Ordinary People and Extra-ordinary Protections

A Post-Kleinian Approach to the Treatment of Primitive Mental States

Judith L. Mitrani

• Publisher: Routledge
• Year: 2009
• ISBN:
  9781134578863
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Many people come to analysis appearing quite 'ordinary' on the surface. However, once below that surface, we often come into contact with something quite unexpected: 'extra-ordinary protections' created to keep at bay any awareness of deeply traumatic happenings occurring at some point in life.

Judith Mitrani investigates the development and the function of these protections, allowing the reader to witness the evolution of the process of transformation, wherein defensiveness steadily mutates into communication.

She lucidly and artfully weaves detailed clinical with a variety of analytic concepts, and her original notions - including 'unmentalized experience' and its expression in enactments; 'adhesive pseudo-object relations' and the way in which this contracts and compares with normal and narcissistic object relations - provide valuable tools for understanding the infantile transference/countertransference and for the refinement of our technique with primitive mental states.

Ordinary People and Extra-Ordinary Protections will prove stimulating and accessible in its style and substance to a broad analytic readership, from the serious student of psychoanalysis to the most seasoned professional.

1
Transference interpretation and the emergence of infantile dependency in ordinary people¹

To say that all communications are seen as communications about the patient’s phantasy as well as current external life is equivalent to saying that all communications contain something relevant to the transference situation.

Hanna Segal (1981, p. 8)

This chapter will focus on beginnings: the beginning of analytic thinking about the transference; the beginning of an analytic treatment; and the beginning of the individual as it is expressed in the transference in the first session. In his early writings, Freud emphasized the centrality of the transference in analytic work (1912; 1913; 1914; 1917). He discovered that the work of analysis revolves around and depends upon the handling of the transference, and was convinced that the war against mental illness would be won or lost on the “battlefield of the transference” (1912, p. 108).

Following Freud’s lead,Melanie Klein and her exponents developed a rigorous technical stance based upon an understanding of the ubiquitousness of internal unconscious fantasy life (Isaacs 1952) and its externalization in both the negative and positive transferences (e.g. Rosenfeld 1947). Kleinian tradition thus emphasized the importance of paying careful attention to transference elements implicit in both verbal and non-verbal modes of expression and to their interpretation in the here-and-now of the analytic hour right from the first moment of contact. Klein (1952b) also proposed that the transference situation encompasses whole constellations of past experiences, emotions, defenses, and object relations.

For many years transference was understood in terms of direct references to the analyst in the patient’s material. My conception of transference as rooted in the earliest stages of development and in deep layers of the unconscious is much wider and entails a technique by which from the whole material presented the unconscious elements of the transference are deduced.

(Klein 1952b, p. 55)

Klein helped us to become more mindful of the fact that the patient

turns away from the analyst as he attempted to turn away from his primal objects; he tries to split the relations to him, keeping [the analyst] either as a good or bad figure; he deflects some of the feelings and anxieties experienced towards the analyst onto other people in his current life, and this is part of “acting out”.

(Klein 1952b, pp. 55–6)

This technique of seeking out and interpretively addressing each indirect reference to the relationship with the analyst serves to acknowledge, to make contact with,and to begin to mitigate the early infantile splits in the ego,allowing the analyst to commence an analytic process with patients who had once been thought of as “unanalyzable.”Additionally, it is a matter of observable fact that by gathering up these widely disbursed or deeply buried aspects of the transference, and by drawing them directly into the therapeutic connection,we may be able to lessen the burden upon the patient’s day-to-day life and his relationships outside the treatment.

Although explicit opposition to the Kleinian approach in London (King and R. Steiner 1991) inevitably spread throughout the mainstream of American ego psychology, it may be of interest to note that, in the last few decades, some analysts (e.g. Gill 1979) supported and even extended the idea that all communications from the patient contain an element of transference, which must be interpreted in the immediacy of the therapeutic situation from the beginning of the treatment.Gill also emphasized the importance of the analysis of a specialized form of resistance – that resistance which is directed toward the awareness of the transference – in order to encourage the expansion of the transference.Additionally, Gill argued that the major work of analysis lies in

examining the relation between the transference and the actuality of the analytic situation from which it takes its point of departure and the new experience which the analysis of the transference inevitably includes;and that while genetic transference interpretations play a role . . . genetic material is likely to appear spontaneously and with relative ease after the resistances have been overcome in the transference in the here and now.

