Abstract
life and death / stand face-to-face, cooing at each other— /
. . . the braided nature of life and death, they pour /and empty each into the other . . .
This volume of Irma Brenman Pick’s collected papers provides the reader the close-up experience of a gifted clinician going about her daily work; we are invited to observe, feel, and learn. The tone of her writing, steeped in theory, is of a theory that has been lived in, used fully and with love. She leans heavily on the work of Melanie Klein and at the same time has a distinctive voice, an analyst who has found her own way. Her voice comes through strong and clear in the book’s first chapter, in what I believe is her most important contribution to our field: the 1985 paper “Working Through in the Countertransference.”
Her particular use of countertransference follows the paradigm shift initiated by Paula Heimann in 1950, a move away from the “ideal of the ‘detached’ analyst”: “My thesis,” wrote Heimann, “is that the analyst’s emotional response to his patient within the analytic situation represents one of the most important tools for his work. The analyst’s counter-transference is an instrument of research into the patient’s unconscious” (p. 81).
Although this broadened view of countertransference has long been accepted, we see in Brenman Pick’s work an exceptionally active stance from inside the countertransference. In this, she offers a response to James Strachey’s question, posed to him by Melanie Klein: “Mrs. Klein has suggested to me that there must be some quite special internal difficulty to be overcome by the analyst in giving interpretations” (1934, p. 159).
In this collection of papers Brenman Pick addresses the “special internal difficulty” we face and are required to work through if we are to make the mutative interpretation Strachey so carefully elucidates: giving . . . a mutative interpretation is a crucial act for the analyst as well as the patient, and . . . he is exposing himself to some great danger in doing so. And this in turn will become intelligible when we reflect that at the moment of interpretation the analyst is in fact deliberately evoking a quantity of the patient’s id-energy while it is alive and actual and unambiguous and aimed directly at himself. Such a moment must above all others put to the test his relations with his own unconscious impulses [pp.158–159].
Brenman Pick takes up this thread at the spot where Strachey and Heimann left us. Over the course of several chapters, she develops a powerful position: the work of analysis must initially take place in the mind of the analyst. From there we turn to the patient strengthened by our own emotional efforts, having a beginning grasp of what it is that dissuades us from giving the transference interpretation and perhaps the patient from receiving it.
Brenman Pick speaks to this difficulty in each chapter of this engaging book. She believes that having lived inside the “storm” of affect the analyst can speak in a way that conveys “something new” and perhaps shocking, but simultaneously transmits her sensitivity to the pain of learning something previously unknown, helping us better tolerate the “disequilibrium” Betty Joseph (1989) has written about so compellingly, which sets in when the patient is confronted with insight or the need/desire to change.
I very much liked Michael Brearley’s foreword to the book; here is a sample: Irma Brenman Pick has suggested that as psychoanalysts we need two hands: one to hold compassionately the needy suffering part of the patient; the other, to hold firmly and grapple with the destructiveness, the perversion, the hatred of life and of thinking and feeling. . . . And Irma is capable of doing just this, being in touch with the pain and desperation that patients bring to analysis, along with their courageous efforts in finding new ways of thinking [p. xi].
This position, a two-handedness and, I would add, a double hearing and vision, is the central quality of Brenman Pick’s work in these chapters. Hence she takes into account the internal object and what the patient projects into the analyst, as well as the external object, the original real object, and how this may be enacted or experienced in the analysis by the real object of the analyst. For example, in considering envy she points out that both the feelings of deprivation that lead to the envious attack and the consequent deprivation that comes from the envy itself must be recognized (p. 221)—what has been done to the patient but also what the patient contributes to the depletion; both hands, both sides of the situation, are taken into account.
As I read and reread this book I came to see that in her taking multiple directions, prism-like, not being held in one place, Brenman Pick creates a feeling of spaciousness, often characterized as “three-dimensionality.” The reader can feel a bit turned around—“which way forward?”—not unlike the patient attempting to accept an interpretation. Yet in pulling apart the threads of a clinical moment, finely splitting its various aspects, an experience of integration is gained—leading to what is so vital to Brenman Pick, an authentic encounter (p. 210).
Her premise is that “indeed, in so far as we take in the experience of the patient, we cannot do so without also having an experience. If there is a mouth that seeks a breast as an inborn potential, there is I believe a psychological equivalent, i.e. a state of mind that seeks another state of mind” (p. 16). In this simple yet profound statement Brenman Pick makes three central points: the analytic encounter consists of two minds having a relation; there is in every adult mind the needs and desires of a baby; the analyst is always having an experience alongside her patient.
And what does it mean to conclude that the analyst has an experience? There is “a question for the analyst, connected with keeping our emotions out. If we do so, in pursuit of so-called analytic neutrality, are we in danger of keeping out the love that mitigates the hatred, thus allowing the so-called pursuit of truth to be governed by hatred? What appears as dispassionate may contain the murder of love and concern” (p. 21).
