WHOSE SLEEP IS IT,ANYWAY? OR ‘NIGHT MOVES’3

The analyst's ‘sleep’ during sessions is a puzzling, troubling, extreme experience, which has rarely been described in the psychoanalytic literature. The author presents a clinical illustration in which her recurring ‘sleep’ during the sessions was approached as an open, central issue. She attempts to explore, understand and integrate this experience theoretically and clinically, first by reviewing and examining the psychoanalytic literature on the subject and on related phenomena, and then, more particularly, by formulating her own explanation of it. She emphasises being in the grip of the psychoanalytic process, and the immersed involvement and converging of patient and analyst, which generate a conjoint state of deep experiential interconnectedness and impact on each other ‐ in particular the impact of the patient's inner world on the analyst. In this context, the author also refers to the notions of ‘the uncanny’, ‘fear of breakdown’ and dissociative self‐states and the mitigation of the patient's dissociative self‐experience via the analyst's vicarious dissociative experience.     

The analyst's narrative function: Inventing a possibility

This article describes a psychic function common to analysts that was gradually revealed through clinical work with children. It is a psychic quality derived from function α, which involves analysts’ capacity for reverie – their narrative function. The author presents two clinical situations where this function developed in the analytic field in relation to patients’ difficulty in symbolizing. In the first case there was an early traumatic experience unavailable for representation. The analyst lent the patient her ability to represent and produced a narrative that made it possible to create a world of phantasies and transform nightmares into ‘dreamable’ dreams. In other words, she removed the quality of unbearable, irrepresentable reality that characterized those raw experiences encrypted in the psyche. In the second case the analyst's narrative function sought to connect with the isolation, the shell that housed a child suffering from an autistic disorder whose ability to represent had not been established. The analyst provided meaning for the patient's repetitive, stereotyped play, thus weaving the child's subjectivity and gradually introducing a notion of alterity. The author seeks to show how this function, in the thematic construction of the session, facilitated both the working‐through of a traumatic situation (with the ability to share representations) and the constitution of the psychic fabric.     

Engagement and suffering in responsible caregiving: On overcoming maleficience in health care

The thesis of this article is that engagement and suffering are essential aspects of responsible caregiving. The sense of medical responsibility engendered by engaged caregiving is referred to herein as ‘clinical phronesis,’ i.e. practical wisdom in health care, or, simply, practical health care wisdom. The idea of clinical phronesis calls to mind a relational or communicative sense of medical responsibility which can best be understood as a kind of ‘virtue ethics,’ yet one that is informed by the exigencies of moral discourse and dialogue, as well as by the technical rigors of formal reasoning. The ideal of clinical phronesis is not (necessarily) contrary to the more common understandings of medical responsibility as either beneficence or patient autonomy — except, of course, when these notions are taken in their “disengaged” form (reflecting the malaise of “modern medicine”). Clinical phronesis, which gives rise to a deeper, broader, and richer, yet also to a more complex, sense than these other notions connote, holds the promise both of expanding, correcting, and perhaps completing what it currently means to be a fully responsible health care provider. In engaged caregiving, providers appropriately suffer with the patient, that is, they suffer the exigencies of the patient's affliction (though not his or her actual loss) by consenting to its inescapability. In disengaged caregiving — that ruse Katz has described as the ‘silent world of doctor and patient’ — provides may deny or refuse any ‘given’ connection with the patient, especially the inevitability of the patient's affliction and suffering (and, by parody of reasoning, the inevitability of their own. When, however, responsibility is construed qualitatively as an evaluative feature of medical rationality, rather than quantitatively as a form of ‘calculative reasoning’ only, responsibility can be viewed more broadly as not only a matter of science and will, but of language and communication as well — in particular, as the task of responsibly narrating and interpreting the patient's story of illness. In summary, the question is not whether phronesis can ‘save the life of medical ethics’ — only responsible humans can do that! Instead, the question should be whether phronesis, as an ethical requirement of health care delivery, can ‘prevent the death of medical ethics.’     

