Psychoanalytic Understanding of Violence and Suicide (New Library of Psychoanalysis 33)

Psychoanalytic Understanding of Violence and Suicide ‘This book is a joy to read, human and theoretically stimulating…The subject is urgently topical…It is a marvellous read which could be a standard work for many years.’ Reviewer for the New Library of Psychoanalysis ‘The clinical material is detailed, vivid, and convincing; the theoretical discussion is wide and the result is a book of great interest to anyone involved in psychoanalysis.’ Ronald Britton, Training and Supervising Analyst of the British Psycho-Analytical Society ‘Perelberg has produced a book of the greatest topical importance to anyone involved in psychoanalysis. The review of the literature is by far the best on the subject. The various chapters of this most skilfully edited book are beautifully written and lay the foundations for a psychoanalytic theory of violence and suicide. They also make an important contribution to a theory of technique that understands symptoms as solutions to conflicts…It should be a standard work for many years to come.’ Joseph Sandler, Late Professor Emeritus in Psychoanalysis, University College London Although there is a vast literature on aggression, comparatively little has been written on the issue of violence and even fewer clinical discussions have been published on the violent patient. This pioneering book presents a collection of case studies by analysts who have treated patients who have committed serious acts of violence either against others or themselves. Each detailed clinical account demonstrates the effectiveness of the psychoanalytic treatment and aims to further our understanding of the nature of violence. Psychoanalytic Understanding of Violence and Suicide also contains a comprehensive review of the existing literature on aggression and violence from America, England and France, drawing out major themes which will be of interest to all those working with violent and suicidal patients. Rosine Jozef Perelberg is a Training Analyst of the British Psychoanalytical Society and Honorary Senior Lecturer in Theoretical Psychoanalytic Studies at University College London. She is researching a project at the Anna Freud Centre which offers subsidised analysis to young adults and is also in private practice.

THE NEW LIBRARY OF PSYCHOANALYSIS

The New Library of Psychoanalysis was launched in 1987 in association with the Institute of Psycho-Analysis, London. Its purpose is to facilitate a greater and more widespread appreciation of what psychoanalysis is really about and to provide a forum for increasing mutual understanding between psychoanalysts and those working in other disciplines such as history, linguistics, literature, medicine, philosophy, psychology and the social sciences. It is intended that the titles selected for publication in the series should deepen and develop psychoanalytic thinking and technique, contribute to psychoanalysis from outside, or contribute to other disciplines from a psychoanalytical perspective. The Institute, together with the British Psycho-Analytical Society, runs a low-fee psychoanalytic clinic, organizes lectures and scientific events concerned with psychoanalysis, publishes the International Review of Psycho-Analysis (which now incorporates the International Review of Psycho-Analysis), and runs the only training course in the UK in psychoanalysis, leading to membership of the International Psychoanalytical Association—the body which preserves internationally agreed standards of training, of professional entry, and of professional ethics and practice for psychoanalysis as initiated and developed by Sigmund Freud. Distinguished members of the Institute have included Michael Balint, Wilfred Bion, Ronald Fairburn, Anna Freud, Ernest Jones, Melanie Klein, John Rickman and Donald Winnicott. Volumes 1–11 in the series have been prepared under the general editorship of David Tuckett, with Ronald Britton and Eglé Laufer as associate editors. Subsequent volumes are under the general editorship of Elizabeth Bott Spillius, with, from Volume 17, Donald Campbell, Michael Parsons, Rosine Jozef Perelberg and David Taylor as associate editors.

ALSO IN THIS SERIES

1 Impasse and Interpretation Herbert Rosenfeld 2 Psychoanalysis and Discourse Patrick Mahoney 3 The Suppressed Madness of Sane Men Marion Milner 4 The Riddle of Freud Estelle Roith 5 Thinking, Feeling, and Being Ignacio Matte Blanco 6 The Theatre of the Dream Saloman Resnik 7 Melanie Klein Today: Volume Mainly Theory Edited by Elizabeth Bott Spillius 9 Psychic Equilibrium and Psychic Change: Selected Papers of Betty Joseph Edited by Michael Feldman and Elizabeth Bott Spillius 10 About Children and Children-no-longer: Collected Papers 1942–80 Paula Heimann. Edited by Margret Tonnesmann 11 The Freud-Klein Controversies 1941–45 Edited by Pearl King and Riccardo Steiner 12 Dream, Phantasy and Art Hanna Segal 13 Psychic Experience and Problems of Technique Harold Stewart 14 Clinical Lectures on Klein & Bion Edited by Robin Anderson 15 From Fetus to Child Alessandra Piontelli 16 A Psychoanalytic Theory of Infantile Experience: Conceptual and Clinical Reflections E.Gaddini. Edited by Adam Limentani 17 The Dream Discourse Today Edited and introduced by Sara Flanders

18 The Gender Conundrum: Contemporary Psychoanalytic Perspectives on Femininity and Masculinity Edited and introduced by Dana Breen 19 Psychic Retreats John Steiner 20 The Taming of Solitude: Separation Anxiety in Psychoanalysis Jean-Michel Quinodoz 21 Unconscious Logic: An Introduction to Matte-Blanco’s Bi-logic and its Uses Eric Rayner 22 Understanding Mental Objects Meir Perlow 23 Life, Sex and Death: Selected Writings of William Gillespie Edited and introduced by Michael Sinason 24 What Do Psychoanalysts Want?: The Problem of Aims in Psychoanalytic Therapy Joseph Sandler and Anna Ursula Dreher 25 Michael Balint: Object Relations, Pure and Applied Harold Stewart 26 Hope: A Shield in the Economy of Borderline States Anna Potamianou 27 Psychoanalysis, Literature & War: Papers 1972–1995 Hanna Segal 28 Emotional Vertigo: Between Anxiety and Pleasure Danielle Quinodoz 29 Early Freud and Late Freud Ilse Grubrich-Simitis 30 A History of Child Psychoanalysis Claudine and Pierre Geissmann 31 Belief and Imagination Ronald Britton 32 A Mind of One’s Own Robert A.Caper

To Sergio, my partner on the journey

NEW LIBRARY OF PSYCHOANALYSIS 33

General Editor: Elizabeth Bott Spillius

Psychoanalytic Understanding of Violence and Suicide Edited and introduced by Rosine Jozef Perelberg Foreword by Leonard Shengold Preface by Ronald Britton

London and New York

First published 1999 by Routledge 11 New Fetter Lane, London EC4P 4EE Routledge is an imprint of the Taylor & Francis Group This edition published in the Taylor & Francis e-Library, 2005. “ To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of thousands of eBooks please go to http://www.ebookstore.tandf.co.uk/.” Simultaneously published in the USA and Canada by Routledge 29 West 35th Street, New York, NY 10001 © 1999 selection, editorial matter and chapter introductions: Rosine Jozef Perelberg; Chapters 2, 3, 4 and 5 © Institute of Psycho-Analysis; all other chapters © the contributors; ‘red-rag and pink-flag’ is reprinted from Complete Works 1904–1962, by E.E.Cummings, edited by George J.Firmage, by permission of W.W.Norton & Company. Copyright © 1991 by the Trustees for the E.E.Cummings Trust and George James Firmage. All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloguing in Publication Data Psychoanalytic understanding of violence and suicide/[edited by] Rosine Jozef Perelberg. (New library of psychoanalysis; 33) Includes bibliographical references and index. 1. Violence—Psychological aspects. 2. Violence—Case studies. 3. Violence—Treatment. 4. Suicide. 5. Psychoanalysis. I. Perelberg, Rosine Jozef. II. Series. RC569.5.V55P794 1999 616.85′82–dc21 98–25639 ISBN 0-203-01390-5 Master e-book ISBN

ISBN 0-415-19931-X (hbk) ISBN 0-415-19932-8 (pbk)

Contents List of contributors Foreword by Leonard Shengold Preface by Ronald Britton Acknowledgements

1

2

3 4 5 6 7 8

Introduction by Rosine Jozef Perelberg Psychoanalytic understanding of violence and suicide: a review of the literature and some new formulations Rosine Jozef Perelberg Towards understanding violence: the use of the body and the role of the father Peter Fonagy and Mary Target The role of the father in a pre-suicide state Donald Campbell A core phantasy in violence Rosine Jozef Perelberg Narcissism and its relation to violence and suicide Anthony Bateman Technique in the interpretation of the manifest attack on the analyst Rosemary Davies The paradox of suicide: issues of identity and separateness Joan Schachter Final remarks Peter Fonagy Index

viii xi xviii xix

1 15

44

63 74 93 105 123 134

141

Contributors

Anthony Bateman graduated in Medicine in Cambridge and is a Member of the British Psycho-Analytical Society. He is also Consultant Psychiatrist in Psychotherapy in St Ann’s Hospital and Fellow of the Royal College of Psychiatrists where he is Secretary of the Psychotherapy of Faculty. For the last ten years he has also been a member of the Young Adults Research Group at the Anna Freud Centre which offers subsidised analysis to young adults. With Jeremy Holmes he has co-authored the book Introduction to Psycho-Analysis: Contemporary Theory and Practice, published in 1995 by Routledge. He has a particular interest in the treatment of borderline and narcissistic disorders and in the application of psychoanalytic thinking to general psychiatry and research. Donald Campbell is a Training Analyst of the British Psycho-Analytical Society. Previously he trained as a Child Analyst at the Anna Freud Centre. He is Principal Psychotherapist and former Chairman of the Portman Clinic, a National Health Service out-patient facility which specialises in the assessment and psychoanalytic psychotherapeutic treatment of delinquent or sexually deviant persons. He is an associate editor of the New Library of Psychoanalysis, published by Routledge in association with the Institute of Psycho-Analysis. He has published on the subject of violence, suicide, child sexual abuse, delinquency and adolescent development. His areas of research are perpetrators of violence, incest and paedophilia. Rosemary Davies is an Associate Member of the British Psycho-Analytical Society. She works in private practice and in the National Health Service. She is a member of the Young Adults Research Group which offers subsidised analysis to young adults at the Anna Freud Centre, where she also teaches. Peter Fonagy is Freud Memorial Professor of Psychoanalysis, UCL, Director of Research at the Anna Freud Centre. He is Vice-President and Chair of the Research Committee in the International Psycho-Analytic Association. He is Director of the Child and Family Centre and Clinical Protocols and Outcome Centre at the Menninger Clinic, Topeka. He is a clinical psychologist and Training and Supervising Analyst of the British Psycho-Analytical Society and also a member of the American Psychoanalytic Association. He is the Director of the MSc in Theoretical Psychoanalytic Studies at University College, University of London. He has authored or edited several books and published over 200 papers in prestigious international scientific journals. His research interests are in attachment and the outcome of psychotherapy. He is also a Fellow of the British Academy. Rosine Jozef Perelberg is a Training Analyst of the British Psycho-Analytical Society. Previously she completed a PhD in Social Anthropology at the London School of

Economics, at the University of London. She worked for many years as a Senior Psychotherapist and Family Therapist in the NHS in London, both at the Maudsley Hospital and Marlborough Family Service. She is an associate editor of the New Library of Psychoanalysis, published by Routledge in association with the Institute of PsychoAnalysis. She is also on the Editorial Board of the International Journal of PsychoAnalysis. She has co-edited with Ann Miller Gender and Power in Families (1990) and with Joan Raphael-Leff Female Experience: Three Generations of British Psychoanalysts on Work with Women (1997), both published by Routledge. She is in private practice and for the last ten years she has also been working at the Anna Freud Centre on a research project offering subsidised analysis to young adults. Joan Schachter is a Training Analyst at the British Psycho-Analytical Society and a Psychiatrist working in the NHS and private practice. Having trained in general psychiatry in Birmingham and London, she worked for six years at the Cassel hospital, an in-patient psychotherapy unit for adults, adolescents and families. She has been a Consultant Psychotherapist in the NHS for 14 years. She has a long-standing interest in working with adolescents and young adults. She worked at the Brent Consultation Centre for three years and since 1991 has been a member of the Young Adults Research Group at the Anna Freud Centre. Leonard Shengold is a Training and Supervising Analyst and former Director at NYU Psychoanalytic Institute. He is a former Vice-President of the International PsychoAnalytical Association and the author of many papers and six books which include: Soul Murder: The Effects of Childhood Abuse and Deprivations (1989); ‘Father, Don’t You See I’m Burning?’ Reflections on Sex, Narcissism, Symbolism and Murder: From Everything to Nothing (1991); ‘The Boy Will Come to Nothing’: Freud’s Ego Ideal and Freud as Ego Ideal (1993), all published by Yale University Press. Mary Target is an Associate Member of the British Psycho-Analytical Society. She has a PhD in Psychology at the University of London. Her first degree was in Experimental Psychology and her Masters degree in Clinical Psychology, both from Oxford University, and she continues research in the areas of psychoanalytic outcome and the assessment of social/emotional development through the life span. She is a Senior Lecturer in Psychology at University College London, responsible for running an MSc course in Theoretical Psychoanalytic Studies. She is also Deputy Director of Research at the Anna Freud Centre in London, and involved in the teaching of another UCL MSc based there on Psychoanalytic Developmental Psychology. She has written or coauthored numerous articles on both the outcomes of treatment for children and adolescents (particularly psychoanalytic treatment), and on psychoanalytic theory. She is a member of policy groups concerning the provision of mental health services to young people, presenting the evidence for effectiveness of various treatments, especially the case for psychodynamic therapy.

Foreword

LEONARD SHENGOLD

Why is there violence in the world? What is the origin of evil? How can benevolent and omnipotent deities permit the triumph, even the existence, of evil and violence? These philosophic and religious questions have preoccupied human beings since the beginning of recorded history, and perhaps even earlier according to archaeological evidence. Homer, the great Greek dramatists and the ancient Hebrew writings dealt directly with these enigmas. The Greeks, in myth and literature, portrayed the gods as immortal and powerful versions of human beings, with all the human faults and passions. The God of the Hebrews, as he evolved from a tribal deity of fearsome and destructive, ‘jealous’ men into an omnipotent Creator, presented more problems. How can evil stem from benevolent omnipotence? If there is an evil God, as powerful as the good God, then there is at least a logical explanation. The Devil is an approach to this position, made much of by the Manicheans. Milton has his rebellious Satan motivated to evil by malignant envy for God’s favouritism in granting Eden to Adam and Eve. Satan does not appear at first in the Bible, although in Genesis sinful rebellion of Adam and Eve is inspired by the evil serpent. The Devil makes his first appearance as The Adversary (Satan is the Hebrew term for adversary) in Chronicles and the Book of Job. In that fascinating and gripping philosophical drama, Satan challenges God to test his good and prosperous servant Job. Both supernatural beings, who play the role of a bad set of parental figures, carry this test out by torturing that innocent man with the utmost cruelty in what can be seen as a parable of child abuse. The Book of Job attempts to address the origin and meaning of the evil in the universe. The answer Jehovah gives poor Job to the question of why the good suffer and the wicked thrive may be true enough but it is far from satisfying: ‘Don’t ask! It’s beyond your understanding.’ At least we can insist on asking, but wisdom dictates keeping hope humble for a really satisfactory answer (philosophic, religious or scientific). Is our nature inherently violent? Are we imbued with some inherent equivalent to a death instinct, as Freud pessimistically intuited? Must we hope for some external miraculous intervention by some extraterrestial supernatural being? Or count on some biologically based evolutionary change of our inner natures? If aggression and evil are an inextricable part of human nature, can proper nurturance modify these forces so that we will not be condemned to destroy one another? Hannah Arendt has made the term ‘the banality of evil’ familiar to us, a familiarity confirmed and extended by subsequent decades of exposure to the reality of its everyday

presence in the world outside our minds from newsprint headlines and especially from watching news events on television. The waxing and waning of individual and mass violence, viewed over the centuries of human history, may not necessarily have changed enough to justify the impression of crescendo in the present. (Modern advances in communications have certainly made for an increased awareness of violence.) I was very much impressed as a boy by the reactions of my mother, generally a rational and rather atheistic person, who would cry out at the news of a murder, not uncommon in New York in the 1930s, ‘God! Let the killer not be Jewish.’ She had experienced pogroms as a child before the First World War, and their shadow had left the expectation of repetition. I thought of her after the 1993 massacre of many Arabs by a Jew at Hebron. He may have been crazy, but the reaction of so many righteous justifiers again showed the banality of violence—what we all can regress to under stress. Here is what the American poet, e.e.cummings (who had been analysed but was not trying to be an advocate for Freudian drive theory) wrote about what was going on in the world as the Second World War approached in the late 1930s:

red-rag and pink-flag blackshirt and brown strut-mince and stink-brag have all come to town some like it shot and some like it hung and some like it in the twot nine months young (1940, p. 497) I view violence as a loss of control of aggressive impulse leading to action. Psychoanalysts rarely have direct contact with violence in their offices and deal mainly with fantasies of violence. Like Hamlet, analysands usually present what Shakespeare calls ‘the show of violence’ (I.i.144) to the analyst who represents a ghost of their parent—that is, analysts get a direct or disguised emotional revelation, expressed usually in words and tone of voice or, rarely, in attenuated or token actions. (Anna Freud was wont to remind us of Freud’s quote from ‘an unknown English writer’ (who might be Hughlings Jackson): ‘the man who first flung a word of abuse at his enemy instead of a spear was the founder of civilisation’ (1893, 36).) Violent action is of course sometimes resorted to by psychotic and psychopathic patients; but even then it usually occurs in the world outside the consulting room. I will not attempt a review of the history of the place of aggression as it developed in psychoanalytic theory (see the excellent review by Perelberg, 1995 and in this volume, chapter 1). I will start with current controversy. No one worthy of serious study doubts the existence of aggression as an internal force central to understanding psychic conflict, defence and motivation; or of violence as a seemingly uncontrollable and ineradicable

human characteristic. However, the origin of aggression has been hotly disputed— especially since instinct theory has come under attack. No one questions the experiential evocation of aggression—aggression as a response to frustration, deprivation, pain, overstimulation. What we do not know is whether it starts from within as an innate drive or is only a reaction to something without. Are we born good and corrupted by civilisation as Rousseau urges; or is life in the state of nature poor, nasty, brutish and short (Hobbes) because we are born full of sin and evil, would-be incestuous murderers and cannibals, and attain civilisation by renunciation, as Freud thought? He quotes Diderot about children: ‘If the little savage were left to himself, preserving all his imbecility and adding to the modicum of reason of a child in the cradle the violent passions of a man of thirty, he would strangle his father and go to bed with his mother’ (Freud, 1917, p. 337). To illustrate pre-Oedipal violence—cannibalism and murder—that merges into Oedipal violence I will quote a passage from the Circe chapter of James Joyce’s Ulysses (1914). Leopold Bloom begins to feel he ‘must eat’ as he is walking through Dublin. His thoughts turn from hunger to sex: ‘Perfumed bodies, warm, full. All kissed; yielded: in deep summer fields, tangled pressed grass, in trickling hallways of tenements, along sofas, creaking beds.’ He then goes into a restaurant: Stink gripped his trembling breath: pungent meatjuice, slop of greens. See the animals feed…. Smells of men. His gorge rises. Spaton sawdust, sweetish warmish cigarette smoke, reek of plug, spilt beer, men’s beery piss, the stale of ferment. Couldn’t eat a morsel here. Fellow sharpening knife and fork, to eat all before him, old chap picking his tooties. Slight spasm, full, chewing the cud. Before and after. Grace after meals. Look on this picture and on that.1 Scoff-ing up stewgravy with sopping sippets of bread…. A man spitting back on 1 A quote from Hamlet: the prince is forcing Gertrude to look at pictures of his father and of Claudius in the closet scene. Joyce is blending the pre-Oedipal with the Oedipal: cannibalism, murder (fratricide and patricide) and incest.

his plate: halfmasticated gristle: no teeth to chewchewchew it…. Bolting to get it over…. Bitten off more than he can chew. Am I like that? See ourselves as others see us. Hungry man is an angry man. Working tooth and jaw [my italics, see below]…. That fellow ramming a knifeful of cabbage down as if his life depended on it. Good stroke. Gives me the fidgets to look…. Tear it limb from limb. Second nature to him…. Out. I hate dirty eaters. He backed towards the door. Get a light snack in Davy Byrne’s…. Every fellow for his own, tooth and nail. Gulp grub gulp. He came out into clearer air and tuned back towards Grafton Street. Eat or be eaten. Kill! Kill! (pp. 167–168)

And as he approaches Davy Byrne’s, Bloom (Ulysses as Everyman) thinks: Hot fresh blood they prescribe for decline. Blood always needed. Insidious. Lick it up, smoking hot, thick sugary. Famished ghosts.2 Ah, I’m hungry. (1914, p. 169) (Genitality—the allusion to Hamlet brings in the Oedipal—yields to orality: Nature red in ‘tooth and jaw’. Bloom’s disgust is pervasive throughout the scene; the anal imagery (‘reeks’, ‘stink’, etc.) marks the anality which both expresses rage and violence and raises powerful forces against their expression (see Shengold, 1988).) There are rage and potential violence at every libidinal level. Abraham and Klein have emphasised and expanded Freud’s ideas about innate preOedipal violent aggression making for a developmental progression of murderousness— an urge to kill that is optimally increasingly transformed and attenuated by defensive psychic structure but never relinquished, with early intensities expressed in fixations and returned to in regression. We need to know more about the earliest development of object relations to be sure of the interplay between it and the aggressive drive. Even if we accept the aggressive drive, we do not know if it is first directed toward the self and projected, or toward the other and introjected, or both? Does it matter? Does aggression have an inborn pattern of relatively fixed timed waves of intensification and recession, as appears to be true in other animals? Infant observers note great differences in the activity and aggressivity of individual newborns, but the facts of psychic life of the first months of existence are going to remain a great mystery. This is the time of the unrememberable (Frank, 1969). There need be no either/or here—nature as well as nurture is involved. Studies of identical twins 2 Freud (1900) is speaking of the indestructibility of unconscious wishes: ‘they are only capable of annihilation in the same sense as the ghosts in the underworld of the Odyssey—ghosts which awoke to new life as soon as they tasted blood’ (p. 553). Joyce’s great novel is of course based on the Odyssey.

(I am thinking of the work, mostly unpublished but presented and widely discussed, of Peter Neubauer and Samuel Abrams) have increased most analysts’ humility in relation to the amount of psychic endowment we are born with. (People in general and psychoanalysts specifically are more comfortable with the potentially more reversible environmentally determined.) But what is experienced—trauma and deprivation that range from the avoidable to the inevitable, from the tolerable to the unbearable— undeniably also leads to reactive aggression and violence. I do not intend to present more than my own way of regarding the onset and power of violent impulses. I base my conviction mainly on my clinical observations; these have been powerfully influenced by drive theory and have in turn contributed to supporting my theoretical bent. (I realise that this can be called circular reasoning.) Drive theory is our mythology, Freud tells us, and in this moot area mythology may turn out as useful as ‘scientific’ observations. I find drive theory perfectly consistent with other explanations,

such as Joseph Sandler’s idea of the central concern for safety (1987). This compatibility is especially obvious in Freud’s range of psychic danger situations which seem to me clinically verifiable—constantly revealed as ‘clinical facts’. Most of us do not remember our murderous impulses from these early and especially earliest times. What have observation and clinical practice to offer? I realise my prejudices and convictions are also influenced greatly by the adults, traumatised as children, whom I have seen in my practice since I started presenting my work on soul murder. It is my conviction that murder, the aggressive drive to violence—central to both the pre-Oedipal and Oedipal in Freudian and Kleinian theory—has been consistently underplayed as a motivational force because it gives rise to so much anxiety and so much resistance in clinical work, on the part of analysts as well as patients. When, in teaching psychic development, I have reached the Oedipus complex and asked students what it is, I have repeatedly had answers featuring incest but often leaving out the negative Oedipus complex and, most frequently, omitting parentocide, the murder of both parents. One patient (not, in my judgement, a soul murder victim), whose father died when he was 5, had a non-psychotic delusion that his father was still alive. He could give lip service to its irrationality but believed it all the same. He had dreams of intercourse with his mother that, at the start of his analysis, bothered him relatively little. In contrast, he never dreamt about the death, much less the killing of, his father. (I realise that one cannot necessarily generalise from this neat illustration of my thesis.) I feel that, like other animals but to a lesser extent, we have inherited patterns of instinctual and ego development that are greatly, sometimes overwhelmingly, influenced by the environment. The most important influence we know for good and bad is maternal care. But there is still so much mystery—disturbed and violent children whose parents seem to be adequate or better; relatively healthy and non-violent children who somehow emerge from an environment dominated by disturbed and even violent parents—that we tend to fall back on what the genes have contributed. We psychoanalysts have mapped out separate lines of development, most useful for our purposes, oversimplifying the kaleidoscopic complexity of each individual’s slightly differing fate. Karl Abraham’s sequence of libidinal and erogeneic development, schematised and oversimple as it may be, still has considerable clinical validity as well as its heuristic usefulness. It has to be coordinated with the development of object relationships (a coordination started by Abraham himself) as well as with ego and superego development. No part of psychoanalytic thought can exist in isolation and if I have so far emphasised drives and object relations, it is important to bring in ego strengths and defences. (For example, Sally Weintrobe (1995) and others have reminded us of the adaptive potential of violence.) An essential part of the mystery of violence, if one accepts the drive to, or at least the ubiquity of, violence and murder, has to do with the development of adequate defences against them. (Optimal defences might be a better way of putting it; enough aggression but not too much should be allowed expression.) How and why does an inadequacy of defense against the discharge of violent impulses arise? We see this deficiency as a characteristic of many psychopaths or psychotics. We see it in people who regress in traumatic or catastrophic circumstances. We all tend toward regression (ego and superego) in the carnival/traumatic atmosphere of war and catastrophe. (Macaulay says that the essence of war is violence.) Inadequacy of defence is a developmentally primitive psychic trait and, to try to mask our comparative

ignorance and helplessness, we ascribe its continuance into later childhood, adolescence and adult life to true but not very useful generalisations like deficiencies in, or damage sustained to, psychic structure or imbalances in instinctual endowment—with subsequent consequences in the establishment of object relationships.3 In all of this we fall back to the mystery of inborn strengths and deficiencies—and to the assumption of a basis for psychic health that is so familiar, so obviously true and yet too general and too subject to exception to be fully satisfying: the presence in psychic development of a consistent nurturing-and-restraining parental presence that has been internalised. Since we can say more about pathology than about health, we are more certain that the existence of a violent (destructive, murderous, sadistic parent); or, perhaps even more damaging, a profoundly negligent one (one who is either incapable of caring about the child or forced to neglect or desert it) can cause harm in a way that frequently brings on violence, directed against the self and/or others. These violent tendencies arise by way of identification with the aggressor, and/or aggressive reaction to frustration and torment. Curiously enough, parents who are fright3 I am convinced of and have written about the central importance of a generally successful passage through the vicissitudes of anal erogeneity and libido in relation to control of aggression and violence. I have called this defensive anality; see Shengold (1988).

ened of anger, weak and over-indulgent can also evoke violent inclinations in ‘spoiled’ children who have consequent deficiencies in internalising the necessary ‘no’ in relation to their impulses and are therefore terrified of them and of their unchecked rage at inevitable frustrations. Civilisation depends on our neurotic renunciations and compromises. Yet violent, or what I have called soul-murdering, or absent, or spoiling, or even non-loving parental presences are not invariably there in the histories of children and adults who show violent tendencies. I am sorry to stress the dissatisfying note of how much we don’t know in my presentation of a theoretical matrix. We feel more secure about understanding violence when we deal with our clinical observations, and certainly feel more comfortable in considering treatment, which I will touch on in a few sentences. Here we know what to do; the mystery lies in how to do it. We cure by love. If—it is a big, sometimes, alas, an impossible, if—the therapist can get the person prone to violence to care about him or her as a separate person, and to tolerate that caring—the control over violence can be achieved or restored. Toleration of caring and loving is not always easy. For those who have been seduced or beaten as children, for example, it was usually the love for, or at least the need for, the parent which led the child toward the overstimulation and torment that ensued. Emotional distance can be felt as mandatory. We have to find individual and sometimes idiosyncratic ways to evoke and sustain caring in each patient. August Aichhorn wrote a book about his own intuitively based method of creating a positive emotional bond with violent and delinquent juveniles and adolescents. We have to try to work out comparable techniques with each patient whose pathology centres on murderously violent feelings and impulses.

References Aichhorn, A. (1925) Wayward Youth. New York: Viking, 1935. cummings, e.e. (1940) ‘Red-rag and pink-flag’, in Collected Poems. New York: Harcourt Brace Jovanovich, 1972. Frank, A. (1969) ‘The unrememberable and the unforgettable’, Psychoanalytic Study of the Child 24:48–77. Freud, S. (1893) ‘On the psychological mechanisms of hysterical phenomena’, Standard Edition, 3, pp. 25–39. Freud, S. (1900) The Interpretation of Dreams, Standard Edition, 4 and 5. Freud, S. (1917) ‘Introductory lectures on psychoanalysis’, Standard Edition, 16. Joyce, J. (1914) Ulysses. New York: Random House, 1934. Perelberg, R.J. (1995) ‘Violence in young children and adults: a review of the literature and some new formulations’, Bulletin of the Anna Freud Centre 18:89–122. (In this volume, chapter 1. ) Sandler, J. (1987) From Safety to Superego. New York: Guilford. Shengold, L. (1988) Halo in the Sky: Observations on Anality and Defense. New Haven, CT: Yale University Press, 1992. Weintrobe, S. (1995) ‘Violence and mental space’, Bulletin of the Anna Freud Centre 18: 149–165.

