On Bearing Unbearable States of Mind

Ruth Riesenberg-Malcolm, Priscilla Roth, Priscilla Roth

• Publisher: Routledge
• Year: 2003
• ISBN:
  9781134627790
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This is a problem almost all practising psychoanalysts will face at some time in their career, yet there is very little in the existing literature which offers guidance in this important area.

On Bearing Unbearable States of Mind provides clear guidance on how the analyst can encourage the patient to communicate the quality of their often intolerably painful states of mind, and how he/she can interpret these states, using them as a basis for insight and psychic change in the patient. Employing extensive and detailed clinical examples, and addressing important areas of Kleinian theory, the author examines the problems that underlie severe pathology, and shows how meaningful analytic work can take place, even with very disturbed patients.

On Bearing Unbearable States of Mind will be a useful and practical guide for psychoanalysts and psychotherapists, and all those working in psychological settings with severely disturbed patients.

Part I

The Internal World in the Transference

Introduction

Priscilla Roth

The papers grouped in this section highlight particularly well Riesenberg-Malcolm’s sensitive and sophisticated analytic attention to the movements of internal objects, and, along with these, the different parts of the self, within the transference. They are, thus, about splitting and projection. They demonstrate the way she receives and contains confusing projections without either projecting them back at the patient or, equally disturbing for the patient, ignoring them by refusing to recognise their intensity and their disturbing quality.

This is beautifully illustrated by ‘The Mirror’ paper, the earliest of her papers to be published here. The patient’s material is disturbing; it is disconnected, strange and uncomfortable to listen to, both in its content and in its emotional tone. This is an experience familiar to all analysts— when what we listen to seems like undigested, unformulatable bits of experience. We deal with this in various, often defensive ways: we try to ignore our mildly uncomfortable feelings, we try to decode the manifest content of the material, or we assign meaning to one or another of its elements. What Riesenberg-Malcolm did here was, first of all, to trust her own experience of the bitty-ness of the material, her sense of unease, discomfort, however subtle and evanescent it seemed, and to use it to help her understand what the patient has done with her own ego and internal objects. In this way Riesenberg-Malcolm began to understand the patient’s anxiety (in this case a fear of curiosity) and the defences the patient used against the anxiety In Kleinian terms, she split her ego into curious and not curious parts. She herself did not feel curious, but her analyst became intensely curious. The patient had an unconscious phantasy of projecting curiosity into her analyst, and she acted in a way that evoked curiosity in Riesenberg-Malcolm.

This is a basic piece of analytic work, remarkable for its economy, simplicity and effectiveness. It is an example of Bion’s description of the maternal conversion of ‘beta’ to ‘alpha’ elements: the analyst, as container of disturbing, unthinkable beta elements of experience, transforms them and renders them, modified by thought, into bearable experience (Bion 1967: 90–4). One expects that the effect on the patient would be one of relief; and in fact this patient responded by agreeing with the interpretation and, much more importantly, by being more able to describe her difficulties in a coherent, more direct manner— her own ego functions were now more available to her. She was able to tell her analyst about her dream, which had disturbed her to such an extent that when she woke from it she felt compelled to masturbate while filling her mind with an habitual perverse sexual phantasy.

The analytic work that followed demonstrated the relationship between the acute anxiety which had led to and was manifest in both the dream of the previous night and the state of her mind early in the session, and the way the masturbation phantasy worked to ‘cure’ the patient temporarily of this anxiety. Throughout the work, the analyst’s attitude to her patient is sympathetic. In stark contrast to The Mirror in the patient’s phantasy, which represents a non-containing object whose only capacity is a remorseless reflecting back of the self, the analyst becomes a person able to carry out the functions of holding, metabolising, and understanding what her patient has offered her.

The way Riesenberg-Malcolm handles such situations of intense projection can also be seen clearly in an example from ‘Interpretation: the past in the present’, the second paper in this section. Early in this patient’s analysis, Riesenberg-Malcolm had noticed a peculiar ‘verbal mannerism’— the patient punctuated her comments to him, and even his own, with a mechanical, seemingly unconscious ‘yes’. Riesenberg-Malcolm’s interest in the symptom grew as she recognised its persistence and ubiquitousness, and she explored its meaning within the analysis, until she began to understand the relationship between the symptom and important aspects of the patient’s object relations. This process of experiencing the patient’s projections—however subtle, confusing or disturbing they might be—and understanding them as a communication from the patient of the most pressing aspects of his object relationships, is the cornerstone of her work.