Private Terrors Sexualized Aggression and a Psychoanalyst's Fear of Her Patient

This clinical paper explores the meanings and evolution of an analyst's reaction of fear in relation to her patient's sexualized aggression. From both an intrapsychic and an intersubjective perspective, the author analyzes the coconstruction of this transference—countertransference phenomenon. Case vignettes illustrate the author's attempts to address her patient's sexualized aggression while struggling to free herself from the feelings of intimidation and fearfulness stirred by his sadomasochistic fantasies and patterns of interaction. The analyst's unconscious identification with the patient's disowned femininity and narcissistic vulnerability is seen as central to this countertransference “stranglehold.” Release from the analyst's masochistic position comes through a shift in her own affective participation. The importance of the analyst's recognizing her own unconscious contributions to this sadomasochistic dynamic is emphasized and elaborated. Discussion also focuses on the relevance of gender to the issue of countertransference fear, as illustrated in this particular male patient—female analyst dyad.     

Fire at the theatre: (Un)reality of/in the transference and interpretation1

Only in Bion's extended idea of ‘waking dream thought’ is the oneiric paradigm of the cure (already an obvious Freudian principle) completely applicable. The author's basic hypothesis is that, by adopting this paradigm thoroughly, one can combine the radical antirealism which is expressed in the postulate by which all the patient's communications are transference‐connected (here meaning ‘false connection’‐i.e. as projection/displacement of elements of the patient's inner psychic world) with the ‘reality’ of the transference, that is to say with the conviction that the facts of the analysis are co‐determined by the patient‐analyst dyad and actually rooted in how they interact. The Freudian metaphor of the fi re at the theatre is reintroduced here to suggest the crisis of the therapist's internal setting and capacity for reverie, which occurs when the irreducible ambiguity of the transference is resolved defensively, either in the patient's external reality or in his unconscious fantasy constellation. The author gives three clinical examples. The fi rst shows some of the not necessarily negative effects of this temporary crisis. The other two vignettes show a way of listening to the traumatic events of the patient's life from a perspective (that of the ‘analytic fi eld’) which is thought to be potentially the most transformative and vital to the analytical relationship.     

Food and violence: Childhood violence and emotional abuse as complicating factors in the inpatient treatment of eating disorders

SUMMARY

This paper considers the treatment, on an inpatient eating disorders ward, of patients who have suffered violence and emotional abuse during childhood. The complex web of relationships surrounding these patients is discussed, and it is suggested that there are multiple transferences — to the institution, to various members of staff, and to other patients — and that splitting of these transferences is inevitable. Staff experience powerful countertransference feelings, related to the patient's violent history. A central task for the staff team as a whole is to understand and contain the patient's disturbance — taking on, tolerating, and processing the projections. This demands the close working-together of the members of the multidisciplinary team, so that staff can together openly examine the patient's interaction with them and their own emotional responses to the patient and to other members of staff. If these responses are not understood by the ward staff, they can lead to conflict and inappropriate decisions. On the other hand, if the staff team together can build up a picture of the patient's relationships on the ward, and their meaning for the patient, this picture, like a particular projection of the world in an atlas, provides a ‘map’ of the patient's inner world. This ‘map’ can be used by the staff team in navigating their interactions with the patient. It can also assist the psychotherapist in her work to help the patient recognise and, eventually, own the split-off parts of herself.     

Death by non-feeding: Not in the baby's best interests

It has recently been suggested that doctors have a duty to act in their patient's best interest and that this duty demands that life-sustaining treatment—including food and fluids—should sometimes be withheld or withdrawn and the patient allowed to die. In this article, the author explores the scope of the ‘best interests principle’ in the context of treatment decisions for seriously handicapped newborn infants. She argues that those who hold that it is permissible to starve or dehydrate an infant to death are mistaken to think that this course of action is in the infant's best interests. While it may be true that there are times whendeath is, everything considered, in an infant's best interests, a slow and distressingmethod of bringing death about is not. Since death by dehydration and starvation is not benign, the withholding of food and fluids is generally not in an infant's best interests. The author concludes by suggesting thatwhenever the withdrawal or non-employment of life-sustaining means imposes a heavy burden on the infant, the ‘best interests principle’ would demand that the infant be killed rather than allowed to die.     

