This article was downloaded by: [Universita degli Studi di Torino] On: 07 November 2013, At: 03:48 Publisher:

Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

The Scandinavian Psychoanalytic Review

Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rspr20

On the capacity to endure psychic pain

Robbert S.G. Wille
a a

Tooropkade 10, 2102 , AA Heemstede , The Netherlands E-mail:

To cite this article: Robbert S.G. Wille (2011) On the capacity to endure psychic pain, The Scandinavian Psychoanalytic Review, 34:1, 23-30, DOI: 10.1080/01062301.2011.10592880 To link to this article: http://dx.doi.org/10.1080/01062301.2011.10592880

PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the Content) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions

Scand. Psychoanal. Rev. (2011) 34, 23-30

Copyright 20// ---THE--SCANDINAVIAN PSYCHOANALYTIC REVIEW ISSN 0106-2301

On the capacity to endure psychic pain 1

Robbert S.G. Wille

Downloaded by [Universita degli Studi di Torino] at 03:48 07 November 2013

Psychic pain, which is an unavoidable part of existence, derives from unconscious layers of the personality and is rooted in early, preverbal experiences, on the border between the somatic and the psychic. The comfort provided by the emotionally attuned mother is internalised by the child and constitutes the core of the capacity to endure psychic pain. Mature pleasure cannot be experienced without having known unpleasure. As the goals of psychoanalysis include experiencing psychic pain and internalising the idea that psychic pain is an inseparable part of life, the analyst must not only be able to uphold a maternal, caring attitude, but also maintain a degree of hardness. In so doing, he helps bring the analysand in contact with his pain and even deepen it. This attitude has a strong impact on transference and countertransference. Several clinical vignettes are given to illustrate these realities.

Key words: psychic pain - analytic goals - analytic 'hardness'- tact

At the beginning of the 1990s, a Dutch colleague and I attended a clinical seminar led by the Scottish analyst James Innes-Smith. My colleague presented a contribution on the analysis of a very inhibited, rational woman who was a high flyer in her profession. The analysis proceeded laboriously owing to the patient's powerful resistance. Innes-Smith suggested that my colleague needed to interpret much less cautiously and more deeply. The analyst objected that her patient would be unable to tolerate this and might decompensate. She opted for a more cautious and more gradual approach. Innes-Smith replied that a breakdown and possible hospitalization might well be just what this patient needed. We found this idea shocking: after all, psychoanalysis was supposed to help people and not to plunge them into even greater psychic distress. This
1

A shorter version of this paper was read for the Dutch Psychoanalytic Group and at the "Third International Congress on the work of Donald W. Winnicott" in Milano, 2005.

was a striking statement that I, as a witness to this dialogue, did not fully understand when it was made. Innes-Smith probably had in mind Winnicott's notions of "fear of mental breakdown" (Winnicott, 1974, p. 103) and "going on being" (1960, p. 586). Winnicott describes the adult's "fear of mental breakdown" as fear of something that has already happened early in development that, because of insufficient psychic development, could not be experienced consciously at the time. The defensive structures that protect against experiencing this early trauma in the present are sometimes so rigid that psychic change will be possible only if a crisis causes them to collapse. Winnicott (1974) writes that an analysis cannot be terminated " ... unless the thing feared has been experienced. And indeed one way out is for the patient to have a mental breakdown (physical or mental) and this can work well" (p. 104). The original breakdown can only be reached emotionally by means of a second, current breakdown. The pathological balance must be disturbed, so that a discontinuity arises. This discontinuity, together with the