(1979, p. 287)

In his writings, Gill made the point that transference interpretation – like extratransferential interpretation and any other behaviour of the analyst – in its turn affects the transference,which then needs to be re-examined if there is to be a minimum of unanalyzed transference.

Joseph’s (1989) technique, with its attention to the minute shifts in the transference,seems to demonstrate this way of working.Joseph takes into account the “acting-in” potential inherent in the analyst’s interpretations as well as in her manifest behavior, which may at times (but not always) respond to the patient’s nudging the analyst to collude with the patient’s unconscious need for and subsequent attempts to maintain psychic equilibrium,which runs counter to his conscious desire for psychic change.

Of course Bion’s (1959; 1962b) model of the container and the contained and of projective identification as the earliest form of pre-symbolic communication between mother and infant has led to the recognition that such “acting” in the transference is related to the baby’s most elemental fears about dependency. When these fears of the “infant” in the child or adult are understood by the analyst, and that understanding is interpretively communicated to the patient, the process of psychic change can begin.

Experience has shown that the setting for psychoanalytic treatment – with its frequency,regularity,and the use of the couch – may further facilitate this process of psychic change.However it has often been called to my attention, particularly by psychotherapists and analysts-in-training,that little has been written about the “introduction” of this setting.As a rule rather than as an exception the majority of today’s patients are ordinary people who come to us seeking psychotherapy on a once- or perhaps twice-weekly basis,whether or not they are aware that they have been referred to a psychoanalyst. In fact, relatively few prospective patients know anything about psychoanalysis, let alone that it is traditionally conducted four or five times per week with the patient reclining on a couch and the analyst seated out of sight behind him.

In light of this situation, some have suggested that we need to educate patients about psychoanalysis to get them to go along with the programme. In fact, in certain circles and in many psychoanalytic training institutes, “instruction” is a recommended practice for candidates wishing to “convert” psychotherapy cases into analytic “control” or training cases. However, others have found that by listening to patients’ needs, desires, and fears for and about closeness and dependency,and by interpreting these in the transference,we may be able to give patients a first-hand experience of analysis; that is, a sampling of our capacity to closely hold them both firmly and tenderly in mind. In this manner we may demonstrate our willingness to welcome and our ability to tolerate the emergence of the infantile aspects of the patient that are perhaps those most in need of contact and understanding, and by doing so we may relieve the patient of his inclination to “hold on” to us with his eyes as well as the compulsion to stoically toughen-up between what he feels must be infrequent and tenuous encounters with an extra-ordinary, unknown and unknowable stranger.

I am indeed emphasizing the need for “learning from experience” (Bion 1962a) which must take place right from the beginning of the analytic work if there is to be a viable process in which the patient can truly be expected to grow. Just as the infant in the act of discovering the world can move forward out of his own sense of agency only when he feels safely held in the attention and gaze of the mother who follows him wherever he goes, so the patient on his way to discovering his internal workings must feel free to explore his mind without suffering the paralyzing fear of becoming lost in the act of compliantly following the analyst’s lead.As Winnicott (1948) suggested, in analysis:

The important thing is that the analyst is not depressed and the patient finds himself because the analyst is not needing the patient to be good or clean or compliant and is not even needing to be able to teach the patient anything.

(p. 94,my italics)

For the analysand, knowing about psychoanalysis must never supersede experiencing and “being” psychoanalysis (Bion 1962a), just as the analyst’s desire to teach analysis must not be allowed to supplant his analytic function.

Perhaps through the clinical vignettes presented in this chapter, I may be able to demonstrate how some ordinary patients commence to experience their needs and/or desires; how they come to feel free to ask (directly or indirectly) for additional hours; and how they may begin to organically wend their way to the couch, rather than be guided there didactically by the analyst.