Impervious and intrusive: The impenetrable object in transference and countertransference

The author describes an internal object that he calls the ‘impenetrable object’ which has two characteristics: being impervious to the projections from the patient and being intrusive, i.e. projecting into the patient. It arises out of an early relationship with a mother who may be generally disturbed or traumatized so that she is unable to take in or tolerate the child's projections and may use the child as a receptacle for her own projections. He links the concept of an impenetrable object with other concepts such as Williams's ‘reversal of the container–contained relationship’ and Green's ‘dead mother’. If such an object dominates the patient's internal world, it can lead to severe difficulties in the analytic process. Interpretations may be experienced as violent projections from the analyst which the patient has to ward off and the analyst may enact an impervious or intrusive object in various ways. The author describes a case in which such dynamics played a significant role. He argues that intensive work in the countertransference is required to detect subtle enactments and allow a shift in the analyst, which in turn can enable change in the patient. He gives clinical material that demonstrates such work by the analyst and illustrates the shift from an impenetrable object to a more permeable one in the patient's internal world.     

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.     

Traumatic effects of political repression in Chile: A clinical experience1

The author examines psychic trauma resulting from human rights violations in Chile. Starting from trauma theories developed by authors such as Ferenczi, Winnicott and Stolorow, she posits the relevance of the subject's emotionally signifi cant environment in the production of the traumatic experience. She describes the characteristics of the therapeutic process on the basis of a clinical case. She emphasizes the need to recognize the damage that may be produced within the reliable link between patient and analyst, pointing out the risk of retraumatization if analysts distance themselves and apply ‘technique’ rigorously, leaving out their own subjective assessments. Therapists must maintain their focus on the conjunction of the patient's intersubjective context and inner psychic world both when exploring the origin of the trauma and when insight is produced. The author posits repetition in the transference as an attempt at reparation, at fi nding the expected response from the analyst that will help patients assemble the fragments of their history and achieve, as Winnicott would put it, a feeling of continuity in the experience of being.     

MAPPING THE LANDSCAPE: LEVELS OF TRANSFERENCE INTERPRETATION3

The author argues that there are distinctly different kinds of transference interpretation, each of which might be valid in particular circumstances in analysis, but which contain and imply different understandings of what is meant by a ‘transference interpretation’. She suggests that transference interpretations may be at any one of four different levels, and she describes these levels as ranging from interpretations that point to links between current events in the analysis and events from the patient's history, through interpretations that link events in the patient's external life to the patient's often unconscious phantasies about the analyst and the analysis, to interpretations that focus on the use of the analyst and the analytic situation to enact unconscious phantasy configurations, sometimes pulling the analyst into the enactment. Material from four consecutive sessions of an analysis is presented to illustrate how all levels of transference interpretation may be part of a lively and meaningful analysis, but how the level of interpretation may change as the level of understanding deepens within a session and from one session to the next.     

Response to “Poison Cookies” Discussions

This is a response to the discussions of the case presented by this author. Responding to the discussions has allowed the author to pull together her own ideas about the case as well as about the work we do. The author sees Sheldon (Shelly) Bach's view of sadomasochism as a particular type of object relationship as informing her own point of view. Next comes a discussion centering on Steven (Steve) H. Knoblauch's emphasizing the importance of the internal symbolic world of the patient. The author makes the point that understanding the level of differentiation of the internal objects in the patient's representational world is important in thinking about the types and timing of interventions the analyst makes; for example, those which Mary-Joan Gerson describes in her comments. Finally, the author addresses Sue Grand's response, especially her emphasis on the importance of siblings in our patients’ histories and the resulting sibling transferences to the analyst.     