Downloaded by [Universita degli Studi di Torino] at 03:48 07 November 2013

accompanying loss of control, constitutes a psychic fault line analogous to a crack in the earth's surface that results in a seismic breakdown. Patients often think the loss of control following a psychic breakdown is irrevocable and will lead to a permanent state of psychic distress. For such patients, psychic breakdown means going mad and staying mad for ever. They have no sense that the breakdown is temporary and that recovery or even growth might thereafter be possible. Any subsequent "going on being" is unimaginable to them. This is in fact consistent with Winnicott's (1974) idea that psychic breakdown is a reversal of the individual's maturational process. Everything built up during development collapses back into the state of nothingness from which we originally emerge. Considered in this light, it is readily understandable that the fantasy of psychic breakdown is accompanied by vast quantities of existential anxiety. Another reason why psychic breakdown arouses so much anxiety is that it presupposes the need to endure intense psychic pain. The avoidance of psychic breakdown thus partly coincides with the avoidance of psychic pain. Although I agree with Winnicott's idea that mental breakdown in the sense of the collapsing of rigid defensive structures is sometimes necessary for real change to happen, I am also of the opinion that such a breakdown should be as much controlled in the analytic setting as possible. Mental breakdown and psychic pain are not goals of psychoanalysis in themselves but are the sometimes inevitable side-effects of the analytic process. In this paper, I shall first review the psychoanalytic understanding of psychic pain, and then proceed to discuss some developmental aspects of it. I conclude by presenting the formidable technical challenges that follow from these views, when applied in psychoanalytic treatment.

THE CONCEPT OF PSYCHIC PAIN Although psychic pain is an omnipresent, unmistakable and unavoidable ingredient of our existence, it is not easy to describe precisely what it involves. In his Project for a scientific psychology, Freud (1950) described psychic pain as the result of the psychic apparatus being flooded by a vast amount of stimuli. In Mourning and melancholia ( 1917), he emphasized the connection between psychic pain and object loss. In Inhibitions, symptoms and anxiety (1926), Freud elaborated on this, compared psychic and somatic pain, and noted that psychic pain is the consequence of a

missed or lost object, whereas somatic pain is the consequence of an injury to the body. The injured part of the body as well as the lost object are libidinally strongly cathected. This leads, according to Freud, to the similar qualities of the experiences of psychic and somatic pain. The choice of the term psychic pain was not coincidential; psychic pain is experienced as if it concerns somatic pain. Several authors after Freud have pointed to the connection between psychic pain and object loss (Joffe & Sandler, 1965; Joseph, 1989; Kahn, 1981; Kogan, 1990; Pontalis, 1981; Weiss, 1934). Dreyfuss ( 1999), however, indicated that psychic pain is not subject to the pleasure-unpleasure principle and that, when sexualised, it should be regarded as suffering rather than as pain. Ramzy & Wallerstein (1958) point to the fact that the concept of psychic pain is used in both a restricted and a wider sense and that it includes a broad spectrum of uncomfortable affects. In the restricted sense, it describes a specific painful feeling. What immediately springs to mind when we think of psychic pain in a wider sense, are anxiety, depression, guilt feelings, envy, mourning and other highly unpleasurable feelings. However, inherent in psychic pain, too, is an intensity that is not necessarily always present in these affects. Psychic pain has an existential connotation, as when patients impress on us that they are suffering from lifethat life itself is painful. It is also more profoundly felt and usually much more persistent than other, "ordinary" affects. Further, psychic pain frequently stems from the deeply unconscious layers of the personality formed in the early stages of development and is experienced as a direct threat to the coherence of the self or even to one's psychic existence as a whole. It is connected to Winnicott's ( 1965) concept of unthinkable anxiety as experienced by the baby. Winnicott mentions four varieties: going to pieces, falling for ever, having no relationship to the body and having no orientation. This kind of pain and the accompanying experiences are often preverbal. When the concept of psychic pain is used in a restricted sense, referring to a specific affect, it should be distinguished from anxiety. Akhtar (2000) concludes that, although there is an overlap between anxiety and psychic pain, they are different affects because "pain is more immediate, lacks readily available discursive content and is a response to a trauma that already has taken place. Anxiety is an evolving sensation, replete with fantasy, and is a response to a trauma that is anticipated in the future" (p. 231 ). The failure to consciously acknowledge or feel psychic pain frequently underlies much psychopathology.

