The Privacy of the Self

Masud Khan

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9780429921834
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

The Privacy of the Self was the first collection of papers showing the development of the author's thinking over twenty five years of clinical work. He was nurtured in the tradition of Anna Freud, John Rickman and D.W. Winnicott, but his contribution to psychoanalytic literature was a distinctive and personal one. What emerges from this book is the natural and private crystallization of his experiences with his patients and teachers.As he says in his preface: "Psychoanalysis is an extremely private discipline of sensibility and skill. The practice of psychoanalysis multiplies this privacy into a specialized relationship between two persons, who through the very nature of their exclusivity with each other change each other. The first thing I wish to say about my work reported in these papers is that my patients have helped me become and personalize my potential of thought, affectivity and effort into a way of life that I find deeply satisfying.

11
Regression and Integration in the Analytic Setting

IN the years following World War II researches in ego-psychology, and a greater understanding of the child-care techniques and the importance of the environment in the primitive stages of ego-development (Winnicott, 1945a, 1954b, 1956a) led to a more sensitive and careful assessment of the role of the analyst and the analytic setting towards the establishment and evolution of the clinical process, which in classical terms is called ‘the transference neurosis’. The writings of Winnicott (1949b, 1954a, 1954b), Balint (1950, 1952), Waelder (1956), Rycroft (1956b) and Little (1957), to mention only a few, amply bear this out. Discussing the importance of the part played by the frame in the painting of pictures, Milner (1952) states: ‘The frame marks off the different kind of reality that is within it from that which is outside it; but a temporal special frame also marks off the special kind of reality of a psycho-analytic session. And in psycho-analysis it is the existence of this frame that makes possible the full development of that creative illusion that analysts call the transference.’ What Milner calls ‘the frame’ in the above quotation I here discuss as the analytic setting.

I wish to make two further notes to clarify my use of the concepts transference and counter-transference in this essay.

Transference as the ‘therapeutic alliance’ (Zetzel, 1956) I shall take for granted. It was a very impressive trait of Mrs X’s personality and behaviour that through the various vicissitudes of mood and emotion in her treatment the ‘therapeutic alliance’ was never once really threatened. In speaking of transference, therefore, I shall be referring mostly to its dynamic and genetic aspects, which one usually associates with the concept of ‘transference neurosis’.

By counter-transference I do not mean here the conflictual unconscious transference in the analyst. I am not pretending that such experiences during this treatment were absent from my relationship to the patient. But I do not think that one gains anything from confessing them to an impersonal audience any more than one would were one to confess them to the patient. By counter-transference, therefore, I mean the conscious and total sensitivity of the analyst towards the patient; it is more than a merely intellectual rapport and comprehension. I mean by it what Balint has called ‘the analyst’s behaviour in the psycho-analytic situation or, as I prefer to phrase it, the analyst’s contribution to the creating and maintaining of the psycho-analytic situation’. It is this aspect which I shall emphasize. I shall try to detail what demands the patient’s transference-needs made on this counter-transference in the analytic setting. Hoffer (1956) calls this counter-tranference the analyst’s ‘humanity’, and he defines it as follows: ‘the analyst’s transference refers to his human appreciation and responses, to the patient’s realistic needs in the various stages of the psycho-analytic treatment’. Heimann (1950, 1956) in her two papers on Transference and Counter-Transference has discussed at length the dynamics of the patient using the analyst as his supplementary ego. What I shall be discussing as the patient’s demand on the analyst in the regressive phase amounts to very much the same thing.

Greenson (1958) describes a clinical syndrome that has become the most frequent case over the past decade or so. He says:

In the early years of psycho-analysis, patients coming for treatment were suffering from symptom neuroses, a relatively clean-cut and well-defined group of pathological formations. The clinical picture changed as society changed and after World War I patients seeking therapy were found to be suffering from character disorders, an ill-defined, heterogeneous form of neurosis. Since resuming practice after World War II, it seems to me that once again there is a change in the prevailing clinical picture of patients coming for psycho-analytic treatment. They are still preponderantly character-disorders, but now the pathology seems to be centred round a defective formation of the self-image, an identity disorder. … These patients are essentially impulsive-depressives with a hysterical superstructure.

The following case, that of Mrs X, seems to me to belong to this type of disorder. The major point of this essay is to show how in these cases the ‘transference neurosis’ takes the form of an anaclitic regression in the analytic setting and thus makes a very specific demand on the personality of the analyst in his counter-transference. The basic question the analyst has to ask himself is: ‘What is the patient’s need now, and from whom?’ Exploration of this can lead to a fruitful discovery of the patient’s subtle attempts to meet the basic needs in such a way that a reactive and defensive character-formation has been established in the personality. This sort of character-formation has the sole function of caretaking of the self, and hence distorts both ego-development and ego-enrichment and militates against genuine instinctual experience as well as object-relationships. Severe and sadistic internal object-relationships are then more operative than a healthy superego formation. Hence in spite of their complex experiences and achievements these patients suffer essentially from a sense of futility, boredom, and purposelessness (Winnicott, 1949b, 1955; Glover, 1943; Greenson, 1958; Fairbairn, 1940).