Intersubjectivity and Receptive Experience

Wilfrid Sellars's iconic exposé of the ‘myth of the given’ taught us that experience must present the world to us as normatively laden, in the sense that the contents of experience must license inferences, rule out and justify various beliefs, and rationalize actions. Somehow our beliefs must be governed by the objects as they present themselves to us. Often this requirement is cashed out using language that attributes agent‐like properties to objects: we are described as ‘accountable to’ objects, while objects ‘hold us’ to standards, and so forth. But such language is either deeply anti‐naturalistic or trades on a set of metaphors in need of a literal translation. We offer an explanation of how the material features of the world, as received in experience, can rationally constrain our beliefs and practices—one that makes no recourse to this imagery. In particular, we examine the structure of ostensive practices (that is, practices of directing one another's attention to objects and features of the world) and the distinctive role they play in making us jointly beholden to how things actually are.     

Trauma,narcissism and the two attractors in trauma1

In this paper, the author sets out to distinguish anew between two concepts that have become sorely entangled‐‘trauma’ and ‘narcissism’. Defi ning ‘narcissism’ in terms of an interaction between the selfobject and the self that maintains a protective shield, and ‘trauma’ as attacks on this protective shield, perpetrated by bad objects, he introduces two attractors present in trauma‐‘the hole attractor’ and the structure enveloping it, ‘the narcissistic envelope’. The hole attractor pulls the trauma patient, like a ‘black hole’, into a realm of emotional void, of hole object transference, devoid of memories and where often in an analyst's countertransference there are no reverberations of the trauma patient's experience. In the narcissistic envelope, on the other hand, motion, the life and death drive and fragments of memory do survive. Based on the author's own clinical experience with Holocaust survivors, and on secondary sources, the paper concludes with some clinical implications that take the two attractors into account.     

At‐one‐ment,intuition and ‘suchness’1

Many senses exist for perceiving sensory experience; there are in turn others which make it possible to perceive emotional experience: intuition is one of these. The author, using W. R. Bion's work, studies intuition psychoanalytically, considering it to be a powerful ‘sense’ in clinical work. He describes the metapsychology of intuition, and proposes models that make it possible to think—from different perspectives— about how to make use of it in an analysis. To this end, he examines a series of useful processes and concepts: growth, tolerance, ‘suchness’, suffering and courage. The author defi nes the intuitive mechanism as a derivation of the renunciation of memory, desire and understanding; such a renunciation, learning from the experience of suffering the pain of facing the Truth in at‐one‐ment, makes it possible to tolerate the frustrations associated with observing the analysand ‘such‐as‐he‐is’. Finally, once immersed in the intelligence of intuition, the author considers ways in which intuition might be linked with concepts, with a view to interpreting the facts that must be transformed in the analysis.     

Full and empty spaces in the analytic process2

In this paper the author discusses two categories of patients which differ in terms of the impact they have in the countertransference. On the one hand, there are patients who create an empty space in the analyst's mind. The response they provoke is a kind of depressive feeling that remains after they leave. The patient may bring dreams and associations, but they do not reverberate in the analyst's mind. The experience is of dryness, a dearth of memory, which may‐at times‐leave the analyst with a sense of exclusion from the patient's internal world. At the other extreme, there are patients who fill the consulting room. They do that with their words, dreams and associations but also with their emotions and their actions. The experience is that the analyst is over‐included in the patient's world. They have dreams that directly refer to the analyst and the analyst feels consistently involved in the patient's analysis. The pathway through which the analyst can understand both these types of patients is via the countertransference or, to put it another way, the analyst's passion. In ‘Analysis terminable and interminable’ Freud suggested that the bedrock of any analysis is the repudiation of femininity. The author believes this statement may be viewed as lying at the crossroads of the discussion about the limits of the theoretical and clinical psychoanalytic formulations which she refers to. In the examples presented the author relates the repudiation of femininity in its connections to the gaps implicit in psychoanalytic understanding.     

