Panel IV
Pseudo-endings and New Beginnings

Joan Rankin, LCSW

I have found it both stimulating and fascinating to attend conferences that feature one clinical case discussed from many different theoretical points of view. The innovative format of this conference was particularly intriguing in that it embodied a non-linear dynamic systems approach in a pluralistic dialogue among clinicians of varying perspectives. This conference and Panel Four in particular, did not disappoint. Here I offer my summaries of the two discussants on this panel: Stephen Seligman, DMH, PhD, and Malcolm O. Slavin, PhD, and add some of my own impressions of the case.

Dr. Stephen Seligman prefaced his thought provoking discussion by informing us of his Intersubjective, Object Relational, and Freudian perspective. He approached his critique by highlighting a number of aspects of the case that he wanted to know more about, which framed his particular perspective on this case.

First, he noticed an idealizing atmosphere in the case and wondered about the potential costs of the idealizing self-object transference and counter transference, which for him seemed to predominate the analytic dyad. He listed all the good things that Dr. Lucyann Carlton offered to her patient Renee: empathy, understanding, containment, attention to linking and de-linking, dissociative process, and both explicit and implicit experiences. He stated that she also offered an unflappable therapeutic stance which is fair, principled, and concerned with helping her patient articulate aggressive feelings more effectively. Furthermore, he saw this stance as "benign. . . almost admiring", creating a counter transference that was solid, affirmative, warm and exuded trust-worthiness.

However, Dr. Seligman noted an emergence of increasing negativity that he felt could be related to Dr. Carlton's therapeutic stance. In particular, he sensed a "cleaning up of the act that went" on which in his view obscured mistrust and destructive impulses. By way of example, he observed that "many interventions named something terrible in a way that detoxified it", and this, he felt, created a risk of Renee not feeling fully recognized in Dr. Carlton's choices to move toward hope in her interpretations. He wondered, " What may have been left out of their dialogue? What can an analyst do with the access to Renee's torturous world made available through her dreams? What got foreclosed?"

As an example of his perspective, Dr. Seligman refers to the following vignette: Upon Dr. Carlton's return from a week's absence, Renee is disorganized, despairing and suicidal. She reports the following dream:

Renee was left to care for an infant while the family was out. Upon their return they didn't care about the baby: it was crying and unhappy. It needed a bath. While in the bathtub it became submerged under water and couldn't breathe. Renee saved it, but not before the baby could experience what it might feel like to not be saved. It would not be comforted. Renee decided to pull it out of the water and wash it because it was dirty, like a baby covered with amniotic fluid, but it remained unclean. It curled up on her.

Dr. Seligman noted that Dr. Carlton interpreted Renee's missing her while gone and then affirmed Renee's choice to live despite the crushing sense of despair related to her absence. Dr Seligman asks, "What would've happened if Dr. Carlton had stayed with the torturous feelings of the dream, rather than taking them both away from the affective intensity of her feelings of destruction, death, infantilization, and destructive fantasy? Would staying with the difficult material have overwhelmed Renee? Would not staying with the difficult material have lead to her self-destructive behaviors manifesting in more virulent ways?"

Additionally, Dr. Seligman asked in response to Dr. Carlton's invitation to be part of this conference, "Did Renee's acceptance of her case presentation at this conference repeat her dissociative compliance with her abusers? Could consenting to the presentation have been a traumatizing re-enactment designed to garner reassurance?" He proposed that Renee's later disorganized re-enactment belied her compliant stance: he saw that her confused state represented "a blurring between self and other, victim and abuser, tortured and torturer, baby who was murdered and baby murderer." This, Dr. Seligman posited, could be a cost of the idealizing self-object transference and counter transference relationship of the dyad. He observed that Renee offered herself to be abused in the transference, but also offered something new in her recognition of her need for this therapeutic relationship so she could navigate her way through her treacherous and trauma filled life experiences.

Finally, Dr. Seligman wondered about Dr. Carlton's own counter-transference feelings shaping the many choices involved in her interventions and wanted to know more. He observed patient and analyst mixed up together. Ultimately, he felt, things turned out ok as a new reality of Renee's story emerged between them.

The next discussant, Malcolm O. Slavin, PhD, offered his views from an Evolutionary- Existential- Self Psychology Perspective, which posited the Darwinian notion that as we became human, we lost an innate sense of identity as a result of our brain-based survival strategy of meaning making. This evolutionary adaptation also brought with it certain tensions, such as the tension between our need for otherness and our need for self-experience. Dr. Slavin's discussion focused on those tensions in his critique of this analytic dyad.

He affirmed Dr Carlton's bold, steadfast and loving stance with this severely traumatized patient. He found it most interesting that Renee wanted Dr. Carlton to show us Dr. Carlton's image of her. Yet she would not see it in print, and she did not want to hear it because it then would not be her story. She was not ready yet to tell her own story.