As the result of three years of analytic work, Mrs X made a very good recovery from an illness which was characterized by chronic and severe depression and marked ego-dissociations. I am using the concept of dissociation here in terms of ego-weakness and ego-strength as discussed by Glover (1943). It is not my intention to discuss the psychopathology of this case. My emphasis will be on the development and vicissitudes of the clinical process in the analytic setting, the interplay of the transference and counter-transference, as the regressive and integrative processes crystallized in the analytic setting.

Clinical Report

FIRST PHASE

What I am delineating here as the first phase lasted just over a year.

Mrs X was referred to me shortly after her breakdown. The circumstances of this were that following her husband’s recovery from a psychiatric hospitalization he had taken a job in another town and the family were ready to leave to go there. On the day of their planned departure the patient had wandered away from home in a state of panic and confusion. She was found wandering in this state and taken to the home of a friend. She could not face returning to her family, which consisted of her husband and her only son. The friends were very disturbed by her agitated state and called in a doctor, who put her on sedatives. When she had gathered herself together a little she got in touch with the psychiatrist whom she had consulted two years earlier about her son, and he referred her to me.

The breakdown, as the patient called it, had happened a week before. Meantime her husband and son had left for the new town, her husband having left her enough money to meet the expenses of the treatment. It had been agreed between them that after two years’ treatment she would join the family. One is tempted to add the cynical comment: ‘and live happily ever after’!

The comment is not as cynical as it sounds. It is very relevant to this patient’s way of handling things at this stage. The material of the first interview, a series of contradictions and dissociations in her behaviour, and her general attitude had made a very distinct, though not easily definable, impression on me. Mrs X was a woman in her early forties. She had had a very unhappy childhood, a disturbed adolescence, and many traumatic social experiences since, both political and familial. Her marriage had been extremely violent in its emotionalism and conflicts. All her experiences had, according to her account, always ended in failure, humiliation, and futility. Though she could always muster strength to meet a crisis, her normal personal existence was one of subsisting in a mood of apathy and depression. She had little sense of personal initiative or direction and yet she had managed to survive some very critical situations. I was struck by her curious sense of self-preservation. She had given a sober account without trying to make it look ‘good’ or interesting.

In spite of the complete breakdown of her reality she was strangely optimistic. Her breakdown had not come as a surprise to her, even though its suddenness had bewildered her. Things seemed to happen to her with a certain inevitability, and her only contribution seemed to her to have been that somehow she always survived it all. Just as her breakdown had presented her with a very distressing situation and with a singular determination she had decided to have treatment, because that had been suggested to her as the only way out.

It is difficult to define this strong impression of dissociation that I experienced in Mrs X in the first interview. It was also clear that she was presenting me with a patient, handing over an ill part of herself. She was a pleasant-looking woman, somewhat obese in build. Her clothes, though extremely neat and tidy, were worn with a distinctive dowdiness. There was unmistakable liveliness in her face, though her general body behaviour was very depressed. In her narrative, helplessness, depression, and futility were mixed and alternated with a sort of phallic alertness, defiance, and a shrewd sense of self-preservation. I was struck by the fact that her latent mood of optimism, in spite of her very chaotic and insecure social situation and acutely disturbed affective condition, had committed me to a complementary optimism, and I had agreed to treat her. I could not help noticing that I had responded to this element of ‘appeal’ in her whole way of being; and yet when I tried to define this ‘way of being’ to myself it amounted to little more than a series of vivid stills held together by a mood of apathy and depression in the patient.

Mrs X started the treatment the day following her first interview with me. From the beginning I was impressed by her resoluteness about having an analysis. The treatment meant everything to her and on it she had pinned all her hopes. It is important to emphasize the fact of her hope from the treatment, because only very gradually was she going to discover and find a capacity to build a relationship to me where I was registered as real. This capacity of hers to endow the treatment with such power and be so dedicated to it saw her through all her vicissitudes of circumstance and disorders of mood in analysis. It never wavered; always she had a good strong rapport with me, as the vehicle of the treatment. The same was true of the analytic setting. Both my setting and I were vehicles of the treatment; and of course all this is clearer to me now, in retrospect, than it was at the time. To get back to the clinical process, Mrs X was always a co-operative and eager patient. She had a considerable facility for expressing herself in words, though it surprised her a great deal that she had never used it before in her relation to people, and even now she could never talk to anyone significantly and with full feeling.

The first seven months of the treatment progressed very smoothly and fruitfully. The analytic material was abundant, and the patient began to relax into what she felt to be the beginnings of a personal life through all the relief and understanding she experienced from getting her past into narrative focus. I am deliberately using the phrase ‘narrative focus’ here to establish the cathartic effect of recollection and recounting of memories and experiences.

The patient’s life-history as we gathered it together in this period was roughly as follows. She was the only child of fairly affluent parents and came from the European continent. Of her father, a teacher, she saw very little during the first years of her life, because of his absence on war service. He was a hard-working man, very popular in the community and very unpopular with his wife. He was a soft-spoken, kind, rather schizoid person who developed great fondness towards his daughter.

