Commentary on Phillips

My remarks begin with a quote from that poet, muse, and troubadour extraordinaire of the Woodstock generation—Joni Mitchell:

An angry man is an angry man.

An angry woman—bitch.

From the first days of our postgraduate psychodynamic training, we are explicitly taught and implicitly begin to understand why clinical practice actually gets harder over the course of a career. The more theories we are exposed to, the more interventions and styles we try out, and particularly after we are repeatedly tested by our most important consultants, our patients, we hone skills meant to last a lifetime only to find ourselves caught up short by how much we do not know and will never master in any given treatment process. To those just getting their sea legs in this field, such testimony might sound daunting, dreadfully depressing, jaded—a “little bitchy”—or surprisingly exciting, encouraging, even daring: You might not have to worry so much about getting it right because it’s much more likely you never can, given the range of materials to draw on and from which you write your distilled, detailed process notes. So we all might reasonably wonder why it is the rare paper, such as this one by Sidney Phillips, that describes in some detail how an experienced analyst goes about making a radical departure in the middle of an ongoing analysis. Apparently both parties survive this about-face, and perhaps even begin to thrive in new ways in the treatment, because the analyst took a leap into the unknown. Phillips made a decision to change everything about the way he was going about his analytic business to save not only the treatment but also Mr. K.’s life. I would not use the word lifesaving lightly, but in-depth psychodynamic psychotherapies and psychoanalyses are as lifesaving as procedures in other healing professions.

It is common in our increasingly pluralistic field to encourage dialogue with colleagues who will always pick up new threads in the material, and, post facto, appear to listen better or move avidly and go on to advise a new technical tack. It is quite a different matter for a senior analyst to publicly admit, in effect: “I got it wrong. Here’s what I missed, and how the patient and I got out of the jam. And now that I have provided some data points from what’s transpired between us, I’ll put some reasonable theoretical ideas around it to think with you about why it might be working now.” A willingness to make such an admission is to my mind a hallmark of what it means to be an ethical practitioner, one who takes on the awesome responsibility of being a psychoanalyst. It is one thing to advise someone during a consultation or supervision (or to tell an author) how a case should have been handled. It’s a totally different order of business to expose how “I (as analyst) need to be different,” a paradoxical strength and vulnerability espoused in Phillips’s writing about Mr. K.’s analysis. Such candor lends credence and authenticity to this report.

But there is nothing novel about that, some may argue. After all, Freud was always changing his mind, at times radically. There is some justification for holding that opinion but also some reason to entertain a different view. One thing that is new is how psychoanalysis as a discipline has had to change its mind about so many things. For example, although some of our European and South American colleagues (e.g., McDougall 1989; Lombardi 2008a,b; Miller 2001) have never lost sight of the psyche-soma and the maladies that befall it as a major topic of psychoanalytic interest, in the United States we have had to rediscover the body. I believe that discussions about race and feminism, and gender and queer studies, have led this charge. We have not only had to grapple with new bodies of knowledge; we have begun to grapple with so many different kinds of bodies altogether, and these bodies are usually encased in psychic skins very different from our own. It is because of this radical change in perspective that Mr. K. can get a very different psychoanalysis today than he would have had decades ago. This is not to say our work is done—far from it—but it is a beginning in which our field and our organization can take some pride.

With some justification, Phillips credits his consultant for helping him shift from penetrating,”hawk-like” transference interpretations (p. 1131), meant to address Mr. K.’s repeated sadomasochistic enactments, to a softer, mirroring, more embracing therapeutic stance, which appears to envelop the analytic pair and stem the threat of separation angst and fragmentation. Yet there is clinical evidence in the report to suggest that this analytic couple were undergoing change even before the consultant made an appearance.

I find such evidence in the sheer volume of references Phillips makes to what was happening in the bodies of both analyst and patient: the sensations and discomforts they were silently holding within and between themselves in the room. As so often happens in psychoanalysis, the body led the way, though it rarely gets due credit. Perhaps because our soma is always with us—there is always so much “there there”—that it remains off our radar until a wild rumpus starts that threatens to engulf or disregulate us.

Words and phrases like “flailing around,” “staying afloat,” wanting to bellow “shut up,” “homophobia,” “immobility,” and “heart-sickening and infuriating” (pp. 1129, 1132–1133) indicate just a few of the physical reference points Phillips uses to let us know how much his body was impacted by the recalcitrant Mr. K. And, long before he could embrace the new, provocative self state of “selfish bitch,” Mr. K. commiserated with anxious reactivity that reached panic proportions, made demands for medication, stayed in a sexless relationship for years, received a diagnosis of HIV, had tantalizing sexual escapes with another man, and threatened suicide several times. Similarly, we can pluck out Mr. K.’s own descriptors: “eye-opening,” “raw,” “wiping out everything,” “los[ing] myself,” and “rushing . . . [being] a little tight” (pp. 1129, 1132–1133). One begins to hear and envision, even feel, the bodies of patient and analyst jump out and grab our attention, and understand why this analytic couple were driving each other just a little mad. They were so stuck to each other, so deadlocked, that you just want to step in to stop the wrestling match!