24

Sometimes the intolerance of psychic pain and the unwillingness to feel it are themselves among the most prominent manifestations of such pathology, as in the following case of Jan.

Clinical illustration Jan, who is in his thirties, leads an anxious and very constricted life; he has never had a sexual relationship and has little social contact. It was only after several years of psychotherapy that Jan dared to take the step of embarking on psychoanalysis. The idea of giving up control and of drowning in a sea of painful feelings aroused panic anxiety in him. In analysis, his enormous resistance to talking spontaneously and telling me what comes into his mind is evident. He keeps things to himself because he is convinced that I will give him a good beating in response to what he might tell me. Everything he says will, he feels, be used to inflict pain on him. "Pain is not nice; I don't want any of it," he often says, like a child. Jan is also very scared of physical pain, which is why he has not been to the dentist for many years. I repeatedly find it difficult not to go along with the sadistic role he assigns to me in his attempts to keep everything superficial. I often get irritated by his weak, lax attitude and am tempted to give him a firm talk, like a strict father would do, demanding more guts and fighting spirit. I realize that Jan projects an unwanted, split-off, aggressive part of himself into me, thus making me want to inflict pain on him and give him a good beating, as he fears - but also wishes. He has the idea that I ought to give his backside a good tanning and he tries to provoke me into doing so. Because Jan has sometimes sensed my irritation, it has gradually become possible to talk about this pattern in the transference, and we are slowly but surely emerging from the atmosphere of deadlock and avoidance. We are now able to talk about the form of, and reasons for, the intense anxiety and its underlying psychic pain. Anxiety evoked by his own sadistic feelings and wish to inflict pain are other relevant themes. Although he is gaining more and more freedom in a variety of areas with the progress of the analysis, Jan does not yet dare to enter into a close relationship with a woman. He has many reasons for avoiding intimacy, which have to do with anxiety about dependence, the loss of control and, first and foremost, the fear that pain may be inflicted on him. It takes a long time before he can begin to feel that this pain is particularly bound up with the idea of being disappointed, abandoned and left alone - again. In a typical session Jan says he could not help cry-

ing like a child at the disappointment he experienced when parting from a seminar group of which he was a member, an event from which he had expected great things. "I can't stand that kind of parting, it causes too much pain, it's always disappointing and every time I feel they're glad to be rid of me. Just imagine if that were to happen to me in a relationship. I wouldn't be able to do anything at all any more. Then I would be so fed up with life that I wouldn't be able to function properly, so I'd get sacked and end up as a lonely vagrant." I tell him that he still feels like an impotent child, a baby who is psychically defenceless against the overwhelming anxiety and pain arising when his mother leaves him alone for long periods, and that his whole life is directed towards never again having to feel the pain and despair he experienced as a baby-vagrant. Jan's mother, an obsessional woman with a pathological fear of dirt, had to have her breasts surgically removed while she was pregnant with him. After the birth she became depressed, which was a heavy burden on the early mother-child relationship. The mother subsequently entrusted his upbringing to a succession of different carers. When she did look after him herself, she would leave him to his own devices for long periods. When he was older, she was never able to mention difficult subjects with him. All problems and anything painful were swept under the carpet, concealed beneath a rigid ban on "behaving like a child" and beneath intellectual ambition. That was the family culture. When the mother was dying, she was unable to say a single word about it to Jan, who was now grown up. Mother's tendency towards denial probably made it impossible for her to teach Jan to endure pain, so that his inability to tolerate pain is directly linked to the many early abandonments and the associated overwhelming anxiety. For Jan, women are threatening beings without breasts, and hence non-nourishing objects, who inflict pain because they will ultimately always disappoint and abandon him.