Preface

This book is based on a project, undertaken at the Anna Freud Centre, London, to study the analyses of patients who have been physically violent to others or themselves. It already has a Foreword by a distinguished psychoanalyst, Leonard Shengold, and an erudite, comprehensive Introduction by its editor, Rosine Perelberg, so what, one might ask, is the function of this Preface? Perhaps it is to send a commendation and recommendation, from a different quarter of the British Psycho-Analytical Society, for a serious, clinically based approach to an important problem which demonstrates that ideas cross institutional and national boundaries when theories are intelligently used to account for well-observed clinical phenomena. The specific phenomenon towards which the inquiry is directed is physical violence and not simply aggression. A distinction is made between pleasure-driven cruelty and the kind of violence discussed in this book, and it is the state of mind associated with apparently arbitrary or desperation-driven, non-psychotic violence that is the focus. The contributions are diverse but thematic and the authors largely relate the phenomenon to the narcissistic disorders which they discuss in detail. I found particularly interesting the link made between violence and a paranoid, existential state of anxiety in which the thoughts and identity of the other are perceived as a threat to self-identity, and also to the suggestion that the emergence of primitive phantasies of the primal scene might lead some patients to a fear of annihilation and a violent response. Other readers will no doubt find other suggestions that grip them. The clinical material is detailed, vivid, and convincing; the theoretical discussion is wide and the result is a book of great interest to anyone involved in psychoanalysis whatever their own school of thought. Ronald Britton

Acknowledgements

I am grateful to the Editor of the Bulletin of the Anna Freud Centre, Dr Yorke, and to his editorial board, as well as to Mrs Anne-Marie Sandler for their invitation to be the guest editor of the issue on violence which led to the creation of this book (The Bulletin of the Anna Freud Centre 18(2), 1995). I would also like to acknowledge the contribution of the participants in the Young Adults Research Group, where the issue of violence has been discussed over a number of years. This group has undertaken analysis of young adults as part of a subsidised scheme and has been meeting twice weekly since November 1990. The initial chairmanship of Dr George Moran was followed, after his death, by the clinical direction of Mrs Anne-Marie Sandler. The aims of the research, whose director is Professor Peter Fonagy, include the study of the efficacy of psychoanalysis with this age group. In addition to Anne-Marie Sandler, Peter Fonagy and myself, participants in the group have been Anthony Bateman, Marion Burgner (who died prematurely in October 1996), Luigi Caparrotta, Rosemary Davies, Rose Edgcumbe, Julia Fabricius, Anne Harrison, Hansi Kennedy, Brian Martindale, Duncan McLean, Joan Schachter, Maria Tallandini, Sally Weintrobe and Anne Zachary. Anne-Marie Sandler has been a source of inspiration over many years with her charismatic leadership, her clear thinking and enthusiasm. From Joseph Sandler I have learnt a great deal about rigour in conceptual research and in psychoanalytic technique. Over the years I have had the opportunity to exchange ideas on the issues discussed in this book with many other colleagues and friends in the British Society. I would particularly like to thank Donald Campbell, Peter Fonagy and Ronald Britton. My thanks also go to the other authors whose contributions have made this book possible. I would like to acknowledge the financial support of the Contemporary Freudians Committee which helped speed up completion of the manuscript. One’s thinking benefits from so many interchanges with supervisors, friends and colleagues over the years. I would like to specially acknowledge Christopher Bollas, Nina Coltart, Mervin Glasser, Pearl King, Egle Laufer, Dinora Pines and Harold Stewart. I would also like to acknowledge the contribution of the British-French Colloquium which is held in Brighton each year, organised by Haydée Faimberg and Anne-Marie Sandler, especially the observations and inspiration of André Green, Marilia Aisenstein and Paul Denis who invited me to present my work to the Paris Psychoanalytical Society and have been instrumental in publishing several of my papers in French. Catherine

Chabert and Philippe Jeammet’s invitation to present my work to the University Hospital in Paris opened up for me another forum of interchange. I am grateful to Elizabeth Spillius for her interest and encouragement throughout the preparation of this book and for her clear conceptual thinking as well as her editorial skills. I am also grateful to Paula Lavis for her interest in my library search and her persistence in getting hold of seemingly unobtainable articles from all over the world; and to Judith Perle for her skills with the English language as well as for being a committed friend. My students have provided a continuous challenge in the various seminars I have taught over the years. I am consistently moved by the way my patients share their innermost feelings and hope that the process of elaborating my thoughts and feelings, inevitably at the centre of the process of editing a book like this one, will ultimately be of benefit to them in my clinical practice. Marion Burgner left us too early when she died in 1996; I miss her sharp and precise mind as well as her warmth and generosity. I thank George and Bella Josef for their example of commitment to one’s ideas and for their love and support, which provide me with a background of safety. Finally I want to thank Sergio for his partnership on my journey and Daniel, for being the representative of the force of life itself. I would like to thank the editor of the International Journal of Psycho-Analysis for kind permission to publish the following papers: Bateman, A. (1998) ‘Thick-and thin-skinned organisations and enactment on borderline and narcissistic disorders’, International Journal of Psycho-Analysis 79(9): 13–25. (The same clinical material is reproduced in this volume.) Campbell, D. (1995) ‘The role of the father in a pre-suicide state’, International Journal of Psycho-Analysis 76(2):315–23. Fonagy, P. and Target, M. (1995) ‘Understanding the violent patient: the use of the body and the role of the father’, International Journal of Psycho-Analysis 76(3): 487–501. Perelberg, R.J. (1995) ‘A core phantasy in violence’, International Journal of Psy-choAnalysis 76(6):1215–31.

Introduction

ROSINE JOZEF PERELBERG This book presents the psychoanalytic treatment of six patients who have committed acts of violence, four patients having been violent towards others and two having attempted suicide. By careful tracking of the vicissitudes of the transference and countertransference and examining the specific determinants of the patients’ violent behaviour from the standpoint of the analytic setting, this book aims to further our understanding of the nature of violence against others and the self. Although there is a vast literature on aggression, comparatively little has been written on the issue of violence and even fewer clinical discussions have been published on the violent patient. As Shengold points out in the Foreword to this volume, psychoanalysts deal most frequently with phantasies of violence, not with the sort of violent behaviour shown by the patients discussed in this collection. Moreover, each chapter contains a detailed clinical account of their treatment. This makes this book a pioneering contribution to the understanding and treatment of violence in the psychoanalytic setting. Most of the contributors to the book, with the exception of Donald Campbell, have been working together for a number of years in the Young Adults Research Scheme at the Anna Freud Centre, where several of the theoretical and technical issues contained in this book have been discussed, although not all the patients presented here are part of the scheme.1 Donald Campbell’s chapter on 1 The work of the young Adults Research Group has been presented at two public encounters. The first was at the 42nd International Colloquium at the Anna Freud Centre in November 1994 on the theme of ‘The Psychoanalytic Understanding and Treatment of Violence in Children and Young Adults’, chaired by Anne-Marie Sandler. This Colloquium provided the inspiration for the present collection, although the only papers pre-circulated to the Colloquium included in this volume are Dr Shengold’s opening

the ‘Role of the father in the pre-suicidal state’, originally published in the International Journal of Psycho-Analysis and included in this book, has influenced the thinking of all the authors in this volume. The problems of the violent patient are not, of course, unique to this group. Many of the same dynamic features are found in borderline and sexually disordered patients. The contributors, each struggling with patients of somewhat different constellations of pathology, arrive at different yet overlapping conclusions. These ideas are the product of continuing clinical discussion and shared struggles to understand and work with this set

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of highly challenging patients. Although the chapters do not present a unified theoretical framework and the intention is not to present a single theory of violence and suicide, certain themes reappear in the chapters. These are as follows: (a) attempts to conceptualise violence; (b) thinking and the violent patient, including the nature of pathology in representations of self and other; (c) the role of the father; (d) violence and sexuality and (e) issues of technique. I will briefly discuss each of these below in relation to the cases in this book. It is only by reading each individual chapter, identifying the richness and complexity of each individual analysis, brought about by the encounter between the idiosyncrasies of each patient’s idiom and each analyst’s individual imaginative understanding of their patients, that these themes can be fully comprehended.

Definitions of violence The first chapter (by the present author) contains a review of the existing literature on aggression and violence from America, England and France and presents some of the main themes contained in this literature. Questions which organise this literature are: (a) whether aggression is innate or reactive; (b) whether the conceptualisation of an autonomous aggressive drive implies the notion of a death instinct; (c) the relevance of aggression in the process of individuation-separation; (d) issues of technique in the analysis of violent patients; (e) the relatively recent distinction between the concepts of aggression and violence. The review highlights the limitations in our current unremarks and an abridged version of my review of the literature. The second public encounter was a conference at the Psychoanalysis Unit at University College London in September 1997 on the theme of ‘Sexuality and Violence in Borderline Young Men’, when the papers by Rosemary Davies and Joan Schachter included in this volume were presented, as well as Professor Fonagy’s concluding discussion. The paper entitled ‘The interplay between identifications and identity in the analysis of a violent young man: issues of technique’, which I presented at the Conference has not been included in this book and will be published in the International Journal of Psycho-Analysis.

derstanding of violence and implies the need for a fuller psychoanalytic description of violence. A starting point for current thinking on violence is Glasser’s work (1979, 1985), in which he links definitions of violence to one widely accepted in the psychiatric literature: violence is ‘the intended infliction of bodily harm on another person’. This definition requires the inclusion of a breach of the boundary of the body. It also confines violence to conscious acts on the body of one person by another person and does not take into account the phantasy that may underlie such an act. It is, therefore, a descriptive definition. Glasser, however, has himself developed another notion, that of a ‘core complex’ present in perversions, that ‘includes an intense longing for indissoluble union with the object’ (typically the mother), which leaves the individual, at the same time, with a fear of being merged and annihilated. Glasser proposes a continuum with, at one extreme, ‘mild psychological sado-masochism passing through sado-masochistic perversions to sexual crimes, on to the other end of the continuum to crimes of violence, the extreme of which is homicide’(1985, p. 9).

Introduction

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Glasser’s notion of the core complex is implicitly relevant to each chapter in this book, in the authors’ concern with identifying what it is that is being attacked in the phantasy attached to violence or suicide. There is a move from a descriptive level to the level of mental representation in the definition. As well as including a breach of the body boundary, violence encompasses bodily representations and phantasies. As Donald Campbell suggests in his chapter on his work with suicidal patients, for these patients ‘it is the body that is treated as an object and concretely identified with the lost and hated person’. This is in agreement with Freud’s work on the melancholic patient: We have long known, it is true, that no neurotic harbours thoughts of suicide which he has not turned back upon himself from murderous impulses against others, but we have never been able to explain what interplay of forces can carry such a purpose through to execution. The analysis of melancholia now shows that the ego can kill itself only if, owing to the return of the object-cathexis, it can treat itself as an object— if it is able to direct against itself the hostility which relates to an object and which represents the ego’s original reaction to object in the external world…. In the two most opposed situations of being most intensely in love and of suicide the ego is overwhelmed by the object, though in totally different ways. In melancholia the individual feels overwhelmed by guilt and hostility which become persecutory, demanding revenge and expiation. (1915, p. 252, my italics) The various chapters in this book, implicitly or explicitly discuss how both violence against others and suicide may be viewed as attempted solutions to this experience of feeling overwhelmed by the object. In each chapter there is also an implicit acceptance that violence or suicide includes an actual attack on the body of another person or on one’s own body that is being treated as an object. As Fonagy and Target state: ‘selfdestructive and (in the extreme) suicidal behaviour is perceived as the only feasible solution to an insoluble dilemma: the freeing of the self from the other through the destruction of the other within the self’. Fonagy describes the process in greater detail in his discussion at the University College London Conference (chapter 8 in this book), elaborating on the way in which the individual self-representation is contaminated by aspects of the object representation and the way in which the body is treated concretely as if it was the mind itself. For all the patients discussed in this book it is the mother or the mother’s body which is attacked in phantasy. I also suggest in my chapter that it is a specific configuration of the primal scene that is both attacked and re-enacted in the act of violence itself, a suggestion that is then discussed by Davies and Bateman. Although there are different phantasies related to suicide, Campbell suggests that each is underlined by a wish for the ‘surviving self’ to ‘merge with an idealised maternal imago’. ‘The suicide attempt thus presents as a solution for this wish for merger on the one hand and the terror of annihilation on the other.’ This idea may also be understood in relation to Schachter’s patient, who had made several suicide attempts. It is, however, also present as a fundamental dilemma in the violent patient (as discussed explicitly by

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Fonagy, Perelberg, Davies and implicitly by Bateman) so that this book does not provide an answer to the question of what determines the choice between violence and suicide, and indeed it shows that some patients may alternate between these two configurations. Such fluctuation is common in borderline patients. Glasser has distinguished between self-preservative violence (‘aggression’) and ‘sadism’. In self-preservative violence the aim is to negate the danger and to remove the source of danger whereas in sadism (malicious violence) the aim is to take pleasure in inflicting physical and emotional suffering on another person. What happens to the object in the first type of violence is irrelevant, whereas it is crucial in the second, which always includes an object relationship. In their chapter Fonagy and Target (1995 and Chapter 2 in this book) develop the distinction between sadism and violence further: ‘The form of aggression which we are describing here can readily be differentiated, phenomenologically, from sadism, where a capacity to imagine the feelings of the other is probably essential to full enjoyment…sadistic behaviour is not an attempt to defend the self (1995, p. 4). They contrast this with the violent individuals described by Meloy (1992), who experience their victim as a profound threat. Davies’ patient Paulo alternated between a state of mind in which he experienced the analyst as a dangerous object that needed to be eliminated and his requirement to preserve her alive for sadistic attack. The present writer’s patient Karl tended to split these two aspects. When he felt very angry with the analyst he retreated by not attending his sessions for weeks, terrified that he would need to murder the analyst in order to ensure his very survival. The contrast between these two patients is important as it allows a detailed distinction between sadism and violence. In his manic grandiosity, in his relentless and brutal contempt expressed towards his analyst, Paulo had managed to bind his feelings of hatred in sadistic attacks (an aspect also present in Fonagy’s patient, Mr T). Davies discusses how gratified her patient felt when he could draw his analyst into an excited battle with him. Karl, in contrast, experienced his violence as unbounded, mindless, and one can conceptualise it as being more related to self-preservation than sadism. On the couch, at the beginning of his analysis, he was immobile, a concrete representation of the immobilised positions he wanted both of us to keep, as he feared that any movement might activate something uncontrollable. Karl exercised his violence in the outside world in order to preserve the analyst and it was some years into his analysis before he could risk feeling really angry with and contemptuous towards his analyst in the consulting room. Fonagy’s patient Mr T and Bateman’s patient Jane sometimes experienced sadistic excitement in the fear they inflicted on their analysts. Schachter’s patient Robert tended to attack himself and was less able to express openly his hostility towards his analyst. Both sadistic attacks and mindless violence had a defensive function, that is, they were designed to prevent intrusion into the patient by a frightening object, often the analyst, and were especially common in the set of patients described.

Violence, thinking and representation of self and object This theme is intrinsically related to the function of the violent or suicidal act for each of the patients discussed. If the body is confused with the actual internal representation of

Introduction

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the object, this is because of a difficulty in these patients’ capacity for mentalisation. In their chapter Fonagy and Target link self-harm and assaults on others with an inability to mentalise. If a characteristic of the human mind is the ability to relate to one’s own as well as to other’s mental states, these patients present a failure in this capacity. Mental and physical processes tend to be confused so that violence becomes an attempt to obliterate intolerable psychic experience. Following on from their work on the theory of mind, Fonagy and Target suggest that this problem can be traced back to a crucial stage in the development of the self, when the child searches in its primary objects for a representation of its own states of mind. When this does not take place either because of inherent difficulties of the child or because of the caregiver’s inability, the child fails to build a coherent representation of its own mental states and those of others. Internal and external reality become confused with each other. Another characteristic present in these patients is a confusion between phantasy and belief (see Britton, 1995). In Campbell’s suicidal patient an unconscious phantasy— which in this case was the patient’s identification between his body and his hated, engulfing primal mother and the phantasy of merging with an idealised mother—became a ‘delusional conviction’ in the presuicidal state (1995 and chapter 3 in this book). Internal phantasies and external facts become confused with each other. The suicidal patient also sustains the conviction that a part of the self will survive, the ‘surviving self’, in Campbell’s term. Schachter also draws attention to the idea that the suicidal act contains a psychotic phantasy that a part of their self will survive the suicidal attack. This theme finds echoes in my own patient’s ‘belief’ that he had been conceived without the presence of a father and allows the suggestion that a delusional quality in the relationship with the internal object is present in violence against the self or others. This perspective has points of contact with Sohn’s suggestion (1995) that the act of violence is itself a truly ‘symbolic equation’ (Segal, 1986), a point which had also been raised by A.H.Williams (1984, 1995). The ‘other’, which in the suicidal patient can be their own body, becomes the container of unwanted and terrifying parts of the self-representation and needs to be eliminated. This observation places studies on violence at the centre of psychoanalytic investigations concerned with the understanding of phenomena which are potentially at the limits of symbolic representation, not only due to mechanisms of repression, splitting, denial and negation, but also because they relate at the same time to something profoundly destructive in the psychic sphere that breaks through the capacity of the mind to contain it (Green, 1993). This suggestion raises questions about processes present in thinking and the mind’s capacity to know itself. In the cases of the patients studied in this volume, the world of internal and external objects has been compromised and this is often expressed in terms of a refusal of the external world, a process that is most acutely present in Perelberg’s patient Karl’s states of dreamless sleep. Violence and suicide are to be understood as expressing difficulties in thinking capacity. As part of this fundamental difficulty in thinking, there is a tendency for body and mind to become confused, so that violent acts on one’s own or another’s body are used to get rid of intolerable states of mind.

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The role of the father In the beginning there was only the mother, who was both the source of love and danger. This idea, central to the notion of the ‘core complex’ echoes many myths of origin in the cultures studied by social anthropologists. In Aegean civilisation, for instance, as in many Asian religions and Latin American belief systems, at the beginning there was a great goddess: the universal mother, in whom were united all the attributes and functions of divinity…. All the universe was her domain…. On earth she caused the products to flourish, gave men riches, protected them in battle, and at sea guided them on their adventurous voyages. She killed or tamed fierce beasts; and finally she also reigned over the underworld: mistress of life, she was also sovereign of death. (in Graves, 1959, p. 85) Marie Langer (1989) has suggested that myths which emphasise the power of the matriarchy arise from the personal history of each individual. The role of the father has been described as representing the ‘symbolic’ order itself, which is interposed on the ‘imaginary’ mother-infant dyad (Lacan, 1966), and as representing the beginnings of the cultural order (Lévi-Strauss, 1949). In the mother, the child sees a mirror of itself. It is the father who interposes himself between the members of the dyad, thus presenting the child with the experience of the relationship between the parental couple. The denial of this third object and his relationship with the mother is one of the tenets at the origin of the modern understanding of perversion (see ChasseguetSmirgel, 1984; Britton, 1989). In all the patients presented here there was little internal representation either of the subject’s relationship with the father or of the different, generative quality of the parents’ relationship to each other. Recognition of both these realities—the subject’s relation with the father and mother and the qualitatively different relationship of the parental couple— is needed to help the individual recognise the differentiation between the sexes and generations. Moreover, as Lacan has pointed out, it is in the process of observing the relationship between the mother and the father that the child is led to the discovery that the ‘you’ which for him is the father or the mother in the relationship to himself, becomes an ‘I’ in the relationship between father and mother. There is, thus, an interplay between the terms ‘I’ and ‘you’ and this discovery inserts the individual in a system of exchange (Irigaray, 1966). The impact of the father’s absence, either literally or emotionally, for the child’s emotional development has been discussed and understood in terms of hindering the creation of internal boundaries in the relationship between mother and child and inserting the child in a chain of reciprocity which requires the presence of the third object (Gaddini, 1974; Stoller, 1979; Burgner, 1985; Limentani, 1991). The role of the father in helping the child to develop a space in which he can see himself as separate from the mother is a theme that permeates this book. The absence of the father or his violence

Introduction

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makes things worse as he is not available to present the child with the experi-ence of a positive relationship between the parental couple. As a result he does not facilitate the child’s capacity to experience of himself in relation to his objects nor does he offer an alternative to the phantasies of fusion with a mother who is experienced as ‘ungiving, dangerous and untrustworthy’ (Campbell, 1995, p. 315). The centrality of this idea finds its echoes in the patients discussed by Fonagy and Target, Perelberg, Bateman, Davies and Schachter. Bateman discusses how through active intervention in relation to his patient when she threatened him with a knife he had acted as a third object preventing a collapse into a dyadic relationship. Campbell stresses the need for the analyst to constantly monitor his countertransference. Bateman and Schachter underline the importance of introducing an outside perspective to a patient locked in a pathological internal relationship. The current author stresses that the importance of the father is felt not only in actual literal references to the father in the patient’s material, but in the analytic setting itself, which is experienced as a symbolic system that stands for the father and thus mediates in the phantasies of fusion with the mother. Fonagy and Target underline the role of the father as a witness of the relationship between mother and child and his consequent capacity to present the child with a reflection of his position in relationships. All the authors agree on the relevance of the research group to the analysts as it enabled them to feel supported by their colleagues in this very difficult work. The patients treated within the framework of the Young Adults Research Group had knowledge of the existence of the research group and this helped them to feel less isolated and threatened when alone in the consulting room with the analyst. Both Schachter’s and Bateman’s patients obtained an additional sense of support and structure from their admission to psychiatric hospital.

Violence and sexuality Most of the patients discussed in this book are young adult men—with the exception of Bateman’s patient Jane—who expressed extreme difficulties in their body and gender representation. All the patients emphasise conflict in their attempts to negotiate a sense of separateness from their primary objects in order to develop a personal and sexual experience of themselves. Their bodies have also become over-invested, as feelings which should be experienced as mental are experienced as bodily states instead and constantly menace a vulnerable and fragile self-representation. Each patient felt trapped in a dyadic relationship with the mother/analyst where the perspective of the father as a third object was lacking. The potential for violence in the consulting room was strongly present in several of the analyses (Fonagy, Perelberg, Bateman and Davies), especially in the early years. Three of the violent male patients were seen by female analysts and the way in which these analysts both understood and dealt with the sexual transference was crucial. We realised progressively how important it was to interpret not only the primitive sexuality but also the struggle towards more mature levels of sexuality. We often realised that an interpretation concerning primitive sexuality could be used defensively by the female analysts themselves, in an attempt to avoid difficulties in dealing with the erotisation of

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the transference.2 However, the interpretation of erotic desires as only primitive may be humiliating for the patient and indeed may hamper his struggle towards maturation. It is therefore relevant to note that several of the patients discussed in this book were able to start a relationship with a girlfriend during analysis, a fact that was relevant to other patients in the Young Adults Research Group. In the formulation of interpretations a crucial balance had to be found between enabling patients to experience themselves as mature young men, on the one hand, and, on the other, monitoring the transference so that it would not be experienced as too erotic, in a way that might impede the analytic work. For some time in each of these three treatments this seemed to be almost impossible as each of the three patients needed to submit their analyst to relentless sadistic attacks. Paulo, Davies’ patient, was intensely abusive to his analyst, enacting his phantasy of obliterating the female part of the creative couple. His relentless attacks on his analyst revealed his core phantasy in the primal scene as a sadistic homosexual encounter of two people buggering each other. Robert, Schachter’s patient, had a passive presentation and tended to turn his violence against himself, although on one occasion the analyst thought that he might be carrying a gun. Fonagy’s patient had a criminal record prior to beginning his analysis and was at times intensely sadistically abusive and menacing to the analyst in the consulting room. All these accounts were eventually understood as a way of keeping the analyst both excited and terrorised. I have suggested that the detailed analysis of these enactments in the consulting room may reveal the core primal scene phantasies harboured by these patients. The typical configuration of Karl’s scenes of violence was one in which he would be beating a man with extreme violence, whilst being witnessed by a tremendously excited woman. In his mind this was present in the transference when he provided his analyst with detailed accounts of his violence. 2 Lebovici has pointed out in a recent interview (in Baruch and Serrano, 1996) that the woman/analyst who appears in the psychoanalytic literature is represented in terms of the ‘good breast’ or the ‘bad breast’ and never in terms of the ‘woman’s breast’. The erotic relationship with the breast disappears. In our discussions we reflected on the defensive function this might have for the analyst.

In alternating between mindless violence and sadism, Fonagy’s patient Mr T ‘felt whole and someone when his penis was erect’. Born with a physical deformity, Mr T felt that his entire body, including his sexual excitement and especially his penis—confused with his deformed back—had never been acceptable to his mother. This was re-enacted in the very first session with his analyst when he took his shirt off to show him his disfigurement. Campbell’s patient Mr Adams’s suicide phantasy was organised around a sadomasochistic relationship with his mother in a similar way as he had experienced his mother’s attempted suicide as an attack on his own life: ‘my mother tried to kill myself’, he said to his analyst. Mr Adams felt that his father had left him stuck in a masochistic bond with a murderous mother and this was also re-enacted in the transference where Mr Adams struggled to find his masculinity. Fonagy’s patient Mr T, Davies’ Paulo, Schachter’s Robert and Perelberg’s Karl all wanted to be admired by their analysts. Schachter comments on how her patient wanted her to admire his body, whilst at the same time he was terrified of the threat of

Introduction

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engulfment. He attempted to keep his analyst ‘enthralled and excited, in a phantasised state of non-separateness’ (p. 150). The phantasy of having utter control of the female analyst is expressed in both Schachter’s and Davies’ patients’ accounts of visits to prostitutes. Karl also expressed in his analysis his fear of an all-female sado-masochistic world where men had no place. This belief took shape from a newspaper article about a brothel for women only, which left him terrorised and prevented him from coming to his sessions for a week. Karl and Robert spoke of guns and the possibility of their actually bringing a gun to the sessions was very real. Bateman’s patient Jane actually brought a knife to her session and threatened the analyst. It was important to her for the analyst to be frightened of her. Fonagy’s patient Mr T had several criminal convictions for assault and had on one occasion caused severe head injuries to a stranger in a bar. All these patients were involved in a furious battle for possession of themselves and of their sexual bodies. However, none of them, despite their threatening behaviour, ever actually physically attacked their analysts. In each of the cases discussed in this volume there are accounts of the analyst at times feeling disgusted and terrorised by the patients’ sadistic attacks. The curative experience in these patients’ analyses might have been that they were repeatedly surprised that their analysts’ response was different from what they had imagined. The analysts were not excited but attempted to reflect on the feelings and anxieties of their patients. There was discordance between the transference and the way the analyst was perceived, which was put across in many different ways in the formulation of interpretations (Donnet, 1995) in the process of which the patients progressively discovered that their analysts had a mind of their own separate from their patients.

Issues of technique The framework in which these analyses took place is one which has become central to most psychoanalysts who belong to the British Psycho-Analytical Society: the patients were in five times a week analysis, and transference and countertransference were the major tools used by the analysts to understand the patients who had been invited to free associate in their sessions at the consultation interview. Concepts like projection, introjection, projective identification, defence, splitting, unconscious phantasies, anxieties, defence mechanisms and conflicts are all crucial to the understanding of the patient’s internal world and to what goes on between patient and analyst in the vicissitudes of the therapeutic process. All the chapters emphasise the centrality of the countertransference as an analytic tool and the important work the analyst had to sustain in attempting to understand their feelings as opposed to immediately discharging them in terms of interpretations (Heimann, 1950 and Davies’ discussion in this book). This facilitates the opening of what Winnicott (1951) described as a transitional space where play and work may take place. Another concept essential for the understanding of the clinical accounts is that of ‘actualisation’ (Sandler, 1976), which includes the idea that in the analytic process aspects of the internal world are externalised in the transference. Sandler’s concept of ‘role responsiveness’ is also relevant, indicating the way in which in the transference the analyst is prompted to re-enact the part of an important figure in the phantasies arising in

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the patient’s internal world. The Sandlers have consistently emphasised that interpretations of the ‘here and now’ of the analytic session, that is interpretations relating to what they describe as the ‘present unconscious’ interpretations that include what is alive in the transference, should precede an interpretation of the past unconscious (Sandler and Sandler, 1994). One may suggest, in any case, that due to the timelessness of the unconscious, the present is associated with the past in terms of après-coup in the field of associations in a session. In the discussions that follow one can also identify Kernberg’s contribution as, in his work with severe personality disorders, he has stressed the need for a systematic clarification of the patient’s experience which in his view should come before an interpretation of the patients’ unconscious phantasies (1992). Consistent discussion of technique in the analysis of these very difficult patients has been crucial at the meetings of the Young Adults Research Group. All the contributors to this book were concerned to develop appropriate techniques for analysing their patients. Fonagy, Bateman and Davies particularly stress the importance of making simple, descriptive interpretations which delineate as accurately as possible the patients’ states of mind. The analysts had to stay alive and in contact with their patients. Long silences were experienced as counterproductive as these patients tended to find them persecutory. Fonagy and Target, Perelberg, Davies and Schachter stress the importance of understanding the defensive framework of violence when the patients experience themselves as defending their very survival. It is thus crucial in such circumstances for the analyst not to interpret the violence as an attack on the analytic setting, as this may not only be experienced as blaming by these patients but may also gratify their sadism. The analyst’s task is to remain in touch with the affective experience which is alive in the session. Interpretations which all of the authors have considered useful tend to be analystcentred (Steiner, 1994) as they are generally not experienced by the patients as persecutory or blaming them for their conflicts (Sandler and Sandler, 1983; Spillius 1994, Bateman and Davies in this book). Analyst-centred interpretations invite the patients to be a witness to their analyst’s thinking. Fonagy and Target suggest the importance of the patient’s perception of the analyst’s mental states and how this may gradually open up what Ron Britton (1989) has described as a ‘triangular space’ for thinking between and about the patient and the analyst. Ultimately what may be new in the patient’s experience in the analytic treatment is the sustained mental involvement with another human being, without the threat of annihilation. Bateman argues that interpretation is only useful as these patients move between thick-skinned and thin-skinned positions, drawing on the distinction proposed by Rosenfeld between thick- and thin-skinned narcissists. He suggests that, on the one hand, this movement constitutes a danger for both patient and analytic treatment as it increases the likelihood of enactments either in terms of violent behaviour or in the shape of selfdestructive acts. On the other hand, it is when these patients are moving between positions that they are more accessible to interpretations. In the paper presented to the University College Conference (Perelberg, 1997) the present writer suggested that some violent patients present an extreme fluidity between identificatory processes, especially between feminine and masculine identifications. Material derived from Karl’s analysis indicates that it is the terror provoked by his feminine, passive, identification that ultimately gives rise to his violence. As the analyst

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is progressively more able to identify the patient’s internal movement between different states and identificatory processes and able to integrate these into interpretations to the patient, the patient is himself more able to tolerate the internal fluidity between identificatory processes. Oscillation between different states of mind is present in all the patients discussed in this collection, so that in different ways most patients alternate between the possibility of violence and suicide. This emphasises the suggestion that attention that should be paid to process and movement, the moment by moment changes in the session, the ‘Petri dish’ of sessional material, as suggested by Davies. This book, therefore, offers a contribution to a theory of technique in the analysis of such patients and attempts to answer the question posed by Fonagy and Target and discussed by Davies: ‘How can a pathological organisation focused on the destruction of empathy and compassion be changed using a technique based on just these qualities?’ The understanding of the defensive function of these patients’ acting-out behaviour was crucial in allowing the analysts to carry on their interpretive work. It was crucial for these patients to feel understood, rather than for the analysts, at least initially, to interpret the contents of their patients’ unconscious phantasies. What, then, can one say that these six patients had in common? They have all inflicted bodily harm either on themselves (in the case of Campbell’s, Bateman’s and Schachter’s patients) or on another person (in the case of Fonagy’s, Perelberg’s and Davies’ patients). In all the cases, perhaps with the exception of Campbell’s, the analysts were at some point in the analysis in a situation of actual physical danger. In each case it was the analyst’s capacity to understand their patients—based on careful tracking of the transference and the countertransference—and on attempts to put this understanding into words that contained the situation. In each of the cases the effectiveness of the treatment, based on detailed ongoing discussions on technique in the context of the Young Adults Research Group, is indicated. In all the analyses described here we see the emphasis of modern ideas about the relevance of the role of the father and the role of the analytic framework as a symbolic system that stands for the father and thus mediates in the phantasy of fusion with the mother. In delineating the themes relevant to the discussion of these patients, this book attempts to contribute to the development of a conceptual framework for understanding and treating the violent patient. The clinical cases and the central themes in their analyses are discussed in much greater detail in the papers that follow.

