Panel I
The Way into the Metal Box
Marcia D-S Dobson, PhD
When Renee and her husband come to Lucyann for help with their only
child, Lucyann finds them articulate and intelligent. She sees Renee as
loving and gentle with her little boy. Renee's children, her
eight-year-old, and the two teenagers from a former marriage speak of
her as a perfect mother.
Little are we to guess that when Lucyann senses Renee's underlying
anxiety and invites her to become her patient, Renee is to reveal a
hair-raisingly traumatized past that has left her highly dissociated,
suicidal, and compulsively addicted to sex and alcohol. Renee quickly
becomes a patient so difficult and dangerous to herself and others that
many therapists would have medicated and hospitalized her. Few of us see
such damaged patients, and for this reason, a number of people at the
conference remarked that this was an inappropriate choice for the major
case presentation in San Diego. Despite clear indications to the
contrary, Lucyann chooses to see Renee in her private practice.
Protocol
Renee has been in psychotherapy for most of her life, including
several years of classical analysis. Like her child, who complains of
not being able to feel his mother's love, Renee can neither feel nor be
present in her life. Renee reports that she had been married three times
since the age of sixteen, has had two children, and three abortions.
Previously, Renee suffered pervasive sexual, emotional and physical
abuse and neglect at the hands of both parents. Her compulsive father
demanded absolute obedience: "I never knew if my dad was going to sweep
me up in his arms when he came home or if he would be angry and
dangerous." Her mother emerges as a "young woman with an undiagnosed
untreated bipolar disorder complicated by alcoholism." Both parents'
pathologies increase markedly in severity over time.
When Renee's parents divorced in her eighth year (the same year as
the age of her child at the time of treatment), her father's behavior
toward her escalated into brutal beatings and rape at gunpoint, with
threats that he would never see her again combined with tender moments.
Her mother took on multiple male partners, made Renee sleep with her in
bed and share her sleeping partners.
Treatment
Lucyann was faced with a beautiful young
woman who could not respond in any way to her "reflections, observations
or inquiries." Lucyann had to make her presence and interest known
through non-verbal means. After several months of listening to Renee's
"charming and talented" story telling, Renee suddenly began to cancel
sessions. After several months, Renee's husband called to say that he
had discovered her lying on the floor of the bathroom in a blackout,
holding a loaded gun in her mouth."
Lucyann calls her: "You must be in so much pain and feeling all
alone. I need you to call me. I want to be with you." Renee comes to
her next appointment dressed like a hooker. Rather than hospitalize
her, Lucyann muses, "I wondered whether this apparently rebellious Renee
would permit a wider range of interaction between us."
During their first year together, Renee inhabits precipitously
shifting worlds of chaos and rigid order. At one moment she is a tender,
engaging, mother, at another, a crazed, addicted and sadomasochistic
'lady of the night,' and at yet another a young woman dressed in sweat
pants and wearing a ponytail that emphasizes her youth and innocence.
Each self-organization provides her different means to avoid feelings
and memories, each foregrounds Renee's feelings of herself as either all
good or all bad. When she feels good, she complies with stringent
external standards, experiencing concomitant high levels of anxiety,
night terrors, panic attacks, and conversion symptoms. When she becomes
her "loathsome self," she spends excessively, engages with dangerous
men, and uses alcohol. In therapy, she is "seductively alluring but
quickly enough became defiant and aggressive when criticized."
Lucyann's first breakthrough with Renee comes when she tells a dream
of taking a journey with Lucyann. Lucyann discovers that while Renee is
unable to tolerate reflections in her awake state, her dreams provide a
safe place to express a fuller range of her emotions, and consequently
the possibility for a more reciprocal interactive experience. Lucyann is
cautious in helping Renee to associate: "Might you experience some part
of our relationship like in the dream. . . being in each other's presence,
but not really connected?" As Renee speaks of increasingly horrendous
trauma, she can see the pain on Lucyann's face and begins to feels her
own feelings. Renee's dreams now suggest that even Lucyann is too
fragile to help her. Lucyann suggests five meetings a week and telephone
calls in the evening. She even turns down the overhead lights,
modulates her voice, works on breathing, and provides a special blanket
for Renee. In their third year together, Renee announces: "I started
here because I wanted a glorious life . . .. But I see now what I will get is
a life. Nothing more, nothing less. I thought I would get those
fantasies that I had lived in my head. But I am giving them up now. I
need to just live."