Downloaded by [Universita degli Studi di Torino] at 03:48 07 November 2013

DEVELOPMENT OF THE CAPACITY TO ENDURE PSYCHIC PAIN The foundations of the capacity to endure psychic pain are laid in the earliest phases of human life when the somatic and the psychic are still hardly, if at all, differentiated from each other, so that psychic and somatic pain more-or-less coincide. This foundation may cast some light on Joseph's (1989) observation that psychic pain is often experienced as quasi-somatic and there-

25

fore seems to be a phenomenon on the boundary between the somatic and the psychic. Earlier, it was assumed that not only a foetus but also a young baby is unable to receive pain stimuli because the neural tissue is not yet sufficiently developed. It is known, however, that not only infants but also, probably, unborn children feel unpleasure or pain (Brazelton & Cramer, 1991). Neural tissue is operational even before myelinization is complete and all receptors are present. A 6-month foetus responds to intense light or sound stimuli by becoming restless and averting its head. A mother who is sufficiently attuned to her unborn child then places a hand on her belly and strokes the restless child through the abdominal wall. This is the beginning of mother-child synchrony. Presumably, such bodily contact and communication between mother and child abolishe or reduce the pain experienced by the foetus, which is then often observed to calm down. Herein is, in my view, the basis of the capacity to endure psychic pain. The mother feels and shares the unpleasure of her unborn child, and literally creates a holding environment that enables her to contain the child's pain. Considered in this light, the pre-object relatedness described by Kumin (1996) is also a prenatal relatedness. Such early mother-child interactions in general constitute the basis for the toleration of all kinds of unpleasurable experiences, such as pain and anxiety, and therefore represent the beginnings of emotional self-regulation processes and of the self as a structure. After birth this process becomes more visible and increasingly differentiated. The newborn baby can communicate its unpleasure to its mother by crying and by a variety of non-verbal signals. The ego is still largely a body ego, and somatic and psychic pain are undifferentiated. A good-enough mother recognises the baby's signals of unpleasure and allows herself to be seduced into picking up and holding the child; she is emotionally attuned to the child and, in the intersubjective space that arises from her holding, able to share the baby's unpleasure, thus unconsciously receiving information about its cause. Since mother and child in this way constitute an emotional unit, this information often takes the form of somatic sensations that coincide with what the child is feeling. It allows the mother to comfort the child, who then calms down. An essential aspect of this interaction is that it literally involves holding and skin contact. The comforting is therefore mediated not only by language, sounds and movement but also by skin contact in the form of caressing, stroking, kissing, fondling and the like. The directness and proximity of the skin contact and the identification that is entailed

Downloaded by [Universita degli Studi di Torino] at 03:48 07 November 2013

in this interaction enable the mother to share the child's pain, and mother and child can then experience it together. The comforting of a mother who is emotionally attuned to her child is internalized by the child. Over the years, a child thus slowly but surely builds up a capacity to comfort itself when in pain and hence to endure pain, whether somatic or psychic. As a child gets older, somatic and psychic pain become more differentiated. The mother can more easily identify emotional feelings in her baby and distinguish them from somatic pain, and learns to deal with them in a comforting way. And, by mirroring and later verbally naming the various feelings, the child too learns to differentiate between them. In the same way as with a baby, the mother of a somewhat older child senses nonverbally how the child is feeling. Just as a baby is comforted by holding and by soothing sounds with corresponding facial expressions, so the mother comforts an older child by identifying with his painful feeling, putting it into words and returning it to the child in a more tolerable form. What matters here is for the child to learn that he need not remain helplessly at the mercy of psychic pain and that its intensity will decline with the passage of time. Psychic pain is thus made tolerable to the child, who learns how to build a capacity to endure it by internalizing such interactions.

Clinical illustration A young woman patient, Linda, told me in her analysis that, as a 5-year-old girl, after the death of her mother, she would often sit still in a corner of her room. When her father found her like this, he would sit down next to her, draw her to him and put his arm round her. They would then sit like that for a while and Linda would sometimes cry softly; sometimes her father too would cry quietly. He would then say that Linda felt so terribly sad and that she missed her mummy so much that it was horribly painful to lose someone you loved so much and never see her again. The father also said that the pain was so bad that she could not imagine it would ever pass. This sensitive father said that they would have to try to get through the pain and sadness together and that it would slowly but surely get less intense. Linda told me how precious the memory of such conversations with her father was to her, how she had made his words her own and carried them with her to this day. They still stood her in good stead at times of inner pain.