Later in the same paper Riesenberg-Malcolm interpreted the precise way the patient’s hurt and angry feelings about being left alone over the weekend transformed his picture of her in his mind, so that he felt her to be an unreliable, untrustworthy person. He felt he had muddled, attacked, and so subjected her to abuse that she would turn her back on him by not understanding him; he believed his attack on her had destroyed his analyst as receptive, containing and thinking and that she would forget how much he needed his analysis. This is an omnipotent belief; the patient could not consider whether or not it was true, he simply ‘knew’ it to be true. ‘The object’s separate existence’, as Riesenberg-Malcolm says, ‘is felt as tantalising. And because of his reaction to this, he feels threatened by the total loss of the good object.’

It should be noticed that Riesenberg-Malcolm’s comments to her patient were not limited to here-and-now transference interpretations. Following the patient’s material, she made links with his current life situation (for instance his plans and worries about university) and with his past history. But her understanding of these external and historical events came from her understanding of the patient’s unconscious phantasies and conflicts which were manifested within the transference relationship.

The two vignettes from this patient’s material illuminate each other: what in the earlier session is perceived as a relationship with an emotionally absent mother becomes elaborated and clarified in the later material. The emotionally absent mother is seen to be experienced as tantalising; she offers hope which is itself tantalising, and therefore feels cruel. Riesenberg-Malcolm returns to this theme, the way in which hope can itself seem tantalisingly cruel, in ‘Conceptualisation of clinical facts in the analytic process’, in Part III of this book.

The third paper in Part I is ‘The constitution and operation of the superego’. While the clinical material in this paper illustrates the type of work I have been describing, the paper has been elaborated since its first publication so that its theoretical section is particularly important to note. In this first, theoretical, section Malcolm tackles two important differentiations. In the first place, she discusses ego and superego development, differentiating the one from the other as regards the process of the internalisation of objects in each: here she is describing the earliest internalisations and identifications, and how they affect on the one hand ego development and on the other the development of the superego. Second, Riesenberg-Malcolm addresses the question of the superego’s capacity to change: what elements of the superego are fixed and unchangeable, and which elements are responsive to developmental and analytic modification. She discusses Freud’s views on ego and superego development, and considers them in relation to Melanie Klein’s views. She points out that Klein, like Freud, appeared to contradict herself about the development of these structures, and she (Riesenberg-Malcolm) presents her own view.

The material she describes in this paper illustrates the points she is making and demonstrates again her view of her analytic function as receiving, containing and understanding the projections of the patient, a function she can only fulfil so long as she can differentiate herself from her patient’s projections into her. It is particularly interesting to notice that the careful work that she is able to do with the second patient she describes here, work which clearly seems to strengthen his ego functioning and render his superego less harsh, rests on her own conviction about the value of the analysis. She believes her patient felt helped by the first session she describes; she holds onto that belief in the face of the patient’s attacks on it and on her. This sturdiness in the face of emotional attack, which includes holding on to or recovering the capacity to think about what is going on, beautifully illustrated by the material, is an essential part of the analyst’s function for the patient.

In ‘Construction as reliving history’, the fourth and last paper of this section, Riesenberg-Malcolm describes her own way of approaching the problem of reconstruction in analysis, and suggests that Klein’s theories of infantile development may do away with need for the patient’s recollections of his earliest history. If the earliest internalised experiences which colour the personality take place at a pre-verbal stage, then the patient cannot remember in words, but can have what Klein called ‘memories in feeling’ (Klein 1957:5) which the patient conveys to the analyst by means of projective identification in the transference. It is these pre-verbal experiences, these ‘memories in feeling’, that the analyst perceives, and it is then the analyst’s task gradually to find ways to describe them verbally to the patient. ‘The analyst’s sensing of the patient’s projective identification is similar to maternal reverie’, writes Riesenberg-Malcolm, ‘but differs from it insofar as the analyst always requires a conscious perception and further elaboration of what he has felt’ (my emphasis) to be able to understand it as a communication. This is the use of the counter-transference as a tool to help the analyst perceive and understand the patient’s material, but Riesenberg-Malcolm is also emphasising the importance of the conscious work the analyst does to make sense of the patient’s communications and to use them to understand the patient’s history as it is being re-experienced within the transference. She describes ‘an interweaving of threads of history as they are experienced in the analysis, and threads of remembered history’ creating ‘a new autobiography’.