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References Britton, R. (1989) ‘The missing link: parental sexuality and the Oedipus complex’, in R. Britton, M.Feldman and E.O’Shaughnessy (1989) The Oedipus Complex Today. London: Karnac. Britton, R. (1995) ‘Psychic reality and unconscious belief’, International Journal of PsychoAnalysis 76:19–23. Burgner, M. (1985) ‘The Oedipal experience: effects on development of an absent father’ International Journal of Psycho-Analysis 66:311–20. Campbell, D. (1995) ‘The role of the father in a pre-suicide state’, International Journal of PsychoAnalysis 76(2), 315–23. (In this volume, chapter 3.) Chasseguet-Smirgel, J. (1984) Creativity and Perversion. New York: W.W.Norton. Donnet, J.L. (1973) ‘Le diven bien tempéré, in Un Diven bien tempéré. Paris: Le Fils Rouge. Donnet, J.L. (1995) ‘L’Enjeu de l’interprétation’, in Un Diven bien tempéré. Paris: Le Fils Rouge. Fonagy, P. (1991) ‘Thinking about thinking: some clinical and theoretical considerations in the analysis of borderline patients’, International Journal of Psycho-Analysis 72(4):639–56. Fonagy, P. and Target, M. (1995) ‘Understanding the violent patient: the use of the body and the role of the father’, International Journal of Psycho-Analysis 76(3):487–501. (In this volume, chapter 2.) Freud, S. (1915a) ‘Mourning and melancholia’, Standard Edition, 14, pp. 239–260. Gaddini, E. (1974) ‘Formation of the father and the primal scene’, in A.Limentani (ed.) (1992) A Psycho-Analytic Theory of Infantile Experience. London: Routledge in association with the Institute of Psycho-Analysis. Glasser, M. (1979) ‘Some aspects of the role of aggression in the perversions’, in I.Rosen (ed.) Sexual Deviation. Oxford: Oxford University Press. Glasser, M. (1985) ‘Aspects of violence’, paper given to the Applied Section of the British Society, London. Graves, R. (ed.) (1959) New Larousse Encyclopedia of Mythology. Twickenham: Hamlyn. Green, A. (1986) ‘The analyst, symbolization and absence in the analytic setting’ in On Privtate Madness, London: The Hogarth Press and The Institute of Psycho-Analysis. Green, A. (1993) Le Travail du Negatif. Paris: Éditions du Minuit. Heimann, P. (1950) ‘Counter-transference’, International Journal of Psycho-Analysis 31. Also in M.Tonnesmann (ed.) About Children and Children-No-Longer. London and New York: Routledge, New Library of Psycho-Analysis, 1989, pp. 73–9. Irigaray, Luce (1966) ‘Communication linguistique et spéculaire (modèles génétiques et modèles pathologiques)’, Cahiers pour l’analyse 3 (May). Kernberg, O.F. (1992) Aggression in Personality Disorders and Perversions. New Haven and London: Yale University Press. Lacan, J. (1966) ‘Le stade du mirroir comme formateur de la fonction du Je telle qu’elle nous est revelée dans l’expérience psychanalitique’, in Écrits. Paris: Éditions du Seuil. Langer, M. (1989) From Vienna to Managua: Journey of a Psychoanalyst. London: Free Association.

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Lévi-Strauss, C. (1949) The Elementary Structures of Kinship and Marriage. Boston: Beacon Press, 1969. Limentani, A. (1991) ‘Neglected fathers in the aetiology and treatment of sexual deviations’, International Journal of Psycho-Analysis 72, 573–84. Meloy, J.R. (1992) Violent Attachments. Northvale, NJ: Jason Aronson. Perelberg, R.J. (1997) ‘The interplay between identifications and identity in the analysis of a violent young man: issues of technique’, paper presented to the University College London Conference ‘Violence and Sexuality in Borderline Young Men’, forthcoming in International Journal of Psycho-Analysis. Sandler, J. (1976) ‘Countertransference and role responsiveness’, International Review of PsychoAnalysis 3:43–47. Sandler, J. and Sandler, A.-M. (1983) ‘The second censorship, the three box model and some technical implications’, International Journal of Psycho-Analysis 64:413–425. Sandler, J. and Sandler, A.-M. (1994) ‘The past unconscious and the present unconscious: a contribution to a technical frame of reference’, Psychoanalytic Study of the Child 49:278–291. Segal, H. (1986) The Work of Hannah Segal. London: Free Association Books. (First published in 1981 by Jason Aronson Inc.) Sohn, L. (1995) ‘Unprovoked assaults—making sense of apparently random violence’, International Journal of Psycho-Analysis 76(3):565–575. Steiner, J. (1993) Psychic Retreats: Pathological Organizations in Psychotic, Neurotic and Borderline Patients. London: Routledge, New Library of Psycho-Analysis. Stoller, R.J. (1979) ‘The gender disorders’, in I.Rosen (ed.) Sexual Deviations. Oxford: Oxford University Press: 100–138. Williams, H. (1984) ‘Violence et “non-digestion” psychique’, Revue Française de Psychanalyse 1057–1068. Williams, A.H. (1995) ‘Murderousness in relationship to psychotic breakdown (madness)’ in Jane Ellwood (ed.) Psychosis: Understanding and Treatment. London and Bristol, PA: Jessica Kingsley Publishers. Winnicott, D.W. (1951) ‘Transitional objects and transitional phenomena’, International Journal of Psycho-Analysis 34:89, also in D.W.Winnicott (1971) Playing and Reality. London: Tavistock.

Introduction to chapter 1

This first chapter was originally pre-circulated to the Colloquium at the Anna Freud Centre in November 1994. I had undertaken a bibliographic search on the issue of violence and was able to trace some 130 papers and a number of books on the issue of aggression, but very few on violence. The chapter discusses some of the main positions in the debate on aggression in America, Britain and France. The paper then returns to Freud to look at the way in which Freud himself used the notion of violence and suggests some differences in the way he used the concepts of ‘aggression’ and ‘violence’ in the body of his work.

1 Psychoanalytic understanding of violence and suicide: a review of the literature and some new formulations

ROSINE JOZEF PERELBERG

Introduction Since Freud postulated aggression as a drive in 1920, this theme has been a source of profound debate among psychoanalysts. Few ideas in psychoanalytic theory have generated more controversy (Blumenthal, 1976; Mitchell, 1993; Perelberg, 1995a, 1995b and Chapter 4 in this book) than the question of whether aggression is a fundamental or irreducible human instinct, whether it is innate or reactive to the environment. A perception of aggression as a drive has been followed by many psycho-analysts, including Klein (1957), Abraham (1924), Solnit (1972), Kernberg (1984) and Shengold (1991, 1993). Others have considered aggression to be reactive to the environment in the tradition of studying the impact of deprivation and trauma on children following Ferenczi’s paper (1933), which focused on the effects of abuse on children (see also Gardiner’s accounts, 1977). Aggression has thus also been seen as a reaction to an experience of danger, such as breaks in attunement (Stern, 1985), impingement (Winnicott, 1971), negative affective experiences (Osofsky and Elberhart-Wright, 1988; Osoffsky, 1993), or as a defence against threats to the psychological self (Fonagy et al., 1993a). Parens (1973, 1979) also found aggression to be reactive. For Kohut (1967, 1971) aggression is related to the experience of empathic failure. Fairbairn (1990) viewed aggression as a result of the infant’s deprivation and lack of gratification (see also Stone, 1971; Stein, 1972; Usdin, 1972; Marcovitz, 1982; Ortmeyer, 1984). Some authors have explored the relationship between murder and suicide (Reichard and Tillman, 1950; Weiss et al., 1960; West, 1966; Maltsberger and Buie, 1980; Lester, 1987). The term ‘aggression’ has been used to cover a wide variety of behaviours, from selfassertion to destructiveness. The various theories of aggression cover the plurality of psychoanalytic formulations, from drive theories to ego psychology and object relations theories. Issues which permeate the literature include the following: (a) whether aggression is an autonomous drive or a reaction to anxiety or narcissistic injury; (b) whether aggression

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implies the notion of a death instinct; (c) the importance of aggression in the process of individuation-separation. This discussion leads to the distinction between healthy and pathological aggression; (d) the connection between aggression and a pattern of ‘transmission’ in the environment; (e) and connections between the concepts of aggression and violence which have only been raised relatively recently; (f) this more recent literature presents a renewed concern with the role of the father, in the mind of both the child and the mother, as well as a concern to ‘reconstruct’ the environment provided by the primary parental objects. I will begin by presenting Freud’s views on aggression. In subsequent sections I will present a review of some of the main positions in the debate on aggression in America, Britain and France. In the sixth section of the chapter I return to Freud: to look at the way in which Freud himself used the notion of violence and suggest some differences in the way he used the concepts of ‘aggression’ and ‘Violence’ in the body of his work. In the final section I will formulate my hypothesis that there may be a core phantasy in violence which is related to the individual’s phantasy about his or her own creation. This definition moves the conceptualisation of violence from the descriptive level to include the level of mental representations.

1 The origins: Freud’s formulations of the drives Freud continuously modified his views on the aggressive or destructive instincts (Akbar, 1993). In his initial theoretical formulation (1905a) the aggressive impulses were considered to be derivatives of a drive for sexual mastery. This view was not modified for some ten years. In ‘Instincts and their Vicissitudes’, Freud traced the origins of the instincts to sources of stimulation within the organism. His central thesis was that ‘the true prototypes of the relation of hate are derived not from sexual life, but from the ego’s struggle to preserve and maintain itself’ (1915a, p. 138). One of the vicissitudes of sexual instincts is the reversal into its opposite, love being transformed into hate. At that point Freud postulated that the drive for mastery, in conjunction with other drives, served selfpreservation and was part of the self-preservative instinct. It is important to indicate that, even at this point in the elaboration of his theory, Freud characterised hate as an ego function, directed towards an object: ‘the attitudes of love and hate cannot be made use of for the relations of instincts to their objects, but are reserved for the relations of the total ego to objects’ (1915a, p.137). Further elaboration in Freud’s formulations stems both from conceptual and clinical developments. Freud had identified the role of aggression in his clinical work (for instance, in his analysis of Dora, his understanding of Dora’s conflicting feelings towards himself (Freud, 1905b)) and in his conceptual framework, such as his formulations on the Oedipus complex, as already in The Interpretation of Dreams (1900; see also Laplanche and Pontalis, 1985). The main theoretical problem Freud faced, however, was how to reconcile an impulse which leads to self-destruction or to the destruction of the other with the frame of reference that postulated the duality of libido and self-preservative instincts. In 1915b, with his work on ‘Mourning and melancholia’, an important break-through occurred in Freud’s theoretical frame of reference, as he, for the first time, gave an account of an object relationship based on projection and identification:

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We have long known, it is true, that no neurotic harbours thoughts of suicide which he has not turned back upon himself from murderous impulses against others, but we have never been able to explain what interplay of forces can carry such a purpose through to execution. The analysis of melancholia now shows that the ego can kill itself only if, owing to the return of the object-cathexis, it can treat itself as an object— if it is able to direct against itself the hostility which relates to an object and which represents the ego’s original reaction to objects in the external world…. In the two, most opposed situations of being most intensely in love and of suicide the ego is overwhelmed by the object, though in totally different ways. (1915b, p. 252, my italics) We will discuss later in this chapter how suicide and violence against others may be viewed as attempted solutions to this experience of feeling overwhelmed by the object. It was with Beyond the Pleasure Principle (1920), and the discussion of the death instinct, that Freud allowed for the emergence of an autonomous aggressive drive (Aggressionstrieb). Aggression against the external world represents an externalisation of the death instinct, with the help of the muscular apparatus. This non-sexual aggressive drive is present from the beginning of life and works continually to unbind connections, in contrast with Eros, which seeks to bind. Freud also distinguished the non-erotic function of the death instinct from sadism and proposed the notion of a primary masochism, a state in which the death instinct is turned against the self, but bound and fused with libido (Freud, 1924; Laplanche and Pontalis, 1985, p. 245). Sadism would designate a fusion of sexuality and violence against others. Laplanche and Pontalis point out, however, that this distinction between violence and sadism is not always maintained by Freud himself. We will return to this discussion later in this chapter (section 7). In 1937 Freud stated: If we take into consideration the total picture made up of phenomena of masochism immanent in so many people, the negative therapeutic reaction and the sense of guilt found in so many neurotics, we shall no longer be able to adhere to the belief that mental events are exclusively governed by the desire for pleasure. These phenomena are unmistakable indications of the presence of a power in mental life which we call the instinct of aggression or of destruction according to its aims, and which we trace back to the original death instinct of living matter. (p. 243) With the development of the structural model of the mind containing the distinctions between the ego, the id and the superego (Freud, 1923, 1926), the ego could not be perceived as being equipped with drives of its own as they were to be conceived as stemming from the id (Hartmann et al., 1949). The development of the concept of the superego also postulated a powerful unconscious critical force, made up of the child’s internalisations of the parental prohibitions. Aggression now became a characteristic of the way the different parts of the mind relate to each other.

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Psychoanalysts have tended to equate the opposition between the life and death instincts with that between sexuality and aggressiveness. As Freud himself did not develop the concept of aggression in the same way as he developed that of libido, psychoanalysts have tended to trace parallels between libido and aggression. The concept of the death instinct, however, contains several related ideas which are connected not only with aggression, but also with passivity, as in the Nirvana Principle (Clancier et al., 1984), and the repetition compulsion, which has no special affinity with aggressive behaviour (Laplanche and Pontalis, 1985). In An Outline of Psychoanalysis (1938a), Freud postulated two basic instincts—Eros and the destructive instinct. The aim of the first of these basic instincts is to establish ever greater units and to preserve them thus—in short, to bind together; the aim of the second is, on the contrary, to undo connections and to destroy things. In the case of the destructive instinct we may suppose that its final aim is to lead what is living into inorganic state. (p. 148) In ‘Analysis terminable and interminable’ (1937), Freud also introduced the concept of ‘free aggressiveness’. Aggression was ‘floating’, ready to attach itself to any instinct whenever it chose to do so. This concept explains the coexistence of love and hate for one and the same object. In ‘Why war?’ (1932), Freud suggested that an instinct ‘scarcely ever operates in isolation; it is always accompanied…with a certain quota from the other side, which modifies its aim or is, in some cases, what enables it to achieve that aim’ (p. 209). Thus the instinct of self-preservation, on the side of Eros, must have a certain degree of aggressiveness at its disposal, in order to fulfil its purpose. In his letter to Einstein, Freud also distinguished between the death instinct—directed against oneself— and the destructive drive, directed against others. It is important to stress the importance Freud attributed to aggression in the development of the individual. It has a propelling function essential for the construction of life. I think that this essential view of aggression was later lost in some of the psychoanalytic literature. In 1924 Abraham explored the roots of destructiveness relating it to the aetiology of mental disturbances.

2 Developments in Britain An analysis of the psychoanalytic literature in Britain uncovers a debate between those who have emphasised aggression as innate and those who emphasised the importance of the mother—child dyad and the traumatic nature of the primary relationships in the shaping of aggression. We thus find both notions of aggression, that is, as a healthy part of development and as a result of pathology. In his 1915 paper Jones stated:

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It should be evident that if an adult were to display the same disregard for the rights and feelings of others, the same indecency and cruelty, and egotism as that characteristic of the infant, he would very definitely rank as an asocial animal…. There can be no doubts that the asocial impulses we are discussing are part of the inherited characteristics of mankind, and it is throughout intelligible that both the infant and the savage stand in this respect nearer to the animals from which we descend. (Jones, 1915, pp. 77–78) For Klein the unconscious is there from the start and has specific contents, namely the unconscious phantasies (Isaacs, 1943; Klein, 1952b). These are perceived by her as constitutional and universal, particularly derived from the death instinct (Klein, 1930, in 1977a, p. 61). The external environment has a fundamental role in the amelioration of persecutory anxiety. Here lies its importance, as emphasised by Klein: ‘The fact that a good relation to its mother and to the external world helps the baby to overcome its early paranoid anxieties throws a new light on the importance of the earliest experiences…’ (1946, in 1977b, p. 98, my emphasis). Throughout the various phases of Klein’s work there are numerous references to the importance of the life instincts which counteract the strength of the death instincts, and to the continual process of interaction between projection and introjection in the development of the infant. Particularly in her later work Klein argued that the reality of the environment has an impact on the infant’s constitutional unconscious phantasies and that good experiences can modify the persecutory, inborn phantasies (e.g. 1952a, in 1977b, pp. 64, 81, 98). An analysis of Klein’s views on psychic life throughout her work, however, indicates that the death instincts play a dominant role and are felt by the individual as fear of annihilation (see also Lebovici and Soule, 1970; Yorke, 1973; Greenberg and Mitchell, 1983, p. 146 and Petot, 1991, pp. 236–239). It is only with Bion and his concepts of the container and contained (1962, 1963, 1967 and 1970) that a theory of development involving the effect of the actual behaviour of the object on the mind of the infant was more explicitly formulated. In Bion’s conceptual framework the environment has a more defined role. I also think that it is only in the work of contemporary Kleinian thinkers that a different equilibrium between the two types of instincts has come to the fore (see Spillius, 1988b). The emphasis on the role of the environment in modulating the child’s aggression was developed in Bion’s concepts of ‘container’ and ‘contained’. The mother’s capacity for ‘reverie’ is essential for the containment of the infant’s overwhelming anxieties and unpleasant sensations linked to the ‘bad breast’ and in transforming them into bearable experiences. Other notions in Bion’s work which are relevant here are ‘attacks on linking’, and the contrast between ‘alpha’ function and ‘beta’ elements. Whereas alpha functions are the basic elements essential for thought, beta elements are undigested facts which cannot be thought about (1962, p. 9; see also Rosenfeld, 1971). ‘Attacks on linking’ are the destructive attacks made by patients on anything that links one object to another. This is not only related to the patient’s inborn characteristics, namely primary aggression and envy (Bion, 1967), but also derived from the mother’s attack on the baby’s link made through projective identification. Stein has formulated that Bion regards violent emotions as ‘destructive forces that burst psychic space and strip the incipient

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formation of concepts of space and time of their meaning; violent emotions (which, in a sense are equivalent to the “psychotic part of the personality”) attack and destroy concepts and thinking’ (Stein, 1991, p. 99). Bion, and his theory of thinking and psychic space influenced members of the British Society from all three groups, in their discussion of borderline personalities. Some of the most influential Kleinians include Hanna Segal (1964, 1986), Edna O’Shaughnessy (1981), Ruth Riesenberg Malcolm (1970), Ronald Britton (see Britton et al., 1989) and John Steiner (1993); Contemporary Freudians include Peter Fonagy (1991) and among the Independents are Harold Stewart (1992) and Christopher Bollas (1993). Thus Bollas develops the notion of ‘fascist states of mind’, which he views as ‘mental mechanisms aimed at eliminating all opposition’ (1993, p. 200), a notion that, as we will see, was also inspired by the work of both Fairbairn (1990) and Rosenfeld (1971). Segal gives aggression a central place in mental life and links it with the death instinct (1964, 1986). The concept, according to Kleinians, is necessary to account for anxiety, conflict and guilt in small children. Early sadistic phantasies are part of normal development and have an important function in the life of the infant. Persecutory anxieties comprise the infant’s dread of annihilation by its own destructive impulses, which arise from its death instinct and which are projected as persecutory objects. Primary aggression can never be seen, clinically, in a pure form, as it is always accompanied by the wish to live (in agreement here with Freud’s notion of the fusion of the instincts), and it is always object related. The conflict between love and hate permeates development. A.H.Williams points out the role of the ‘traumatic experience’ which remains undigested (1984) and stresses the importance of feelings of guilt for the therapeutic outcome. This includes depressive anxiety about the damage inflicted in reality or phantasy against the object. When the pathway is opened for depressive anxiety to be experienced, it is also opened for favourable developments (1984, p. 1064). In 1995 A.H.Williams related murderousness to a failure to emotionally metabolise ‘problems to do with death’. The massive projection of these result in homicide or, if there is massive introjection, in suicide. He further suggests that at times these unmetabolised experiences to do with death are encapsulated within the mind until they might be triggered by internal or external factors into, for instance, an epileptic fit. An important point underlined by this author is that the study of some murderers and their deeds indicate that mental breakdown and the abandonment of effective reality testing allows the individual to do what he might otherwise not have done. A.H.Williams discusses several ways in which a murderer might remove himself from the scene of a crime: through suicide, amnesia, alcohol, drugs, a not-caring state of mind, religious conversion or even the seeking of therapeutic help. An essential feature of murderous deeds is the slip from symbolic thinking to symbolic equation, a position that has also been put forward recently by Leslie Sohn (1995). In a recent collection of papers, Christopher Cordess and Murray Cox stress the role of the psychotherapeutic process, with the emphasis on the transference and countertransference, in the understanding of criminal acts. In the same book, Temple describes the extreme pressure on the therapist, who by definition wants to be helpful, when experienced as persecutory and dangerous by the patient (1996, p. 35). This point is also raised by Fonagy (Chapter 2 in this collection) and Davies (Chapter 6 in this

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collection). The only psycho-analytic treatment discussed in Cordess and Murray Cox’s book is by the Dutch psychoanalyst Nikolaas Treuniet, who is part of a research project offering analysis to patients who committed murder. Treuniet stresses the role of guilt as the instigator of the outburst in patients who commit such violent crimes. Amongst the members of the Independent Group in the British Society, Winnicott equated initial aggression with activity (1950). Aggression can be traced very early on in life, ‘to the impulses of the fetus, to that which makes for movement rather than stillness, to the aliveness of tissues and to the first evidence of muscular eroticism. We need a term here such as life force’ (1950–55). For Winnicott the environment is not merely outside the individual but is part of the individual’s own personal development. The mother plays a mirror-role for her baby. The baby, looking at its mother’s face, sees himself or herself. ‘If the mother’s face is unresponsive, then a mirror is a thing to be looked at but not to be looked into’ (1971). In the beginning, aggression and love are fused with each other. In the process of creating a transitional area, if the object survives the aggression of the child, it assumes a quality of permanence, independence and reality (1965, 1971). A child or adult will have to risk a hostile, potentially destructive attack on the relationship with the loved one in order to internalise the imago of that person. The loved one must be slain, meta-phorically, in order to become a separate person in reality. Aggression and destructiveness are thus seen as necessary for the separation between self and object (1956). The same person is loved and hated, sought and attacked, with the child trusting in its survival. The object can then be ‘used’ (1969). This implies an experience of separation from the object, but this can only be achieved if the mother has the capacity to survive the attacks. This is expressed in the way the child treats the ‘transitional object’, this area of illusion which is neither ‘me’ nor ‘not-me’, which is both affectionately cuddled and mutilated. The transitional object must survive the aggression of the child. In later life Winnicott suggests that destructiveness is an attempt to seek a ‘circle which had as its first example the mother’s arms or the mother’s body’ (1956, p. 310). Winnicott distinguishes between ‘aggressiveness’ as a life force, necessary for development, and ‘anti-social behaviour’ which is, for him, linked to emotional deprivation in the environment. Balint (1968) distinguishes between aggressiveness as a survival mechanism, as a defence against the realisation of dependency and innate sadistic tendencies. The demands for primary love lead to frustration and the response to this is aggressiveness. Hate, for Balint, is a consequence of this process, and requires self-object differentiation. It is, thus, an object-related experience. In the analytic situation Winnicott suggested that the projections of destructive parts of the self are tolerated by the analyst who should never retaliate. It is in the process of being able to tolerate and interpret attacks that the analyst survives the patient’s attacks and has his existence established as separate from the patient’s. These ideas were later developed in the works of Bollas (1987) and Stewart (1992). Glover distinguished between on the one hand aggression which is ‘in a fixed state of fusion with libidinal energy, constituting a permanent source of inner excitation…and on the other the more reactive types of aggression which are activated by frustration and by other forms of psychic danger’ (1964, p. 148–149). Gillespie was to see the death instinct, as a capacity for destructiveness, as mobilised when the individual feels there is a threat to his life and as intrinsic to a healthier life. In sustaining this perspective he departs from the way both Freud and Klein viewed the death instinct (1995).

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Fairbairn sees aggression as coming later in development, in the second oral stage. It is only at this stage, according to Fairbairn, that differentiated aggression as well as libido may be directed towards the object, thus instituting ambivalence towards the object (1990, p. 49) and giving rise to the conflict ‘to love or to hate’, or ‘how to love the object without destroying it by hate’. Fairbairn’s views on aggression are complex and derived from his view of the mental apparatus as constituted of a central ego (the ‘I’), a libidinal ego, and an aggressive persecutory ego, which he designates as the ‘internal saboteur’ (p. 101) and later as ‘the antilibidinal ego’ (pp. 129, 166). Fairbairn regards the origin of aggression as a result of the situation of frustration that the infant is inevitably subjected to in the relationship with its mother. In his account Fairbairn explicitly departs from Freud in that he does not take the Oedipal situation as a central explanatory concept for the psychoanalytic understanding of the mind and as at the origin of repression. He puts the infant’s ambivalent relationship with its mother at the centre of his theory. The maternal object, which is both the source of good and bad experiences, is then split into two and it is the bad object that is internalised in an attempt to control it. This internal object is in turn split into an exciting and needed object and a rejecting object. There is a repression of both these objects through the deployment of a certain measure of aggression. According to Fairbairn these various measures, based on internalisation and splitting, mitigate the experiences of frustration in the child’s relationship with the mother. The excess of libido is taken by the libidinal ego, and the excess of aggression by the internal saboteur (the aggressive and persecutory ego). The attacks of the internal saboteur upon the exciting object represent, according to Fairbairn: a persistence of the child’s original resentment towards his mother as a temptress inciting the very need which she fails to satisfy and thus reducing him to a bondage—just as, indeed, the attack of the internal saboteur upon the libidinal ego represents a persistence of the hatred which the child comes to feel towards himself for the dependence dictated by his need. (p. 114) Anna Freud (1949a, 1949b, 1972) in a different way also subscribed to a ‘frustration theory’ which emphasises that a child is likely to react with aggression when an instinctual wish is not satisfied or is thwarted through interference by the environment. Aggression is here also seen as an ego function. In clinical practice, sexuality and aggression appear in a combined way. It is the fusion between the two which allows the child to assert himself in relation to love objects, to display curiosity towards others and towards his body, obtain satisfaction and possession of his food and destroy it by eating it (1949b, p. 147). Both instinctual drives are directed and experienced towards the same person, so that a child will experience both love and hate towards his mother. A member of the Contemporary Freudians in the British Society, Joseph Sandler has consistently pointed out the basic need for safety as a feeling state present from the earliest experiences of need satisfaction:

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The feeling of safety is not connected a priori with ego boundaries or with the consciousness of self, but develops from an integral part of primary narcissistic experiences, and must exist in rudimentary form from the time of earliest experiences of need satisfaction. Later, of course, it becomes attached to different ego activities and structures, and to mental content, and we can postulate safety signals in the same way as we do signals of anxiety. (1959, p. 4; see also Edgecumbe, 1971; Sandler and Freud, 1985) Sandler suggests that in order to preserve its feelings for safety, the ego will make use of whatever techniques it has at its disposal. I think this principle is helpful in the understanding of what is perceived by the observer as aggressive behaviour; it can be viewed against a background of a need for safety, or in the service of the preservation of the psychological self (Fonagy, 1991; Fonagy et al., 1993b). In the 1971 panel on ‘Aggression’ at the 27th International Psycho-Analytical Congress, Sandler (in Lussier, 1971) pointed out the need for a more descriptive, explanatory and metapsychological term (the following is derived from Lussier’s summary, 1971). The term ‘aggression’ covers a variety of phenomena ranging from overt belligerent behaviour to affects of rage and anger which, according to Sandler, do not seem to be totally drive derivatives and can be responses to external stimuli. The risk is that of a descriptive concept becoming an explanatory one. Sandler suggested differentiating between the ‘capacity to be aggressive’ (mobilised by the ego in order to avoid unpleasure and pain) on the one hand and ‘the drive impulses’ on the other. Aggressive behaviour is not always the result of an aggressive instinctual impulse. The example given is that of identification with the aggressor where the main motivation is anxiety, and aggression is initiated by the ego. Sandler also stressed the importance of the mental representation involved in the aggressive act. In a subsequent paper, both Edgcumbe and Sandler (1974) point out that the descriptive concept of aggression should be avoided since what appears to be aggressive behaviour to the observer does not necessarily reflect a destructive or aggressive impulse in the child. They distinguish between aggressive behaviour and the aggressive wish, which implies a specific stage in development, with the development of intentionality, and differentiation between self, object and aggressive aim. They suggest that with a shift of emphasis on the aggressive wish—which could be derived from internal or external sources—the debate between ‘instinctual’ and ‘reactive aggression’ would disappear. In 1979 Mervin Glasser proposed a distinction between aggression and sadism in terms of the ‘attitude to the object at the time at which the act is carried out’. In aggression the aim is to eliminate and destroy the object and the object’s fate is irrelevant whereas in sadism the aim is to frighten and humiliate the object and thus the reaction of the object is crucial (1979, p. 281). Glasser views aggression as destructive behaviour (p. 286) and at this point, does not distinguish between violence, aggression and sadism. He also suggested the notion of a ‘core complex’ that ‘includes an intense longing for indissoluble union with the object’, which leaves the individual, at the same time, with a fear of being merged and annihilated.1 ‘This will provoke the ego to intense aggression which is aimed at the preservation of the self and the destruction of the mother.’ Glasser

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also discusses various defence mechanisms used by the ego to deal with the anxiety; these include splitting, denial and somatic displacements. In perversion the solution is to sexualise aggression, transforming it into sadism. Also members of the Contemporary Freudians Group, Moses Laufer and Egle Laufer developed their work at the Centre for Adolescent Breakdown, which offers psychoanalytic treatment and psychoanalytic psychotherapy to adolescents. In discussing violence against the self in adolescence E.Laufer (1987) suggests that the meaning of the suicidal act is an attack on the adolescent’s new sexual body. Laufer also stresses the break with reality that is expressed in the suicidal episode. The papers in the Laufers’ 1989 book discuss adolescents who attempted suicide and had been treated at the Centre. Suicidal attempts are understood as actions which allowed the adolescents to feel more in control of their own bodies (Laufer and Laufer, 1989, M.Laufer, et al., 1995). In the cases presented the suicidal act is thus ultimately seen as these adolescents’ attempts to regulate their distance in relation to their internal objects (which they identify with their bodies) and achieve separateness (either by abandoning their objects as they themselves had been abandoned or by attacking them as they felt they had been attacked). We will see that the main body of work in the contemporary psychoanalytic literature on violence in Britain has been among Contemporary Freudians, perhaps because of their concern with developmental issues and their emphasis on the role of the father in the separation of the mother—baby dyad. We will be discussing the centrality of Glasser’s formulations on aggression and violence to the thinking of Contemporary Freudians in section 5, when we discuss the concept of violence. 1 One could identify some points of contact between Glasser’s notion of the ‘core complex’ and the notion of the defensive states against surrender to resourceless dependence, as they have been developed by A. Freud (1952), Guntrip (1968) and Khan (1971). Guntrip suggests that ‘The schizoid person, to whatever degree he is schizoid, hovers between two opposite fears, the fear of isolation in independence with loss of his ego in a vacuum of experience, and the fear of bondage to, of imprisonment or absorption in the personality of whomever he rushes to for protection’ (p. 326).

