herself as a continuing subject of experiences implies that we cannot be released from any duty that we might have not to harm him or her. In short, Tooley's argument in support of his analysis actually implies that infanticide may well be impermissible.     

Emotion-Focused Therapy: A Synopsis

The basic principles of an emotion-focused approach to therapy (EFT) are presented. In this view, emotion is seen as foundational in the construction of the self and is a key determinant of self-organization. As well as simply having emotion, people also live in a constant process of making sense of their emotions. Personal meaning emerges by the self-organization and explication of one’s own emotional experience, and optimal adaptation involves an integration of reason and emotion. In EFT, distinctions between different types of emotion (i.e., primary versus secondary, adaptive versus maladaptive) provide therapists with a map for differential intervention. Therapists are viewed as emotion coaches who help people become aware of, accept, and make sense of their emotional experience. Four major empirically supported principles of emotion awareness, emotion regulation, emotion transformation and reflection on emotion guide emotion coaching and serve as the goals of treatment. A case example illustrates how the principles of EFT helped a young woman to overcome her core maladaptive fears and mobilize her ability to protect herself.     

Changes in self- and object representation as revealed by reflection response

This article considers the three Rorschach tests obtained over an 8-year period for one female patient who struggled around her image of herself and others. Her struggle is revealed in the vicissitudes of the reflection responses over the three testings. A formulation is advanced regarding the meaning and significance of the reflection response as an indication of an emerging self-experience.     

"Dwelling in the Past": The Role of Rumination in the Treatment of Posttraumatic Stress Disorder

Prolonged exposure, a cognitive behavioral therapy including both in vivo and imaginal exposure to the traumatic memory, is one of several empirically supported treatments for chronic posttraumatic stress disorder (PTSD). In this article, we provide a case illustration in which this well-validated treatment did not yield expected clinical gains for a client with PTSD and co-occurring major depression. After providing an overview of the literature, theory, and treatment protocol, we discuss the clinical cascade effect that underlying ruminative processes had on the treatment of this case. Specifically, we highlight how ruminative processes, focusing on trying to understand why the traumatic event happened and why the client was still suffering, resulted in profound emotional distress in session and in a lack of an "optimal dose" of exposure during treatment.