1

The Mirror

A Perverse Sexual Phantasy in a Woman seen as a Defence against Psychotic Breakdown

In this paper I intend to discuss the use of a perversion as a defence against psychosis. I have come to recognise in the material of the patient I shall discuss that her personality could be divided into psychotic and nonpsychotic parts in the manner described by Bion (1957). The psychotic parts are encapsulated within a perverse syndrome which allows the rest of the personality to establish some contact with reality and to maintain at least a modicum of normal functioning.

The psychotic state I shall describe consists of a condition in which the internal objects are destroyed and fragmented; the main anxieties are of disintegration. To cope with this situation the perversion has been erected as a protection against breaking into pieces.

History

The patient was forty-two at the beginning of treatment. She is the eldest of three children. The family used to own a shop in a small village in Northern Ireland. The mother attended to the customers while the father manufactured the products which were sold in the shop. When very young the children were expected to help either in the shop or with the housework. The patient describes the mother as weak, very much dominated by her husband and afraid of him. She was concerned about her children’s well-being and education but was not very sensitive. The father is said to have been tyrannical, ill-tempered and rigid. The mother was felt to abandon the children because of the father’s demands on her. Father had suffered a mental breakdown in his youth. Life at home was described as gloomy, restricted and isolated. The patient’s relationship with her next younger sister, four years younger than the patient, was characterised by intense jealousy and rivalry. With this sister the patient had a homosexual relationship for five years, from when the patient was ten until she was fifteen. The next sister, seven years her junior, has always been her favourite. She is the person she loves most in life, but this is because she feels it to be an exclusive relationship. This sister is unmarried and it sounds as if she is a very isolated person. At school there were innumerable behaviour problems, mainly stealing and lying. The patient had very few friends and remembers it as a very unhappy time. She left school at sixteen against her mother’s wishes, got a secretarial training and started work at seventeen. She lasted in the job only for a few weeks and had to leave it because of what appears to have been a paranoid breakdown. Following this she had several jobs, and after the war went overseas to work for an international corporation. During this time she was very promiscuous and eventually had to be brought home after some eighteen months because of a mental breakdown requiring hospitalisation.

On leaving hospital she enrolled at a university to read science. In spite of great difficulties, and having to go to hospital for a short time from university, she managed to get a good degree. After leaving the university she joined a convent as a postulant, remaining there for some months.

She has been unable to work in her own field and has been working as a secretary in a research laboratory for some years, where she seems to be efficient and capable. During the past twenty years her sexual life has consisted exclusively of masturbation with perverse phantasies which have a compulsive character. They take up a large part of the patient’s time, during which she either practises them directly or is preoccupied by thoughts about them. ‘The Fantasy’ (she refers to it by this name) consists of a ‘mirror with one-way vision’ inside which a number of sexual activities take place. These activities are generally violent, including openly sadistic actions. The experiencing of humiliation is fundamental and must be felt by every participant in the action. The participants often form incestuous couples. They are described as ‘a man’, ‘a mother’, ‘a father’, etc. , with no individual or personal characteristics. There are often openly grotesque or bizarre couples. The duration of the intercourse is usually extremely long; the couples are prevented from reaching a state of satisfaction by frequent interruptions. In general the satisfaction that is allowed to them is very meagre, and cruelty is a prevailing factor throughout. In The Fantasy, homosexual activities occur frequently, sometimes parallel with, sometimes simultaneous with, and sometimes consecutive to the heterosexual ones. During The Fantasy the patient feels that she ‘is’ or she ‘is in’ each one of the participating characters.

While these events take place inside The Mirror, outside The Mirror are several onlookers. These onlookers can be ‘just people’, but more often they are specified as photographers, cameramen, or reporters. The presence of the onlookers outside The Mirror is an essential part of The Fantasy. These spectators are often excited by what they are witnessing inside The Mirror, and they have to put up a struggle against this excitement. If they succumb to it, they become drawn inside The Mirror. Once inside, a partner has to be provided, as unaccompanied persons are not allowed in The Mirror. The number of people from outside The Mirror who are attracted and drawn into it varies. The temptation to succumb to the excitement is always made great for them.

The thesis of this paper is that The Fantasy represents an attempt to reconstruct the parental couple as a means of reconstructing the patient’s ego which is otherwise felt to be in bits, like the destroyed parental intercourse contained by her.