What is the function of faith and trust in psychoanalysis?1

Unlike other concepts such as ‘illusion’, ‘capacity to tolerate frustration’ and ‘libidinal investment’, the concept of faith has not yet found a well‐defined position in psychoanalytic theory. Bion focused on faith and placed it in an unusual context: scientific work. Through the Act of Faith a researcher can give some consistency to certain ideas, hunches or intuitions that may appear during observation, though he cannot represent them by existing theory. Through the Act of Faith an analyst can ‘see’, ‘hear’ and ‘feel’ those mental phenomena, the reality of which leaves no practising psychoanalysts in doubt, even if they cannot represent them by current formulations. In this paper, the author aims to expand Bion's proposals into the clinical and therapeutic fields. In the first part, the author examines how faith and trust overlap, and how they depart from each other, and he gives an example. Faith possesses an igniting and driving force which trust doesn't possess to the same extent. In the second part, the author looks at F as a psychic function of the analyst, which aids him in supporting a depressed and hopeless patient while waiting for the return of the patient's desire to live. In the final part, he focuses on F from the patient's point of view and studies the transformations of F that may occur during an analysis.     

PATIENT‐ANALYST “WITHNESS”: ON ANALYTIC “PRESENCING,” PASSION,AND COMPASSION IN STATES OF BREAKDOWN,DESPAIR, AND DEADNESS

This paper focuses on the analyst's “presencing” (being there) within the patient's experiential world and within the grip of the psychoanalytic process, and the ensuing deep patient–analyst interconnectedness, as a fundamental dimension of analytic work. It engenders new possibilities for extending the reach of psychoanalytic treatment to more disturbed patients. Here patient and analyst forge an emergent new entity of interconnectedness or “withness” that goes beyond the confines of their separate subjectivities and the simple summation of the two. Using a detailed clinical illustration of a difficult analysis with a severely fetishistic‐masochistic patient, the author describes the kind of knowledge, experience, and powerful effects that come into being when the analyst interconnects psychically with the patient in living through the process, and that relate specifically to the analyst's compassion.     

Handling and self-handling: An object relations perspective on leisure exercise

This paper considers participation in exercise activities as a form of ‘self-handling’. The focus is on individual exercise rather than on activities, such as those involved in some sports and martial arts, which involve pair or group interaction.

The author suggests that the way in which physical activity is used, abused, or avoided in adult life is linked to the quality of primary relationships and in particular to childhood experiences of handling (Winnicott 1962a, 1970). She suggests that exercise evokes ‘memories-in-feeling’ (Klein 1957) of early experiences of handling and is thus essentially object related. A number of different psychic functions of exercise are considered in relation both to theory, particularly Winnicottian theory, and to clinical material.

As we are all aware, not everything a client does in the external world is raised for consideration in the context of the therapeutic relationship. The author reflects on the need to consider the meaning of the client's introduction of the subject of exercise into the therapeutic discourse, as well as the meaning of the physical activity itself.     

Arnauld's Verbal Distinction between Ideas and Perceptions

In his dispute with Malebranche about the nature of ideas, Arnauld endorses a form of direct realism. This appears to conflict with views put forward by Arnauld and his collaborators in the Port-Royal Grammar and Logic where ideas are treated as objects in the mind. This tension can be resolved by a careful examination of Arnauld's remarks on the semantics of ‘perception’ and ‘idea’ in light of the Port-Royal theory of language. This examination leads to the conclusion that Arnauld's ideas really are objects in the mind, and not perceptual acts as many commentators hold. What Arnauld denies is that these mental objects are really distinct from the external objects they represent. Instead, Arnauld holds that, by the act of conception, the external objects themselves—not copies—come to be present in the mind and are therefore called ‘ideas’.