But how could it be otherwise? A few bits of tragic developmental history shed light on this essential clinical fact: Mr. K. was a hated child, hated for the body he was born with and could not change; Mr. K. tells us that his mother had wanted him to be a girl. By virtue of a Y chromosome, Mr. K., from the first moments of his life, resided in a body and psyche his mother found abhorrent. And, while we will never know her side of the story, Mr. K.’s reminiscence and reconstruction in his analysis seems highly plausible. Whenever he or his brother took normative steps toward individuation, his mother had psychosomatic collapses ranging from “belching and shortness of breath” to panic attacks that landed her in the emergency room, what Mr. K. referred to as “her dying every three months” (p. 1127). There it is again and originally: the body, sounding out a clarion call for solace, tenderness, and rescue. This extreme form of parent-child disharmony between Mr. K. and his mother transmits itself from the outer skin envelope to the deepest internal organ systems of a human being. What appears to have left Mr. K. in despair is his wish to extinguish his corporeal existence as a male in consequence of his lack of normative maternal reverie or, more aptly, maternal love for the little boy he was.

The beneficent results of the radical shift in Phillips’s analytic stance make additional sense to me in this context. The creation of a “selfish bitch” is a developmental achievement for Mr. K. It signifies, among other things, a newfound capacity to enter the belly of the beast as he experienced it through identification. Mr. K. needs to fully get to know this “selfish bitch”—his (at best) narcissistic, somatically preoccupied (and likely psychotically organized) first caretaker from the inside out—and to unconsciously inhabit some of her unseemly attributes for the first time. And, as he is embracing his “selfish bitch,” other sides of a self are strengthened. Notice how Mr. K. now permits himself to feel sad, to cry, and to be more human and real—in effect, to mourn the hurt little boy who can never be—in order to heal. For this he needs to identify in a positive way with the embodied men in his life—like the cabaret artist Alan Cummings—who obviously serves as a supportive stand-in for Phillips.

Which brings us back to Joni Mitchell’s lyric, the euphonious “angry man is [just] an angry man” giving way to the discordant, maladroit thud of the “b-word” as a synonym for “angry woman.” Mitchell—like Mr. K.—is quite aware of the contempt for women expressed in the word “bitch.” Poet and patient align in their knowledge of the ease with which defensive splitting can be used by both sexes to help manage anger in women, giving it a nasty name to make it seem bigger and more monstrous than it is.

But might taking on a pejorative moniker not be a transitory but liberating first step in overriding lifelong submission and owning feeling states that heretofore were negative, even anguishing? The late feminist scholar and psychodynamic psychotherapist Abby Stein thought so. Writing about her work with abuse victims in the criminal justice system, she concluded that all manner of things thought to be contemptuous can be “repurposed” in healthier ways to redress “overpowering feelings of humiliation—as opposed to terror and pain” (Stein 2011, pp. 82–83). If considered a way of repurposing what feminists call “the outlaw emotions” of anguish, Mr. K.’s use of the phrase “selfish bitch” serves not to besmirch women as a sex or class but to gain agency over violation. He is on his way to laying claim to the dignity, moral clarity, and affective integration that was denied him as a little boy subjected to humiliation and invalidation.

Sadly, remnants of the sometimes forgotten, misused, misunderstood, even hated child, like Mr. K., abound in our practices and not just in the familiar places of abject trauma, addictions and eating disorders, racism or sexism. They are found everywhere, even in persons who make seemingly healthy adaptations to life, people in analysis and people who have been analyzed. They sneak up on all of us, sometimes because they are us—the very youngest part of ourselves who had no words but now embody distress. When we can help our patients give voice to these feelings, a more intimate connection to a bodily self may evolve. Psychoanalytic clinicians, whatever their orientation, must consider how much we miss our own bodies and our patients’ when we are too much just in our heads, privileging mind and intellectual mastery over the unruly, the malodorous, the “raw” and otherwise “flailing-around” anlagen of felt experience that rises up from the underground.

I am not saying that we have been listening with the wrong organs all these years; it is just that we have not always tuned in to all of them.

To conclude: it is my guess that Phillips and his patient will need to linger with this inner “selfish bitch” a while longer before Mr. K. can take another leap in his development toward becoming a fully individuated man—his own man, a gay man, a man of good conscience, a man in full—however he might want to name, construct, identify, or consider himself as male in these early years of the twnty-first century, but an individual man nonetheless.

Phillips’s admirable clinical work to date has brought Mr. K. to life in new ways. But I would predict that the ride is about to get a lot bumpier; we know that embodied countertransference reactions become turbulent as our patients come more to life (Miller 2001; Zerbe 1991, 2008; Zerbe and Bradley 2018). It is not the end of the road for this dyad but a beginning, and as we all know, in every corner of our psyche-soma-sociopolitical being, those beginnings are essential for change.