26

TOLERANCE OF PSYCHIC PAIN AS AN IMPLICIT ANALYTIC GOAL The interactions described above between children and their primary objects include many aspects that also play a part in the analytic relationship. During an analysis, aspects of the interaction are also internalized. However, the analyst cannot be just a comforting mother figure. The pain must also be experienced in an analysis. An exclusive orientation towards the relief of psychic pain would be tantamount to collusion with old forms of defence and hence have a counterproductive effect on the analysis. Frustration of the demand to be relieved of pain gives rise to distance and space, so that the pain and its causes can be examined. In so far as psychoanalysis is a treatment, it is one conducted without an anaesthetic. This usually causes much tension in the transference and countertransference relationship, as the "Barbara" vignette at the end of this paper shows. As doctors or psychologists, analysts have learned to help and cure, relieve and solve problems. As psychoanalysts we must to some extent "unlearn" this attitude and develop an analytic stance or identity (Wille, 2008), directed mainly towards investigating the internal world and towards enabling the patient to feel what can no longer, or yet, be felt. This is required of us at the same time as we are in touch with intense feelings of pain that are sometimes almost unbearable. The first goal of psychoanalysis is not to achieve relief but to increase the range of emotional experience and to enrich it. Implicit in this idea is the assumption that a reasonably satisfying life presupposes contact with your psychic pain, and that a full and balanced psychic existence is not possible without psychic suffering. Pleasure cannot be experienced without enduring unpleasure (Bion, 1970). The experience of having endured psychic pain- I am not talking about masochistic gratification - allows us to be in touch with our hate, destructiveness, guilt and mourning and makes for a balance in our psychic functioning and integration. Suffering can stimulate sublimation, as Melanie Klein (1940) wrote in connection to mourning:
Thus, while grief is experienced to the full and despair is at its height, the love for the object wells up and the mourner feels more strongly that life inside and outside will go on after all, and that the lost object can be preserved within. At this stage in mourning, suffering can become productive. We know that painful experiences of all kinds sometimes stimulate sublimations, or even bring out quite new gifts in some people, who may take to painting, writing or to other productive activities under the stress of frustrations and hardships. (p. 143)

Downloaded by [Universita degli Studi di Torino] at 03:48 07 November 2013

So, if one goal of psychoanalysis is to get in touch with psychic pain, another implicit one is the gradual internalization of the idea that psychic, emotional pain is an inseparable part of our existence as human beings. For this reason, the development of the capacity to endure psychic pain is an important change during an analytic process. The goal of a psychoanalysis is of course for the patient to feel better and be able to lead a more satisfying life. However, this can at best be a long-term goal that, it is hoped, will follow from the primary goal of exploring the internal world and thereby creating greater inner space and flexibility. Furthermore, this "feeling better and being able to lead a more satisfying life" does not mean that there will be no more pain. Idealized conceptions of psychoanalysis as a method that brings happiness without pain are very misleading and ultimately lead to disappointment. Yet this is what some patients expect of analysts, and even what analysts sometimes expect of themselves.

TECHNICAL ASPECTS The fact that psychoanalysis is less disposed than are other therapies to accede to patients' demands to have their problems solved and to reduce pain as quickly as possible gives rise to certain problems of technique. From their very first contact, patient and analyst haveat least in part - different goals. The handling of the tension of the initial contact calls for great analytic skill and may be decisive for what follows. The way the analytic couple deal with the issue of "pain relief" often gives a reliable indication of the possibility of a collaborative alliance. There is much to be said about this, but the point on which I wish to concentrate now is a specific technical requirement, namely, the firmness and stamina of the analyst. As an analogue to the title of this paper, this could be called "the capacity to inflict necessary pain". Besides the maternal, caring side of analytic technique with its emphasis on empathy, containment and holding, there is a more paternal, disruptive aspect, whose central features are abstinence, confrontation and interpretation. The latter side requires the analyst to have a certain degree of hardness, by which I mean a capacity to desist from complying with all the patient's attempts to seduce the analyst into avoiding or taking away psychic pain, but instead let this pain be, in order for it to be felt or even deepened. The analyst must thus not only resist his own inclination to offer succour and relief but also be able to withstand powerful emotional appeals for help as well as the sometimes monstrous