3 Developments in North America: libido and aggression In North America the debate on aggression has been marked by the question of whether aggression is an innate drive or is reactive to the environment. My understanding of this literature is that, on the whole, it tends to emphasise the role of the individual’s experiences in the structuring of the psyche. Aggression is thus perceived as reactive to a frustrating or depriving environment, although great stress is laid on the distinction between healthy aggression, necessary for development, and pathological aggression, the result of too much deprivation. The question of the link between an aggressive drive and a death instinct was dealt with very early on, with the Americans on the whole rejecting the notion of a death drive. Amongst the Americans there is also a preoccupation with the distinction between aggression and sadism, which aims at inflicting suffering on an object, and is charged with sexuality. Although regarding aggression as a drive, Hartmann, Kris and Loewenstein (1949) separate it from the concept of the death instinct. For the supporters of an autonomous

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ego, there is an autonomous aggressive drive. They start from the assumption of the existence of an undifferentiated phase of psychic structure when libido and aggression are difficult to distinguish from each other. There is an emphasis on an energetic model in that the initial discharges of aggression are viewed as related to a damming up of energy when it exceeds a certain degree of unpleasure. It follows that the discharge is a source of pleasure. Hartmann et al. suggest that both libidinal and aggressive drives are usually discharged in the same act. Musculature and motility are apparatuses for the discharge of aggression and they contribute to the process of differentiation between self and other through action. These authors distinguish sadism from aggression. Sadism is the pleasure derived from inflicting pain on and humiliating the object and thus can only be viewed in the context of a complex object relation. They distinguish between the ‘conflict with the object’, which they designate as conflict with reality and ‘conflict concerning the object’ (instinctual conflicts). ‘Conflict with the object’ introduces the role of the ‘interactions with the environment’. They also discuss the interplay between libido and aggression at different phases of development. Menninger was one of the first supporters of psychoanalysis in America and together with his father, Dr C.F.Menninger, founded the Menninger Clinic. Following Klein, Menninger accepts that psychoanalytic investigations have established beyond any question the murderous destructive wishes which arise in earliest infancy. His work over several decades since 1919 has examined the role of aggression and destructiveness in human behaviour and has included the analysis of suicide (1932) and self-mutilation (1935), which are understood by him as connected with castrating or mutilating phantasies originally directed towards parents and siblings. Menninger, however, also stresses the ‘homeostatic effector’ of the ego under stress in order to keep a level of tension which is experienced as both tolerable and safe to the organism (1954a, 1954b, also 1963). The ego’s aim is to maintain the integrity of the organism. This is accomplished by the discharge of the dangerous and destructive drives, most of which fall back upon the individual himself. In the interests of self-preservation, however, the aggressive drive is at times directed at the environment. Menninger quotes Robert Lindner: ‘Viewing apparently maladjustive behaviour not as an end-result but as an automatic striving for the recovery of balance, as homeostatically initiated and sustained, our job is to make acceptable behaviour serve the same purpose’ (1963, p. 229). Menninger’s papers and books are permeated with clinical examples which give access to the very serious cases of violence he saw during his career (see also 1938, 1942, 1968). He suggests that all cases of violence have meaning: they represent an effort to avoid something worse. The person may rather kill than suffer a completely disruptive disintegration. Thus murder is often committed in order to preserve the individual’s sanity (1963, p. 240). Menninger’s work seems to me to combine a vocabulary that emphasises the primacy of drives and behaviour, while also including the role of phantasies and affects. There is a long-standing tradition, both in America and Britain, which emphasises the relevance of the quality of the environment. Spitz (1953, 1965) stressed that in the first year of life, if the baby does not form appropriate libidinal cathexes, aggression, rage and violence can dominate its behaviour. ‘In-fants without love’, he suggests, ‘end up as adults full of hate.’ Spitz considers that the differentiation of drives is a developmental

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process, so that libido and aggression are differentiated out of a reservoir at the narcissistic stage (1953, p. 128). It is the relationship with the love object that will have an impact on the way the infant elaborates its aggressive behaviour. Spitz includes in the manifestations of the aggressive drive activities such as grasping, which are not experienced as hostile (1953, p. 132). According to Parens (1979), there is no evidence of destructive or injurious behaviour in children in the absence of significant experiences of pain, deprivation or frustration. Parens observed infants into toddlerhood, using observers to interpret the children’s behaviour (see also 1973). His book stems from the Early Childhood Development Project of the Children’s Unit of the Eastern Pennsylvania Psychiatric Institute and the Medical College of Pennsylvania. In my review of the literature I found that his work is the most widely debated in the literature on aggression (see, for instance, Gedo, 1982; Grotstein, 1982; Lichtenberg, 1982). Parens dismisses Hartmann’s concept of an undifferenti-ated phase and thinks that libido and aggression are distinct from the beginning. Cruelty and sadism, on the other hand, are not drives, but result from a prolonged failure of the environment to neutralise rage in the infant. Sander (1975) discusses the fashion by which infant—mother interaction establishes from birth onwards the patterns by which sleep and hunger rhythms are regulated. An important variable in aggression is the affective tone of the relationship between mother and father. A psychoanalyst who has also created a paradigm in the understanding of the relationship between the individual and the environment is Kohut (1959, 1966, 1971, 1977). In his 1967 paper Kohut focused on ‘narcissistic rage’, which he viewed as aggression provoked by events in the patient’s life, and not as an innate discharge. Narcissistic patients are sensitive to external provocations and have ‘rage and rage-andrevenge-prone personalities’. The desire is to turn a passive experience into an active one, a mechanism of identification with the aggressor, and thus to inflict on others that which the individual is afraid of suffering himself. Finally, Kohut specified that rage is only one form of human aggression, and mentioned ‘aggressions that are under the control of the ego’ (p. 652), which he suggested represent more mature forms of aggression than rage. After 1977 Kohut viewed the fragmentation of the self as preceding rather than following rage and delineated the various forms of aggression. Kohut distinguished destructive rage from non-destructive aggression, which has a developmental line of its own, caused by exposure to extreme frustrations (Shane and Shane, 1982, p. 270). Stoller is also an author who emphasised the role of the environment and who identified hostility towards the object as a central dynamic in perversion (1975). Perversion is seen as an attempt to reverse the trauma of childhood humiliation by triumphing over the humiliating object: ‘Perversion serves to channel murderous hatred out into calmer currents of the imagination’ (1975, p. 218). Hostility is a necessary component of normal eroticism. Sadism is reactive to threats to the child’s sense of developing gender identity, or sense of gender self. Humiliation stimulates the defensive manoeuvres of ‘identification with the aggressor’ in order to master the traumatic situation. Both Parens and Stoller believe that hostility in sexuality is reactive, although Parens would not agree that hostility is an essential component of all sexual excitement. There is, thus, confluence between the thinking of Parens, Stoller and Kohut in that all three see aggression as reactive to the experiences of the individual: ‘What this striking merger of three divergent theories would point to is the likelihood that hostile aggressive

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sexuality is best conceptualised as reactive rather than primary’ (Shane and Shane, 1982, p. 280). More recently, Cooper (1991) has suggested that Stoller’s work is specially relevant to the understanding of perversions because it articulates the older emphasis on castration and fetishism with newer concepts derived from more modern understanding of the preOedipal phase, narcissism and needs for safety with the problems of separationindividuation in relation to primary objects. I think this observation will also be significant in terms of a modern understanding of the distinction between aggression and violence, as I will indicate in subsequent sections. On the question of whether aggression is a separate drive, Solnit (1972) suggests that we must realise that libido and aggression coexist, can almost never be viewed separately in the actual functional situation, have broad areas of overlapping, similar and converging functions, and still remain a psychic, metaphoric reference, best described as the demand the body and its functions make upon the mind. (p. 438) What is innate in both aggression and libido is the energy of both drives. Solnit emphasises the importance of the fusion of instincts and the paralysing quality of defused aggression upon the symbolic functions of children. Brenner, in contrast, thought that there was no evidence in support of the existence of an aggressive instinct (1971); aggression, for him, is a psychological concept. Aggressive aims vary with development and are not always the destruction of the object: aggression is variable and related to experience and ego functions. Both libido and aggression are on an equal footing in relation to their role in the creation of psychic conflict and both must be analysed in clinical work. Brenner also thinks it is not possible to state whether libido and aggression are separate at birth or whether they differentiate progressively from a common matrix (p. 140). In the 1971 panel on ‘Aggression’ at the International Psycho-Analytical Association Congress in Vienna there was agreement on the importance of the fusion of both drives for development and of the role of the environment in the organisation of the psychic apparatus (see Kestemberg, 1971). Loewald (1969), in discussing the negative therapeutic reaction, outlines a certain group of patients who present in analysis as thoroughly masochistic. They are impermeable to analytic work. He suggests that what seems to be unanalysable is a deleterious balance between the inner forces of Eros and Thanatos, between the selfdestructive and libidinal tendencies. Loewald suggests, however, that this imbalance is rooted in early stages of psychic development, pre-dating the Oedipus complex and the formation of the superego. In its more intractable forms the negative therapeutic reaction relates to the pre-Oedipal phase of development and is less amenable to interpretations that relate to guilt, consciousness and the need for punishment. Loewald takes the view that libidinal-aggressive development takes place within the identificatory interactions within ‘the dyadic mother-child field’ (p. 321). These drives are thus not autochthonous forces seeking discharge but are a product of a relational phenomena, ‘codetermined by the “environmental factors” that enter into their very organisation as motivational forces’

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(p. 322). In his approach the life and death instincts are dependent on the early environment and are the result of ‘primitive interactions’ (p. 322). Loewald believes that Freud underplayed the importance of the individual’s early environment. The need to distinguish between different types of aggression is also found in Kernberg who regards hate as ‘a complex affect derived from rage, itself a primary affect at the core of the aggressive drive’ (1991a, p. 209; see also 1991b). Kernberg discriminates a spectrum of severity of hatred in the transference, ranging from the wish to destroy the object (or to destroy oneself in identification with the object) at one extreme, to milder forms of hatred, expressed in the wish to exercise power over a submissive object. In the middle of the continuum, Kernberg suggests, there is an intermediary zone in which it is not the wish to eliminate the hated object but rather the need to make the object suffer physically or mentally while preserving it which is predominant. In this intermediary zone Kernberg includes sadism, which may take the form of a sexual perversion, or of charactereological sadism, part of malignant narcissism, or sado-masochistic personality structure (1991a, p. 219, 1991b, 1992). Stolorow (1984) discusses the difficult treatment of a borderline patient who displayed aggressive and threatening behaviour in his analysis. Inspired by Kohut’s work, he understood the patient’s sado-masochism as an attempt ‘to restore a tenuous sense of integrity and stability to his crumbling self experience’ (p. 648). Authors such as Mitchell (1993), Meers (1982) and Buie et al. (1983) have suggested that it is the motivation involved in overcoming an obstacle that defines behaviour as aggressive, and not the behaviour itself (see also Meissner, 1991). Buie et al. identify a range of presentations in their clinical examples: they suggest that the common factor between these various behaviours lies neither in the behaviours themselves nor in the affect but in their motivational aspects. The analyst’s task is to uncover the unconscious intent of the patient’s behaviour and thus identify the function of the aggressive behaviour. They agree with Mitchell in regarding aggression as a biologically rooted drive which requires stimulus to elicit response, thus emphasising a ‘motivational’ theory of aggression. (In the following section I will contrast this view of the drives with Green’s.) The patient’s aggression may also have a positive side, that of the patient’s ‘striving to become more independent, autonomous and whole’ (p. 168). The debates in America have thus pointed to the following themes in the study of aggression: (a) the adaptive role of aggression, a position that emphasises the role of the environment; (b) an emphasis on a biological conception of the drives; (c) a relative absence of reference to the analyst’s psychic functioning, in a way that restricts the concept of the object. This was to be given greater emphasis by the various schools of thought in Britain and France.

4 The French and other Continental psychoanalysts: aggression as structured by the object Two themes predominate in the French literature on violence and aggression: (a) the relevance of the notion of the death instinct for the conceptualisation of violence. In France this concept has developed along different lines from the way it came to be used by Kleinians in Britain, and refers to a higher level of abstraction. The French analysts

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tend to regard the death drive as mute, pre-existing the object; (b) the importance of the mother’s murderous phantasies towards her child for the constitution of the child’s internal world. There is also more reference to the category of ‘Violence’ than I have encountered in the American literature, which is more centred on the notion of aggression. Clancier et al. (1984) have suggested that Freud’s theory of narcissism led to a new conceptualisation of aggression, as a consequence of the interaction between the individual and the external world. In the last twenty years clinical practice has developed and analyses are carried out with individuals with psychic structures less marked by the Oedipus complex. It is more difficult to conceptualise aggression as hate towards a triangular situation; it manifests itself as a more archaic force. These authors indicate the need to distinguish between different types of aggression: this was already present in the work of Freud, who distinguished between sadism (a component of the libidinal drive) and the destructive drive (linked to the death instinct). In 1966 Diatkine suggested that it was meaningless to talk about aggression before the recognition of the object and proposed a view of aggression as structured by the object. In 1972 with Lebovici, however, he proposed a distinction between aggression (in the service of the ego) and aggressivity (in the service of the death instinct). He felt that English contained a terminological confusion because in English ‘aggression’ means ‘the tendency to act aggressively’ while in French it means the realisation or the actualisation of that tendency (see also Lussier, 1971). For French-speaking analysts these metapsychological concepts are useful for understanding how the patient’s productions are organised within the unconscious. Also, according to Freud’s formulations, libidinal and aggressive impulses can never be perceived separately: to isolate them is to repeat Adler’s error, which was refuted by Freud. In 1984 Diatkine stated that aggression and violence are interactional concepts which have meaning only in terms of a subject who is active and an object who is attacked. He suggested that in more general terms aggression is every movement (in action or representation) which attempts to destroy a character which has a positive meaning for the subject (p. 939). The translation of Bemachtingungstrieb as ‘instinct of mastery’ was proposed by Grunberger (1971), and the term was accepted by French analysts to indicate possession and the wish for power. Gillibert (1984) suggested that the ‘instinct for mastery’ is neither sexual nor self-preservative. In France, Pasche (1969), Grunberger (1977, 1982) and Green (1983), following the discussion developed in America by Kohut and Kernberg (as discussed p. 32 and 34), reintroduced the concept of narcissism as a fundamental dimension of the understanding of psychic functioning. In his discussion of the anal type of object relationship, Grunberger emphasises how the issue of power is at stake. What is important is the control of the object and a ‘balance of power’ which guarantees that control. Green distinguished between positive narcissism and negative narcissism. Positive narcissism is a unifying factor for the ego and aims to achieve ego cohesion. This is counter-acted by negative narcissism which arises from the destructive instincts and aims to reduce ego cathexes to nought (1983, 1993). In negative narcissism the ego lacks interest in itself as well as in the object, yearning to vanish into death or nothingness. Green sees this as a manifestation of the death instinct, and distinguishes between this

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and aggression or primary masochism. Negative narcissism aspires to reach a state of absolute neutrality, and there is a barrier against any exchange with both the ego and the object. In the latter case, patients attempt to neutralise the presence of the analyst, who is experienced as intrusive and as representing external reality. In the development of his work on the ‘negative’, Green discusses the limits of the symbolic domain. Green views aggression as taking place when the external object does not perform his mirroring function, of a container and auxiliary of the ego. Recent developments in France have also tended to concentrate more on the infant-mother dyad, focusing on the interactions between the individual and the environment. Green has suggested that we might be facing a ‘third model’ (in addition to the topographical and the structural), where the theoretical poles are the individual and the object. The role attributed to the death drive in order to explain aggression becomes negligible in connection with the relationship between self and object. R.Diatkine discusses aggression in terms of a reaction to the concrete realisation of a desire. He gives an example of the analysis of a young adult where, each time that an element (material or human) presented such an obstacle, this man had to make it disappear. He also gives a second example of an autistic child, who reacts with aggression against anyone who is not compatible with the system of representations which he has built up in order to maintain his equilibrium (1984, p. 942). Both their reactions are to destroy that which creates a dissonance in the harmony of representations. Rochlin (1982) also defined aggression as a response to narcissistic demands, requiring gratification and protection (see also G.Diatkine, 1988). For Bergeret (1984), violence is the echo of the murderous violence existing in the mother. The relevance of the parents’ phantasies, especially the mother’s, in the constitution of their children’s internal world has been important in the French literature and has also been discussed recently in the work of Kaës, Faimberg, Enriquez and Baranes (1993). It is interesting that, with all the emphasis on the mother’s reverie or containing function in Britain, little importance has been placed by British analysts on the mother’s phantasies about her child. In her writings Chasseguet-Smirgel has tended to discuss the category of ‘perversion’ rather than aggression (see, for instance, 1984). This author outlines what she thinks is the hatred and envy of the breast-mother found in perverse patients, and the attempt to preserve an image of the mother which allows no room for the difference between the sexes (1984). The perverse universe is an attempt to deny the difference between the sexes and the generations. In this universe, separation from the mother is not necessary, the father is non-existent and pregenitality is idealised. All the French authors stress the role of the environment, even if it is represented in terms of the mother’s phantasies about the child. A distinction seems to be present between violence, as the expression of something inherently destructive, a function of the death instinct, and aggression, as a reaction to the impingements of the environment. This distinction is not present in the American literature, as I have already noted.

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5 Aggression and violence Psychoanalysts have recently attempted to establish a distinction between aggression and violence. Several analysts who have worked at the Portman Clinic, an out-patient NHS clinic that offers treatment to patients who are delinquent or present perverse symptoms, have written on the issue of violence and perversion, such as Adam Limentani (1984, 1991), Mervin Glasser (1985) and Donald Campbell (1995 and chapter 3 in this book). Glasser (1985), following Walker (1968), defines violence as ‘the intended infliction of bodily harm on another person’. The definition thus confines violence to conscious acts on the body of one person by another person. While aggression is potentially built into human beings by biology, as a reaction to danger, violence is ‘the bodily actualisation of aggression which aims to negate the danger’ (p. 3). Glasser expanded his previous distinction between aggression and sadism in order to discriminate between two types of violence. In self-preservative violence (or aggression), the aim is to negate the danger and to remove the source of danger; in sadism (malicious violence), the aim is to inflict physical and emotional suffering. What happens to the object in the first type of violence is irrelevant, whereas it is crucial in the second, which always includes an object relationship. Self-preservative violence is always accompanied by anxiety, whereas malicious violence is not. Glasser proposes a continuum with, at one end, ‘mild psychological sado-masochism passing through sado-masochistic perversions to sexual crimes, on to the other end of the continuum to crimes of violence, the extreme of which is homicide’(p. 9). Limentani (1991), in discussing the notion of violence, quotes Professor Percy Cohen, from the London School of Economics, who suggested that an act is not violent unless it is clearly apparent that the perpetrator of the act intended to inflict physical damage on a person. Limentani suggests that this definition ignores unconscious motivation. It is interesting to note that this specific paper, which Limentani dedicated to his reflections on violence, has a more general and sociological tone, perhaps indicating how it has been difficult for psychoanalysts to make a contribution to the understanding of violence derived from detailed clinical practice, perhaps because of lack of experience of psychoanalytic work with the violent individual. Limentani, however, suggests that threats to the individual’s integrity and self-esteem can provoke violent reactions. Following Freud he also indicates the role of the superego, stating: when the superego takes the ego as the object for its aggression, an unbearable sense of guilt will ensue, which in its extreme form will lead to suicide. On the other hand, the externalisation of aggression can find a suitable target in those persons who symbolise the superego, such as school authorities, political parties, the police, prison officers, nurses in psychiatric hospitals, social workers and so on. (1991, p. 211)

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Limentani himself puts forward the question, which he does not answer in that specific work: ‘how can we distinguish aggressivity from hate, hostility and sadism?’ (p. 210). Meloy (1992) suggests a distinction between ‘predatory violence’ and ‘affective violence’. The former is encountered in psychopathic characters, and is violence that is planned, purposeful and emotionless. The latter is a reaction to a specific threat (closer to Glasser’s ‘self-preservative violence’). The intra-psychic aspects of violent attachments appear to constellate around the rapprochement subphase of separation individuation, or earlier periods of development…. Such traits may predispose an individual to violence…. The intrapsychic aspects of these violent attachments are organised at a borderline or psychotic level of personality. (Meloy, 1992, p. 18) Meloy is attempting to combine attachment theory with psychoanalytic formulations and infant research. Shengold (1989) has suggested the term ‘soul murder’ where ‘the deliberate attempt is to eradicate or compromise the separate identity of another person’ (p. 2). This can be found in ‘parents who treat their children as extensions of themselves, as objects to satisfy their desires’. Ordinary defences for the children are not enough and ‘analnarcissistic defences’ become established. He quotes Ferenczi: ‘the [abused] child changes into a mechanical obedient automaton’ (Ferenczi, 1933, p. 163). ‘But the automaton’, adds Shengold, ‘has murder inside’ (1989, p. 25). The former victim will follow a compulsion to repeat, in a process of identification with the aggressor: ‘the compulsion to repeat dominates the lives of people who have been seduced or beaten by psychotic and psychopathic parents’ (p. 86). Shengold suggests that the relationship between Oedipus and Jocasta (as the Sphinx) illustrates the fate of children who have been murdered by overstimulation or seduction by their parents. He suggests that the Sphinx represents the pre-Oedipal relationship to the mother, the primal parent, before the child has solved the riddle of the distinction between the parents. Shengold indicates the rage that victims of soul murder are subject to, a rage that is created both through identification with the murderous aggressor and as the legacy of overwhelming traumata. In 1991 and 1993 Shengold developed the idea that rage is a universal experience present at the ‘loss of the promise of everything’. In terms of the debate as to whether or not aggression is a drive, Shengold states: ‘Freud calls the theory of instinctual drives “our mythology” (1932a, p. 95) and states that the drives are mythical entities we cannot do without’ (1991, p. 113). De Zulueta (1994) has distinguished between aggression and violence. The former ‘is a form of behaviour studied by ethologists, biologists and psychologists, whereas violence is more about the interpretation that is given to a form of social behaviour, an interpretation that is essentially determined by the social context in which we live’ (p. ix). De Zulueta further suggests that violence is essentially human and ‘relates more to the meaning we give to a destructive form of interpersonal or even personal behaviour’ (in Cordess and Cox, 1996, p. 175). Violence is an attempt to give meaning to interpersonal behaviour. She notes the way in which the terms violence and aggression are used interchangeably in the literature.

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Fonagy and Target (1995 and Chapter 2 in this book) developed the distinction between sadism and violence. ‘The form of aggression which we are describing here can readily be differentiated, phenomenologically, from sadism, where a capacity to imagine the feelings of the other is probably essential to full enjoyment…sadistic behaviour is not an attempt to defend the self’ (p. 4). They contrast this with the violent individuals described by Meloy (1992), who experience their victim as a profound threat.

6 Aggression and violence: returning to Freud We have seen that Freud discussed the concept of aggression consistently and that he outlined theories on aggression. I have also indicated that the body of the psychoanalytical literature contains a massive discussion of this concept. The various authors attempt to discriminate between different types of aggression, with the implicit and at times explicit understanding that the concept of aggression covers a variety of behaviours, feelings and representations, from attempts to master the environment to something that is perceived as destructive. I have attempted to find out whether, in the body of Freud’s work itself, one can isolate any differences in the way he used the notion of violence. I had a hypothesis in mind, derived from my own reading of Freud over the years, which was that Freud tended to relate ‘Violence’ to the child’s phantasies about the primal scene and to the Oedipus complex. Although Freud used the word ‘violence’ in these contexts, he did not discuss this conceptually. Indeed he seems to have been unaware of establishing this link. According to the Freud Concordance, there are 104 references to ‘violence’ (Heftigkeit) in the texts that make up the Standard Edition. After studying each of them, I feel able to put forward the following suggestions: : 1 There are 24 references to ‘violence’ in the letter to Einstein ‘Why war?’ In this text the word is used to designate a relationship of power and imposition and implies an object relationship: ‘Conflicts of interest between men are settled by the use of violence’ (Freud, 1932a, p. 204). The paradigm for this relationship is the unrestricted violence of the father towards his sons in the ‘primal horde’. Freud expands his theory about the beginnings of culture to the understanding of war between men. 2 In the other texts, the term ‘violence’ is predominantly used by Freud in contexts in which he is talking about the Oedipus complex and primal scene. I will give some examples taken from Freud where the term ‘violence’ is used. These constitute a selection, and many others might also have been included.2 In each case, violence is linked to the primal scene. The Interpretation of Dreams (1900): p. 584 [A 27-year-old man had a repeated dream of a man with a hatchet pursuing him…] While he was still preoccupied with the subject of violence, a recollection from his ninth year came to him. His parents had come home late and had gone to bed while he pretended to be asleep; soon he had heard sounds of panting and other noises…. He had subsumed what had happened between his parents under the concept of violence and struggling…

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‘On the sexual theories of children’ (1908) p. 221 it appears more often that the connection is overlooked by them for the very reason that they [the children] have interpreted the act of love as an act of violence. p. 221 And so the child who is believed to be asleep (or who is pretending to be asleep) may receive an impression from his mother which he can 2 Other examples are Freud, 1901, p. 178, 1909a, p. 41, p. 134, 1910, p. 115–116, 1921, p. 122, 1927, p. 40, 42, 43, 1929, p. 141–142, 1938a, p. 192, 1938b, p. 81.

only interpret as meaning that she is defending herself against an act of violence. ‘Analysis of a phobia in a five-year-old boy’ (1909a) p. 134 The widdler must have something to do with it, for his own grew excited whenever he thought of these things—and it must be a big widdler too, bigger than Hans’ own. If he listened to these premonitory sensations he could only suppose that it was a question of some act of violence performed upon his mother, of smashing something, of making an opening into something… p. 41 His father, he thought, also did that enigmatic forbidden something with his mother which he replaced by an act of violence such as smashing a window-pane or forcing a way into an enclosed space. p. 100 In presenting the case one ought perhaps to insist upon the violence of his anxiety [about intercourse and where babies come from]. ‘From the history of an infantile neurosis’ (1918 [1914]) p. 45 when the patient entered more deeply into the situation of the primal scene, he brought to light the following pieces of self-observation. He assumed to begin with, he said, that the event of which he was a witness was an act of violence, but the expression of enjoyment which he saw in his mother’s face did not fit with this… ‘An outline of psycho-analysis’ (1938a) p. 192 If the little savage were left to himself, preserving all his foolishness and adding to the small sense of a child in the cradle the violent (violence in French) passions of a man of thirty, he would strangle his father and lie with his mother. [Quoted from Diderot, in French. This quotation appears three times in Freud’s work, twice in French and once in German (1917, p. 338; also in The Expert Opinion in 1931 [1930]).] ‘Leonardo’ (1910) p. 116 For his mother’s tenderness was fateful to him; it determined his destiny and the privations that were in store for him. The violence of the caresses, to which his phantasy of the vulture points, was only too natural.

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In these and most of all Freud’s 104 references to violence, it is related to a founding myth about the beginnings of man’s history, and the Oedipus complex. It is a creation myth of mankind which, for Freud, is repeated in the history of each individual and which includes murder and robbery. Ingredients of this story include: children’s beliefs that the sexual act is an act of violence; the idea that if left to themselves, sons would kill their fathers and sleep with their mothers; the notion that the prohibition of incest is related to the founding of civilisation. In 1968 Lévi-Strauss interpreted the myth of Oedipus as containing a fundamental question for human beings about their origins. The myth, according to Lévi-Strauss, attempts to mediate a conflict between a theory that attributes to the individual an autochthonous origin, and the knowledge that any individual is in fact born from the union between a man and a woman. The myth is an attempt to understand and elaborate the question of how one can be born from two.3 The idea that parental intercourse is an act of violence in the phantasy of the child has also been present in Klein (1946) and post-Kleinian writers (see Britton et al., 1989).

7 The function of violence: hypothesis Since Freud, the relevance of the pre-Oedipal period to the story of both boys and girls has been much more consistently emphasised. The understanding of the phantasies about the violence of one’s beginnings has been extended to the relationship with the ‘preOedipal’ mother, as we have seen in the work of Deutsch (1925); Brunswick (1940), Chasseguet-Smirgel (1970), Kernberg (1992), Shengold (1989) and others discussed above. The powerful character of the primitive maternal imago is experienced by children of both sexes. I would like to stress, however, that when we use the term ‘pre-Oedipal mother’ we are using it as shorthand, to express the perspective of the patient’s phantasies and experiences. From the analyst’s perspective there is no such thing as a pre-Oedipal mother, because any mother—child relationship presupposes the existence of a father (see Perelberg, 1997, also 1995b). The impact of the absence of the father, either literally or emotionally, for the child’s emotional development has been discussed and understood in terms of hindering the creation of the internal boundaries in the relationship between mother and child and inserting the child in a chain of reciprocity which requires the presence of the third object (Gaddini, 1974; Stoller, 1975; Glasser, 1979; Herzog, 1980, 1982; Burgner, 1985; Limentani, 1991; Schachter, 1993; Campbell, 1995 and chapter 3 in this book; Fonagy and Target, 1995 and chapter 2 in this book). Blos (1965) discussed the importance of the father in adolescence to counteract the terrifying phantasies about the pre-Oedipal mother. One of the themes that permeates all the chapters in this collection of papers is 3 A recurrent connection between aggressive behaviour and primal scene phantasies is made in the literature about children, adolescents and young adults. In his analysis of the Rat Man, Freud interpreted the violence of the patient’s dreams as a defensive attempt to cope with his sexual wishes and castration fears within an Oedipal framework (see also Greenacre, 1950; Crocker, 1955; Harris and Pontius, 1975; McDougall, 1978; Grotstein, 1982; Bonnet, 1986; Letarte, 1987; Shengold, 1991; Biven, 1994). Glasser has suggested a link between aggressive behaviour and the core complex giving an example where a burglar’s entrance into a house represented entrance into

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his mother’s body and his leaving it represented his ability to escape being engulfed (1979, p. 289). Anthi (1982) has suggested that the theme of murder in detective novels is unconsciously motivated by traumatic primal scene experiences.

an emphasis on the role of the father in helping the child to develop a space where he can see himself as separate from the mother.