Anthony

The first patient I wish to discuss is Anthony,a single man in his early thirties who was referred for therapy by a colleague.During the course of initial consultations, which took place on a Monday and Thursday of the same week, Anthony sat in a chair and quite calmly and matter-of-factly presented a very well-organized history of his “very ordinary” early childhood, education, and career, as well as a description of his relationships to date. Nearly emotionless, Anthony ended each of the interviews right where he had begun: with a simple statement that he wanted to see a therapist because there was something that did not feel quite right.

Anthony seemed deeply unhappy and alone in spite of what appeared to be an uneventful childhood and college experience, and some satisfactory if not intimate or close relationships with both male and female friends. I sensed that there was some aspect of Anthony’s experience that we had not yet arrived at in these interviews, something that he was helpless to know or to tell me about.

This feeling was especially strong in me at moments when there would be a pause in his otherwise smooth narrative. During these pauses,Anthony seemed to focus his gaze on my couch, positioned to the left of me against the wall opposite from the chair in which he sat. He said he felt “oddly comfortable” with me and wanted to make another appointment for the following week, although he did not know what we might accomplish.

In our next meeting, the patient reported the following dream in which:

He is sitting in a room,watching over a baby lying in a crib.He senses there is something wrong and begins to feel anxious.Then he notices that the sides of the crib have either been left down or are missing altogether. Only the two ends are there. He also notices that the baby’s head is unsupported and it seems uncomfortable to him. He thinks that the baby needs a pillow or a cushion, but wonders at the same time if very little babies can suffocate with a cushion.

He looks across the room from where he sits and sees a pillow on a couch. However he feels suddenly unable to move in order to reach it. His arms and legs are weak and unsteady and he knows he needs help, perhaps to pull up the sides of the crib so that the baby won’t fall out.

A woman sits in a black leather chair, not far from him. He has some thoughts that she might be able to help, but he is unsure that she would want to. He thinks in the dream, “she would need to carry me over to put the sides up, but what if she doesn’t want to? Or perhaps she can’t.” He feels hesitant at first to ask the woman for help. Finally he calls out, but she can’t hear him and he wakes up frustrated, crying.

After a pause Anthony said that he didn’t have any idea what the dream meant. As if in his defense, he quickly added that he didn’t have much experience with babies. Glancing away, he mentioned that the black chair in the dream was something like the one in which I sat.Then he paused and looked directly at my couch. Suddenly he blurted out “You know, that’s an odd piece of furniture! It looks rather like a cot, not like a couch at all.” He said that he had noticed that there were no cushions at the back, only at one end.“Do people really lay down on those things?”

I offered that it seemed to me that there might be a baby-he, like the baby in the dream, who needs watching over: a little-one who suddenly appeared after our meetings last week and whom he felt he had been left by me to care for all by himself over the weekend. I added that I thought that perhaps he’d been worrying that this baby-he was in danger of falling, with only the ends of the week in place. Anthony seemed surprised and interested in what I was saying to him, so I continued,wondering aloud if he might be expressing a wish to ask for my help to secure the baby-him with two more hours per week as a way of supporting his mind and giving him both comfort and a feeling of safety. However, perhaps he was also expressing a concern that I could not or would not be able to “carry” him, and was also somewhat concerned that so much contact between us, like a cushion,would feel dangerously suffocating for him.

Anthony responded sheepishly,confirming that he had indeed been wondering if anyone ever came to see me more often than twice per week.Then he had the thought that he might not be able to afford to come more frequently. I probably wouldn’t agree to adjust my fee to accommodate him. He had also wondered, many times during our sessions in the previous week, if he could lie down on the couch and what it would feel like if he did. However this had seemed too scary even to ask about it.

After a few moments,Anthony said that he had just remembered something that he’d long forgotten.To my surprise his eyes welled-up with tears. He told me that,as a baby,he had been adopted.When he was in his early teens his adopted parents had explained to him that his “real” parents had been too young to keep him.Thus,they had “given him up”at birth. He said that he now wondered why he had not thought much about it over the years until now.

I told Anthony that perhaps the missing parents of his birth were like the sides of the crib that were missing. I thought he was telling me that we needed all four sides – four hours per week on the “cot” with the pillow – so that he might feel safe with and comforted by me while he gave some thought to these childhood losses, even though it was clear that we would need to be mindful of a baby-he who could be in danger of being overwhelmed both by such close contact with me and also by his feelings about what he may have missed long ago and was more recently experiencing missing.

