October 5, 1999
International Psychoanalytic Scholar Lecture
Containment, Enactment and Communication
presentation by John Steiner, M.D.
Dr. John Steiners reports on his clinical work regularly show the extent to which he can be productively busy with two analysands at once: the patient and himself. However, in each of these two analyses, his focus is not exactly the same. In his self-analysis, after focusing on what he is feeling at the moment about himself, his patient and the total psychoanalytic situation, he tries to sort out from this complex of feeling the ways in which, and the extent to which, the patient has played a part in bringing it about. In contrast, his analysis of the patient on the couch focuses on how that patient is using him to fit significant figures and relationships into his or her internal world, many of them derived from the past and elaboratedoften grossly exaggeratedin unconscious fantasy.
Dr. Steiner derives much of the patients use of him from how he or she has constructed leading fantasies about him: his aims, his attitudes, his defects and his strengths. These fantasies have been instigated by, and more or less filled in with, projective identifications, and their content usually expresses disturbing aspects of the patients self that the patient feels it imperative to be rid of. The patient attempts to make further use of him by enticing him into enactments in which he actualizes the patients unconscious fantasies. It becomes evident that however different the two concurrent analyses may be in their details, they are both in the service of analyzing the patient. This mode of working is representative of contemporary Kleinian work, especially as it is practiced in London. Dr. Steiner has contributed much to its development.
In relation to these closely related analytic modes, Dr. Steiner may be said to be performing professional therapy upon himself, acquiring appropriate perspective on the clinical r
lationship and becoming better able to think about the patient and intervene with greater analytic effect.
Dr. Steiner does not believe the analytic job is the same for each of the participants. His reasons are familiar to and accepted by analysts steeped in the traditions of psychoanalysisthat is to say, as a rule, being further removed from intense personal conflict, the analysts ordinary position is to be regarded as the more stable, responsible, coherent and objective of the two. His or her function in the psychoanalytic situation remains highly specialized and on the whole differentiated from the patients role. The patient stays in the center of the field, while a major aim of the analysts self-analysis is to understand the patient better either directly by interpreting projective identifications and enactments, and other fantasies and defenses, back to their source or by clearing away his own obstructions to analyzing effectively, or, as is often the case in the intertwined analytic relationship, both.
For instance, analyzing the patients distortions remains an important and appropriate function of the analyst. In no way is it assumed that that function sets the analyst apart as a faultlessly impersonal, objective observer. When Dr. Steiner presented his paper Containment, Enactment and Communication as the climax of his visiting lectureship, he demonstrated this way of working and the assumptions on which it is based.
In this new contribution, Dr. Steiner presented vignettes of his analytic work with two patients who, although different in many essential ways, produced in the analyst a state of confusion, a difficulty in understanding both the patients spontaneous material and the patients response to his efforts at analytic interpretation. Ultimately this state of affairs led him to feel frustrated and filled with rage and hatred. He showed how he was then able, with the help of his self-analysis, to arrive at a way of looking at the total analytic situation in a new light that helped him regain perspective and intervene in a way that was potentially more useful to the patient. Through self-analysis he reestablished a reality-oriented focus on the patientmore exactly, on the patients psychic state in relation to him as an analyst.
At the center of Dr. Steiners writings, many of which have been pulled together in his invaluable book Psychic Retreats (1993), is an acute concern with the stress experienced by both patient and analyst whenever the work seems to have reached an impasse. Psychic retreat refers to a relatively impregnable emotional position taken by the patient. Although this position includes both fantasy-ridden and defensive elements of the paranoid-schizoid position, it serves mainly to prevent moving either more deeply into the paranoid-schizoid position or forward into the depressive position, the transition forward involving considerable pain of its own, about which more soon will be said below.
The more primitive of the two positions is the paranoid-schizoid position. It is organized narcissistically, and it features fantasies of omnipotence and persecution. This position can, when extreme, preclude any movement toward dependency or mutuality; it rejects the possibility of good objects and is ever ready to spoil goodness enviously; and it leaves little room for growth beyond the concrete or presymbolic modes of thought and object relations other than those that are sadomasochistic or detached.
