Imprisoned Pain and Its Transformation

Joan Symington

• Publisher: Routledge
• Year: 2018
• ISBN:
  9780429914782
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

In this chapter Anne Alvarez describes how supervision with Sydney Klein played a decisive part in transforming her understanding of the importance of the grammar of interpretation—that not all interpretations have to unmask hidden desires on the negative side but, rather, can help the evolving process of growth and understanding. This is particularly important in borderline patients in whom such unmasking interpretations may be ego-depleting in that they do not take into account the immediate meaning of the child's communication.

CHAPTER ONE

Moral imperatives in work with borderline children: the grammar of wishes and the grammar of needs

Anne Alvarez

In this chapter Anne Alvarez describes how supervision with Sydney Klein played a decisive part in transforming her understanding of the importance of the grammar of interpretation—that not all interpretations have to unmask hidden desires on the negative side but, rather, can help the evolving process of growth and understanding. This is particularly important in borderline patients in whom such unmasking interpretations may be ego-depleting in that they do not take into account the immediate meaning of the child’s communication.

I first came in contact with Sydney Klein’s supervision in a clinical seminar organized for qualified child psychotherapists sometime in 1969 or 1970. At one point I presented some case material from a usually depressed, rather cut-off boy named “Stephen”, who had returned from the summer break somewhat excited: walking on the moors during his holiday, he had found the skull of a sheep. I reported that I had explored with Stephen what I saw as the rather disturbing idea of his fascination with the skull. I had linked this with possible destructive phantasies connected with anger about the break from treatment—that is, why and how, in the transference, might I have “been turned into” a skull instead of a live object? Dr Klein listened, I think with some impatience, and then offered several other possibilities: perhaps Stephen was not indulging his aggressive phantasies; perhaps he was, on the contrary, disturbed by them, and indeed even afraid that they had been realized—that his object had been stripped down or denuded in some way. Or, he added, perhaps Stephen was fascinated because he was relieved and moved at the evidence of the skull’s—and his object’s—survival over time. What Klein said made me appalled by the narrowness and meanness of my own thinking, and eventually I managed to have individual supervision with him.

A few years later, he referred a little boy called “John” to me, telling me with some sympathy about the child’s despair about not being able to fly paper aeroplanes. He seemed to take for granted that I would understand that one could see flying—in this case, at least—not as a manic defence against depression, but as a natural and desirable expression of exuberance, hope, life, and ambition. Again I was appalled—where had I got the idea that ascent to the heights should be equated with mania and remaining in the depths with gravitas and mental health?

This chapter describes the psychoanalytic psychotherapy of a 10-year-old boy, “Richard”, whom I treated from 1967 until 1973. The supervision with Sydney Klein began in 1971. All good ideas seem to go through a period when their range of application is over-exaggerated, and some elements in Melanie Klein’s theories are no exception: her concept of the power of unconscious envy, of manic processes as defences against depression, and her related technical recommendations regarding the importance of putting the patient in touch with his deepest anxieties, his deepest guilts, and his deepest hatreds may have been among these. Spillius (1983) has pointed out that in the 1950s and 1960s the Kleinian Membership papers for admission to the British Psycho-Analytical Society were inclined to “emphasize the patient’s destructiveness in a way that might have felt persecuting to the patient” (p. 324), but that destructiveness gradually began to be interpreted in a more balanced way.

My patient had, after the first four years of treatment, become less psychotic, but was by now intensely preoccupied with phantasies of sadistic attacks on small animals. Indeed, he had begun to act upon them. Other colleagues and supervisors had suggested that this was a not unusual development in a previously psychotic patient. Dr Klein, however, asked why I was persecuting Richard with such cruel interpretations; he added that the child probably felt that his vulnerable infantile self was feeling very attacked by this, and that he was probably in identification with a persecutor when he was attacking small animals. I soon stopped persecuting Richard, and he began to soften very quickly! Sydney Klein seems to have been among the earliest analysts to breathe clinical and technical life into Bion’s ideas about the normality and neediness of some projective identifications and to show the humanity and breadth (I use that word advisedly instead of “depth”) that lay in them. I feel I have spent the last three decades trying to understand the implications of this radical change in theory and technique.

This chapter, then, presents material from work with a borderline psychotic 10-year-old boy who started intensive treatment with me over thirty years ago. Over that period, the impact of Bion’s (1962b) extension of Melanie Klein’s (1946) concept of projective identification, and the consequent implications for technique explored by Rosenfeld (1987a), Joseph (1989b), and others, have made a tremendous difference to the work with these patients. I was using a technique with Richard that was uninformed by these developments and was more appropriate to work with neurotic patients. For a period I think it was positively harmful to him. The technique, which I shall try to illustrate, had elements of an unmasking quality designed to reveal the depression and loss that underlay what I thought of then as his manic, omnipotent, and paranoid defences. I think now that these so-called “defences” were desperate attempts to overcome and recover from states of despair and terror—they carried, that is, elements of basic developmental needs: for protection, preservation, for a sense of agency and potency, and even for revenge and justice. Richard was full of violence, bitterness, and persecution, but unlike patients who have a more psychopathic accompaniment to their borderline problems, he was filled up with violence, rather than being dedicated to it or excited by it. And unlike neurotic patients, he had little ego functioning. His “defences” were inadequate to manage his overpowering feelings. He needed, for example, to be able to project, to split, and certainly to repress and forget. I shall consider the difference, in the neurotic patient, between a desire that things could be, or could have been, otherwise and, in certain borderlines, a desperate need that things should be, or should have been otherwise.