Authenticity is developed in the crucible of this shared experience: the analyst’s emotions are “worked through,” thus forming the basis of the mutative interpretation. Several times in the book, Brenman Pick quotes Roger Money-Kyrle, a psychoanalyst not well enough known in American psychoanalysis. She provides a link to his thinking, an appreciation for his insight and clarity. He wrote that the analyst must grasp the emotional disturbance in himself in order to recognize the impact the patient has had on him, and lastly its effect on the patient. In moving from inside to outside, the analyst can see the patient in a more separated or objectified state, thereby becoming free to “emphasize with and not react to” the patient (1956, p. 363).
This ongoing movement between inside and outside, beautifully developed in “Working Through in the Countertransference,” is most striking in that paper’s central case. Mr. A comes into a session announcing he is ill, having the same symptoms as his young daughter: “I was determined to come, even if that risks you getting my illness.” Brenman Pick feels that the patient is frightened of the illness, and she is aware of her own countertransference: “I found I was worrying about being infected and becoming unable to cope with work the next week. . . . I interpreted his fear and referred to the part of him that wished me to ‘catch the illness’ of that fear” (pp. 23–24).
The subtlety of this interpretation lies in its slight shift—rather than interpret the patient’s wish to make her ill, it is “to catch the illness of that fear,” an unease and worry he aims to stir up in her, which she points out to him. This keenness and fine detail, led by her countertransference, places her clinical acumen in its own category, a special attunement; the patient is gathered such that he may be receptive to this confrontation with both sides of himself, as she describes, “holding the patient with two hands,” his own fearfulness and a need to pass the fear on to his analyst—the coexistence of his vulnerability and harmful impulses.
Brenman Pick, in making the shift from the concrete to the inner world of unconscious fantasy, makes contact with a deeper level of the patient’s ambivalence in searching for the “mind of the other”; how will she cope with her fear of illness and incapacitation? This links directly with Melanie Klein’s emphasis on the “epistemophilic instinct” (1928)—the baby’s intense desire to know initially what is inside the body of the mother (i.e., where do babies come from?) and later what lies inside the mind of the mother, leading eventually to a broader curiosity and search for knowledge.
As the session continues, Mr. A describes his hurt and anger that his wife did not accompany him to their daughter’s school play, “he felt lonely, unsupported by family.” Brenman Pick interprets his anger; she had not supported him “as family,” as she could not change the time of his hour, so he had missed it to attend the daughter’s event, with a holiday only a week away.
The patient agrees and then recalls attending an event in which psychoanalysis was under attack for not supporting the patient sufficiently and that she had handled this very well. Brenman Pick reports: I felt flattered and then needed to think about this. I interpreted that I was being flattered into a belief about how well I had coped with this charge while in fact I was being watched to see how I manage when I feel alone, unsupported, and assailed by persecutors, external or internal [p. 24].
Mr. A goes on to report a dream.
In the dream Freud was undergoing an operation for shoulder lesions. There was a worry that the operation was not fully successful—when Freud tried to lift up his arm he could not do so. A group of people, the patient among them, were trying to protect Freud in various ways, including sedation, so he would not have to bear the pain. [p. 24].
Mr. A claimed in his dream that he wanted to support Freud (and of course, in the transference, his analyst), but Brenman Pick points out he had “said at the beginning of the session that he needed my help even if that meant not supporting me. There was a seductive, spurious quality to the sedative support.”
Brenman Pick reminds her patient that Freud’s surgery was not for shoulder lesions but for cancer related to his smoking cigars. The patient had seen his analyst smoking at this same public meeting referred to earlier. “I felt a strong urge to avoid this area,” she writes, but then can say to the patient, you seem “to be protecting me from this issue, as though that would put too much on my shoulders” (p. 25). This question of how the analyst is managing her state of mind carries on throughout the hour: how will she manage her worry about illness, will she succumb to a need for false flattery, and can she face her own “cancerous activity”? This progression is mapped through the analyst’s countertransference from start to finish.
Brenman Pick reviews this material as follows: We could say that the patient projected into the analyst parts of himself and his internal objects. He presented two models; the one coped impeccably, the other was broken down. In the session I was affected by his projections and found myself lured into having experiences in both directions (“I’m terrific” or “I’m awful”). I had to remind myself that I was neither [p. 25].
She describes the consequences: “In part, I do share, or am infected by the child’s symptoms, idealisation or persecutory fear, in which the depressive position mother gets lost. This has to be recovered . . . [otherwise] the child’s need to be protected and cared for gets lost” (p. 25).
In another, completely different sort of clinical case we see the range of Brenman Pick’s therapeutic sensitivity. Maxi is a “prematurely born, grossly disturbed and learning-disabled 7-year-old” (p. 40). During the first session with this young boy the analyst is ignored while the boy is fixated on “the light hanging in the centre of the room.” After making the light swing he alternately cowered in the corner and looked with an ecstatic gaze at the light, to and away from the light. The analyst interpreted: the light was all the world to him, that he wanted it to shut everything else out, and to take it as something very good into himself. . . . [After trying to catch the light he] started to make clear sucking movements with his mouth and asked for water [p. 40].
The analyst had “stimulated his wish to communicate and his thirst; was he also thirsting to communicate about his earliest experiencenof being in an incubator with only a light to cling to? (p. 40).