27

reproaches and hate that arise when this help is not forthcoming. Patients can arouse a powerful sense of guilt in us if we seem to add to their suffering without any other apparent reason than maintaining our professional attitude. A step beyond failing to provide relief is the active infliction of pain to the patient, which may occur through confrontation or interpretation. Freud's likening of the analyst to a surgeon, usually in the context of abstinence and technical neutrality, can also be understood in this sense: cutting and the infliction of pain are sometimes necessary. This almost always gives rise to negative transference reactions. So the greater the analyst's personal need for a harmonious working relationship, the more he must overcome his own inclinations, if he is to be able to give an inevitably painful interpretation. The temptation to avoid the negative transference is always lurking in the wings. A technique excessively oriented towards gentleness can act as a defence against the giving of disturbing, painful (if not pain-inflicting) interpretations. It is another matter, and a serious danger, if the analyst acts out his sadistic inclinations under the cloak of "necessary hardness". There are limits to the endurance of psychic pain, and furthermore this aspect of technique must never be an end in itself, but should always be embedded in an empathic, containing attitude. In this connection, Poland (1975) has drawn attention to the importance of tact as an analytic function. Tact, he writes, follows empathy. Empathy refers to feeling what is going on in the patient, while tact makes use of this knowledge of the patient's inner life in order to shape the interpretation in such a way that the patient can tolerate and integrate it. Tact presupposes a profoundly empathic contact, which facilitates the acceptance of painful interpretations by virtue of the underlying object relationship with the analyst. Timing and dosage are aspects of tact. Poland points out that the word "tact" and hence also "contact" are derived from the Latin tangere, meaning to touch. This underlines the somatic foundation, referred to earlier, of these psychic processes. As the analysis proceeds, the patient must gain the conviction that the toleration of pain represents a positive step in his development. In this sense, the interpreting and disruptive aspect can be included in a more empathic and containing atmosphere in the analytic relationship. The analyst can share the patient's pain and the patient can then feel that the analyst is feeling it with him. This presupposes that the analyst is fully attuned to the particular patient's specific pain. Such moments may be rich with highly intense feeling and contact. The pain may be made more tolerable if

the analyst can genuinely feel it with the patient and sometimes share the patient's weeping inside himself. Kahn ( 1981) has noted that the presence of another person is often necessary in order to experience psychic pain.

Clinical illustration

Barbara, an ambitious and successful professional woman, is in the seventh year of her analysis. She is struggling with intense anxieties and obsessional ideas of harming herself and her child. She keeps having fantasies of suicide and sometimes experiments with risky behaviour involving drugs or unsafe sex. At moments of extreme tension, she scratches her arm or pulls out her hair and eyelashes. Relationships are complicated for Barbara. She has a powerful propensity to attract and repel, and is plagued alternately by intense attachment anxiety and abandonment anxiety. Although she has been able to keep up a lasting relationship in the last few years, she thinks that this is only because of the analysis, and that it will break down when the analysis comes to an end. Barbara's mother was ailing and psychically unstable. She neglected her children in every respect. She intensely envied Barbara, the eldest child, for her youth, attractiveness, intelligence and the particular bond she had with her father. Barbara was the reason the parents had to marry. The mother was often angry with her as a child, and would then give her prolonged beatings. When Barbara imitates her mother in the analysis, there is a witch in the room. She had a much better relationship with her father, who, however, was often away for long periods on business, and even when he was there he had no appetite for conflict with the mother. Barbara's powerful resistance to having to experience all these terrible feelings in herself is a dominant theme in her analysis. She gets very angry at my confronting her with this. She says that I am a sadistic brute who is even worse than her mother, because if I wanted to, I could help her properly, if necessary by arranging for her to get medication. Such reproaches are often so violent that I have great difficulty in not gratifying her wishes. Her insistence that I avoid interpreting her primitive, disturbing feelings is powerful- I sometimes debate with myself whether not she may be right. She has the capacity to make me doubt whether I have already overstepped the boundaries of sadism and become a mother-witch myself. These countertransference feelings are often followed by hate at what she is doing to me. Barbara is frequently tormented by the idea of hav-