One might see, in this example,how a dream presented in the very beginning of the treatment can readily be taken up in the transference; how this works to mobilize additional unconscious material while establishing a close connection between analyst and patient, thus affording the patient an experience of the analyst’s willingness to contend with a burden the patient has felt unable to bear on his own. One can also observe how anxiety-ridden issues of frequency of sessions, fees, and the use of the couch might be heard in the patient’s material and addressed early on in the work.

Now of course, it is not always the case that a desire for greater frequency of hours or a curiosity about the couch will develop this early in the treatment. Other patients work up to this more gradually, as trust in the analyst’s ability grows more slowly. I will now give an example of such a case brought to me for supervision by a colleague.

Cora

Cora was in the process of undergoing intensive fertility treatments, including artificial insemination, when she began analytic therapy twice weekly. Within a few weeks Cora’s material began to speak to a desire for “more frequent treatments, which were needed to facilitate conception.”The analyst told the patient that she thought that she was also speaking about a felt-need for more frequent meetings, in order that the analytic couple might be able to conceive of a baby-Cora who wished to be brought to life in the mind of a mother-analyst. The patient was very moved by this interpretation and the frequency of sessions was subsequently increased to three per week.

During the next several months of the treatment, there was evidence in the patient’s associations that she experienced herself and her analyst as “growing more and more compatible with each other.”The material also spoke in a roundabout way to Cora’s sense that her analyst was becoming “more receptive and able to conceive” of her. Indeed the analyst felt, during this time, that she could better understand and could now begin to formulate and to transmit, in a timely way, some rudimentary understanding of her patient’s most primitive fears.

However, each week, over the four-day break, the patient would become seriously depressed and hopeless and the material presented during these times seemed to throw up images of a baby being dropped, aborted, or drained away in a bloody flow. Cora communicated her sense of a womb that was not adequately constructed to sustain an embryo that would consequently be “sloughed off soon after conception.” Complaints that the fertility treatments were wasted, the money spent on these flushed down the toilet,and the feeling that her fertility doctor was not available when needed, led Cora’s therapist to interpret these communications as expressions of the disillusionment with the analyst suffered by the patient during the too-long four-day weekends,and her experience of the bloody battles which she would engage in with her analyst on Mondays when she returned in an enraged state after the break.

Although it was clear that Cora was incapable of sustaining the experience of contact with herself over the breaks and that during the sessions she often wasted time by arriving late, this line of interpretation (in which the therapist adopted the patient’s vertex,² taking responsibility rather than augmenting her already harsh super-ego) seemed to open the way for the patient, while feeling less persecuted,to be more direct with her therapist about her discontents. Cora’s increasing sense of being understood,and the experience of someone who could tolerate that which she could not, seemed to be connected with her request for an additional hour.

While still sitting up in a chair, Cora now began to bring dreams of a baby needing to be held in her mother’s lap and in her arms close to the breast; of an infant with a heavy head,too little to sit up; of fearsome predators attacking from behind; and of a father who fondles her and a mother who comes at her in a jealous rage with a knife,while she lies prone and helpless in her bed.Taking up these dreams in the transference as an expression of Cora’s wish to be close to her therapist,her desire to lie on the couch,as well as her fear of being vulnerable if she does so, eventually enabled the patient to use the couch.The subsequent deepening of the transference relationship in all its many positive and negative forms was further facilitated, and within a short time the patient requested a fifth hour.

Finally, I would like to give an example of those patients who quite frequently become aware of their desire for more contact with the analyst early on, just as Anthony did,but who feel financial...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Foreword
• Acknowledgements
• Introduction
• 1 Transference interpretation and the emergence of infantile dependency in ordinary people
• 2 Extra-ordinary protections: the evolution of the theory of adhesive identification
• 3 Ordinary people and extra-ordinary protections
• 4 The “flying Dutchman” and the search for a containing object
• 5 Chloe: from pre-conception to after birth
• 6 Unbearable ecstasy, reverence and awe, and the perpetuation of an “aesthetic conflict”
• 7 Never before and never again
• 8 Changes of mind: on thinking things through in the countertransference
• 9 Concluding thoughts
• Notes
• Bibliography