This touching example brings Bion’s notion alive: the patient will “wait for appropriate events to provide him with the ideograph his impulse to communicate require[s]. . . . The extraordinary thing is the tour de force by which primitive modes of thought are used by the patient for the statement of themes of great complexity” (1957, p. 274). And of course he needs an analyst who can be there to catch the meaning of this communication.
In her more recent work on countertransference in the supervisory situation, Brenman Pick demonstrates the mingling of transference, countertransference, and the supervisor’s carrying of both in the consultation, being uniquely positioned to share this experience and assist in opening up the situation. Brenman Pick reminds us that the oscillation between introjection and projection is rapid and frequent. The analyst is receptive, introjects, identifies with her patient, and then projects in the form of an interpretation. This movement fails, she quotes Money-Kyrle, “whenever the patient corresponds too closely with some aspect of himself which he has not yet learned to understand . . . causing strain and anxiety for the analyst” (p. 59).
In other words, Brenman Pick catches the analyst’s state of mind-in-action catching the state of mind of her patient. In one of many powerful vignettes, an elderly analyst carries a heavy bag into the consulting room, appearing to need help. It becomes clear that the burden she carries is a “too close” identification with her patient; as things develop, it is made clear that the analyst is wearing her patient’s look, trousers made of the same fabric and pattern—“gray-and-white stripes . . . the ‘clothing’ of a miserable, left-out person” (p. 55), clothes her patient wears that her own mother had sewn for her as a little girl. Brenman Pick takes in this identification, eventually encountering a deep loneliness. Here are generations of women; supervisor of an analyst, analyst of a patient, and finally mother of a daughter. Brenman Pick raises a crucial technical question: How is it possible to take up the analyst’s own loneliness as it is projected into the patient (where there is real loneliness at some level) avoiding the coldness of overexposure or the maternal “heat” of overprotection? (p. 56).
In another moving vignette Brenman Pick reports a session in which she felt she had nothing to offer to her supervisee, parallel to the analyst’s experience with a terminating patient (whose mother had died when she was an infant). In the midst of the supervisory hour she described her internal experience of being with a lot of “chatter, covering something deadly underneath” (p. 59): As I tried to convey this I found myself asking if she had ever had the experience of being with a dying person in a hospital ward; this incongruous experience of life/chatter going on outside while a person is dying. Suddenly I thought, . . . this patient’s mother died in a hospital ward while the patient was a baby, and they are talking about ending the analysis (p. 59).
In these vignettes Brenman Pick can hear the feeling of death under the noise of chatter, see the lifesaving function of a hanging lightbulb, hold the burden of loneliness in the gray-and-white stripes of a pair of trousers, and, in her most detailed clinical account, track movement such that we witness the unfolding of the “mutative” interpretations achieved by deep countertransference work.
It is not possible to explore in depth more of the work presented here, but I will make brief mention of two intriguing concepts: “the wish to grow big by stealing” and “sustenance . . . maintained by illusory means” (p. 82); and “precocious concern [as] an obstacle to the development of real concern” (p. 92). These and many other observations open up the huge area of inauthenticity, the many alternatives to something more real in human relations. This is developed from several directions having to do with feminine identity.
From the ordinary interplay of authenticity and the not-real comes her moving insight into a little girl: “Watching a small girl push a dolly in her buggy, it is not difficult to recognize both aspects of identification. That is, both a real internalization of—maternal function, as well as a little girl in a delusional state of mind—‘the mother’ is walking out with the father and ‘their baby’” (p. 125).
The little girl’s development depends a great deal on “how she takes in the breast, and how she feels the mother takes her in, and therefore what kind of internal mother she establishes, [which] will be critical in enabling her to bear the first castration (for both boy and girl), that of losing the breast in its absence” (p. 149; emphasis added).
And here lies a connection between mothering and analytic work; we know they are not the same, nor should they be, but the baby’s sense of how the “mother takes her in,” which occurs alongside the infant’s taking in of the mother, is in fact a schema of a caring relationship, and is the countertransference work we are considering here in Brenman Pick’s work. The working through in the countertransference allows the analyst to “take in” her patient at the right level, feeling what is real and not real, hurt and hurting.
Brenman Pick believes, as most of us do now, and Klein originally formulated, that “there is always an unconscious knowledge of both the vagina and womb” (p. 125). Nevertheless, the continued “taking over and subsequent diminishment of the feminine maternal function of interiority by the child, the adult, the culture,” she suggests, is seen in the baby girl’s “lack,” which is “projected into the mother—an inauthentic proposition—which a collusive consensus keeps in place . . . leading to the way in which in Western culture those in what we might call ‘maternal’ roles . . . carers generally—are paid at devalued rates. . . . Meanwhile, those involved in creating ‘inauthenticity’ seem instead to be massively overvalued” (p. 125). An insightful contribution toward an understanding of our time and place.
I conclude this review of a most helpful, moving, and eye-opening book with a general depiction of Brenman Pick’s clinical stance: The patient is always to be viewed from a lens of the analyst’s own internal experience such that the subject of her study feels like a known human being and not merely “the other,” thus offering us a model of deep and sincere analytic work.