Academic journal article International Journal of Psychoanalysis

Comments on the Case of Raquel

Academic journal article International Journal of Psychoanalysis

Comments on the Case of Raquel

Article excerpt

Clinical material can always be looked at in many different ways and, having been given a free hand by the editors, I have chosen in this instance to look at the patient's attitude to the setting and the structure of the analysis. The importance of the setting, or as some people have called it the analytic frame (Bleger,1967), has been widely recognised. It plays an essential role in containment because if the patient is able to feel confident in the stability, adaptability, and humanity of the setting he/she can, within its protection, feel contained and hence free to express him/herself both positively and negatively. Segal (1967) has emphasised that the most important aspect of the setting is the attitude of the analyst and it is this that is expressed by the various practical aspects, such as the layout of the consulting room, the frequency and timing of the sessions, the fee, etc. Klein (1936) suggests that the most important aspect of the analytic attitude is that "our whole interest is focused on one aim, namely on the exploration of the mind of this one person who for the time being has become the centre of our attention. Correspondingly everything else, including our own personal feelings, has temporarily lost importance".

We all recognise that such an attitude is difficult to sustain and that the analyst will invariably enact his own conflicts as other preoccupations occupy his mind. Indeed, part of the analytic attitude is to accept how difficult it is to sustain and preserve the setting. Moreover, we must also recognise how difficult the patient finds it to be contained within the setting and this was true of the patient described here, who was often assailed by claustrophobic feelings and felt the need to attack the structure in what seemed to her to be a bid for separateness and freedom. I thought that the patient found the setting quite persecutory at times, but that she was also greatly appreciative of the analyst's struggle to preserve it in a humane and flexible way.

Despite her poor background, with a psychotic, alcoholic father and a preoccupied and unavailable mother, Raquel was successful in business and came across as a capable and feisty woman. At times she seemed to be unable to tolerate the setting and then made moves to extricate herself often in a destructive and threatening manner. This seemed to have been her reaction to the analyst's initial attempt to work with her when, after eight months of treatment, she took flight and leftthe analysis to return to her former therapist who was described as a better secretary. This condescending attitude appeared at several points in the sessions and seems to represent the adoption of a narcissistic superiority probably to deal with feelings of smallness and inferiority.

However, she was able to return some two years later following a period of acting out that mostly seemed disastrous but which did leave her with a baby. At that time she felt that she was unable to love or to feed the baby and she was somewhat preoccupied by paranoid themes, feeling betrayed by her homosexual partner and wronged by a colleague at work. At this point she had also mentioned the three bullet holes in the plaster beside her bed. These were shots fired by her psychotic father, not at her but leaving reminders of his disturbance. I suspect that like other sources of distress, these holes remained unrepaired and played with, as if the patient wanted to keep the memory alive. I thought that by coming back to her analysis she was giving the analyst a second chance and at the same time warning her how difficult that task would be. Nevertheless, it seemed to me that she gradually developed a respect for the analysis and felt valued and contained by the analyst's sensitive and careful work.

A further attack on the setting took the form of reducing the sessions from four to three per week. The analyst was obliged to accept the reduction even though she held onto her view that this was undesirable. …

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