Summary In this chapter I have examined the main literature which deals with the issues of aggression and violence, both clinically and conceptually. I started with Freud and reviewed the differing views he held on aggression. I then proceeded to examine the work of some of the most important thinkers in North America, Britain and the Continent. The main issues debated are, first, whether aggression constitutes a drive or is reactive to some form of failure in the environment. Specific aspects in the environment which have been pointed out are deprivation and aggression, even if this is of a subtle quality. Another aspect which has been emphasised is the importance of the father: his absence or violence seems to make things worse as he is not available to present the child with the experience of a third person whose emotional presence changes the mother—child dyad into a triangle. A third area of discussion has been the identification of the developmental problems encountered in groups of patients seen in analysis: narcissistic injury in the phase of separation-differentiation, and pre-Oedipal phantasies. A fourth area of discussion in the literature concerns the attempt to discriminate between different types of aggression (healthy and pathological aggression). Most authors attempt to establish distinctions between what is perceived as healthy assertiveness, and acts which are defined as aiming to destroy and humiliate the object or inflict pain in the service of sexual pleasure (sadism). A fifth theme concerns issues of technique in the analysis. Analysts, with some exceptions, have been reluctant to express their fears of their patients. There are very few accounts of patients actually attacking their therapists but there is also a consensus in the literature that patients who come for analysis are more disturbed than they used to be. I also note that in the literature the issue of aggression and violence is discussed without emphasising the relevance of the gender of the analyst for the risks implied in the treatment, both physically and sexually. In the last section of this chapter I returned to Freud in order to examine the specific contexts in which he used the word ‘violence’. I have suggested that in the body of Freud’s work there is an association between violence and phantasies about the primal scene, the Oedipus complex, and Freud’s mythological account about the origins of humankind. I suggest that this formulation, which I will develop further in my clinical chapter (chapter 4) establishes a link between violence and an individual’s beliefs about his origins.

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References Abraham, K. (1924) ‘A short study of the development of the libido’, in Karl Abraham (1927) Selected Papers in Psycho-Analysis. London: Hogarth. Akbar, M. (1993) ‘The psychoanalytic concept of aggression’, Journal of the Indian Psychoanalytical Society 47(4):118–128. Anthi, P.R. (1982) ‘The primal scene in Sandemose’s murder mysteries: creativity in writing and in psychoanalytic treatment’, Scandinavian Psychoanalytic Review 5(1):91–104. Balint, M. (1968) The Basic Fault. London: Tavistock. Bergeret, J. (1984) Généalogie de la destructivité’, Revue Française de Psychanalyse, 1021–1036. Bion, W.R. (1962) Learning from Experience. London: Karnac. Bion, W.R. (1963) Elements of Psycho-Analysis. London: Karnac. Bion, W.R. (1967) ‘Attacks on linking’, in Second Thoughts: Selected Papers on Psycho-Analysis. London: Maresfield Library. Bion, W.R. (1970) Attention and Interpretation. London: Karnac. Biven, B.M. (1994) ‘Sadists and serial killers: the role of the dehumanising principle’, paper presented to the Association of Child Psychotherapists Annual Conference. Blos, P. (1965) ‘The initial stage of male adolescence’, Psychoanalytic Study of the Child 20: 145– 164. Blumenthal, M.D. (1976) ‘Thinking about violence: an overview’, Humanitas 12(2): 207–220. Bollas, C. (1987) The Shadow of the Object: Psychoanalysis of the Unthought. London: Free Association. Bollas, C. (1993) Being a Character: Psychoanalysis and Self Experience. London: Routledge. Bonnet, G. (1986) ‘En proie aux affres du remords: psychanalyse d’un meurtrier’, Psychanalyse à L’Université 11(42):309–332. Brenner, C. (1971) ‘The psychoanalytic concept of aggression’, International Journal of PsychoAnalysis 52(2):137–144. Britton, R., Feldman, M. and O’Shaughnessy, E. (1989) The Oedipus Complex Today. London: Karnac. Brunswick, R.M. (1940) ‘The pre-Oedipal phase of the libido development’, Psychoanalytic Quarterly 9:239–319. Buie, D.H., Meissner, W.W., Rizzuto, A.M. and Sashin, J. (1983) ‘Aggression in the psychoanalytic situation’, International Review of Psycho-Analysis 10(2):159–170. Burgner, M. (1985) ‘The Oedipal experience: effects on development of an absent father’, International Journal of Psycho-Analysis 66:311–320. Campbell, D. (1995) ‘The role of the father in a pre-suicide state’, International Journal of PsychoAnalysis 76(2): 315–323. (In this volume, chapter 3.) Chasseguet-Smirgel, J. (1970) ‘Feminine guilt and the Oedipus complex’, in J.Chasseguet-Smirgel (ed.) Female Sexuality. London: Maresfield Library. Chasseguet-Smirgel, J. (1984) Creativity and Perversion. New York: W.W.Norton. Clancier, A., Faure, S. and Pragier, G. (1984) ‘Situation Métapsychologique de l’agressivité dans les travaux Français’, Revue Française de Psychanalyse 48(4):917–935. Cooper, A.M. (1991) ‘The unconscious core of perversion’, in G.I.Fogel and W.A.Myers (eds) Perversions and Near-Perversions in Clinical Practice. New Haven and London: Yale University Press. Cordess, Christopher and Cox, Murray (1996) Forensic Psychotherapy: Crime, Psychodynamics and the Offender Patient, vol. I, Mainly Theory and vol. II, Mainly Practice. London and Bristol, PA: Jessica Kingsley. Crocker, D. (1955) ‘The study of a problem of aggression’, Psychoanalytic Study of the Child 10:300–335.

Psychoanalytic understanding of violence and suicide

38

Deutsch, H. (1925) ‘Psychology of women in relation to the function of reproduction’, International Journal of Psycho-Analysis 6:405–418. De Zulueta, F. (1994) From Pain to Violence. London: Whurr Publishers. Diatkine, R. (1966) ‘Agressivité et fantasmes d’agréssion’, Revue Française de Psychanalyse 30:15–92. Diatkine, R. (1984) ‘Agréssion et violence’, Revue Française de Psychanalyse 48(4): 937–946. Diatkine, G. (1988) ‘Danger de mort’, Revue Française de Psychanalyse 52(3): 777–784. Edgcumbe, R. (1971) ‘A consideration of the meaning of certain types of aggressive behaviour’, British Journal of Medical Psychology 44(4):373–378. Edgcumbe, R. and Sandler, J. (1974) ‘Some comments on aggression turned against the self: a brief communication’, International Journal of Psycho-Analysis 55(3):365–367. Fairbairn, W.R.D. (1990) Psychoanalytic Studies of the Personality. London: Routledge. (First published 1954.) Ferenczi, S. (1933) ‘On the confusion of tongues between adults and the child’, in Final Contributions to the Problems and Methods of Psychoanalysis. New York: Basic Books, 1955, pp. 155–167. Fonagy, P. (1991) ‘Thinking about thinking: some clinical and theoretical considerations in the analysis of borderline patients’, International Journal of Psycho-Analysis 72(4): 639–656. Fonagy, P. and Target, M. (1995) ‘Understanding the violent patient: the use of the body and the role of the father’, International Journal of Psycho-Analysis 76(3):487–501. (In this volume, chapter 2. ) Fonagy, P., Moran, G.S. and Target, M. (1993a) ‘Aggression and the psychological self’, International Journal of Psycho-Analysis 74(3):471–485. Fonagy, P., Steele, M., Moran, G., Steele, H. and Higgitt, A. (1993b) ‘Measuring the ghost in the nursery: an empirical study of the relation between parents’ mental representations of childhood experiences and their infants’ security of attachment’, Journal of the American Psychoanalytical Association 41(4):957–989. Freud, A. (1949a) ‘Aggression in relation to emotional development: normal and pathological’, Psychoanalytic Study of the Child 3–4:37–42. Freud, A. (1949b) ‘Notes on aggression’, Bulletin of the Menninger Clinic 13:143–151. Freud, A. (1952) ‘A connection between the states of negativism and of emotional surrender’, in Indications for Child Analysis and Other Papers. London: Hogarth, 1969. Freud, A. (1972) ‘Comments on aggression’, International Journal of Psycho-Analysis 53: 163– 171. Freud, S. (1900) The Interpretation of Dreams, Standard Edition, 4 and 5. Freud, S. (1901) Psychopathology of Everyday Life, Standard Edition, 6. Freud, S. (1905a) ‘Three essays on the theory of sexuality’, Standard Edition, 7, pp. 125–245. Freud, S. (1905b) ‘Fragment of an analysis of a case of hysteria’, Standard Edition, 7, pp. 3–122. Freud, S. (1909a) ‘Analysis of a phobia in a five-year-old boy’, Standard Edition, 10, pp. 3–149. Freud, S. (1909b) ‘Notes upon a case of obsessional neurosis’, Standard Edition, 10, 153–320. Freud, S. (1910) ‘Leonardo’, Standard Edition, 11, pp. 59–151. Freud, S. (1915a) ‘Instincts and their vicissitudes’, Standard Edition, 14, pp. 109–140. Freud, S. (1915b) ‘Mourning and melancholia’, Standard Edition, 14, pp. 237–260. Freud, S. (1917) ‘Introductory lectures on psychoanalysis’, Standard Edition, 16. Freud, S. (1918[1914]) ‘From the history of an infantile neurosis’, Standard Edition, 17, pp. 3–122. Freud, S. (1920) ‘Beyond the pleasure principle’, Standard Edition, 18, pp. 3–64. Freud, S. (1921) ‘Group psychology and the analysis of the ego’, Standard Edition, 18, pp. 67–143. Freud, S. (1923) ‘The ego and the id’, Standard Edition, 19, pp. 3–66. Freud, S. (1924) ‘The economic problem of masochism’, Standard Edition, 19, pp. 157–170. Freud, S. (1926) ‘Inhibitions, symptoms and anxiety’, Standard Edition, 20, pp. 77–174. Freud, S. (1927) ‘The future of an illusion’, Standard Edition, 21, pp. 3–56. Freud, S. (1929) ‘Civilisation and its discontents’, Standard Edition, 21, pp. 59–145.

Psychoanalytic understanding of violence and suicide

39

Freud, S. (1931 [1930]) ‘The expert opinion in the Halsmann case’, Standard Edition, 21. Freud, S. (1932) ‘Why war?’, Standard Edition, 22. Freud, S. (1932a) ‘New introductory lectures on psychoanalysis’, Standard Edition, 22. Freud, S. (1937) ‘Analysis terminable and interminable’, Standard Edition, 23, pp. 209–253. Freud, S. (1938a) ‘An outline of psycho-analysis’, Standard Edition, 23, pp. 141–207. Freud, S. (1938b) ‘Moses and monotheism’, Standard Edition, 23, pp. 3–137. Gaddini, E. (1974) ‘Formation of the father and the primal scene’, in A.Limentani (ed.) (1992) A Psycho-Analytic Theory of Infantile Experience. London: Routledge in association with the Institute of Psycho-Analysis. Gardiner, M. (1977) The Deadly Innocents: Portraits of Children Who Kill. London: Hogarth. Gedo, J.E. (1982) ‘On black bile and other humours’, Psychoanalytic Inquiry 2(2):181–191. Gillespie, W. (1995) Life, Sex and Death: Selected Writings. London: Routledge in Association with the Institute of Psycho-Analysis. Gillibert, J. (1984) ‘Généalogie de la destruction’, Revue Française de Psychanalyse 48(4): 987– 1019. Glasser, M. (1979) ‘Some aspects of the role of aggression in the perversions’, in I.Rosen (ed.) Sexual Deviation. Oxford: Oxford University Press. Glasser, M. (1985) ‘Aspects of violence’, paper given to the Applied Section of the British Society. Glover, E. (1964) ‘Aggression and sadomasochism’, in I.Rosen (ed.) The Pathology and Treatment of Sexual Deviations. Oxford: Oxford University Press, pp. 146–161. Graves, R. (ed.) (1959) New Larousse Encyclopedia of Mythology. Twickenham: Hamlyn. Green, A. (1983) Narcissisme de vie et narcissisme de mort. Paris: Minuit. Green, A. (1993) Le Travail du négatif. Paris: Minuit. Greenacre, P. (1950) ‘General problems of acting out’, Psychoanalytic Quarterly 19:455–467. Greenberg, J.R. and Mitchell, S.A (1983) Object Relations in Psychoanalytic Theory. Cambridge, MA: Harvard University Press. Grotstein, J.S. (1982) ‘The spectrum of aggression’, Psychoanalytic Inquiry 2(2):193–212. Grunberger, B. (1971) Le Narcissisme: essais de psychanalyse. Paris: Payot. Grunberger, B. (1977) ‘Study of anal object relations’, International Review of Psycho-Analysis 4(1):99–110. Grunberger, B. (1982) ‘Narcisse et Anubis’, Revue Française de Psychanalyse 921–938. Guntrip, H. (1968) Schizoid Phenomena, Object Relations and the Self. New York: Basic Books; London: Hogarth. Harris, J.E. and Pontius, A.A. (1975) ‘Dismemberment murder: in search of the object’, Journal of Psychiatry and Law 3(1):7–24. Hartmann, H., Kris, E. and Loewenstein, R.M. (1949) ‘Notes on the theory of aggression’, Psychoanalytic Study of the Child 3–4:9–36. Herzog, J. (1980) ‘Sleep disturbance and father hunger in 18–28-month-old boys’, Psycho-analytic Study of the Child 35:219–233. Herzog, J. (1982) ‘On father hunger: the father’s role in the modulation of aggressive drive and fantasy’, in S.W.Cath, A.R.Gurwitt and J.M.Ross (ed.) Father and Child. Boston: Little, Brown. Isaacs, S. (1943) ‘The nature and function of phantasy’, in M.Klein, P.Heimann, S.Isaacs, J.Riviere, Developments in Psycho-Analysis. London: Hogarth, 1952. Jones, E. (1915) ‘War and sublimation’, in Essays in Applied Psychoanalysis. London: Hogarth, 1951, vol. 1, pp. 77–88. Kaès, R., Faimberg, H., Enriquez, M. and Baranes, J.J. (1993) Transmission de la vie psychique entre generations. Paris: Dunod. Khan, M.M. (1971) The Privacy of the Self. London: Hogarth and the Institute of Psycho-Analysis. Kernberg, O.F. (1984) Severe Personality Disorders. New Haven and London: Yale University Press. Kernberg, O.F. (1991a) ‘The psychopathology of hatred’, Columbia University Centre for Psychoanalytic Training and Research and the Association for Psychoanalytic Medicine

Psychoanalytic understanding of violence and suicide

40

Symposium on Rage, Power and Aggression (1989, New York). Journal of the American Psychoanalytic Association 39:209–238. Kernberg, O.F. (1991b) ‘Sexual excitement and rage’, Sigmund Freud House Bulletin 15: 3–38. Kernberg, O.F. (1992) Aggression in Personality Disorders and Perversions: New Haven and London: Yale University Press. Kestemberg, E. (1971) ‘Discussion: panel on role of aggression in child analysis’, International Journal of Psycho-Analysis 53:321–323. Klein, M. (1930) ‘The importance of symbol-formation in the development of the ego’, in Love, Guilt and Reparation and Other Works, 1921–1945. New York: Delta, 1977a. Klein, M. (1946) ‘Notes on some schizoid mechanisms’, in Envy and Gratitude and Other Works 1946–1963. New York: Delta, 1977b. Klein, M. (1952a) ‘Some theoretical conclusions regarding the emotional life of the infant’, in Envy and Gratitude and Other Works, 1946–1963. New York: Delta, 1977b. Klein, M. (1952b) ‘On observing the behaviour of young infants’, in Envy and Gratitude and Other Works, 1946–1963. New York: Delta, 1977b. Klein, M. (1957) ‘Envy and gratitude’, in Envy and Gratitude and Other Works, 1946–1963. New York: Delta, 1977b. Klein, M. (1977) ‘On observing the behaviour of young infants’, in Envy and Gratitude and Other Works, 1946–1963. New York: Delta. Kohut, H. (1959) ‘Introspection, empathy and psychoanalysis’, Journal of the American Psychoanalytic Association 7:459–483. Kohut, H. (1966) ‘Forms and transformations of narcissism’, Journal of the American Psychoanalytic Association 14:243–272. Kohut, H. (1967) ‘Thoughts on narcissism and narcissistic rage’, in Psychoanalytic Study of the Child 27:360–401. Kohut, H. (1971) The Analysis of the Self. New York: International Universities Press. Kohut, H. (1977) The Restoration of the Self. New York: International Universities Press. Lacan, J. (1966) ‘Le stade du mirroir comme formateur de la fonction du Je telle qu’elle nous est revelée dans l’expérience psychanalytique’, in Écrits. Paris: Éditions du Seuil. Langer, M. (1989) From Vienna to Managua: Journey of a Psychoanalyst. London: Free Association Books. Laplanche, J. and Pontalis, J.-B. (1985) The Language of Psycho-Analysis. London: Hogarth and the Institute of Psycho-Analysis, 1967. Laufer, M.E. (1987) ‘Suicide in adolescence’, Psychoanalytic Psychotherapy 3(1):1–10. Laufer, M. and Laufer, M.E. (1989) Developmental Breakdown and Psychoanalytic Treatment in Adolescence: Clinical Studies. New Haven and London: Yale University Press. Laufer, M. et al. (ed.) (1995) The Suicidal Adolescent. London: Karnac Books. Lebovici, S. and Diatkine, R. (1972) ‘L’aggréssion est-elle un concept métapsychologique?’, Revue Française de Psychananlyse 26. Lebovici, S. and Soulé, M. (1970) La Connaissance de l’enfant par la psychanalyse. Paris: PUE Lester, D. (1987) ‘Murders and suicide: are they polar opposites?’ Special Issue: Homicidal Behaviour, Behavioral Sciences and the Law 5(1):49–60. Letarte, P. (1987) ‘Des caves de la Sorbonne a la drague rotative’, Revue Française de Psychanalyse 51(2): 737–749. Lévi-Strauss, C. (1949/1969) The Elementary Structures of Kinship and Marriage. Boston, MA: Beacon Press. Lévi-Strauss, C. (1968) Structural Anthropology. London: Allen Lane. Lichtenberg, Joseph D. (1982) ‘Frames of reference for viewing aggression’, Psychoanalytic Inquiry 2(2):213–232. Limentani, A. (1984) ‘On some aspects of human violence’, in Between Freud and Klein. London: Free Association, 1989.

Psychoanalytic understanding of violence and suicide

41

Limentani, A. (1991) ‘Neglected fathers in the aetiology and treatment of sexual deviations’, International Journal of Psycho-Analysis 72:573–584. Loewald, H.W. (1969) ‘Freud’s conception of the negative therapeutic reaction, with comments on instinct theory’, in Papers on Psychoanalysis. New Haven and London: Yale University Press, 1980, pp. 315–325. Lussier, A. (1971) ‘Discussion: panel on aggression’, International Journal of Psycho-Analysis 53:13–19. Malcolm, Ruth Riesenberg (1970) ‘The mirror: a perverse sexual phantasy in a woman seen as a defence against a psychotic breakdown’, in E.Spillius (ed.) (1988) Melanie Klein Today: Mainly Practice. London: Routledge in association with the Institute of Psycho-Analysis. Maltsberger, J.G. and Buie, D.H. (1980) ‘The devices of suicide’, International Review of PsychoAnalysis 7:61–72. Marcovitz, E. (1982) ‘Aggression: an overview’, Psychoanalytic Inquiry 2(1): 11–20. McDougall, J. (1978) ‘The primal scene and the perverse scenario’, in Plea for a Measure of Abnormality. London: Free Association, 1990. Meers, D. (1982) ‘Object relations and beyond the pleasure principle revisited’, Psycho-analytic Inquiry 2(2): 233–254. Meissner, W.W. (1991) ‘Aggression in phobic states’, Psychoanalytic Inquiry 11(3):261–283. Meloy, J.R. (1992) Violent Attachments. Northvale, NJ: Jason Aronson. Menninger, K.A. (1933) ‘Psychoanalytic aspects of suicide’, International Journal of PsychoAnalysis 14:376–390. Menninger, K.A. (1935) ‘A psychoanalytic study of the significance of self-mutilations’, Psychoanalytic Quarterly 4:408–466. Menninger, K.A. (1938) Man Against Himself. New York: Harcourt Brace. Menninger, K.A. (1942) Love Against Hate. New York: Harcourt Brace. Menninger, K.A. (1954a) ‘Psychological aspects of the organism under stress’, Journal of the American Psychoanalytic Association 2(1):67–106. Menninger, K.A. (1954b) ‘Psychological aspects of the organism under stress’, Journal of the American Psychoanalytic Association 2(2):280–310. Menninger, K.A. (1963) The Vital Balance: The Life Process in Mental Health and Illness. New York: Viking. Menninger, K.A. (1968) The Crime of Punishment. New York: Viking. Mitchell, S.A. (1993) ‘Aggression and the endangered self’, Psychoanalytic Quarterly 62(3): 351– 382. Ortmeyer, D.H. (1984) ‘Aggression in clinical psychoanalysis: a symposium: an inter- personal view’, 40th Anniversary Conference of the William Alanson White Institute, ‘Psychoanalytic Controversies and the Interpersonal Tradition’ (1983, New York). Contemporary Psychoanalysis 20(4):. O’Shaughnessy, E. (1981) ‘W.R.Bion’s theory of thinking and new techniques in child analysis’, in E.Spillius (ed.) Melanie Klein Today, vol. 2: Mainly Practice. London: Routledge in Association with the Institute of Psycho-Analysis. Osofsky, J.D. and Elberhart-Wright, A. (1988) ‘Affective exchanges between high-risk mothers and Infants’, International Journal of Psycho-Analysis 69:221–231. Osofsky, J.D. (1993) ‘Violence in the lives of young children’, position paper for the Carnegie Corporation Task Force on Meeting the Needs of Young Children. Unpublished. Osofsky, J.D. and Fenichel, E. (eds) (1994) Caring for infants and toddlers in violent environments. Virginia: National Centre for Clinical Infant Programs. Parens, H. (1973) ‘Aggression: a reconsideration’, Journal of the American Association 21(1): 34– 60. Parens, H. (1979) The Development of Aggression in Early Childhood. New York: Jason Aronson. Pasche, F. (1969) A partir de Freud. Paris: Payot.

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Perelberg, R.J. (1995a) ‘A core phantasy in violence’, International Journal of Psycho-Analysis 76(6):1215–1231. (In this volume, chapter 4.) Perelberg, R.J. (1995b) ‘The psychoanalytic treatment of young adults as a rite of passage. Discussion of the Conference on the Anna Freud Centre’s Young Adults Research Scheme’, Bulletin of the Anna Freud Centre 16(1):195–203. Perelberg, R.J. (1997) ‘Introduction’, in J.Raphael-Leff and R.J.Perelberg, Female Experience: Three Generations of British Women Psychoanalysts on Work with Women. London: Routledge. Petot, Jean-Michel (1991) Melanie Klein, Vols I and II. Madison, CT: International Universities Press. Reichard, S. and Tillman, C. (1950) ‘Murder and suicide as defences against schizophrenic psychosis’, Journal of Clinical Psychopathology 11:149. Rochlin, G (1982) ‘Aggression reconsidered: a critique of psychoanalysis’, Psychoanalytic Inquiry 2(1):121–132. Rosenfeld, H. (1971) ‘A clinical approach to the psychoanalytic theory of the life and death instincts: an investigation into the aggressive aspects of narcissism’, in International Journal of Psycho-Analysis 52:169–178. Sander, L. (1975) ‘Infant and caretaking environment: investigation and conceptualization of adaptive behaviour in a system of increasing complexity’, in E.J.Anthony (ed.) Explorations in Child Psychiatry. New York: Plenum Press, pp. 129–166. Sandler, J. and Freud, A. (1985) The Analysis of Defense: The Ego and the Mechanisms of Defense Revisited. New York: International Universities Press. Schachter, J. (1993) ‘A young man’s search for a masculine identity’, Bulletin of the Anna Freud Centre 16(1):61–72. Segal, H. (1964) Introduction to the Work of Melanie Klein. London: Heinemann. Segal, H. (1986) The Work of Hannah Segal. London: Free Association. (First published in 1981 by Jason Aronson Inc.) Shane, M. and Shane, E. (1982) ‘The strands of aggression: a confluence of data’, Psycho-analytic Inquiry 2(2):263–282. Shengold, L. (1989) Soul Murder: The Effects of Childhood Abuse and Deprivations. New Haven and London: Yale University Press. Shengold, L. (1991) ‘Father, Don’t You See I’m Burning?’ Reflections on Sex, Narcissism, Symbolism and Murder: From Everything to Nothing. New Haven and London: Yale University Press. Shengold, L. (1993) ‘The Boy Will Come to Nothing’: Freud’s Ego Ideal and Freud as Ego Ideal. New Haven and London: Yale University Press. Sohn, L. (1995) ‘Unprovoked assaults—making sense of apparently random violence’, International Journal of Psycho-Analysis 76(3):565–575. Solnit, A.J. (1972) ‘Aggression: a view of theory building in psychoanalysis’, Journal of the American Psychoanalytic Association 20(3):435–450. Spillius, E. (ed.) (1988a) Melanie Klein Today. Developments in Theory and Practice, vol. 1: Mainly Theory. London: Routledge and the Institute of Psycho-Analysis. Spillius, E. (ed.) (1988b) Melanie Klein Today. Developments in Theory and Practice, vol 2: Mainly Practice. London: Routledge and the Institute of Psycho-Analysis. Spitz, R.A. (1953) ‘Aggression: its role in the establishment of object relations’, in R.M. Loewenstein (ed.) Drives, Affects, Behaviour. New York: International Universities Press. Spitz, R. (1965) The First Year of Life. New York: International Universities Press. Stein, M.H. (Chairman) (1972) ‘Panel on aggression: panel discussion at 27th International Psychoanalytic Congress, Vienna, 29 July 1971’, International Journal of Psycho-Analysis 53(1):13–19. Steiner, J. (1993) Psychic Retreats: Pathological Organizations in Psychotic, Neurotic and Borderline Patients. London: Routledge, New Library of Psychoanalysis. Stern, D. (1985) The Interpersonal World of the Infant. New York: Basic Books.

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Stewart, H. (1992) Psychic Experience and Problems of Technique. London: Routledge in Association with the Institute of Psycho-Analysis. Stoller, R.J. (1975) Perversion: The Erotic Form of Hatred. New York: Pantheon. Stone, L. (1971) ‘Reflections on the psychoanalytic concept of aggression’, Psychoanalytic Quarterly 40(2):195–244. Stolorow, R.D. (1984) ‘Aggression in clinical psychoanalysis—a symposium: Aggression in the psychoanalytic situation: an intersubjective viewpoint’, Contemporary Psychoanalysis 20(4):643–651. Usdin, G. (1972) Perspectives on Violence. New York: Brunner-Mazel. Walker, N. (1968) Crime and Punishment in Britain. Edinburgh: Edinburgh University Press. Weiss, J., Lamberti, J. and Blackman, N. (1960) ‘The sudden murderer: a comparative analysis’, Archives of General Psychiatry 2:669–678. West, D.J. (1966) Murder Followed by Suicide. Cambridge, MA: Harvard University Press. Williams, A.H. (1984) ‘Violence et “non-digestion” psychique’, Revue Française de Psychanalyse 1057–1068. Williams, A.H. (1995) ‘Murderousness in relationship to psychotic Breakdown (madness)’, in Jane Ellwood (ed.) Psychosis: Understanding and Treatment. London and Bristol, PA: Jessica Kingsley Publishers. Winnicott, D.W. (1950) ‘Aggression in relation to emotional development’, in Collected Papers: Through Paediatrics to Psycho-Analysis. London: Tavistock, 1958. Winnicott, D.W. (1956) ‘The antisocial tendency’, in Collected Papers: Through Paediatrics to Psycho-Analysis. London: Tavistock, 1958, pp. 306–315. Winnicott, D.W. (1965) The Maturational Processes and the Facilitating Environment. London: Hogarth. Winnicott, D.W. (1950–55) ‘Aggression in relation to emotional development’, in Through Paediatrics to Psycho-Analysis. London: Hogarth and the Institute of Psycho-Analysis, 1982. Winnicott, D.W. (1969) ‘The use of an object’, International Journal of Psycho-Analysis 50:711– 716. Winnicott, D.W. (1971) Playing and Reality. London: Tavistock. Yorke, C. (1973) ‘Some suggestions for a critique of Kleinian psychology’, Psychoanalytic Study of the Child 26:129–158.

Introduction to chapter 2

In this paper Peter Fonagy and Mary Target formulate the hypothesis that both self harm and violence against others are linked to failures in the capacity to mentalise; the lack of capacity to think about mental states in the self and others may lead individuals to deal with thoughts and desires primarily in the realms of body states and processes. If a characteristic of the human mind is the ability to relate to one’s own as well as to others’ mental states,the borderline patient presents a failure in such capacities. The authors suggest that the problem can be traced to a crucial stage of development of the self when the child searches the face of his primary object for a representation of his own states of mind. Failure to find this forces him into pathological solutions to achieve a containing organisation. The authors explore the meaning of gender difference in the direction of aggression, and the way in which the child has a second chance to foster a secure psychological self through his relation to the father, even when the mother has been unable to support and to separate successfully. In this Fonagy and Target have been influenced by Donald Campbell’s stress on the role of the father in the analysis of a young suicidal patient (in this volume, chapter 3). The chapter also explores issues of technique in the treatment of a violent young man. Fonagy and Target’s line of thinking can be traced to psychoanalytic writings which emphasise the relevance of the maternal environment in the containment of the child’s anxieties, where the mother’s capacity to reflect on her child’s experiences becomes a representation for his own experience. Fonagy and Target believe that at the core of the self is the other, but this other represents the self. These ideas have had an impact on contemporary psychoanalytical thinking in Britain, as can be seen from some of the other papers in this collection.