The mother, a woman of vigorous hysterical character, was excessively emotional, aggressive, ambitious, and felt very wronged by her husband. Everything, the mother felt, had gone against her. She had wanted a son and instead had given birth to this daughter, who as a child was plain, fat and clumsy. To top it all the child had started to squint at the age of five, and this had completed the mother’s misery. She tried everything, from doctors to bribes, to make something presentable of this child. But the more she bullied and coerced her daughter the more had the daughter obliged her with disappointment. A very sado-masochistic relationship with the mother established itself, further reinforced by, and repeated with, a series of governesses who were equally sadistic and severe; and the patient had given them all every opportunity for exercising their talents in this direction. Her major and unfailing way of defeating them was to be always sunken in an apathetic lethargic depressive mood. She was no good at games; she had hardly any memories of playing with other children or of having any friends. She had a very apathetic latency, characterized by loneliness, misery, endless humiliations, and racial segregation.

From this period she had also another set of memories, and in contrast to those of her mother and governesses these were highly idealized and precious ones, of two women who had been very kind to her. The first was her peasant nurse, who had looked after her from the start till she was three. She was a very cosy, plump, huge lap of a human being. She had indulged and spoilt the patient, and during this phase of the treatment she was the one ideal good rescuing object. The other was a music teacher who taught her for a short time when she was eight. The patient had lived in a mute and ecstatic relation with her. Like the nurse, she had suddenly disappeared one day from the patient’s life.

About her tenth year she built a good and fond relationship with her father, and this had started her on her development. She began to study and to take an active interest in her work for the first time. It was clear that what had created this very special bond between father and daughter was a shared sense of deprivation in relation to the mother; they were also in alliance against this bully of a woman.

The father died suddenly when the patient was sixteen. She had reacted to this loss not with grief but with dissociation. Suddenly, the mother and daughter both became maximally alert and effective. The mother, instead of experiencing her self-pitying bouts, now took over the tending of the family interests, while the daughter went to university and blossomed out into hyperactivity and over-enthusiastic exploration of the world around her. How the patient was to repeat this pattern again and again could hardly be exaggerated. The relationship between mother and daughter as such never improved.

In college she had at first passionate and vehement attachments to girls, which never became physically intimate. A little later, guided and sponsored by romantic erotic reading, both psychiatric and literary, she abandoned herself to a promiscuous exploration of heterosexuality. None of these relationships ever achieved stability or any deep emotional value. I would like to say in parenthesis here how similar, while working through this stage, the picture was to those described by Anna Freud in her paper ‘Certain Types and Stages of Social Maladjustment’ (1949). The suppression of phallic masturbation and the flight from it to heterosexuality with a corresponding flooding of ego-activity with sexual content was extremely typical of her affairs. Later she was to repeat this sequence in her marriage and very soon to act it out in what I shall be describing as the manic phase in her analysis.

One great advantage of this expansion in the adolescent period had been that it had put the patient in touch with her ego-capacities. It was, however, to have a traumatic and sudden end. She had just qualified at the university as a teacher when her country was invaded. She managed to escape, but never saw her family again, as all of them perished in gas chambers. During this phase of treatment she had little feeling and very little conscious guilt about this loss. Her typical reaction was one of humiliation at the total collapse and failure and acute rage at it.

The patient escaped to England where for six years she had to do very menial jobs in order to survive. But this made little impact on her for her inner rhythm had already changed. The exuberance of her adolescence was over, and she had sunk back into the apathetic depressive dullness of mood that had characterized her childhood and latency. From one aspect this enabled her to survive what otherwise she might have experienced as too overwhelming and painful. To use her own phrase, she had lived in this blanket ever since, for nearly fifteen years. If actions were demanded of or insisted upon from her she always woke up to provide them. She made a very useful, passive, menial worker. She had also turned completely against instinctual needs with little sense of their reality or existence. She had no friends and made none. To her this phase of her life seemed a curiously benign, parasitic existence; she felt humiliated and crushed but safe.

After the war she had to return to her native land. Just before this she had met a young Englishman who had become very fond of her. When she returned to her country she was amazed at the changes, yet with her typical shrewdness she realized that things were no better and she would perish if she stayed there. When the young man suddenly asked her to marry him she readily agreed, because then she could live in England. I would like to stress here that this motivation was clearly derived from self-preservation rather than from calculated mercenary schemes. The marriage started traumatically with the discovery that her husband was a drunkard. This frightened her so much that for the first time she thought of suicide, but instead sank into the apathy in which she stayed until her breakdown.

The patient had been married for eight years when she started treatment. Soon after her marriage she became pregnant, and the ensuing months were distressing and full of ugliness and rows. The stress led to a very difficult labour which, owing to the husband’s panic and the doctor’s precipitate interference, constituted one of her worst experiences. The condition of the husband deteriorated rapidly. At the same time, the patient’s relationship to her son was extremely ambivalent and sh...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• CONTENTS
• Preface
• Acknowledgements
• Theoretical Papers
• Clinical Papers
• Bibliography
• Index