The major theoretical change to which I am referring concerns ideas about the purpose of and motives for projective identification processes. [It has some areas of overlap with the reformulations of Anna Freud and Sandler (1988), Kohut (1971), and Stolorow and Lachmann (1980) on the difference between ordinary defences, and early structurings, protective manoeuvres, or pre-stages of defence.] Racker (1958, cited by himself, 1968) had emphasized that countertransference was the expression of the analyst’s identification not only with the id and ego of the patient, but also with those of his internal objects, and should be used as such. Bion (1962a) also made the connection between countertransference and projective identification when he pointed out that the psychoanalyst may play the part of the patient’s lost self not only in the patient’s mind, but in his own mind too—that is, the patient may project so powerfully that he may not only feel that his analyst is frightened or depressed, he may make him become frightened or depressed. But in the 1950s and still in the early 1960s, Bion (1957) and others were still describing the projective identification as arising from destructive or defensive and pathological motives. Bion (1962a) then went further: his concept of the analyst as receptacle or container of these projections began to carry the implication that the receptacle could be inadequate, sometimes making the patient project even harder. [Grotstein (1981) has pointed out that this introduced the concept of deficit in the object long before Kohut (1971)]. Bion (1962a) suggested that some projective identifications expressed a need to communicate something to someone on a very profound level: he compared the analyst’s “containment” and “transformation” (1965) of the patient’s feelings and thoughts to the primitive but powerful pre-verbal communications that take place between mothers and tiny infants. This, he suggested, is how feelings become bearable and thoughts become thinkable. This—in a way—more democratic two-person psychology leaves room for either term in the equation to affect the interactions. There is more room in such a model for the object, external or internal, to have an impact on the system. (I shall use the term “internal object”, with which I am familiar, for what others would call the representational other or internal working model.)

The technical implications of this increased attention to inadequacies of the object have been profound. Rosenfeld (1987a) emphasized the dangers of interpretations to borderlines that over-valued the analyst’s contribution. He stressed the importance of the health that could lie in resistances, and of not breaking down idealization too quickly. Money-Kyrle (1977) thought the issue of distinguishing a desperate projective identification from a destructive one a matter of great technical urgency. Betty Joseph (1989b) has spent a life-time working on this problem. She has expanded the notion of the communicative use of projective identification both technically and theoretically, and she has drawn attention to how very pressuring projections may include a need to communicate something that may require lengthy containment and exploration in the analyst and should not be shoved back too prematurely at the patient. It is often better for the analyst to hold and explore the experience in himself—for example, “you feel that I am stupid” (without adding that it is the patient’s projection of his stupidity). The patient may need to feel, she points out (Joseph, 1978), that you are willing to carry the projections long enough to experience the missing part of the patient, or else to experience his previously unexamined internal object. A disappointing or fragile parental object, say, whose weakness has always been denied, may need gradual uncovering, not explaining away—a move one could describe as a move from a grammar of explanation to a grammar of description. Steiner raises the issue in his discussion of analyst-centred versus patient-centred interpretations (1993).

Bion (1962a) stressed the normalcy of the need for a container of such communications as a very early infantile human need to be in the company of a mindful mind. An implication is that these communicated emotions are not necessarily emotions the patient wants rid of—they may be emotions that he needs his object to have on his behalf. They may be emotions he needs to explore in us and only gradually own himself. Furthermore, these need not be negative emotions. Positive states of mind can be conveyed, however confusedly and crazily, through this process of unconscious communication just as powerfully as Bion’s earlier examples of fear and murderousness can. Bion said that the psychotic has pain but does not suffer it: one might add, the psychotic also has pleasure but does not enjoy it. Preconceptions need turning into conceptions in both areas for normal development to proceed.