2 Towards understanding violence: the use of the body and the role of the father

PETER FONAGY AND MARY TARGET

Introduction This chapter concerns the understanding of some violent patients. We aim to extend the thinking developed in previous papers (Fonagy, 1991; Fonagy et al., 1993), which described the use of aggression in some cases as a defence of the psychological self, weakened by childhood experiences of abuse or neglect, and threatened in all subsequent relationships. In this chapter, we consider cases in which no such abusive experiences have occurred, but a similar pattern of apparently senseless violence develops, towards either the self or other people. We also attempt to identify one route to this form of pathology in the disruption of early triadic relationships (Britton, 1989). Finally, we hope to illustrate that violence, aggression directed against the body, may be closely linked to failures of mentalisation, as the lack of capacity to think about mental states may force individuals to manage thoughts, beliefs and desires in the physical domain, primarily in the realm of body states and processes. Psychoanalytic thinking on aggression has been distracted by the controversy over the relative importance of innate destructiveness and environmental influences. As Mitchell (1993) has made clear, these polarised positions have important clinical implications. This is illustrated by the diametrically opposed views of Kernberg (1984) and Stolorow et al. (1987) on the technical handling of aggressive borderline patients, based on their differing views of the meaning of this behaviour. Mitchell himself adopts a position consistent with that put forward in our previous paper (Fonagy et al., 1993), that aggression is biologically rooted, but arises in response to perceived threats to the psychological self. In this chapter, we have tried to explore what it is that is felt to be endangered, what environmental and constitutional circumstances are likely to lead to such a sense of threat, and hence when aggression is likely to develop as a habitual response. We have offered a model (Fonagy, 1991; Fonagy et al., 1993) of the way in which physical or emotional abuse in childhood may lead to aggression. In such cases, we suggested, four things happen: (i) the child’s psychological self remains fragile, because the reflective process (capacity for mentalisation) underlying this part of the self is

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jeopardised. A child’s ‘theory of mind’ (Premack and Woodruff, 1978; Morton and Frith, 1995), his appreciation of the mental foundations of human behaviour, crucially depends on his developing awareness of the psychological world of his attachment figures. Perhaps even more importantly, it depends on the capacity of the mother (or primary caregiver) to demonstrate to the child that she thinks of him as an intentional being whose behaviour is driven by thoughts, feelings, beliefs and desires (Fonagy et al., 1991). This essential intersubjective process is compromised if the caregiver’s thoughts about the child are often malevolent, and the child no longer feels safe to think about his object’s thoughts about him or to see people as thinking. (ii) As a second step, aggression is brought in to defend the fragile psychological self from the assumed hostility of the object. (iii) A third stage is reached, when self-expression and aggression are associated so regularly that a pathological fusion can occur between the two (self-expression becomes isomorphic with aggression). (iv) Finally, the reduced capacity to mentalise, to picture the mental states of the other, reduces inhibition of aggression by representing the victim as devoid of thoughts, feelings and the capacity for real suffering. It is relatively easy to discern this pathway to violence in patients whose background is part of the so-called cycle of abuse. There are, however, other patients with an apparently similar psychic structure, who also tend to respond with violence under little or no provocation, but whose environments appear to have been relatively benign (Weiss, et al., 1960; Blackman, et al., 1963). We suggest that in these cases also certain forms of violence have been done to the child’s psychological self, but that these were more subtle, hard to pinpoint in external relationships, and usually only become clear in an intensive personal encounter, such as psychoanalysis. Nevertheless, they may be seen to have led to the same end-point, a fragile capacity for mentalisation, protected by aggression aimed at anything challenging this capacity. The form of aggression which we are describing here can readily be differentiated, phenomenologically, from sadism, where a capacity to imagine the feelings of the other is probably essential to full enjoyment. Glasser has made a similar distinction, between what he calls self-preservative violence and sadism or malicious violence (Glasser, 1986). The most extreme form of the more sadistic type of aggression is the planned, purposeful and emotionless violence of the psychopathic character. However, it is possible that a similarly fragile capacity to envision the state of mind of the other may be involved. Sadistic individuals may need an amplified experience of the other’s thoughts and feelings to experience intersubjectivity; they are unable to love, as this represents an insufficiently dramatic experience of psychological closeness (Fonagy, 1993). Therefore they may need to create a stereotyped form of interaction in which the thoughts and feelings of both partners are intensely involved, in order to feel in contact. However, although such a character may share a blunting of the ability to mentalise, there is an essential difference from the aggression we consider here, in that sadistic behaviour is not an attempt to defend the self. In contrast, the violent individuals we consider here, having sought proximity, then feel trapped by a persecutory object (Meloy, 1988). The act of mindless aggression is characterised by an inexplicable build-up of uncontainable tension and rage just before the violence, the perception of the victim as a threat, and feelings of being out of control during the violent act. The act is aimed at reducing this threat and regaining intrapsychic equilibrium (Meloy, 1993). We wish to explore the nature of the phantasy enacted in this act of preservation of the psychological self through violence.

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In many cases of violence, there is aggression towards both other people and the self. The central thesis of this chapter is that in both cases the underlying motive is the same, a wish to attack thoughts, in oneself or in another. As one of our patients shouted in a tirade: ‘If I kill you, I won’t have to think about what you think.’ Similarly, attacks on one’s own body, such as self-cutting, may be seen as an attempt to blot out intolerable thoughts or images in the patient’s own mind. We hope the cases described below will illustrate this point. A further issue we consider is that of analytic technique with aggressive patients, when because of the fragility of the psychological self, analysis may be the most threatening situation which such individuals can experience. How can a pathological organisation focused on the destruction of empathy and compassion be changed using a technique based on just these qualities? Case illustration1 Mr T came to see me feeling depressed and empty, worried that his psycho-logical difficulties were threatening his promising career. He had a congenital deformity of the spine that, despite several operations, gave him increasing pain and difficulty in walking. Mr T was of medium height but his unkempt hair, unshaven pale face, dirty clothes and piercing look give him a sinister appearance. He drank heavily to blot out physical and psychological pain, but when drunk became violent and had several criminal convictions for assault, the most serious of which was an unprovoked assault with a beer bottle, causing severe head injuries to a stranger in a bar. As he recounted the story, Mr T felt 1 The analyst was the first author.

overwhelmed by rage, provoked by the thought that the stranger had been mocking his deformity. Subsequently, he realised that he simply had no idea what that person had been thinking or feeling. In this way, he gave me an early indication, demonstrated repeatedly in the transference, that his understanding of the mental states of others, as well as his own psychic functioning, was at best partial. Whilst asking for my help, Mr T immediately showed contempt for what I might have to offer. His mother was a doctor, who knew lots of ‘shrinks’. ‘They cling on to their patients.’ I suggested that he was frightened that analysis might bring his own need to cling closer to the surface, and that no one, including me, would be able to cope with that. Needless to say, he sneeringly rejected my interpretation. Mr T gave me an immediate taste of the potent mix of self-punishment and cruelty which organised his life. He started his first analytic session by suddenly taking off his shirt to reveal his deformed back, leaving it exposed for the entire session. I felt revulsion, confusion and then shame, eventually commenting to Mr T about what might be his terror of rejection, and his perhaps habitual way of pre-empting this anxiety by trying to control the feelings of those around him. He reacted with derision: ‘That’s shit, and you know it.’ I believed that what I had said was true, but I sensed that my understanding had no meaning for Mr T. It seemed that any further attempt at empathy with the sense of injustice and hurt which seemed to drive his bitter hatred would be

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futile. At this stage I simply added: ‘It seems that you feel safer when someone is uncomfortable.’ To this he readily agreed. In this initial session, Mr T demonstrated a pattern of interaction between us which was to become familiar: a persecutory, cruel but damaged object (in this session represented by his back) and a figure seen as shamed, uncomfortable and weak (sometimes himself and sometimes me). Perhaps even more characteristically, I found myself the reluctant recipient of thoughts and feelings which his behaviour brutally forced upon me. I began to feel that for Mr T, language and symbolic communication could not adequately convey psychic experience. He was forced to resort to communication through his body to convey to me the most important aspects of his experience of himself, his sense of inadequacy and his experience of his mother’s shame and revulsion. Mr T was the only child of an unusual family. His mother, 25 years younger than his father, had had an affair throughout most of Mr T’s childhood and adolescence. When Mr T was about 5, his mother embarked on medical training and he was looked after by a housekeeper. He was sent away to boarding schools from the age of 6. Mr T’s father died of a chronic cardiac failure when his son was 17 years old. His dominant memory of him was as someone constantly ill, sometimes suicidally depressed, and in later years confined to a wheelchair. Mr T did not mourn his father’s death, but from that age suffered a series of major depressions with manic episodes, drank heavily and abused drugs. He had his first breakdown whilst still at school. He withdrew and refused to work. At this stage he had two compulsive activities: reading computer magazines, and masturbation. He felt ‘whole and someone when [his] penis was erect’. Mr T went on to music college, where he specialised in self-destructive performances, for example, in a well-attended leavers’ concert, he played ‘silent music’, drumming his fingers on the side of his head. Early in the analysis Mr T frequently sat in the chair or on the couch saying very little, but these silences never felt totally isolating. He spoke just enough for me to know I was in the company of a torturing superego. He habitually denigrated his analyst and other patients, criticised my consulting room, kicked my books or the furniture. Although I made strenuous efforts not to deprive him of any analytic time, I would find myself blamed for obstructing his progress and for not giving him extra time when he was late. He mentioned no relationship which was not characterised by exploitation, hatred, envy or criticism. All experiences of understanding in the transference and outside it were seen as evidence of weakness and fear, and love was ‘crap’. Mr T would reject my attempts at making links, and used this to confirm my uselessness as an analyst. He was terrified of mental disintegration and was often confusing and almost incoherent. He controlled his anxiety between sessions by taking cocaine and ecstasy. In the session he physically intimidated me, rushing around the room wildly, standing in front of my chair or on the table, at other times curling up like a baby, locking himself in the lavatory, or leaving in the middle of the session kicking my chair as he went. Although frequently menacing and abusive, he never actually hit me and, after starting his analysis, reduced his tendency to violence outside, provoking no further arrests. I tried to stand my ground, careful not to interpret his actions as attacks on me or the analysis, or to give them unconscious meaning, beyond that of an ordinary human

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gesture. I felt we were in a space without meaning. He acted impulsively, unable to put into words the feelings and ideas which made him behave this way. At this stage, my task was to offer him recognition, however tentative and however quickly rejected. For example, when he stood on the table, I said ‘I know you are frightened that you look ridiculous, but doing things like this simply exaggerates your vulnerability.’ At another time, when he lay on the floor in a foetal position, I walked over to him, sat down somewhat wearily, and said: ‘Oh well, if you want to be like a baby in here that’s fine, but let’s carry on talking anyway.’ My interventions restored contact with him at a human level, and usually some kind of analytic dialogue would resume. The challenge was to experience both what Mr T conveyed by talk and what he conveyed by projection (or perhaps by projective identification) while at the same time preventing him, through interpretation and confrontation, from living out his defensive phantasy in the transference. Unless I was alert, he used the analysis as a refuge from life, as opposed to a process which could regenerate life. My sense was that in Mr T’s mind we needed one another, not as part of a mutually beneficial and satisfactory relationship, but because our dissatisfaction with one another kept a greater fear away, the terrifying mental void left by an absence of thoughts and reflectiveness. He recalled a dream of two hens pecking at one another. Behind the hens was a dangerous rabid dog but the hens took no notice—they were too busy fighting. I understood this as indicating that the constant conflict with me diverted attention from something far more frightening, which would confront and overwhelm us if we had space to reflect. The dream also suggested an anxiety connected with a third figure, an onlooker. This theme was to recur in many forms. Mr T came half an hour late to a session, shortly before the Christmas break. He did not lie down on the couch, but limped painfully round in circles. When I tried to interpret his lateness and restlessness in terms of the approaching break, he dismissed this and said ‘You know, being here with you makes me feel worse. I feel worse now than I have ever felt.’ I replied ‘I am not surprised you feel bad if you walk round in circles, hurting yourself and making yourself dizzy.’ He sat down, with a smile, and told me a dream. In this dream there was a big drum. He was on top of it, and by moving, he could make the drum roll around, yet stay on top. However, at the same time he pictured himself as terrified, trapped inside the drum, about to lose his balance and fall over as it moved. He was also aware of people on a balcony, who were apparently indifferent to his struggle to keep balance. I interpreted that he wanted to be on top and be in control of me and the analysis, but in so doing he threw himself off balance. He felt that I was not really part of what was happening, but just on the balcony, able to see him but not to rescue him. To this he responded by getting up, hobbling round the room and finally saying he wasn’t sure where he was. I said: ‘I think you know that you need me, because you feel that a part of you is supported and sustained by me thinking about your struggles. I think you are terrified that you will lose yourself completely over the Christmas break.’ Although he looked thoughtful, he did not respond to this interpretation and eventually left the session early. Mr T portrays himself accurately as terrified of being locked into an infantile dyadic relationship with his mother-analyst. He sees himself as trying to control his mother, but in fact at the mercy of the slightest changes in her position, and frightened of being trapped inside her. He might fantasise that he is on top and in control, but this barely

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disguises his sense of helplessness: where the drum goes, he goes. To be liberated from this horrific predicament, he would have to gain a third perspective—a lifeline from the outsider (father) on the balcony. However, the people on the balcony are indifferent and ineffectual. In the second and third year of his analysis, Mr T’s deadening form of defensive organisation was gradually replaced by something almost its opposite. He had panic attacks on the couch, his body visibly shaking. Underlying the panic was deep rage about the unfairness of our situation: nothing anybody could say or do could give him the body that a person might be proud of rather than disgusted by. We began to talk more meaningfully of his anger about his disfigurement and his envy of me as able-bodied. Mr T’s sense of his mother’s disgust with his body began to emerge, and overtly entered the transference. There was a screen memory of the mother looking away from him with revulsion, as he was trying to show off how straight he could stand. This material emerged as Mr T began to discuss his girlfriend’s distaste about his sexuality. There were also memories of his childhood exhibitionism, for example, at age 6 or 7, standing at the window exposing his penis to passers by. It seemed that, in the incident with his mother, his back was also a displacement from his erect penis. His experience was that his entire body including his sexual excitement was unacceptable to her. I had the impression that Mr T did not possess a maternal ‘good object’ in his mind who saw him as a whole and could love him in spite of his imperfections, and who could mourn the loss of a perfect child. In part, he seems to have retreated from the rejection through identification with a paternal object whom he perceived as similarly damaged and rejected. At the same time, he withdrew from the world of other people, and became very isolated. He remembers, as a child, filling his time with carving, particularly making very sharp, elaborately decorated knives from wood, and with breaking old musical instruments, which he then burned. Mr T’s own damaged body and the infirmity of his father appeared to have left a legacy of hatred and intense guilt, which made it unbearable for him to be aware of any concern. This was illustrated when he assumed that a session cancelled by me was due to a hospital appointment. His familiar attacks took on a renewed viciousness and hatred; his panics increased in the sessions and outside. Repeated interpretations of his anxiety about feeling concern, which might overwhelm him, brought the memory of his father’s heart attack into the material. One night his father, near collapse, had stumbled into Mr T’s room and said he could not breathe. My patient had replied: ‘So what, I don’t care!’ and had gone back to sleep. My immediate reaction was of horror at his callousness. My counter-transference together with his reaction to my supposed illness made me appreciate the depth and reality of his need to destroy his paternal object. As these matters became the dominating themes in Mr T’s material, his external situation improved. He has become increasingly productive and successful, and rekindled a relationship with an old girlfriend who admired and supported him, although he has remained frequently contemptuous of her. He uses the analysis more positively; he has turned into a prolific dreamer and talks coherently in most of his sessions. His testing of the analytic boundaries has lessened, but he sometimes comes late or leaves a few minutes early. He can see the analysis as helpful in containing his impulsivity, and his attacks on the relationship are outweighed by periods of genuine contact.

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A further session might help to illustrate this. Mr T was on time. He was evidently filled with excitement and he actually ran into me. He lay down and talked very rapidly. He said that he had to talk fast because he had three dreams to tell me about. In the first dream a boy was feeding ducks at the riverside he stayed at on holiday. He remembered the ducks stretching their necks to be the first to reach the food. He associated to this dream a holiday incident when he was feeding swans, and a memory of being a small boy and going to feed the ducks with Ruth, the housekeeper who looked after him. He remembered being afraid of offering food to them in case they bit his finger. In the second dream he was on a trampoline kicking against the elastic surface, soaring into the sky. In the third and most disturbing of the dreams he had an image of a house which falls down because the roots of an adjacent tree undermine the foundations. He had an image of the roots growing into the bricks and mortar. He was silent for a while. I said: ‘You feel torn in two directions. There is some part of you that is so excited to see me that you almost want to jump into me. But for another part of you, wanting to be so close is terrifying because you feel that it would undermine the foundations of the analysis.’ He gave something like a ‘hmm’ of agreement but he continued in a less manic way to talk about his holiday. He gave many details about where he had been, how they drove around and where they stayed. I noticed how he became increasingly anxious and critical as he touched on the subject of how eager and greedy people were to get into a concert in one of the places he stayed at, reaching across each other’s shoulders to get at the cashier who was giving out the tickets. I said he was frightened to be seen to be wanting to reach out to people, and went on ‘I think your way of dealing with this is to attack first, but I think you want me to know that there is a little boy inside you with a yearning hunger for the analysis, but it is very frightening in case the excitement and demandingness get out of hand and you feel overwhelmed by the wish to push others out of the way.’ Mr T did not reply directly but his anxiety seemed again to subside. Mr T said he supposed he was quite complicated to understand. He talked of his mother and how she at times implicitly understood him. When he got into a tantrum she would take him into her bed to soothe him. Then he said how he and Andrew, an older boy who seduced him when he was 10, used to play out fantasies, pretending to each other they were dreams. If something is a dream you don’t have to feel guilty about it. Despite the double-edged nature of this communication Mr T sounded sincere. I felt he was both trying to twist the real contact he felt at the beginning of the session (when he felt like jumping right into me) and at the same time telling me about an aspect of himself. I said that I thought he was feeling that he was being quite complicated at the moment because he wanted to do two quite opposite things: he was trying to get us twisted together but was frightened in case the tangle would become a destructive one, that his wish for affection would be mistaken for a homosexual overture. But at the same time he wanted to tell me how the realness and power of his fantasies could frighten him. Mr T surprised me by responding in quite a warm and natural tone that he thought that was true. He went on to say that as a child, on family walks, he used to run ahead of the family and hide. When the rest of the family passed him he would jump out and frighten them. He now realised that he had hoped that he would be looked for and found. When they showed no sign of this he would frighten them to cope with his disappointment. I said: ‘I think you know it’s near the end of the session and you are frightened that I will

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not look for you and find you tomorrow. I think you feel that you almost have to frighten me in some way, like jumping off the couch and leaving early, so you can be sure that I won’t overlook you and will keep you in mind until tomorrow. By manipulating me and getting tangled within me you could be sure that I would not leave you and walk past you when I returned.’ He considered what I said and added that it seemed to him that for him the analysis was ‘for real’.

Discussion Inevitably, there are many ways of understanding Mr T’s material. His deformity, and his experience with a seductive yet rejecting mother may have created a deep uncertainty about his self-worth, and undermined his sense of identity. His ability to negotiate Oedipal experiences adequately is likely to have been jeopardised by his father’s vulnerability and his own disfigurement, together with his mother’s overt neglect of both men in the family. Damaging oneself may be a displacement from the other to the self, part of a desperate attempt at achieving control over murderous rage and guilt. For example, Mr T’s primitive guilt about the damage he might have done to his objects may have led him to attack and degrade himself, the murderous act condensed into selfdestruction and self-abasement. The need to hurt himself may also have been a response to a sense of emptiness and deadness. Mr T’s alcohol and drug abuse, his desperate searching for sensation and excitement, may have counteracted the experience of internal, emotional vacuum. Without questioning the importance of these and other perspectives on the case we have described, we would like to explore three particular lines of thought, for their contribution to understanding Mr T and others who readily resort to violence. We suggest first of all that a dysfunction of mentalisation is a central feature of such disorders. A second, related aspect of Mr T’s complex disturbance may have been his tendency unconsciously to represent his own mental states in bodily terms, and consequently to feel that the minds of others were accessible via their bodies. The third theme that we address is the role of the father in the psychic development of violent individuals. In a final section, we point to some technical issues in the management of such individuals in a psychoanalytic setting. The root of violence in the fragile psychological self We suggest that Mr T’s difficulties began with a failure to integrate his mother’s perception of him into his self-image. Her perception was likely to have been of a freak whom she had created. This painful, shaming image could not be assimilated, probably by either of them, and the formation of Mr T’s self structure was disrupted. The dialectical theory of self-development (first stated by Hegel)2 assumes that the psychological self develops through perception of oneself, in another person’s mind, as thinking and feeling (Davidson, 1983). We speculate that the narcissistic injury to the mother of having her only child born deformed was so catastrophic that she could not think about him, particularly about his true experience of himself. There was no physical abuse, but where in his mother’s mind there should have been a child with thoughts and

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feelings, there was too often emptiness, a space, nothing on which he could build a viable sense of himself as thinking, believing or desiring. Habitual violence towards either the self or another may reflect a failure to meet the fundamental need of every infant to find his mind, his intentional state, in the mind of the object (see Fairbairn, 1952). For the infant, internalisation of this image performs the function of ‘containment’ (Bion, 1962), which Winnicott has written of as ‘giving back to the baby the baby’s own self’ (Winnicott, 1967, p. 33). Failure of this function leads to a desperate search for alternative ways of containing thoughts and the intense feelings they engender. The search for alternative ways of mental containment may, we suggest, give rise to many pathological solutions, including taking the mind of the other, with its distorted, absent or malign picture of the child, as part of the child’s own sense of identity. This picture then becomes the germ of a potentially persecutory object which is lodged in the self, but is alien and unassimilable. There will be a desperate wish for separation in the hope of establishing an autonomous identity or existence. However, tragically, this identity is centred around a mental state which cannot reflect the changing emotional and cognitive states of the individual, because it is based on an archaic representation of 2 ‘Self consciousness exists in and for itself when, and by the fact that, it so exists for another; that is, it exists only in being acknowledged. This has a two-fold significance: first, it (the self) has lost itself for it finds itself as an other being; secondly, in doing so, it has superseded the other for it does not see the other as an essential being, but in the other sees its own self. First it must proceed to supersede the other independent being in order thereby to become certain of itself as the essential being; secondly, in so doing it proceeds to supersede its own self, for this other is itself’ (Hegel, 1807, p. 111).

the other, rather than the thinking and feeling self as seen by the other. Winnicott (1967) wrote: What does the baby see when he or she looks at the mother’s face?… ordinarily, the mother is looking at the baby and what she looks like is related to what she sees there…[but what of] the baby whose mother reflects her own mood or, worse still, the rigidity of her own defences…. They look and they do not see themselves…what is seen is the mother’s face. (p. 27) Paradoxically, where the child’s search for mirroring or containment has failed, the later striving for separation will only produce a movement towards fusion. The more the person attempts to become himself, the closer he moves towards becoming his object, because the latter is part of the self-structure. This is illustrated in Mr T’s dream of the drum, in which his mental movements and the mother’s were bound together; the most he could hope for was the illusion of mastery, quickly dashed by the sense of being trapped inside. This in our view accounts for the familiar oscillation of borderline patients, between the struggle for independence and the terrifying wish for extreme closeness and fantasised union. Developmentally, a crisis arises when the external demand for separateness becomes irresistible, in late adolescence and early adulthood. At this time,

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self-destructive and (in the extreme) suicidal behaviour is perceived as the only feasible solution to an insoluble dilemma: the freeing of the self from the other through the destruction of the other within the self. Consistent with this, a number of writers have described a central fantasy common to states of mind preceding suicide attempts (Maltsberger and Buie, 1980; Campbell, 1995 and chapter 3 in this book). ‘By projecting the hated, engulfing or abandoning primal mother on to the body and then killing it, the surviving self is free to fuse with the splitoff idealised, desexualised, omnipotently gratifying mother’ (Campbell, 1995, p. 13). Here, we see the desperate bid to break free of a mother felt to have invaded the child’s mind, rather than having given the child a sense of his own mind, first perceived in hers. We suggest that the absence of the experience of having been recognised in this way left a deep longing, in Mr T, for a mother who could have made the child feel loved, as a separate person with separate experience which could be tolerated within her mind; instead, his overtures to the mother may have faced a shrinking rebuff. The use of the body Where a patient cannot easily conceive of an object at a psychological level, he may seek identifications or create representations of mental states via the body, and this can predispose to acts of physical violence directed at himself or others. Mr T’s attacks on his own body were in part, we believe, attacks on the mother’s mental state (whether of revulsion or of emptiness), a desperate attempt to clarify the distinction between his own sense of himself and his mother’s sense of him. The patient’s unconscious fantasy may be that ideas reside in the body—they can be held together by holding the penis, driven out by drumming on the head, fended off by attacking another person’s head, or his books. Mr T’s disturbance is perhaps echoed by many individuals who harm themselves. A 23-year-old woman, suffering from intense panics, with a history of anorexia nervosa and serious self-mutilation, brought a dream in the first months of her psychotherapeutic treatment. In the dream, she was aware of a feeling of terrible tension which she could only relieve by opening up her veins and watching her blood flow. The blood ran in tributaries which joined up and made a river. The river became wider and wider and flowed into an ocean. Her associations quickly led to the waterways of her mother’s country of origin, which her mother had often talked to her about in her early years. Making the link between her lines of thinking about her mother over past sessions and her experience of relief in ‘bloodletting’ led her immediately to share the fantasy that her mother somehow resided within her own body. As this image was elaborated over subsequent sessions, both patient and analyst became aware that she experienced her mother as living within her skin, that starving herself or self-cutting were both aimed at attacking this other being, and relieving her of the fantasy of a shared existence. We suggest that patients such as Mr T experience the bodily self as a refuge (Steiner, 1993) in which they have some sense of safety and understanding. If objects cannot be properly represented as thinking and feeling, they may to some extent be controlled, distanced or brought into proximity through bodily experiences. As self-cohesion is limited by inhibition of the capacity to reflect on and integrate mental experiences, these patients call upon bodily experiences to provide a sense of consolidation.

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The incomplete structuralisation of the self also enables patients such as Mr T partially to disavow ownership of their bodies. This is of primary importance in patients who control their thinking by harming themselves, since the pain and discomfort (as when Mr T walked round and round in my office) is probably only bearable because of a pathological separation of the psychological self-representation from the representation of the physical state. Maltsberger and Buie (1980) in their study of states of mind preceding suicide attempts, demonstrate that this separation is starkly evident in the thinking of many people intending suicide. As bodily states are to a certain extent represented outside the psychological self, the former are available as a stage upon which the nature and functioning of the mental world can be actualised and enacted (McDougall, 1986). A pernicious problem faces those who try to use this defensive manoeuvre to by-pass the mind, but whose bodies are actually damaged. This was the case with Mr T, who fell back on his body as the theatre of his mental experience, but was confronted with a denigrated, defective object. This is also the case for individuals with chronic physical illnesses (e.g. diabetes), whose use of the body to represent psychological states frequently leads to self-damaging acts with irreversible longterm consequences (Fonagy and Moran, 1993). Naturally, such individuals may always have been more vulnerable to inhibition of the psychological self because, as was the case for Mr T, their early relationships have often been profoundly distorted by their parents’ feelings about their physical disabilities. It is interesting, in this context, that Mr T had in fact exaggerated his disability, so that his posture and gait had become more abnormal over the years, and more than could be explained by his physical condition. This may have represented partly an increasing identification with the handicapped father, and partly the accumulation of mental suffering expressed through his physical state. The role of the father Loewald wrote in 1951 of the castration threat as the danger of engulfment of the emerging ego by the mother—infant unity, and he pointed to the crucial way in which the father could help the child: ‘Against this threat of maternal engulfment, the paternal position is not another threat or danger, but a support of a powerful force’ (Loewald, 1951, p. 15). Greenacre (1960) and Mahler (Mahler and Gosliner, 1955; Mahler et al., 1975) both note the importance of the father to the pre-Oedipal child as a figure ‘less contaminated’ by the ambivalence which affects the maternal image, or a ‘breath of fresh air’ in the separationindividuation process. Stoller (1979) sees the father as a shield to protect the child against the mother’s wish to prolong symbiosis, and thus a facilitator of the separation-individuation process. Abelin (1971, 1975) postulated an ‘early triangulation’ in the second year, an essential precursor to the Oedipal triangle, which is seen as ensuring the transition from mirroring one-to-one interactions to symbolic representation of more than one object, including the self. We suggest that Mr T’s father might have performed two important roles in mitigating the effects of the deformity on both mother and child. Had he been able to share mother’s burden and grief in the face of his son’s handicap, she might have been freed to think of Mr T in ways other than as a cripple. Equally important, we suggest, is father’s role in the development of the child’s mental self: the child needs to experience the father as

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somebody looking at his relationship with the mother, and at his attempt to find a viable image of himself in her mind. In favourable circumstances, the father enters the mental world of the child in the first year of life (Burlingham, 1973; Stern, 1994). A secondary caregiver, his role goes beyond that of developing his own dialectical relationship with the child, it has an extra dimension. The child sees in the father not only a perception of himself as a psychological entity, but also the father’s perception of the child in relation to the mother. Thus, even should the mother—infant relation be seriously flawed, the child can enter into an intersubjective relationship with somebody who sees him as interacting; this extends the psychological self. Abelin argues, along lines very similar to the current formulation, that in the loving interaction of one attachment object (the mother) with the other (the father), the toddler perceives and recognises for the first time his own frustrated wish for the object. Abelin (1971, 1975) basing his thinking on the work of Piaget, assumes that triangulation arises out of the conflict between two ways of interacting, between two ‘sensorimotor schemata’ representing patterns of interaction between the child and each caregiver. Seeing the possibility of two ways of interaction breaks up the symbiotic unity with the mother. Contrary to Abelin, we see the essential difference between the mother-infant and father—infant relationship not in terms of contrasting sensorimotor patterns, but of contrasting perceptions of the child’s mind, and, even more importantly in the case of the father, an external perspective on the child’s primary object relationship. It is this latter aspect which may be necessary in some cases to release the child from a pathological symbiotic unity. However, this crucial safety net may also be absent. Mr T, with his elderly, sick father, rejected by the mother, was not offered a way out through his father’s image of him and of his relationship with the mother. Instead, he was confronted by another mental absence, or at best the equally painful perception of his father’s recognition that the mother—child relationship was riddled with disappointments. He was left to struggle with the diffuse and confusing primary dyadic relationship, unable to differentiate what was him and what was her. There is much evidence of the adverse impact of the absent father (see for example, Neubauer, 1960; Herzog, 1980, 1982; Burgner, 1985; Stoller, 1985; Wallerstein and Blakeslee, 1989), and some of this points to a link with attacks on the self or others. Herzog (1980, 1982) in particular highlights how absence or loss of the father during the first years can undermine the infant’s capacity to modulate aggression. Campbell (1995 and in this volume) has also highlighted the damaging effect of a father’s absence when the mother—child relationship is unsatisfactory, through examination of fantasies in suicidal patients. The patients’ suicide fantasies articulated in the present represented internalised early pathological relationships between mother and child and father. The pre-Oedipal father’s role was often obscured by the patient’s relationship with the mother which dominated the suicide fantasy and by the father’s absence or ineffectiveness. However, it was during the presuicide state that the internalised father’s failure to intervene in the pathological mother—child relationship became most critical. (Campbell, 1995 and in this book, p. 82)

