On Bearing Unbearable States of Mind
Published by Taylor & Francis
Pb © 1999
ISBN/ISSN: 0-415-20519-0, Price: US $29.99, UK £17.99 Pp.202.
On Bearing Unbearable States of Mind provides clear guidance on how the analyst can encourage the patient to communicate their often intolerably painful states of mind and how to 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, Riesenberg-Malcolm examines the problems that underlie severe pathology and shows how meaningful analytic work can take place, even with very disturbed patients. Bearing Unbearable States of Mind should be a useful and practical guide for psychoanalysts and psychotherapists and all those working in psychological settings with severely disturbed patients.
'I was most struck by the details of her clinical work with the array of patients that constitutes an analyst’s practice. Firmly based in Kleinian theory and technique, Riesenberg-Malcolm shows sensitivity in working closely with the clinical material of patients who represent the severe psychopathologies. Her elaborate descriptions of clinical material, starting in the first paper in the collection, on “The Mirror”, allow readers to immerse themselves within the deeply disturbing world of perversion and borderline-psychotic states. Even from a differing clinical vantage point one can follow her clinical logic through the evolution of her interpretations. Excellent case descriptions permit us to form our own ideas about aetiology and clinical intervention, a possibility not always afforded readers when briefer vignettes are provided'.
Review in IJPA 83 (1), 2002
Review by Erika Bard
This book is a collection of clinical papers given by Riesenberg Malcolm, mostly at psychoanalytic conferences and symposia over the period 1970 to1998. Some of these papers have not been published before and some have been updated. They are a remarkable series of papers, noteworthy for their clarity on what many analysts are concerned with today: the complex issue of the positions of mutual influence in the consulting-room — the ways in which the patient through projective identification exerts a subtle pressure on the analyst to recreate early object relations and the manner in which the analyst as a recipient of these projections is inevitably drawn into this in some way, and under these pressures is ‘recruited’ to enact something of the patient’s disturbing primitive object relations. She elucidates these aspects of the analytic situation with alive and authentic clinical material, showing how she, as analyst, had to struggle to contain the projections and to experience the emotional disturbance while sustaining, or indeed recovering, a capacity for reflective thought by working through the countertransference and transference experience. She illustrates this vividly, in eleven papers, where she shows a deep sensitivity to her patients’ often-unbearable projections, and an enormous capacity to find the words which really capture the uncertainties, depth and complexity of the archaic enactments in the transference. This she does on the basis of a working model in her mind based on the theories of Klein, Bion, particularly his theory of reversible perspective, Rosenfeld, Joseph, and her concept of the total transference, Steiner, and his concept of psychic retreats, as well as other contemporary Kleinians.
The book is divided into three sections grouped by subject. There is an excellent introduction to each by Priscilla Roth. The first section is devoted to ‘the internal world in the transference’, and focuses on splitting and projection. Riesenberg Malcolm shows how she follows closely the movements of the internal objects in the transference, and how complex this process of noting these subtle shifts is, especially when the patient splits so much that the analyst may be drawn into following one split and neglecting the other to some extent. She demonstrates to the reader how she describes the countertransference experience to herself to start with, and how part of the work is to find out where and how the contact with the analyst breaks down. She is keenly aware of patients who are unconsciously determined to trap the analyst in defensively repetitive styles of relating, and she illustrates in her paper ‘The Mirror’ how the patient’s perverse fantasy was both a trap and an important communication about her internal world, rather like an encapsulated second-skin defence, an auto-sensuous effort at self-cohesion in the face of annihilating anxieties. She describes how the bringing of the fantasy directly into the analysis was a turning-point as it enabled both analyst and patient to see its function for both the sane and ill parts of the patient she can talk to, to see if there is a potential area for development, where the patient is more capable of seeing what effect they have on their analyst.
The second section of the book consists of five papers which address organised defences against experiencing various aspects of the depressive position. A prominent feature in the defences have become organised into a particular mental structure which John Steiner has described as a ‘pathological organisation’ which has become inseparable from the person’s character. The aim of these structures is to protect the individual from the mental pain of sorrow, regret, remorse and loss involved in working through the depressive position. Through detailed clinical vignettes, Riesenberg Malcolm illustrates work with patients who operate on the principle that ‘no change is the only protection from pain and disaster’. She explains how Bion’s concept of ‘reversible perspective’ underpins her conceptual understanding of these different defensive organisations where the patient tries secretly to achieve a stagnant position in the analysis.