In contrast, the depressive position represents a shift of emphasis away from projective identification and the defenses associated with it and a shift away from the fantasies mentioned above. In their place is an increased capacity to contain ones own ambivalence, to feel concern and responsibility, and to bear the pangs of guilt; also, confidence in the capacity to love and effect reparation in the face of ambivalence. The move toward the depressive position is envisaged not just in terms of what ones fantasies and impulses are concerning what one might do; that move involves fantasies about the destructive effects of what one has done in fantasy as well as reality to parental figures and others. Consequently, the crushing burden of reparative work seems to lie ahead, along with painful feelings of loss and grief at all that will be left behind of self and old attachments, even if to bad objects. It is the retreat from this painful transition that is often at the heart of analytic stalemates and regressions. Life, in general, cannot escape from flux in this respect; we shift more or less between those modes or levels of function all the time, though ordinarily not to the great extent observed in troubled patients.
The psychic retreat is a manifestation of the pathological organization of defenses and fantasies that are ongoing aspects of the way the patient has been leading his or her life. In certain ways, the concept of pathological organization overlaps with the concept of character as it has been used in classical analytic discourse. However, the two concepts are not identical. Pathological organization has its own identity in connection with the many constituents singled out for emphasis by the Kleinians. Dr. Steiners extensive and creative studies in Psychic Retreats of different aspects of pathological organizations develops previous work by Kleinian analysts, perhaps particularly the work of Herbert Rosenfeld.
While here, Dr. Steiner conducted two workshops with members of the faculty, and he also met with the candidates. Jules Kerman presented his clinical work at both faculty meetings and did an excellent job of it, one that allowed Dr. Steiner to show in action how he thinks about fresh analytic material. Also, I have had the privilege of observing Dr. Steiner conduct conferences at the borderline seminar at the Tavistock Clinic in London. He led that seminar for many years. In addition, I have observed him lead a number of other workshops here in New York. Each of these begins with another analyst volunteering a presentation of some background material on a carefully disguised patient and some detailed process notes. Then Dr. Stein asks the other members of the group what each of them felt as they listenedthat is, what their emotional experience was. After a silence, often a prolonged silence, someone will pipe up, then a second and a third. Now and then, Dr. Steiner might throw in a comment or a question to draw out these first volunteers, following which the group as a whole usually engages in lively discussion. Often, however, much of the initial discussion consists of attempts by the group members to bypass the emotional experience of the session and move directly into interpretation of the content of the material reportedalmost as though that interpretation is helping the interpreters escape from the participation of the self by moving directly into an impersonal case conference format or a detached supervisory format.
As the group process continues, however, Dr. Steiner more actively pulls together bits and pieces of the groups contributions, doing so in a way that summarizes what he infers the session did feel like to the participants in the workshop as well as to himself. He then expounds on the close relationship of that set of feelings to the psychoanalytic, object-related, transferential-countertransferential sense of all the material presented. He does this in an unassuming but masterful way. In the end, he provides an impressive example of one effective mode of analytic working and analytic teaching. In a sense, he brings about in the group process a re-creation of the experience of an analyst listening to a patient, slowly piecing together clues and reactions, and finally getting sufficiently in tune with the patient to arrive at a provisional understanding of what is happening and perhaps an intervention as well. In all his published clinical papers and in the paper he presented at this meeting, Dr. Steiner shares with us how he goes through this process and how he tries to pull together its complex and elusive aspects.
In response to a comment from the audience of his prepared paper praising his candor in reporting on his negative countertransferences and his enactments, Dr. Steiner good-naturedly mentioned that one would not praise that quality highly if one knew all the difficulties he had knowingly left out of the presentation. With this admission, he only added to our appreciation of his undefensive and not so usual presentation of the trials and tribulations of actual analytic work. The meeting concluded on this agreeable note.