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In classical psychoanalytic theory, the paradigmatic violent act is the Oedipal murder of the father. Ron Britton (1989) has given a compelling account of the importance of the father in the child’s developing thinking, and his description in many ways overlaps with ours. He describes the way in which the child needs to be able to accommodate the perspective of a third person, the father, opening up the Oedipal situation into a triangle, allowing space to think. He relates the profound difficulties of certain patients in analysis to the lack of this third dimension. Britton sees the wish to obliterate the third position as the child’s attempt to avoid thinking of the reality of parental intercourse, that the thinking of the analyst is similarly thought of as representing this intercourse, and therefore as a threat which has to be annihilated. We follow Britton in seeing violence, and specifically destructiveness towards the analyst and analysis, as expressing a wish to obliterate unbearable thoughts, to destroy reality and to restore omnipotence. However, at least in some cases, such as that of Mr T, we feel that the notion of destroying the image of parental intercourse seems not to be the most important basis of the pathology. In this case, and we would suggest in others, it is necessary to consider another aspect of the role of the father, which gives the child an additional perspective on himself, and (crucially) enables him to think about himself in relation to another. We suggest that this patient, in wanting to let his father die, wanted to destroy his father’s awareness that Mr T, too, was ignored and discarded by mother. Mr T could relieve himself of the burden of this view if he did not allow the perspective of a third. So, the Oedipal situation in a sense is turned on its head: we may see a wish to murder father, to eliminate not a rival but a witness. To kill the crushing confirmation, by the father, of the failure and unreality of the child’s omnipotent Oedipal fantasy. This formulation may be seen as an extension of Grunberger’s (1979) exploration of the narcissistic repercussions of Oedipal experiences. The child’s capacity to withstand the stresses and strains of normal development requires that he has someone whose capacity to reflect upon his relationship experiences he can internalise and identify with. Sometimes, the mother herself will be able to communicate to the child not only a perception of his psychological self, but also of the child in relationships with herself and others. However, at other times the mother cannot supply this independent perspective, perhaps because of a persistence of primary maternal preoccupation (Winnicott, 1956), or, more pathologically, because of entanglement in her own past (Main, 1991), or because of current preoccupations (as in maternal depression, Green, 1983). The father’s capacity to present the child with a reflection of his place in relationships then becomes essential to the child’s developing capacity to perceive himself in relation to the object. This leads us to a related problem: why do aggressive men more often direct their hostility towards others, while self-mutilation is more common in women? We believe that both forms of violence suggest an attempt to be rid of an intolerable phantasy of the thoughts in somebody’s mind, originally the thoughts of a parent. The gender imbalance may then reflect a wish to attack the thinking of the same-sex parent (with whom identification is potentially more painful and inescapable). For both girls and boys, the mother’s thoughts about the child have generally been intersubjectively experienced earlier, and are represented as within the child’s mind. The father’s thinking is represented in both sexes as external. The intolerable mental presence of the same-sex parent is then felt to be inside the woman’s mind, but outside the man, in other people or

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objects which represent the father. In contrast, as we have said above, for the man (as for the woman) trapped in a sense of engulfment by mother, escape may be sought in suicide. A predisposition to mindless violence is a probable outcome in cases, such as Mr T, where the child’s identity remains diffuse, poorly separated from that of the mother, and the primary relationship cannot be reflected on. The sense of self is fragile and readily threatened, and the pathological amplification of the intentional stance, aggression, may become the only way in which the individual can see himself existing in relation to others. The girl is more likely to try to resolve this confusion, and rid herself of the mother in her mind, by attacks on herself; the boy more often directs his aggression at the father’s thinking, represented by others. In the transference, both may be expressed in attacks on the analyst. Technique with violent patients We suggest that the interpretation of aggression towards the analyst as attacks on the analysis is futile in cases such as this, and frequently actually counter-productive. Patients such as Mr T try to exert total control over the analyst’s mind and use it as a vehicle for their projections in order to deny the separateness of the fragile psychological self and the object which has become incorporated in it, and thus to deny the possibility of the object’s loss. True progress may only be made when the bondage of the analyst’s independent mental functioning is abandoned by the patient. This may be achieved by facilitation of the process of mourning of the illusory omnipotence which merger with the object provides. Interpretations need to address the confusion from which violence emanates, and the illusory clarity that it brings. The obstacle is the patient’s terror of a mind which offers understanding, which in the transference is the one which so disastrously failed him in the past. Steiner (1993) has described patients who wish to understand, and others who wish only to be understood. Furthermore: a few patients appear to hate the whole idea of being understood and try to disavow it and get rid of all meaningful contact. Even this kind of patient, however, needs the analyst to register what is happening and to have his situation and his predicament recognised. (Steiner, 1993, p. 132) For a considerable time, Mr T was certainly a patient of this kind, and the analyst was only allowed to offer recognition rather than understanding. How does this ‘recognition’ help an individual dedicated to the avoidance of reflection? Interpretations may remain helpful, but their function is certainly no longer limited to the lifting of repression and the addressing of distorted perceptions and beliefs. As Winnicott put it: ‘Psychotherapy is not making clever and apt interpretations…. It is a complex derivative of the face that reflects what is there to be seen’ (Winnicott, 1967, p. 32). We believe that the developmental help offered by the active involvement of the analyst in the mental functioning of the patient, and the reciprocal process of the patient becoming actively involved in the analyst’s mental state, has the potential to establish this reflection and gradually to allow the patient to do this within his own mind. The route to

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this involves brief, accurate and simple statements of the analyst’s perception of the patient’s current mental state vis-a-vis the analyst or the patient’s own self. Superficially such interventions may seem less than full analytic interpretations because mostly they stop short of the interpretation of conflict or unconscious mental contents. Their goal is the reactivation of the patient’s concern with mental states, in himself and in his object; a revitalisation of a dormant mental capacity or mental process (Fonagy and Moran, 1991). The importance of this developmental stance is critical at times when the patient has moved to a psychological position of expression through a physical stance (enactment), when full interpretations of unconscious anxieties and conflicts are unlikely to be heard. If the analyst finds himself insisting on providing such understanding, the most likely outcome is a deep therapeutic impasse where the patient comes to rely on the analyst to reflect on his mental states, but these are neither genuinely understood nor experienced as of concern or relevance to the patient’s core self. The critical step may be the establishment of the patient’s sense of identity through the clarification of the patient’s perception of the analyst’s mental state (Steiner’s ‘analystcentred interpretations’; Steiner, 1994). It seems that gradually this can offer a third perspective, opening up a space for thinking between and about the patient and the analyst. In this way it has been possible for Mr T to perceive and experience his humiliation, and mourn the absence which was his actual relationship with his father. We suggest that the experience of sustained mental involvement with another human being, without the threat of overwhelming mental pain and destructiveness, ultimately helped to free the inhibition of Mr T’s mental functioning, liberating him from using his body to represent his mental states.

Summary We offer some thoughts about the roots of habitual violence in patients who are not part of the ‘cycle of abuse’. We suggest that both self-harm and mindless assaults on others may reflect inadequate capacity to mentalise. Poor functioning of this capacity tends to lead to mental states being experienced as physical, in both the self and others, and the violence is seen as an attempt to obliterate intolerable psychic experience. This experience is felt to belong to somebody else, originally to mother or father. The problem can be traced back to a crucial stage of the development of the self when the child searches the face of his primary object for a representation of his own states of mind. Failure to find this forces him into pathological solutions to achieve containing organisation. We explore the meaning of the gender difference in the direction of aggression, and the way in which the child has a second chance to foster a secure psychological self through his relation to the father, even when the mother has been unable to support this and to separate successfully. These issues and others of technique are explored in the treatment of a violent young man.

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References Abelin, E.L. (1971) ‘The role of the father in the separation-individuation process’, in J. McDevitt and C.Settlage (eds) Separation-Individuation: Essays in Honor of Margaret S. Mahler, pp. 229–252. New York: International Universities Press. Abelin, E.L. (1975) ‘Some further observations and comments on the earliest role of the father’, International Journal of Psycho-Analysis 56:293–302. Bion, W.R. (1962) Learning from Experience. London: Heinemann. Blackman, N., Weiss, J. and Lamberti, J. (1963) ‘The sudden murderer, III: clues to preventive interaction’, Archives of General Psychiatry 8:289–294. Britton, R. (1989) ‘The missing link: parental sexuality in the Oedipus complex’, in J.Steiner (ed.) The Oedipus Complex Today. London: Karnac, pp. 83–102. Burgner, M. (1985) ‘Oedipal experience: effects on development of an absent father’, International Journal of Psycho-Analysis 66:311–320. Burlingham, D. (1973) ‘The pre-Oedipal infant-father relationship’, Psychoanalytic Study of the Child 28:23–47. Campbell, D. (1994) ‘The role of the father in a pre-suicide state’, International Journal of PsychoAnalysis 75:315–324. Davidson, D. (1983) Inquiries into Truth and Interpretation. Oxford: Oxford University Press. Fairbairn, W.R.D. (1952) Psycho-Analytic Studies of the Personality. London: Routledge. Fonagy, P. (1991) ‘Thinking about thinking: some clinical and theoretical considerations in the treatment of a borderline patient’, International Journal of Psycho-Analysis 72: 639–656. Fonagy, P. (1993) ‘The inseparable bond in child analysis: a case study of the relationship of research and practice’, in S.O.Hoffmann (ed.) Forum der Psychoanalyse. Berlin: SpringerVerlag. Fonagy, P. and Moran, G. (1991) ‘Understanding psychic change in child analysis’, International Journal of Psycho-Analysis 72:15–22. Fonagy, P. and Moran, G.S. (1993) ‘A psychoanalytical approach to the treatment of brittle diabetes in children and adolescents’, in M.Hodes and S.Moorey (eds) Psychological Treatments in Disease and Illness, pp. 166–192. London: Gaskell Press. Fonagy, P., Moran, G.S. and Target, M. (1993) ‘Aggression and the psychological self’, International Journal of Psycho-Analysis 74:471–485. Fonagy, P., Steele, H., Moran, G.S., Steele, M. and Higgitt, A. (1991) ‘The capacity for understanding mental states: the reflective self in parent and child and its significance for security of attachment’, Infant Mental Health Journal 13:200–217. Glasser, M. (1986) ‘Identification and its vicissitudes as observed in the perversions’, International Journal of Psycho-Analysis 67:9–17. Green, A. (1983) Narcissisme de vie. Narcissime de mort. Paris: Minuit. Greenacre, P. (1960) ‘Considerations regarding the parent-infant relationship’, in Emotional Growth, vol 1. New York: International Universities Press, 1971, pp. 199–224. Grunberger, B. (1979) Narcissism: Psychoanalytic Essays. New York: International Universities Press. Hegel, G. (1807) The Phenomenology of Spirit, translated by A.V.Miller. Oxford: Oxford University Press, 1977. Herzog, J.M. (1980) ‘Sleep disturbance and father hunger in 18- to 28-month-old boys: the Erlkonig syndrome’, Psychoanalytic Study of the Child 35:219–233. Herzog, J.M. (1982) ‘On father hunger: the father’s role in the modulation of aggressive drive and fantasy’, in S.W.Cath, A.R.Gurwitt, and J.M.Ross (eds) Father and Child. Boston: Little, Brown, pp. 163–174.

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Kernberg, O.F. (1984) Severe Personality Disorders. New Haven, CT: Yale University Press. Loewald, H.W. (1951) ‘Ego and reality’, in Papers on Psychoanalysis. New Haven, CT: Yale University Press, 1980, pp. 3–20. Mahler, M.S., and Gosliner, B.J. (1955) ‘On symbiotic child psychosis: genetic, dynamic, and restitutive aspects’, Psychoanalytic Study of the Child 10:195–212. Mahler, M.S., Pine, F. and Bergman, A. (1975) The Psychological Birth of the Human Infant. New York: Basic Books. Main, M. (1991) ‘Metacognitive knowledge, metacognitive monitoring, and singular (coherent) vs (incoherent) models of attachment: findings and directions for future research’, in P.Harris, J.Stevenson-Hinde and C.Parkes (eds) Attachment Across the Lifecycle. New York: Routledge. Maltsberger, J.G. and Buie, D.H. (1980) ‘The devices of suicide’, International Review of PsychoAnalysis 7:61–72. McDougall, J.J. (1986) Theater of the Mind. New York: Basic Books. Meloy, J.R. (1988) The Psychopathic Mind: Origins, Dynamics, and Treatment. Northvale, NJ: Jason Aronson. Meloy, J.R. (1993) Violent Attachments. Northvale, NJ: Jason Aronson. Mitchell, S.A. (1993) ‘Aggression and the endangered self’, Psychoanalytical Quarterly 62: 351– 382. Morton, J. and Frith, U. (1995) ‘Causal modelling: a structural approach to developmental psychopathology’, in D.Cicchetti and D.J.Cohen (eds) Developmental Psychopathology, vol. I: Theory and Methods. New York: John Wiley, pp. 357–390. Neubauer, P.B. (1960) ‘The one-parent child and his Oedipal development’, Psychoanalytic Study of the Child 15:286–309. Premack, D. and Woodruff, G. (1978) ‘Does the chimpanzee have a theory of mind?’ The Behavioral and Brain Sciences 4:515–526. Steiner, J. (1993) Psychic Retreats. London and New York: Routledge. Steiner, J. (1994) ‘Patient-centred and analyst-centred interpretations: some implications of containment and counter-transference’, Psychoanalytic Inquiry 14:406–422. Stern, D.N. (1994) ‘One way to build a clinically relevant baby’, Infant Mental Helath Journal 15:36–54. Stoller, R.J. (1979) ‘Fathers of transsexual children’, Journal of the American Psychoanalytical Association 27:837–866. Stoller, R.J. (1985) Presentations of Gender. New Haven and London: Yale University Press. Stolorow, R., Branchaft, B. and Atwood, G. (1987) Psychoanalytic Treatment: An Intersubjective Approach. Hillsdale, NJ: Analytic Press. Target, M. and Fonagy, P. (1996) ‘Playing with reality, II: the development of psychic reality from a theoretical perspective’, International Journal of Psycho-Analysis 77:459–479. Wallerstein, R.S. and Blakeslee, S. (1989) Second Chances. New York: Basic Books. Weiss, J., Lamberti, J. and Blackman, N. (1960) ‘The sudden murderer: a comparative analysis’, Archives of General Psychiatry 2:669–678. Winnicott, D.W. (1956) ‘Primary maternal preoccupation’, in Collected Papers: Through Paediatrics to Psycho-Analysis. London: Tavistock, 1958, pp. 300–305. Winnicott, D.W. (1967) ‘Mirror-role of mother and family in child development’, in P. Lomas (ed.) The Predicament of the Family. London: Hogarth Press, pp. 26–33.

Introduction to chapter 3

In his chapter ‘The role of the father in a pre-suicide state’ Donald Campbell also stresses the use of attacks on the body to get rid of a painful mental state. For suicidal patients ‘it is the body that is treated as an object and concretely identified with the lost and hated person’. Although there are different phantasies related to suicide, Campbell suggests that each is underlined by a wish for the ‘surviving self to ‘merge with an idealised maternal imago’, that is, suicide is intended to kill the bad, annihilating mother and to permit fusion with the ideal mother. The particular patient Campbell discusses had throughout his life felt let down and neglected by his father, abandoned to a sado-masochistic relationship with his mother. In the analysis he convinced his analyst that he was improving, inducing the analyst to be less vigilant about suicide than usual and hence to become ‘neglectful’ as the patient thought his father had been; the patient then absented himself from sessions and made a serious suicide attempt. The dynamic of the suicide attempt was later understood and worked through in the analysis. This paper may be inserted in the line of papers discussed in the review of the literature which point out to the relevance of the role of the father in enabling a child to separate from his mother. Although the patient’s suicide fantasies were based on a pathological bond with his mother, during the pre-suicide state the internalised father who had failed to protect his son from the father was evoked in the counter-transference to function as a sanction for the suicidal act.

3 The role of the father in a pre-suicide state

DONALD CAMPBELL

The pre-suicide state and the suicide fantasy In 1910 the Vienna Psychoanalytic Society held a symposium ‘On Suicide’: with particular reference to suicide amongst young students. Wilhelm Stekel’s contribution identified revenge as a motivating factor in the suicide act: The child now wants to rob his parents of their greatest, most treasured possession: his own life. The child knows that he will thereby inflict the greatest pain. Thus the punishment the child imposes upon himself is simultaneously the punishment he imposes on the instigator of his sufferings’. (Stekel, 1967, p.89) Freud explored aggression turned against the self in suicide further in his paper ‘Mourning and melancholia’ (1917). Freud observed that in melancholia, after a loss or a ‘real slight or disappointment’ coming from a person for whom there are strong ambivalent feelings, the hate originally felt toward the person may be redirected toward a part of the self now identified with the person. Instead of letting go of the person there is a regression to identification and sadism influenced by the ambivalence toward the person. Freud took this observation further: It is this sadism alone that solves the riddle of the tendency to suicide which makes melancholia so interesting—and so dangerous…. The analysis of melancholia now shows that the ego can kill itself only if…it can treat itself as an object—if it is able to direct against itself the hostility which represents the ego’s original reaction to objects in the external world. (Freud, 1917, p. 252) In the suicidal individuals I have analysed it is the body that is treated as an object and concretely identified with the lost loved and hated person. My understanding of suicidal

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patients is influenced by Freud’s observations and begins with the view that in these patients a split in the ego has resulted in a critical and punitive superego perceiving the body as a separate, bad or dangerous object. Whatever else is said about suicide, it functions as a solution born of despair and desperation. An individual enters a pre-suicide state whenever the normal selfpreservative instinct is overcome and their body becomes expendable. In some cases, the patient’s rejection of his or her body comes silently, or may appear only indirectly in the material—about which I will say more later—but once this has occurred a suicide attempt may be made at any time. During a pre-suicide state the patient is influenced, in varying degrees, by a suicide fantasy, based on the self’s relation to its body and primary objects. The fantasy may or may not become conscious, but at the time of execution it has distorted reality and has the power of a delusional conviction. The suicide fantasy is the motive force. A person’s promise or conscious resolve not to kill themselves, or even a strong feeling that suicide is no longer an option, does not put them beyond the risk of another attempt on their life. As long as the suicide fantasy is not understood and worked through, the individual is in danger of resorting to suicide as a means of dealing with conflict, pain and anxiety. I have paid particular attention to suicidal patients’ fantasies about death and their affects and thoughts during the build-up to a suicide attempt in which they clearly intended to kill themselves. Their attitude towards death by suicide and their suicide fantasies confirm Maltsberger and Buie’s (1980) observations of suicidal patients and their formulations. While each patient expected his or her body to die, they also imagined another part of them would continue to live in a conscious body-less state, otherwise unaffected by the death of their body. Although killing the body was a conscious aim, it was also a means to an end. The end was the pleasurable survival of an essential part of the self, which I will refer to as the ‘surviving self’, a self that will survive in another dimension. This survival was dependent upon the destruction of the body (Maltzberger and Buie, 1980).

Merging with mother and annihilation anxiety From the analysis of my suicidal patients it was possible to form a general picture of an object, which, in Freud’s terms, was now identified with the body, in order to understand why the body became expendable. In each case the narrative point of origin of the psychopathology (Stern, 1985) was built around a mothering object who was perceived as dangerous and untrustworthy. Separation and individuation had proved too painful for these patients and they withdrew cathexis from others while maintaining a fantasy of a regressive move to merge with an idealised mother who would meet all their needs. However, these patients felt themselves to be in a double bind. While being preoccupied with this wish to merge with mother, they become anxious about being engulfed by the object if they should succeed in merging, or being abandoned to starve if they should be unsuccessful in getting into the object (Glasser, 1979). Although there were different types of suicide fantasies (see Maltzberger and Buie, 1980; Campbell and Hale 1991) each fantasy was underpinned by a wish for the

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‘surviving self’ to merge with an idealised maternal imago. The suicide fantasy represented a solution to the conflict which results from the wish to merge with mother, on the one hand, and the consequent primitive anxieties about annihilation of the self, on the other. By projecting the hated, engulfing or abandoning primal mother on to the body and then killing it, the surviving self is free to fuse with the split-off idealised, desexualised, omnipotently gratifying mother represented by states of oceanic bliss, dreamless eternal sleep, a permanent sense of peace, becoming one with the universe or achieving a state of nothingness (Maltzberger and Buie, 1980). Just as there was a split between the good ‘surviving self’ and the bad body, there was also a split between the hated, engulfing or abandoning primal mother, now identified with the body, and the idealised one with which the ‘surviving self’ would safely fuse once the bad mother/body had been eliminated. The case of Mr Adams1 Mr Adams was a ‘mummy’s boy’, who was alternately indulged and abandoned according to the whims of his narcissistic mother. He felt rejected by his father who was seldom at home and appeared to favour his older brother. Mr Adams wanted to join in the family business after A levels and was hurt when father sent him off to university in Glasgow. His father died of cancer shortly after Mr Adams returned to Edinburgh with his degree. At the age of 30, while under severe stress at work, Mr Adams took an overdose of Valium. A year later, on the brink of a business failure, he took another overdose and cut his wrists. When he was 40, Mr Adams came to see me looking dishevelled and unshaven after he had gambled away all of his money—half a million pounds. He looked and sounded melancholic—feeling impoverished (as he was in reality), slighted and unjustly treated. He told me that when he went to a casino he often started with a little money but soon won thousands, only to lose it all at 1 I have written about Mr Adams from another perspective in an earlier paper (Campbell and Hale, 1991).

the end of the night. His older brother had taken over his financial affairs, blocked all of his bank accounts, left him with a weekly allowance and went off to Japan for a holiday. Mr Adams said that he felt suicidal and then made a slip, saying ‘father’ instead of ‘brother’ had left him and gone off to Japan. When I called his attention to his slip he referred to his suicidal thoughts and added, ‘it all started with my father’s death’. After Mr Adams’ father died, his mother confided only in him that she would one day commit suicide. In passing he said that his mother also confided to him that she had ‘killed’ her own mother with a drug overdose after she had a paralysing stroke. After associating to his fear that his wife might leave him, Mr Adams added that he didn’t understand why he always avoided his mother. One month after Mr Adams started five times weekly analysis, his mother made a serious but unsuccessful suicide attempt at home in Edinburgh. Mr Adams wasn’t surprised. ‘I didn’t go to see her because my brother is there. I’m glad he’s upset and had

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to come back from Tokyo. I stayed in bed all day yesterday.’ Mr Adams justified his coldness by referring to his family’s very rational attitude to death. Without recognising the failure of this defence, he described his father as ‘paranoid, full of fear and panic during his last week. His face at the funeral home was distorted and ugly. I tried to push his lips into a calm expression. My mother is always calm.’ The next day he was furious that his brother advised him not to sell his shares to settle his debts, but to keep them and gamble that they would increase in value. I linked his rage at being put at risk to satisfy his brother’s wish for excitement with his mother’s secret which had put him at risk as the passive, guilty accomplice, waiting for a predicted self-murder. I then took up what I thought was his fear that I would put him at risk by not taking seriously his earlier attempts to kill himself. In the sessions Mr Adams regularly complained that I did not give him advice and suggestions. I interpreted this behaviour in the transference in terms of his view of me as distant and withdrawn and his efforts to get compensation for what his mother failed to give him by actively demanding more from me. This was often followed by transient regressed states featuring rambling and mumbled conversation and narcissistic withdrawal into drowsiness, which I interpreted as Mr Adams’ identification with his narcissistic mother. This appeared to be what Pearl King (1978) refers to as a reverse transference, that is, the patient relating to the analyst in such a way to give the analyst the experience of the patient as a child by relating to the analyst as the parent had done. My interpretations seemed to have a positive effect and there were obvious signs of improvement in Mr Adams’ appearance. Mr Adams’ gambling represented a manic solution to his feelings of helplessness, impotence and despair. I understood the self-defeating, self-impoverishing aspect of his gambling behaviour as Mr Adams dicing with death, particularly after his mother’s suicide attempt increased his anxiety about his own sur-vival. I was worried about the suicidal component of his gambling. As his wish to triumph over the odds intensified, I took up his pattern of losing money as a way of demonstrating his mother’s failure by leaving him bereft and without resources. His failures also invited his mother to rescue him and it was now clear he wanted me to do the same. These interpretations also appeared to have an effect; Mr Adams stopped gambling. Furthermore, his attitude became more positive and he began investing again in his work and family. At this point, Mr Adams interrupted his analysis in an optimistic frame of mind to go to Edinburgh, his home town, to try to generate business for his neglected company. However, once there business did not go well and he couldn’t face his old friends. On a Sunday afternoon he felt lonely and suicidal and called his wife in London, hoping she would express sympathy and come to join him. Instead, Mrs Adams complained about his using suicide to blackmail her. She couldn’t stand his threats any more and told him to get on with it if he was going to kill himself. At first Mr Adams felt shattered, hurt, rejected and totally alone. However, once he decided to kill himself he felt great relief and calm. He took seventy 10 mg tablets of Valium and lay down feeling at peace. As the pills took effect he felt he was drifting off into another dimension. There was a sense of oneness, a merging into another kind of existence. He was found by accident and rushed to hospital in time. I was shocked when I heard the news. I felt that I had missed something and had let Mr Adams down.

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I now want to report what I learned from Mr Adams after his suicide attempt and what I had learned by thinking again about what he had told me before the attempt. I compared my thoughts about Mr Adams with what I had learned previously from my other suicidal patients.

Counter-transference during a pre-suicide state My assessment of Mr Adams’ suicide attempt began with the fact that I was shocked when I heard the news. I assumed that understanding my response would shed some light on why I was caught by surprise. Sandler’s (1976) concept of the analyst’s role response provided a useful framework for considering my reaction. Sandler (1976) draws attention to the patient’s unconscious attempts to provoke the analyst to behave in such a way as to confirm the patient’s illusory (transference) image of the analyst. The analyst may hold his response to this prodding in his consciousness (King, 1978, referred to this as his ‘affective response’), and make use of it to understand the transference. Failure to hold responses and the enactment of them in behaviour, attitude or remark represents the analyst’s unconscious role response. Sandler suggests that: very often the irrational response of the analyst, which his professional conscience leads him to see entirely as a blind spot of his own may sometimes be usefully regarded as a compromise-formation between his own tendencies and his reflexive acceptance of the role which the patient is forcing on him. (1976, p.46) Sandler views this type of counter-transference reaction as a piece of behaviour or an attitude that results from the overlap of the patient’s pathology and the analyst’s. Consequently, the professional is only likely to become aware of his role in a countertransference interaction by observing his own feelings and behaviour after the fact, after he has responded. Nevertheless, by viewing his counter-transference behaviour as related to the patient, and thinking of it as a compromise between his own tendencies or propensities and the role relationship which the patient is unconsciously seeking to elicit, the analyst can deepen his understanding of the transference and his part in the patient’s suicide scenario. It became apparent that an essential ingredient of the pre-suicide state is the patient’s attempt to involve the analyst in an active way in the suicide scenario. Straker (1958) pointed out: ‘A decisive factor in the successful suicide attempt appears to be the implied consent or unconscious collusion between the patient and the person most involved in the psychic struggle.’ The unconscious collusion is buried in the analyst’s countertransference. Asch (1980) has demonstrated the vulnerability that the therapist of the suicidal patient has to being provoked into negative counter-transference attitudes which are experienced by the patient as collusion in the suicidal fantasy. This collusion confirms for the patient the analyst’s active participation in a regressive sado-masochistic fusion,

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places the therapist in the role of the executioner, and gives the patient justification for retaliation via a suicide attempt. The sado-masochistic dynamic may also manifest itself in the subtle, superficially benign form of the patient’s feeling of being at peace which contributes to increased selfassurance and confidence (Laufer and Laufer, 1984). Depressive affects, anxieties and conflicts are no longer communicated. This narcissistic withdrawal cuts the therapist off from moods and behaviour which would normally elicit an empathic response of alarm or worry and may result in the sudden loss of subjective emotional concern (Tahka, 1978) for the patient. In a narcissistic regression, which dominated my patients during the pre-suicide state, there is the prospect of imminently fulfilling a merging suicide fantasy. As far as these patients were concerned, they were already at peace because they had crossed a rational barrier of self-preservation, identified the assassin/mother with their body, and had no doubts about killing it. The analyst, burdened with anxieties about his or her patient’s life or exhausted by the patient’s relentless attack on hope or angry about being blackmailed (often before a holiday break from treatment), may be tempted to retaliate by giving up on his or her patient or using the patient’s sense of peace to justify relaxing his therapeutic vigilance. In my case, external signs of decreased stress and improvement in the patient were used to defend against my unconscious wishes to retaliate by letting go of the suicide risk.

The father and the pre-suicide state The questions remained, ‘Who was I in the transference? Who was the object evoked by Mr Adams and enacted by me?’ It was clear from Mr Adams that he felt distant and alienated from his father. The absence of his father in Mr Adams’ material was consistent with their relationship. My failure to perceive and respond interpretatively to Mr Adams’ suicide risk confirmed my role as the distant, uninvolved father. I had the impression that Mr Adams’ father had failed his son during an early phase of development. In normal development, both pre-Oedipal parents represent to the child the world outside the exclusivity of the mother—infant relationship, e.g. the realities of time and place and objects. For the purpose of this chapter I will only consider the role that the ‘good-enough’ pre-Oedipal father plays as friendly rival with both his child and his wife, in offering each of them a dyadic relationship that is parallel to and competes with the mother—child unit. In ‘good-enough’ fathers the pleasure of procreation and the birth of his child is accompanied by feelings of envy and exclusion from the mother—child relationship as well as adjustment to a secondary role with the child. Initially, fathers can defend against this change by supporting the mother and making use of passive feminine aspects of their make-up to identify with the mother. However, a more active, masculine identification will emerge in the father’s relationship with his child and wife. On the one hand, the attractive and attracting father stakes a claim on his child and, with mother’s help, enables the child to move from the exclusivity of the infant—mother relationship into an inclusive position as part of a pre-Oedipal triad.