Dr. Slavin asks, "If Renee's exposure as the subject of this conference was not a repetitive traumatic violation, then what else did it mean to her?" He goes on to say that what he felt was primary for her was not the exposure, but the story itself, which was still Dr. Carlton's fairytale about her. Perhaps, he suggests, it was a story Renee wanted to believe, but was not yet hers. He asserted that Renee let Dr. Carlton use or abuse her in order to stave off the threat of the fairytale eroding the complex identity that she needed to preserve in order to feel real.

Interestingly, Dr. Slavin watched Renee use her implicit ways of knowing in her challenge to Dr. Carlton's ability to see her fully. She did this by bringing a dramatic re-enactment to the session: the charming storyteller with a fairy tale ending now had to see the self-destructive, dissociated and disorganized states that still inhabited her. All of these pieces of her experience were real for her. Later, Renee came to a session with dissociative writing episodes and gave the letters to Dr. Carlton, fearful of reading them alone. Dr. Slavin saw them as containing all the angry, aggressive, and torturous feelings about her defective, rotten core which did not fit the fairy tale. Renee, in bringing these writings to Dr. Carlton, revealed her overt aggressive angry feelings which she had not previously been able to reveal. Dr Slavin wonders, "If Renee's subjective experience was organized around dissociative ways of knowing, then in Dr. Carlton's exploration of conflict between various self-states, was there a risk of having her self taken over in a way that leads to personal annihilation?" Dissociation in this case was seen as a strategy to keep parts of oneself alien, so as not to lose them: to have them known by another was equated with losing them, leading to a reduced sense of realness. For example, Dr. Slavin noted that in her dream, making the baby feel the pain and possibility of dying before she saved it was a manifestation and illustration of her dissociative process. It seemed clear to him that Renee felt violated and objectified by being seen as a "study" for Dr. Carlton, and wondered if she was real for Dr. Carlton, or "work" to her.

Dr. Slavin wondered if Renee could come to be and feel real while going through the painful process of destroying the images of others in her self. He felt it risked usurpation of her identity. He posits, "Will she come to have her own real identity and agency in the world or will she adopt a pathological self-ideal? Is Renee identified with her abusive violating mother in an attempt to stay alive?" He recounted the dream of the ghostly blue, dead finger inserted and rotting in her, a dead but living part object. He asked, "Does this keep her feeling trapped in her self: in this terrible introject of her mother, propelling her into chaotic states?"

Finally, he noted that Renee knew that she idealized Dr. Carlton. Her aggressive core broke through demanding to be addressed in her need to be fully known. Perhaps she hoped to be able to take in Dr. Carlton's story of her, including the story telling and biases, one day when they finished treatment. And Dr. Carlton, he felt, necessarily sequestered her responses to Renee in a box of her own in order for Renee to utilize her.

In my experience, this case presentation was fascinating because it focused attention upon how our theories and treatment methods, which we hold dear, are inexorably intertwined, especially as this applies to severe trauma victims. We heard the gamut of opinions range from questions of the analyzability of this patient to the laudatory praises of the work by both analyst and patient in their dynamic and complex dyadic system. What I admired most about the work of Dr. Lucyann Carlton was her flexibility in integrating and offering many approaches to this severely traumatized person, based upon Renee's (and perhaps her own!) rapidly oscillating self-states. Lucyann offered a continuous, stable, enduring and loving working relationship which was necessary, vitalizing, and terrorizing for Renee, the vicissitudes of which comprised the presentation. I found myself holding a lingering observation and question throughout the conference. Let me begin with the observation that Lucyann was clearly dedicated to allowing us, the audience, to hear Renee's voice as Lucyann experiences her in their tense, trauma filled and affectively charged sessions. This, I am quite sure, is a reflection of her dedication to the needs and stated desires of Renee who stridently states, "I want my story told, with my name, my job, accurate details of my life, nothing altered."

Lucyann completed this task with an ease and thoroughness which was exemplary. As I listened closely to grasp the experience of the analyst, as I often do in this world of bi-directionality, it seemed to me that some of Lucyann's experienced in her counter-transference was clearly stated. In my opinion, most of it was left to our imagination with caveats such as "Imagine my excitement at. . .."

I was left with the global sense that Lucyann may have carried the voice of her patient more effectively than she carried her own, which I, at least, wanted to hear more of. As a result, the questions that formed in response to my wonderings follow: What must it have been like for Lucyann to sit in the room with the intensity of affect which this kind of trauma brings with it? If she had to sequester parts of herself, as she stated, to be there in a way that Renee needed her, what parts were those? What affects did they hold for her and how did they impact her interventions? What aspects of her personal experience of both herself and the patient were stabilized and supported by her training analysis and supervision of Renee which she alluded to?

I am fully aware that in the clinical hour as well as in presenting case material one needs to be measured in the amount of self-disclosure that we are each comfortable with. And I am aware that in this intersubjective, non-linear systems view of treatment that the therapeutic relationship remains asymmetrical. However, the wonderful richness of this case tilted in the direction of showing us the affective arc of Renee, and I longed to hear more of the affective arc of this remarkable analyst treating this remarkable patient.

I appreciated this leading-edge forum about the multiplicity of psychoanalytic voices in the chorus of contemporary psychoanalysis.

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