Discussions (The Pizers and Joseph Lichtenberg)
Barbara and Stuart Pizer speak of how deeply touched they are by this
analytic journey. They speak of Lucyann's courage and how nobly she
holds the "hope without the expectation" that Renee may reach the other
side of her suffering. They struggle (as did many of us) to stay
organized in the face of hearing about this "electrifying. . . struggle."
They focus on how Lucyann's attempts at vicarious introspection are
thwarted time and again by the "impenetrable curtain" of Renee's
"barrier," expressed so lucidly by Renee's own poem of the metal box
that she is locked up in with only a pinhole of light to the outside
world, to which she alone holds the key. They comment on how Renee's
use of projective identification leaves both Renee and Lucyann feeling
alone and in the dark. Only the dream offerings provide a pathway out.
Renee's four dreams lead to a shared space where she finally begins to
admit Lucyann as a witness and companion: "What was once garaged in the
messy confines of an airless enclosure of last resort, clogged with ugly
refuse, has transformed into a shared space, a transitional shelter, a
refuge for letting go and the cleansing of a defiled self where there
may be potential to be safely alone in the presence of another. . .." The
Pizers speak of Renee needing an environmental mother to dare to come
into being before she can even begin to protest: "the connection made by
presence, both inside and outside, preceded the capacity for protest."
They praise Lucyann's restraint at the beginning of this therapy, as,
caught between "abuse and neglect," she makes the important choice not
to inquire into the multiple and contradictory transference meanings."
Joe Lichtenberg addresses the problems of having a patient this
traumatized in self-psychological analysis. Lichtenberg suggests that no
empathic responsiveness can "provide the momentum to deconstruct Renee's
pathological identities." He remarks that self psychology's critics
"would have a field day" in showing the deficiencies of mirroring and
establishing oneself as a good object with Renee, "each of whose
intentional experiences developed as a distinct variant of an expression
of aversiveness rather than need or desire." Our rationale must lie,
says Lichtenberg, "in our understanding of, and belief in, an implicit
non-linear process that is occurring largely at a pre-symbolic level."
This process largely has to do with Renee's testing Lucyann for trust,
and a power play that invests every moment of the therapy. Renee needs
to have the power to determine her destiny. Lucyann has to grant all
power to Renee while remaining as a container for her affects. How
long, Lichtenberg asks, can or should Lucyann surrender her own freedom
to investigate and comply with Renee's unconscious demands? He remarks
that we hear little of Lucyann's own process or supports in her
presentation.
Lucyann replies that in fact she had nothing to support her except
Renee's husband, and her conviction that healing occurs in human
relationship. Renee, too, has told Lucyann that she knows she is
"different" and that there is something "different for her with me."
Lucyann explains that she was quieted in her own doubt by Dr.
Lichtenberg's understanding of transference with traumatized patients,
when he says that "being with" a traumatized patient is more critical
than doing or even relating. This is what keeps her from interpreting
the negative transference, and instead just "being" with her
patient.
Comment
Both the Pizers and Dr. Lichtenberg addressed central concerns of the
audience: Is this patient analyzable? Why didn't Lucyann hospitalize
her? What is nature of the transference with such traumatized patients?
Is this a suitable case for presentation at a self-psychology conference
when there is so little possible discussion of the transferential
interaction between analyst and analysand? Some with whom I spoke were
distressed at the flamboyance of the case, wondering why we seem to hear
the most sensational cases and not those more subtle ones which might
help us more in our work with our less injured patients. Nevertheless,
many of us were held spellbound by the immediacy of Lucyann's
presentation of Renee as well as by the lyricism of the Pizers' caring
response. We sustained hope that we would hear more about the emerging
transference as the case progressed.
Top of this Page Newsletter Front Page
|