Space will not permit me to describe the five papers, but I will single out a few I found particularly interesting and helpful. In ‘Self Punishment as a Defence’, Riesenberg Malcolm shows how the patient turns to sado-masochistic and self-punitive behaviours, not in a transient way, but in a way which is chronic, fixed and compelling. What emerges in the analysis is a whole defensive organisation imbued with erotic satisfactions. I think this also raises the interesting question about identifications. We know there is an internal world in which identifications are made, and, if they are transient rather than fixed, a disidentification can be made. However, in some patients, such as the one described in this paper, the identification feels so powerful and long-standing that it brings up the issue of a malignant superego and interminable analysis. In this analysis it seems the patient had a manic identification with a sadistic object which occurred in a fixed and rigid way, and it interfered with any attempts to move towards a more benign superego and reparation. One of the things which makes this paper interesting is the fact that Riesenberg Malcolm decided to terminate the analysis, and gives her reasons why. She raises intriguing questions about whether there is something specific to the patient’s make-up or whether the patient touches on areas of the analyst’s internal identifications related to his or her own personal ways of dealing with depressive anxieties which can lead to an over-extended treatment.
She gives detailed material from three phases of the analysis. The first phase she called ‘the psychotic transference’, which was chaotic and full of confusion. She notes how many of her interpretations were tentative. She carefully observes how material emerged through the patient’s reactions to her interpretations which seemed to be a kind of archaic enactment of a pathological infantile situation where feeding was unsatisfactory and broken up. She shows how working through these bits of evidence slowly gave the patient some relief and some real progress took place in the analysis. However, in the second phase of the work, she is very aware of how the patient’s need for extreme control of his objects dominated everything. She describes bizarre and difficult sessions where the patient would torment her with reciting the alphabet, sadistically throwing out questions to see what they do to the object. Her interpretations, based on her own countertransference fears of being endangered, centred mainly on a torturing gang and a situation where guilt has got all mixed up with something torturing and malignant. The paralysis of the analysis seemed to this patient to be both tormenting and exciting. The sadistic aspects in the patient’s personality were getting intense gratification from punishing the object (the analyst in the transference) which also allowed the patient to maintain the omnipotent belief that the object was not lost.
Riesenberg Malcolm suggests that when the analyst gets close to a patient such as this one, it stirs up a perverse excitement which spoils the patient’s contact with his objects, and that, in effect, what is sexualised is ‘pain’. I think she is describing patients who seem almost unreachable, as any intimacy with aspects of themselves or with others is terrifying because it poses a threat to their defensive organisation of the self, and it mobilises destructive impulses against others. She describes how she decided to bring the analysis to an end, and the difficulties which confront the analyst with this sort of patient, as it is the analyst who experiences the anxieties linked with guilt and the failure of reparation, as well as a fear for the patient’s disintegration. She notes how these unbearable feelings may push the analyst to act in an anxious way, either consciously or unconsciously, to over-extend the treatment, or to introduce parameters or modifications of the treatment. She believes that to concede to these pressures would only increase the patient’s anxiety as well as the patient’s sense of triumph.
I will make a brief mention of her paper, ‘As-if: the phenomenon of not learning’, where Riesenberg Malcolm describes a different constellation of narcissistic defences which aim to keep the analyst and patient in agreement so that there is no possibility of triangulation. This ‘as-if’ patient makes a pretence of wanting to be understood, and tends to use interpretations for something other than their original currency, so the interpretation appears to be accepted, but no sooner does the patient hear it than it is being dissected and there is a psychic revitalisation of the work. She illustrates how she uses dreams, association and her countertransference thoughts and feelings to elucidate in the material whether it is envy or despair at different times which prevent the patient from using the analysis to develop. A prominent feature which emerges in all of these papers is the patients’ reluctance to allow either the analyst or themselves to escape from the familiar interactions, and how through analytic work one can see moments when the patient emerges from the psychic narcissistic retreat and is then faced with terrible anxieties about the damage done to his objects. Riesenberg Malcolm illustrates how, as long as the patient is sufficiently protected by the pathological organisation, he does not have to feel any guilt, and the analyst is experienced as a danger to his fragile self-cohesion.
The third section of the book contains two recent papers which deal with the theory and technique of interpretation and the conceptualisation of clinical facts. The author delineates how she understands and processes the communications coming from her patients based on her theory of mind, but what is the key factor is the orientation of the interpretation to where the patient is and using the countertransference as a kind of sense-organ. She sees the analyst as a participant in co-creating the analytic data, and she believes this is something to be seriously studied. The major strength of this book is the author’s generosity in showing her own thinking, as it evolves in the interplay of the two unconscious processes in the consulting-room. She shows how she puts her countertransference to creative use to find a thoughtful and sensitive way to help the patient think and feel what is true.
Paradoxically, one of the major assets of this book, which is the wealth of clinical detail, with vivid illustrations of what transpires in a session and over time in an analysis, is also at times a drawback. I felt that in one or two papers Riesenberg Malcolm was over-inclusive, particularly when she tried to illustrate a whole series of factors in the work, and the reader can get a bit lost in all the detail. However, I liked the fact that she raised questions about the work in the discussion, and I think the clinical accessibility of her papers allows the reader to assess, agree or modify his or her own thinking about the analytic work. Therapists will be richly rewarded by the thoughtful and detailed descriptions of analytic work with patients who often seem unreachable. I believe they will find their clinical thinking deepened and challenged by this book.
Member of the British Psychoanalytical Society