The Fantasy and Promiscuity

As I have mentioned, The Fantasy ‘settled in’ in the patient’s life some time after a period of intense promiscuity which ended in her first admission to hospital with a breakdown in which she felt unable to cope and had feelings of ‘falling to pieces’.

During this promiscuous episode she had drifted from man to man for sexual relations, occasionally perverse, characterised by lack of personal contact with her partners and by an excited childish attitude, tinged with cruelty, and followed by a masochistic reaction. The sadism was often expressed in her thoughts towards the men but was sometimes also expressed directly in her behaviour in an intense and uncontrollable way. For instance on one occasion when asked by a man to masturbate him manually, she got hold of his penis and started banging it up and down and pulling at it with extreme violence, unable to let go in spite of the man’s screams of horror and pain.

The breakdown after this episode could, in my view, be explained as the result of the intense projective identification which went on with her different partners. They always contained ‘the desire and the wish’. The patient felt sexually cold and had an intense contempt for her partner’s excitement. During the sexual relation she felt how humiliating it was for her partner to be prey to such intense desire. Immediately after intercourse she felt humiliated and tried to rationalise this humiliation by the thought that things never worked or developed, or that the man did not love or respect her. The continuous change and drifting from man to man seemed to have been accomplished by intense splitting of herself such that each man came to contain a different part of herself with which she was unable to establish any proper contact, so that in the end she was left in bits, as represented by the different men going off in different directions. Once she had split herself and projected these split-off parts, they seemed to be lost for her, thus leaving her feeling impoverished and unable to reintroject or to bring these parts together, feeling that there was not sufficient core in her with which to do this, and she broke down. Later on she tried to deal with the consequences of this fragmentation by encapsulating the fragments in The Mirror fantasy.

This tendency to disintegrate, as seen in the promiscuous episodes, often seemed to overwhelm the patient. She used various devices to try to cope with it. When things appeared about to overpower her, particularly when at home by herself, she would lock herself into a cupboard as a means of getting inside a concrete container where she could feel a little safer. For a time she entered a convent. By entering the convent she tried to cope with her anxieties not only by finding a safe, restricted container, but also by cutting out sexuality altogether, trying to become part of an idealised asexual world. It is worth noting that her description of her stay at the convent made it clear that the characteristics of that institution did not differ very much in her mind from the cupboard. Both were expected to be solid, with unchangeable borders, but lifeless.

None of these methods of defending herself from madness seemed to work for any length of time; each just helped her out of the immediate situation for a short time. Only the masturbation phantasy has had more lasting effects, and when she has felt that she is falling to bits it has helped her for a longer period of time.

Work Situation and the Fantasy

In spite of having a good training in science the patient has never been able to use it directly in her work. Work is the central aspect of her life, but she is completely unable to take any part in the real scientific life of the laboratory where she works; she cannot participate in discussions or use her knowledge in the creative aspects of the work. In her post as laboratory secretary she is constantly witnessing, listening to, and observing the discussions and experimental work being carried on by others. She projects parts of herself in phantasy into the different members of the staff, with whom she then feels identified, managing in this way to believe that she is part of the work being done and at same time that she is not. Thus there is the endless repetition of being an onlooker, the secretary who is only on the periphery of the practical aspects, recording them, reporting about them, while secretly feeling she is the one who ha...

Table of contents

• Cover Page
• Half Title Page
• Frontmatter
• Series Page
• Title Page
• Copyright Page
• Contents
• Acknowledgements
• Dedication
• General Introduction
• Part I: The Internal World in the Transference
• 1 The Mirror A Perverse Sexual Phantasy in a Woman Seen as a Defence against Psychotic Breakdown
• 2 Interpretation The Past in the Present
• 3 The Constitution and Operation of the Superego
• 4 Construction as Reliving History
• Part II: Defences Against Anxieties of the Depressive Position
• 5 Self-Punishment as Defence
• 6 Technical Problems in the Analysis of a Pseudo-Compliant Patient
• 7 As-if The Phenomenon of Not Learning
• 8 Hyperbole in Hysteria ‘How can we know the Dancer from the Dance?'
• 9 Pain, Sorrow and Resolution
• Part III: Theoretical Refinements
• 10 The Three ws: What, Where and when the Rationale of Interpretation
• 11 Conceptualisation of Clinical Facts in the Analytic Process
• Notes
• Bibliography
• Index