I would now like to explore the idea that such unconscious projective communications may, like more ordinary verbal communications, have a grammar. This grammar’s variations may bear some correspondence to where the patient is on the neurotic/psychotic continuum—that is, to his level of ego development and also to the level of urgency and desperation of his needs. Both the neurotic and borderline child may boast in a manic or grandiose manner, or protest and complain of injustice. We may be pressured to admire or sympathize. The countertransference may be similar in both cases, but the motivation of the child may be vastly different in the two situations. In fact, we may be driven to be even more unmasking with the borderline child, whose immaturity may make his boasts sound ridiculous and silly. Yet our interpretive response needs to be carefully structured in grammatical terms that take account of the difference between a desire for omnipotence and a need for potency (Alvarez, 1992). The normal or neurotic child may wish or even demand that things be otherwise, but he can just about bear to acknowledge the way things really are, in external reality and in his own heart. He can usually juggle and compare two realities (Stern, 1985), manage a dual perspective (Reid, personal communication 1989) or binocular vision (Bion, 1950) and two-tracked “thinking in parentheses” (Bruner, 1968). He can hold a thought in reserve and consider the thought within the thought and the thought beyond the thought. He can manage meta-cognitive processes (Main, 1991) and self-reflective functions (Fonagy, Steele, Steele, Moran, & Higgitt, 1991) and some degree of symbolic functioning (Segal, 1957). Borderline patients, on the other hand—in their psychotic moments, that is—are concrete, one-tracked, overwhelmed by the singularity of their state of mind, and in danger of symbolic equations and massive splitting and projection. Are we in danger of producing premature integrations when we refuse to stay with their urgent imperative single-minded states? Could it even be that there is, at certain very early stages of emotional development, a need for something like a symbolic equation, the nearly perfect fit?

There has been much work by developmentalists on how the baby’s mind grows and how intersubjectivity becomes internalized as intrasubjectivity (Stern, 1985; Trevarthen, 1978). It is a fascinating moment when autistic or other mindless children begin to discover that they like doing something, then that they like liking doing it. (When they go further and finally get a dual perspective that there are two different ways of looking at the same toy, for example, language and pretend play can begin.) Mothers follow their babies’ direction of gaze long before babies begin to follow theirs (Collis, 1977). Infant observation shows us time and again the way in which mothers light up as they see what has caught a baby’s glance—“Oh, it’s the movement of the tree!” Both developmentalists and psychoanalytic observers seem to be agreed that if a mind is to grow, it requires a meeting of minds and not too many “missteps in the dance” (Stern, 1977) between infant and caregiver—but also not too few—mismatch, disillusion, and separateness are fundamental too to learning about reality. Yet the balance between match and mismatch in our interpretive work needs to be carefully tuned to the developmental level at which the child patient is functioning at any given moment. Easier said than done!

This brings me back to grammar. I shall suggest that interpretations that stress separateness and difference from ideal objects or ideal self—that is, that make use of the language of wishes and wants—may be appropriate for patients with some ego development, some sense of trust in their objects, and some sense of worth in themselves. However great their anxieties and angers and depressions, such patients have sufficient ego equipment with which to examine the gaps in the fabric of the universe. In Latin a verb containing doubt (you wish, you fear, you think, you hope …), would be followed by the subjunctive or conditional. An “I may go” is weaker than “I am going” or “I will go”. For instance, the language of “You wish, but we both know that you cannot or did not or will not” is tolerable where the real alternative is just bearable. I found that if I said, “You are afraid that you will die without me on the weekend”, the neurotic patient could hear the implications and the alternative possibilities implied in such statements (namely, that he would probably not). From his dual perspective he can think about both more or less at once. I learned to my cost that the borderline patient often cannot. His panics, and even his manic denials, may express a need for us to understand that he should have—that is, he has a rightful need of—assurance, safety, protection, and even justice. He may need to hear something along the lines of “It’s hard for you to imagine that you might make it through till Monday” or, “You feel I should not be leaving you at this time”. This need not involve collusion or seduction or false promises. [See Kut Rosenfeld and Sprince (1965) of what is now the Anna Freud Centre on the ease with which interpretation of anxiety can escalate anxiety in borderlines.] The child’s rightful need for assurance needs understanding, and—except under the most dire of emergency conditions—reassurance should not be necessary. Interpretations of anxiety or loss to an already despairing child can weaken him. Other grammars, the grammar of imperatives, may enable his ego to grow stronger.

Case study: “Richard”

“Richard” was referred to me in spring 1967, when he was 10 years old. The referring psychiatrist found him a very mad boy with a suspicious, strained appearance and bizarre hand gestures, as though warding off blows to the head. Richard’s mother was a manic-depressive psychotic and had beaten him often when he was a baby. She left abruptly when Richard was 18 months and his younger brother 4 months old. She had visited very seldom. When Richard came to me, he was not learning much in a sort of nursery school. After his mother left, he had lived with his paternal grandmother for a few months, then with his father and a Nanny, to whom he was very attached. When she left, his paternal grandmother moved into the father’s house to take care of the children. Father and grandmother were very kind and intelligent people, but very genteel, and I suspect they would have found it difficult to take the grief and horror and outrage that was in Richard, had it ever displayed itself when he was an infant. His aunt, a warm and sensible woman, also had some hand in the children’s care.

I started seeing Richard twice a week in May 1967 and soon increased this to four times per week.

I am going to go through the early sessions in some detail. It seems a rather masochistic and pedantic exercise, because I was pretty green at the time, and the work is not good for lots of reasons. But I want to look at the grammar and the theoretical and technical implications behind the grammar, and so I h...