Downloaded by [Universita degli Studi di Torino] at 03:48 07 November 2013

28

ing to choose between her partner and her child. If she loves her partner and attends to him, she neglects her child just as her mother neglected her, and then the child will hate her just as she hates her own mother. If she gives her child love, her partner will reject her as her father repeatedly did, and then she will lose him. In the transference, she experiences the same impossible choice between her partner and myself. B. (crying bitterly): I don't want to feel this. You must get rid of it by magic. I expect you to give me a solution, to help me. But instead you're pushing me further and further into misery. What good does that do me? I lie awake at night with anxiety. A.: You are so terribly afraid of the overwhelming, desperate feelings of that helpless little girl who is so torn between mother and father. You can't stand I do away with all of this for you by magic.

B.: What the hell is this ghastly pain? Is this what you
want? How do you know I can stand it and won't really go mad and murder someone? It's sheer torture. A.: It feels as if I am doing this to you and torturing you, but it's the pain you've been carrying around with you for many, many years and it can only be lessened by feeling and enduring it. (As I speak, I realize that this intervention is after all reducing the tension.) B. (a little more calmly): You're just as much of a sadist as my mother is. That doesn't get me anywhere. I've never cried so much in my life, and felt so anxious. I feel as if I'm dissolving in my own tears and being slowly sucked in by the couch. A.: The pain is so overwhelming that it feels as if you will vanish into thin air if you give way to it. At the end of the session, Barbara does not shake hands as she usually does, and departs angrily. Yet she is already much calmer and even seems to some extent relieved. The next day she is at first silent for a time.

Downloaded by [Universita degli Studi di Torino] at 03:48 07 November 2013

B.: Bullshit - why are you doing this to me? I'm so

afraid of losing everyone, so afraid. I dare not go outside any more, I'm afraid of losing myself. I don't want to die. I could murder you for doing this to me. I can't feel love and warmth any more. I can't get through to anyone. All I can feel now is hate and emptiness. You must hold me tight. [Screaming out loud.] Hold me tight, hold me tight, damn you!
(I am frightened by this violence, which is unusual even for her, and feel panic about what to do next. She stretches out her arm as if she really wants to be held, but in such a way that I could only do so by getting up and standing beside the couch. I notice that I am so tense that I am pressing hard into the armrest of my chair with my fingers and nails, perhaps to counteract my intense inclination to really hold her tight, so that I hold on to the chair instead. At the same time the image of her scratched arm flashes through my mind. While she cries, I can start thinking again. We have been through this many times before and I have often sat there with tears in my eyes myself. I decide to try not to reduce the tension but to put her more in touch with her feelings. At the same time I wonder if I am not thereby turning into the cold analyst and making an appallingly unempathic mistake.)

B.: I was furious for a while at first and had decided

again to stop there and then. But in the evening it occurred to me that you too were moved. (A silence, as if she is waiting for an answer.) A.: Yes, I was. Terrible as it is, I have nothing better to offer you- I can't do "magic".

B.: Yes, now that I'm calmer, I can understand that.

We just have to go through it, there's no other way.

CONCLUSION Bion (1963) wrote that the experience of analysis is necessary in order to increase the capacity to suffer. Barbara already knew perfectly well what psychic suffering means. But in her analysis she has learned to experience her feeling instead of acting it out, and to endure the associated psychic pain; as a result, she less and less has a need to take flight into obsessional fantasies and self-harming behaviour. During the process, she alternately turns me into a good mother, who holds her tight, and a bad mother-witch, who tortures her.

A.: You want me to hold on tight to your hate and murderous wishes because you are afraid you might murder yourself or me if you were to own these violent feelings fully.

29

Downloaded by [Universita degli Studi di Torino] at 03:48 07 November 2013

In a situation replete with such intense affects, it is easy for the analyst to succumb to the temptation to act out his own aggressive feelings, emotional needs and unconscious defensive attitudes. With Barbara, I, in fact, had an inclination to comfort her by holding her hand. If it ever is good thing to do this, in Barbara's case I think I would have deprived her not only of the space to feel her pain, but also, and in particular, of her hate towards me. Repeated interpretations embedded in empathy and tact, in which the ongoing object-relatedness was intrinsic, put her in touch with painful feelings she did not want to experience, which she was increasingly able to tolerate in our relationship. Acceptance of her rage at these disruptive and separating interpretations offered a form of emotional holding that made it possible for her to endure pain, whereas actual, concrete holding, with or without some short-lived relief, would probably have induced severe anxiety. Patient and analyst alike must learn to endure psychic pain. The analyst must in addition learn to inflict pain lovingly.

a study in their interrelationships. Psychoanal. Study Child, 13: 147-189. Weiss, E. (1934). Bodily pain and mental pain. Int. J. Psychoanal., 15: 1-13. Wille, R.S.G. (2008). Psychoanalytic identity: psychoanalysis as an internal object. Pschoanal. Quarterly, 4: 1193 1229. Winnicott, D.W. (1960). The theory of the parent-infant relationship. Int. J. Psychoanal. 41, 585- 595. -(1965). Ego integration in child development. In: The maturational processes and the facilitating environment. Studies in the theory of emotional development. London: Hogarth: pp. 56-83. -(1974). Fear of breakdown. Int. Rev. Psychoanal., 1: 103-107.

Robbert S. G Wille Tooropkade I 0 2102 AA Heemstede The Netherlands

rsg@wille.demon.nl

REFERENCES Akhtar, S. (2000). Mental pain and the cultural ointment of poetry. Int. J. Psychoanal., 81: 229-243. Bion. W.R. ( 1963). Elements of psycho-analysis, p. 62. London: Karnac. - ( 1970). Attention and interpretation. London: Tavistock. Brazelton, T.B., & Cramer, B. G. (1991 ). The earliest relationship. London: Karnac. Dreyfus, P. (1999). Der psychische Schmerz. Unpublished paper. Freud, S. (1917). Mourning and melancholia. S.E., 14. -(1926). Inhibitions, symptoms and anxiety. S.E., 20. -(1950). Project for a scientific psychology. S.E., I. Joffee, W.G. & Sandler,]. (1965). Pain, depression and individuation. In: Sandler, J. (ed): From safety to superego, Guilford: New York, 154-179. Joseph, B. (1989). Psychic equilibrium and psychic change. London: Routledge, ch. 6, pp. 88-97. Kahn, M.R. (1981). From masochism to psychic pain. Contemp. Psychoanal., 17:413-421. Klein, M. (1940). Mourning and its relation to manicdepressive states. Int. J. Psychoanal.,21:125-153. Kogan, I. (1990). A journey to pain. Int. J. Anal., 71: 629-640. Kumin, I. (1996). Pre-object relatedness. New York: Guilford. Poland, W.S. (1975). Tact as a psychoanalytic function. Int. J. Psychoanal., 56: 155-162. Pontalis, J.B. ( 1981 ). Frontiers in psychoanalysis: between the dream and psychic reality. New York: Int. Univ. Press. Ramzy, I. & Wallerstein, R. (1958). Pain, fear and anxiety:

30