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Father’s gender role identity and parental Oedipal impulses influence the idiosyncratic nature of the claim he makes on his child. For instance, his conscious and unconscious fantasies and anxieties about female sexuality will affect the way he relates to his daughter from the beginning. She may be ‘daddy’s little girl’. Gender influenced relating will also play a part in the way a father helps his son dis-identify from mother (Greenson, 1968) and father’s view of the way his wife relates to his male offspring. The father may even be conscious of not wanting his wife to ‘feminise’ his son. Whatever form this process of claiming his child takes, and there will always be infinite variations influenced by mixtures of projections and reality, the child will become aware that he or she occupies a place in father’s mind that is separate and distinct from mother. The child also becomes aware of a place for mother in father’s mind and a place for father in mother’s mind. Father reclaims his wife by seducing her back to him and rekindling her adult sexuality. The father who reclaims his wife and engages his child on his own terms protects them both from lingering overlong in a ‘fusional’ or symbiotic state and facilitates the separation and individuation process (Mahler and Gosliner, 1955). Freud (1931) recognised the little girl’s attachment to her father as a refuge from her first attachment to mother. Loewald (1951) referred to the child’s positive, pre-Oedipal relationship with the father who stands for a paternal veto against the engulfing and overpowering womb which threatens to undermine the ego’s orientation to reality and its efforts to establish boundaries between self and other. The father’s twofold response supports the child’s right to an independent existence that is separate from mother while providing the toddler with a means of coping with its longing for her. Abelin (1978) postulates that at around 18 months this process results in an early triangulation in which the toddler identifies with the rival father’s wish for mother in order to form a mental representation of a self that is separate and longing for mother. The good-enough father provides a model for identification as well as an alternative relationship to the child’s regressive wish to return to a ‘fusional’ state with mother with subsequent anxieties about engulfment. In the analysis of my suicidal patients it became apparent that they perceived their fathers as either withdrawn or actively rejecting them, and as having failed to reclaim their wives. Each patient had felt abandoned to their anxiety about surviving as a differentiated self when left with a disturbed mother. The patients’ suicide fantasies articulated in the present represented internalised early pathological relationships between mother and child and father. The pre-Oedipal father’s role was often obscured by the patient’s relationship with the mother which dominated the suicide fantasy and by the father’s absence or ineffectiveness. However, it was during the pre-suicide state that the internalised father’s failure to intervene in the pathological mother—child relationship became most critical.

Discussion It was clear that Mr Adams intended to kill his body while maintaining the fantasy that part of himself would survive. After taking the overdose Mr Adams felt calm, as he had described his mother, and expected to pass into ‘another dimension’ and wondered what it would be like.

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A detailed analysis of Mr Adams’ suicide fantasies would take us beyond the aims of this chapter. I will not develop further Mr Adams’ identification with his suicidal mother (for instance, while talking about his suicide attempt he made a slip saying his mother was 40—his age). It also emerged in his analysis that Mr Adams hoped that his suicide would serve as revenge against both his parents. Mr Adams’ suicide fantasy was organised around a sado-masochistic relationship with his mother whose shared secret had tortured him by making him an accomplice in a homicide (the overdose that she had administered to her mother) and her own planned suicide. His mother’s unsuccessful attempt on her life increased his guilt2 because he had ignored her explicit warnings that she would kill herself. His fear that she would kill him increased as well. He slipped in telling me of his mother’s suicide attempt, saying ‘My mother tried to kill myself.’ Mr Adams felt his father did not relate to him in his own right. For instance, father could not support his son’s wish to join him in the family business. Mr Adams associated feeling suicidal to being left by his father, and then recalled that his suicidal fantasies started with his father’s death. However, Mr Adams felt abandoned to his mother by his father long before his father’s death. Father and brother had paired off while he was left with mother. Without his father as an alternative object with whom to identify, Mr Adams was left in a masochistic tie to a murderous mother. Although Mr Adams’ suicide fantasies were the outcome of a pathological bond with his mother, during the pre-suicide state his relationship with his father, particularly father’s failure to protect him from his mother, functioned as the sanction of the suicidal act. Mr Adams relied upon splitting of the self and the object to survive his mother’s suicide attempt, which he experienced as an attack on his life. The resulting suicide fantasy during the pre-suicide state had two components: an unconscious fantasy and a delusional conviction. Mr Adams’ unconscious fantasy which identified his body with a bad mother initially came into the analysis as non-verbal communications in his neglect and mistreatment of his body. After his suicide attempt this identification was put into words by Mr Adams: ‘Mother couldn’t care for her body and she couldn’t care for mine. How could I care for myself?’ Getting rid of his bad mother, now identified with the object of his suicidal attack—his body—would make it possible for his split-off surviving self to merge with the split-off idealised mother—the nameless ‘other dimension’. There was a breakthrough of his unconscious identification of his body with his mother and his sadistic revenge against the bad mother, represented by his wife, when he made a slip: ‘I can’t say to my wife “I want to kill yourself.”’ 2 See Barnett and Hale (1985) for an analytic study of a son’s guilt following his father’s suicide.

The fantasy of merging with an idealised mother (which was on his mind when he took the pills) became a delusional conviction during the pre-suicide state. Mr Adams’ slip of the tongue, ‘My mother tried to kill myself’, represented a breakthrough of a preconscious awareness of mother’s sadistic attack on him via her suicide attempt and formed the basis of his identification with the aggressor. In proceeding with his suicide plan Mr Adams turned passive into active, and shifted from a masochistic to a sadistic role, in order to extract revenge. Mr Adams’ depression lifted as

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he planned the details of his execution which included collecting Valium tablets, returning to his birthplace, and deceiving others about his intentions by appearing more sociable and optimistic. He stopped gambling. In sessions he talked about his earlier suicide attempts as well as his mother’s attempt on her life. At this critical point in the analysis I saw myself, in retrospect, as a guard going to sleep at his post. In this case, the decisive factor in precipitating the suicide attempt was the relaxation of my vigilance regarding the suicide risk, a lessening of my empathic contact with the patient, and an enactment of his father’s withdrawal3 and failure to stake a claim for his child’s right to a relationship with him by not protecting Mr Adams’ analytic time and place with me. Later, in his analysis, it became clear that fantasies enacted in his gambling had been displaced on to his suicide fantasy including the belief that he would omnipotently triumph over the loss of his father and be chosen by fate/mother. The pre-suicide state, like gambling, is a manic flight from judgement into narcissism. Mr Adams was unconsciously in the grip of a repetition compulsion and had tested me to see if I would repeat his earlier experience with his father. My role response to Mr Adams’ behaviour (e.g. an apparent improvement and the undetected meaning of a narcissistic withdrawal) coincided with his breaking of the analytic structure (by cancelling sessions) which I failed to prevent. My failure was experienced by the patient as a failure to maintain the reality of our relationship, that is, the realities of time and place, thereby leaving the patient without an alternative to the timeless merging fantasy of his suicide scenario. Mr Adams left me to return to his mother. I failed to analyse the merging fantasy that was gratified in this way and the destructiveness inherent in it. My empathic failure was experienced by Mr Adams as an enactment in the transference of the neglectful pre-Oedipal father who sanctioned his youngest son’s return to a seductive and ‘murderous’ mother. In this way, I unwittingly entered into and played a role in the patient’s suicide fantasy. 3 Limentani (1991) has observed a similar counter-transference phenomenon in the analysis of overt or latent homosexuality in males and females.

Summary Just prior to attempting suicide Mr Adams cancelled his sessions. At the same time, I underestimated the imminence of the suicidal act. There is no explicit or implicit suggestion that these two features occur only with suicidal patients, but these features may have particular meaning during a pre-suicide state. The analysis of a pre-suicide state based on material from before and after Mr Adams’ suicide attempt illuminated the father transference which had been enacted in my counter-transference and the cancelled sessions. The transference was to a father who failed to claim his child for himself, who abandoned him to a smothering, ‘murderous’ mother, and who did not offer an alternative to an exclusive mother/child fusion. The father had not stood in the way of a regressive pull to a sado-masochistic relationship with mother which formed the core of the suicide fantasy. This experience of the

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abandoning father was reversed by the patient who, in turn, left the analyst to join his mother—in death.

References Abelin, E. (1978) ‘The role of the father in the pre-Oedipal years’, Journal of the American Psychoanalytic Association 26:143–161. Asch, S. (1980) ‘Suicide and the hidden executioner’, International Review of Psycho-Analysis 7:51–60. Barnett, B. and Hale, R. (1985) ‘A singular form of death: some aspects of the psychological sequelae of the loss of the father by suicide’, paper presented at the Congress of the International Psychoanalytical Association, Hamburg. Campbell, D. and Hale, R. (1991) ‘Suicidal acts’, in J.Holmes (ed.) Textbook of Psychotherapy in Psychiatric Practice. London: Churchill Livingstone, pp. 287–306. Chasseguet-Smirgel, J. (1985) The Ego Ideal. London: Free Association. Freud, S. (1917[1915]) ‘Mourning and melancholia’, Standard Edition, 14, pp. 237–260. Freud, S. (1913) ‘Female Sexuality’, Standard Edition, pp. 223–243. Glasser, M. (1979) ‘Some aspects in the role of aggression in the perversions’, in I. Rosen (ed.) Sexual Deviations, 2nd edn. Oxford: Oxford University Press, pp. 278–305. Greenson, R. (1968) ‘Dis-identifying from mother’, International Journal of Psycho-Analysis 49:370–374. King, P. (1978) ‘Affective response of the analyst to the patient’s communications’, International Journal of Psycho-Analysis 59:329–334. Laufer, M. and Laufer, M.E. (1984) Adolescence and Developmental Breakdown. New Haven and London: Yale University Press. Laufer, M. and Laufer, M.E. (1989) Developmental Breakdown and Psychoanalytic Treatment in Adolescence. New Haven and London: Yale University Press. Limentani, A. (1991) ‘Neglected fathers in the aetiology and treatment of sexual deviation’, International Journal of Psycho-Analysis 72:573–584. Loewald, H. (1951) ‘Ego and reality’, International Journal of Psycho-Analysis 32. Mahler, M.S. and Gosliner, B.J. (1955) ‘On symbiotic child psychosis, genetic dynamic and restitutive aspects’, Psychoanalytic Study of the Child 10:195–212. Maltzberger, J.G. and Buie, D.H. (1980) ‘The devices of suicide’, International Review of PsychoAnalysis 7:61–72. Sandler, J. (1976) ‘Counter-transference and role-responsiveness’, International Review of PsychoAnalysis 3:43–78. Stekel, W. ([1910] 1967) ‘Symposium on suicide’, in P.Friedman (ed.) On Suicide. New York: International Universities Press, 1967, pp. 33–141. Stern, D.N. (1985) The Interpersonal World of the Infant. New York: Basic Books. Straker, M. (1958) ‘Clinical observations of suicide’, Canadian Medical Association Journal 79:473–479. Tahka, V.A. (1978) ‘On some narcissistic aspect of self-destructive behaviour and their influence on its predictability’, Psychopathology of Direct and Indirect Self Destruction, Psychiatra Fennica, Supplementum 59–62.

Introduction to chapter 4

In this chapter I describe how, in the course of trying to understand and treat psychoanalytically a violent young man, I began to identify a plot or narrative in his material which expressed an unconscious phantasy, a personal myth, namely that he was born of a violent intercourse between his mother and himself; no father was involved in his conception. This phantasy had attained the status of belief, that is, it was thought to be true while simultaneously known to be false. The patient’s view of the pre-Oedipal mother was that she was utterly desirable and infinitely dangerous, and his view of the primal scene was that it was particularly violent and destructive. I suggest that in the psychoanalytic treatment of the violent patient one may have access to the core phantasy which is expressed in the act of violence itself and that these phantasies are related to the individual’s beliefs about his own procreation. The violent act tells a story, which is a personal myth of creation and contains both their pre-Oedipal and distorted Oedipal theories. I discuss these ideas in the context of Freud’s use of the term ‘Violence’ (Heftigkeit). As I suggested in my review of the literature, although he does not point it out explicitly, Freud uses the term almost entirely in the context of the primal scene and the Oedipus complex. I also discuss the idea of a core phantasy in violence in relation to a second violent patient, a woman, whom I have also treated psychoanalytically. The chapter also discusses issues of technique in the treatment of such patients. It is essential to understand that the patient’s experience in the analysis is that they are attempting to survive in the face of what they experience as a terrifying object. My patient needed to feel he could terrorise me in order to feel safe in the consulting room. Interpretations which centre on this experience—which are ultimately based on the analyst’s anxieties in the counter-transference—have an important impact on the patient and in the case of my patient paved the way for violence to give way to depressive feelings.

4 A core phantasy in violence

ROSINE JOZEF PERELBERG In this chapter I would like to discuss my understanding of the function of violence in the analysis of a violent young man. I will describe how, in the course of trying to understand and treat him psychoanalytically, I began to identify a plot or narrative in his material which expressed an unconscious phantasy, a personal myth of origin, namely that he was born of a violent intercourse between his mother and himself. I will indicate how these phantasies were externalised in the transference and apprehended in the transference and counter-transference in the course of his analysis. Although there is an extensive literature on the understanding of aggression in psychoanalysis, mostly from the 1970s and 1980s (see Perelberg, 1995 and chapter 1 of the present book), little material is available on the role of violence. Most authors, however, do attempt to discriminate between different types of aggression and to establish distinctions between what is perceived as healthy assertiveness and acts which are defined as aiming to destroy and humiliate the object or inflict pain in the service of sexual pleasure (sadism). Specific concern with defining violence can be found in the work of Glasser (1985), Shengold (1989, 1991, 1993) and Fonagy and Target (1995 and chapter 2 in this book). Following Walker (1968), Glasser (1985) defines violence as the intended infliction of bodily harm on another person. This definition thus confines violence to conscious acts on the body of one person by another person. While aggression is biologically built into human beings as a reaction to danger, violence is ‘the bodily actualisation of aggression which aims to negate the danger’ (p. 3). In self-preservative violence (or aggression), the aim is to negate the danger; in sadism (malicious violence), the aim is to inflict physical and emotional suffering. What happens to the object in the first type of violence is irrelevant, whereas it is crucial in the second. Fonagy and Target also attempted to distinguish between sadism and violence: ‘sadistic behaviour is not an attempt to defend the self. In contrast, the violent individuals we consider here, having sought proximity, then feel trapped by a persecutory object’ (1995, p. 488). In the light of an analysis of a violent patient they discuss the hypothesis of violence as a ‘wish to attack thoughts, in oneself or in another’ (p. 489). Thus, although psychoanalysts have been able to discriminate between sadism and aggression, recent attempts to do so indicate how difficult it has been to define violence.

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Clinical material: Karl Background information Karl is a man in his early twenties whose father left his mother before he was born and who describes his relationship with his mother as very close and special. His mother married when he was still a baby, and this man adopted Karl as his son. A few years later the couple had a baby girl and a few years later another girl. Karl feels, however, that his mother always let him know that he was the most important person for her in this family. At the same time, he experiences his mother as unable to tolerate his sexuality and even less his being a man. He said recently that his mother used to tell him that she wished he was gay because gay people never leave their mothers. His father was violent towards him throughout his childhood, hitting him frequently around the head. He recalls being frightened of his father, never fully being able to differentiate when his father was playing with him or actually threatening him. Recently in his analysis, for instance, he recalled an incident in the swimming pool, when his father was pulling him by his legs. He felt he was drowning and felt that his father was actually trying to kill him. In his late teens Karl decided to study martial arts and feels that his father then became frightened of him and stopped hitting him. A year after entering university Karl sought help at a psychotherapy out-patient department. He complained of having difficulties in his relationships with peers, that he was failing academically, that he had got involved in rows with his tutors at university and had returned to live with his parents. He was assessed and accepted for analysis in the Young Adult Research Scheme.1 The full extent of his violent behaviour became clearer only after a few months of his analysis. During the period Karl has come to analysis, he has been involved with serious criminals of whom some have gone to prison (one for murder), others have been hurt in knife fights and, recently, two have committed suicide. 1 I am grateful to the members of the group for helpful discussions of my patient. I am also particularly grateful to Donald Campbell and Ronald Britton who have both helped me in critical moments in the analysis of this patient.

The analytic process: the patterns of the transference In his first consultation Karl presented me with a question that he felt had become an obsession for him and which expressed his concern about the nature of his parents’ sexuality. He told me that his parents were involved in ‘sado-masochistic games’. He ‘knew’ it since his childhood because he and one of his sisters had listened to them behind their bedroom door. They had been reading to each other passages from a book where there were details of sado-masochistic games. Later they had ‘practised’ these games and the children had ‘heard’ them. At the consultation I experienced that there was a great deal of confusion in Karl’s account, but also that his account represented a screen memory for a primal scene phantasy. The confusion of his account was also derived from the fact that the book he mentioned was a well known bestseller and I found myself

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scanning my memory of the book for any such scenes. In this same consultation, Karl started to let me know about the extent of the violence he had been engaged in. At university, he had got involved in serious violent situations with other young men and in escalating violence in his sexual relationship with a girlfriend. He returned home, afraid that the police were after him. In his analysis Karl has attempted to escape from an experience of losing his mind completely each time he achieves some understanding from his analyst. He believes that he will cease to exist if he does not retreat. When the analyst understands him, he has to disappear by not coming to his sessions for a while. At the beginning of the analysis this was expressed basically in the states of sleep Karl would get into, from which he could not be awakened, either by several alarm clocks or by his mother shouting at him. He could disappear from the sessions for a week, for instance, without realising that this time had passed since his last session. The interpretations during this period consistently pointed to this complete retreat both from the encounter with the analyst and from the obstacles Karl inevitably experienced in his relationship with me. Karl’s sleep was dreamless, and I interpreted this as a flight not only from me, but also from the experience of having a mind. Karl also compulsively played computer games where violence was expressed in a robotic way against dehumanised enemies. In the fourth week of analysis, for example, he smashed a friend’s computer after having been beaten by a computer game. At the time, in the context of the session, I interpreted to him that he feared that I would inevitably become useless to him. I would either be unable to understand him or, if I did understand, he would experience me as ‘beating him’; then he feared he would have to destroy me, again making me useless. In a subsequent session he described a nightmare that had terrified him: he unbuttoned his shirt and discovered he was a computer. It became progressively clearer that he had been persecuted and excited by violent phantasies since childhood. He remembered two films that persecuted and terrified him, The Omen and The Vampires of Salem. We talked about these films over a few sessions. The scene in The Omen he specifically talked about was that of a journalist who had come to investigate the facts about the Omen, and was decapitated by the Omen. In the film about the vampires, the memorable scene was one in which the boy’s best friend had become a vampire and had tried to get the other boy to open the window for him to let him in. The boy could not resist and therefore also became a vampire. Karl seemed to understand my interpretation about his fear of not resisting homosexual invitations; but became frightened by my formulation that he was afraid either he or I were being experienced by the violent part of him (the Omen) as the journalist who had to be decapitated because of our research into aggression and sexuality. In fact, he might well believe that he had already succeeded in decapitating his thinking self in his dreamless sleep and absence from sessions. Karl gradually revealed how difficult it was for him to maintain contact with real living people, since this involved levels of frustration, violence and terror that he simply could not tolerate. Yet as his confidence in the analytic relationship grew, his thoughts and aggressive interactions outside the sessions became more vividly present in his accounts during the sessions. At times he inundated me with accounts of extremely violent behaviour which left me frightened and hopeless about any possibility that

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analysis would have any impact on him. I often also wondered if he had any idea of the effect he was having on me. Karl would also tell me both about his longing for and flight from encounters with women. It seemed to me that his phantasised and actual violence towards men protects him from his terror of women. His refuge is less than comfortable because it immediately confronts him with his own impulses. These two aspects—the violence against other men and the problem of relating to women—seemed to form a pair and he himself could not fail to acknowledge the simultaneity of these accounts as I consistently pointed them out to him in sessions. At this stage I felt able to say no more than that his violence seemed to follow on from his fear of my intrusiveness in the transference. He responded by telling me that he had got a gun and cartridges and had been keeping them at home. As he talked about this, it became progressively clear that he was keeping a part of himself and me as hostages, terrorised by his potential destructiveness. Inevitably my interpretations were rooted in the anxiety I felt in the counter-transference, which allowed me to show him that he needed to know if he could terrify me, as a way of protecting himself from his own fear of me.2 My interpretations led him to get rid of the gun but this left him without the power to terrorise me, leaving him lost, abandoned and deeply 2 Being able to detect fear in me had the function of reassuring Karl that the fear was no longer in himself which would then allow him to feel safer. Sandler (1959) has suggested that in order to preserve its feelings for safety, the ego will make use of whatever techniques it has at its disposal and gives examples of the way in which defence mechanisms can operate in the service of this ‘safety principle’.

depressed. To counteract his depression, he intensified his accounts of criminal activities. He consciously acknowledged, without initially realising the implications of what he was letting me know, that it was easier for him to come to the sessions after dangerous criminal encounters, such as obtaining and selling stolen diamonds. This gave him a sense of omnipotence. I suggested that this was because he felt less frightened of my power over him. His criminal activities thus served to distance him from me and while they have many determinants, one transferential aspect was undoubtedly the wish to avoid a meaningful emotional relationship. This presented a technical challenge which I believe is present for many patients who need to make use of this primitive destructive narcissistic process of protecting themselves. For Karl, understanding in the transference was unbearable because to engage in a meaningful dialogue would submerge and destroy his fragile sense of self and identity. My attempts to understand him were experienced as a seduction into a relationship which he could not survive, a relationship which would destroy his vulnerable sense of self. He took flight from it into what he believed was a male world. The paradox, though, is that he found no escape as he again fell into the perverse universe of his mother. After all, she promised him cover for selling some stolen jewellery, thus giving him permission for his criminal activities. Karl felt confused, and did not understand when I pointed out to him the contradictions between his different projects: analysis and college on the one hand and his criminal career on the other. For him, they are equivalent, an illustration of a chaotic internal universe where there is no differentiation or separation.

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At the time we were also able to examine the way in which the sessions he missed were like the stolen diamonds, especially as his treatment was subsidised by the Anna Freud Centre. The fact that I continued to see him or waited for him at each session was also experienced by him as my being like the collusive mother. The only avenue to me was that of carrying on attempting to put into words the many binds and paradoxes present in his analysis at the time. These configurations have important implications for analytic technique. My challenges to his way of relating are experienced as the phallic mother taking over; this leads him to find an escape in a world where he feels surrounded by his male friends. There, however, the relationships are also filled with violent and murderous phantasies. If I leave a space between us, this is experienced as leaving him to the terror of sadomasochistic homosexual relationships. His response to the first could be murder, to the second, suicide. In his analysis it has been possible to trace, in the vicissitudes of the transference, the contexts in which violent thoughts and behaviours surfaced. They were, each time, related to the terrifying anxiety about a breakdown in the emotional distance he attempted to maintain in the transference to me. He is afraid of becoming imprisoned and succumbing to what he experiences as his mother’s wishes for him to have an exclusive relationship with her. The dilem-mas for the transference are obvious, and he attempts to deal with his terror of me by carefully regulating his attendance and spending the time he was supposed to be at his sessions sleeping a sleep that is profound and dreamless. If there is an obvious sado-masochism implied in frequently keeping me waiting, and in the process of letting me know of the various criminal activities in which he is engaged in the outside world, I feel that the main function of all this is not to attack me, but to defend his very survival. For a long period of time, interpretation of affect had to precede interpretation of the terrifying phantasies. An important aspect of working with such a violent patient is that it seems to me that a degree of ‘acting out’ is inevitably present during the process because of the actual threat of violence breaking into the consulting room (in the patient’s mind such violence may be derived either from me or from him). I think that a great deal of intellectual understanding is progressively built up and goes ahead of the process, providing a kind of scaffolding that will allow enactments to be progressively brought into the consulting room. I learnt to know that in the periods when Karl was away from the sessions, an important process of trying to safeguard the analysis was taking place. It was important, therefore, to accept his pace. Each time when Karl came back, it was possible for us then to discuss the function of his absence. As he finds himself wanting to relate to a woman, Karl is in a state of terror of the woman’s poison, of her trickiness and perversion. His reaction is that of flight from the woman/analyst/girl, which leaves him feeling ashamed, humiliated and confused. He engages in criminal activities with his male friends but is then overtaken by an extreme state of anxiety about his homosexual feelings. He attempts to deal with them by aggression and violence, which again leave him frightened and persecuted. This configuration is present in many of his sessions: the primitive Oedipal anxieties and the oscillation, from which there is no escape. In the following more detailed clinical material of sequences within sessions, some of the important themes connected to the core phantasy in violence will be illustrated:

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violence as a defence against overwhelming anxiety about abandonment, and violence as present in the relationship between a dangerous couple. In the first session after the second summer break Karl spent the session telling me about a fight he had got involved in with a group of ‘scientologists’ who had opened an office ‘next to his home’. They had been taking money from the girlfriend of a friend of his, and he had started a fight with them about it. Several of his friends had joined in, and their ‘campaign’ against the scientologists had involved threatening phone calls, letters and aggressive visits. He had spent a great deal of his holiday studying their ideas, after borrowing books from the local library, and said that they were really crazy. He told me that they had been founded by Hubbard, who has now died. He was worried about the number of his ‘heroes’ in show business who had become scientologists, and mentioned Michael Jackson and Tom Cruise. ‘They had to be stopped’, he had said. I told him that his campaign against the scientologists during the holiday break had echoes of his feelings towards me and his analysis during the break. In my absence he had become afraid that psychoanalysis was something crazy and exploitative, and that analysts had to be stopped by someone. He then said that he himself had had vague thoughts about possible connections between the two. He mentioned that on one of the occasions he went to their offices he had become so nearly out of control that he was glad when the police arrived, because then he had pulled himself together. I related this to his relief about my coming back, and a ‘policing’ role that he also attributed to me. On the following session, a Friday, he told me that at the beginning of the holiday he had kept a tape recorder by the side of his bed and recorded his dreams. Then they started to be more and more disturbing, and for a few days he could not remember them. He said: ‘I want to tell you about the first dream I had during the holiday, because it was so upsetting. It was with Freddie. It was so odd, I was speaking with a childish voice into the tape saying that Freddie had died. I do not know why. He has not died in reality and I have no idea as to why I would dream about him.’ I wondered what came into his mind about him. Karl said: ‘Freddie was the husband of my child minder when I was little. I used to go to them during the day in the year before I went to school because my parents had to work. I had not thought about them for ages. I remember that I used to spend a great deal of time with Freddie, and that he was so supportive, really encouraging. I remember telling him that the world was round, so that if you send something in a straight line, it would actually go out of orbit. He had been really impressed with that, for some reason. They had a son called Philip, who was a few years older. Philip once made a drawing which they had put in the kitchen, of a lonely man in the moon. I was really impressed by that drawing.’ Karl then talked about going to school the following year and missing them very much. Philip gave him the drawing, which he had treasured. He then talked about not liking going to school, and finding it too big. ‘You know, you felt like the lonely man in the moon, like the man in the drawing.’ I said, ‘I think that is the way you felt over the holiday too, missing me, like you missed Freddie when you went to school.’ He said: ‘I remember at the beginning of the holiday thinking that I could not discuss with you what was happening with the scientologists. But then I forgot about it.’ I said: ‘At the beginning of the holiday you could experience me like the supportive childminder’s husband, who was supportive of your explorations. You were then afraid, however, that during the break I had died. You could not talk to me. You forgot about me, I think, because you experienced me as forgetting about you.’

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He then remembered that they used to look at the atlas together, and that Freddie probably taught him about the continents. I said that he also experienced me as helping him to explore his internal world, his internal continents. He said he sounded so childish in the tape, he could not recognise his voice and added that the violence in the dreams had also started to increase. Then Stephen, his friend, had taken the tape recorder away. I said that he was describing the violence in the dreams as connected with his anxiety about the childish voice and the child in him who missed Freddie and who missed me during the break. Stephen represented the part of him who wanted to get rid of the tape recorder because he was frightened of his increasing anxiety. Karl then went back to talking about the scientologists, and what he and his friends had planned to do, such as planting a bomb in their office. He also went through an elaborate description of a kidnap plan. Karl also added that now he felt it belonged to another moment in time, and that he did not think they were going to do it any more. I interpreted to him: ‘I think that when you feel that you miss me and the analysis you also get frightened of these feelings of dependence and you try to get rid of them by making plans which are full of violence. My absence makes you feel you are thrown back into this violent internal world. I then become like the scientologists, whom you experience as harming people. I think that you scare yourself with this violence, even if it makes you feel less vulnerable, at the same time.’ (I also felt that he sounded more incoherent at that point, and that this incoherence was a consequence of the part of the session when we had made more contact.) He said that they were not going to do any of it any more. They had scared them enough. He laughed. It was time to finish. A session a few months later provides a good example of his belief in the dangerous experience of the mother-analyst. Karl had missed the Monday session, because he had been unable to wake up for it. On Thursday he had started the session saying that he could not understand why he could not wake up to come to all his sessions. When he came he always felt better afterwards because he had learnt something new about himself. He wondered whether it was difficult to wake up because he was literally waking up ‘to his mother’ (she was the one who tried to wake him up), and that perhaps he should stay with a friend and see if anything different happened. I pointed out to him that this became a way of regulating his distance both from me and the analysis—he felt that he was waking up for his analyst as well as to his mother. Then he remembered fragments of a dream from the previous night. He had good feelings in this dream, and a sense of being where he wanted to be. He was visiting somewhere really foreign, the Incas, he said. That was all he could remember. He continued that the Incas were a tribe in South America, or Central America. Then he asked me if I knew where they were from. He remembered that as a child he had gone on a trip to South America with his parents and sister. Venezuela was full of wildlife. He described the animals he saw, even at the airport. Then they visited the Andes, and went on a trip on the Orinoco River. He was, at the time, fascinated by the piranhas. He was amazed how they could eat a whole man. He briefly described some of the fights between various animals he had read about in books and told me of his feelings that the piranha would beat all of them. He spoke about people being frightened of sharks, which he was not. There was something about piranhas, perhaps related to the disproportional size of their mouth in relation to their bodies. At the end of the trip his mother gave him a stuffed

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piranha. He was obsessed with them, read a lot about them, and at home gave a talk about the piranhas to his whole class. I interpreted his description of his experience about this trip as containing some echoes of his experiences in his analysis. He felt it was like a trip to this far away place, into the wilderness of his mind, a place full of interesting wild-life, that attracted and excited him, but also frightened him. Although he knew about piranhas, he was frightened of them, like I think he was also frightened of me and the analysis. He needed to keep the sessions stuffed and dead—as when he was absent—otherwise they became dangerous to him. There was a great deal of elaboration on this theme, from him and from me. I felt this was the counterpart of the dream he had had a long time ago, of a crocodile eating Caroline, his first girlfriend. Unless he eats, he is eaten up, and this becomes his belief about relationships between people. He said that a month ago he was offered another stuffed piranha, this time an antique, from someone who had stolen some antiques. He had bought it for £10, but had kept it in a friend’s house. He did not know where his other one was, perhaps hidden somewhere in the house. Now the two piranhas were a couple, and he could build a family. He spoke about crocodiles as being driven entirely by their drives, as well as terrapins. I felt he was frightened of experiencing both of us like piranhas, a mutually destructive homosexual couple. If my words were experienced by him as a source of understanding and containment, he was also afraid that I would take him over. Later in the session I pointed out to him that asking me if the Incas were from South America might express his wondering about where I came from.

Comments The first session after the holiday illustrates Karl’s experience during the break when his father-analyst had left. He believed that he had been thrown into the chaotic maternal universe made up of the scientologists whose founder and father, Mr Hubbard, had died. The dream he had at the beginning of the holiday break, that Freddie had died, represented his equation between his analyst’s absence and death. Karl activated violent thoughts and behaviour to deal with the terrifying feelings of being left to the scientologists, and attempted to find an alternative. In the letters he wrote to the scientologists during the holiday, he said that a new group, named ‘The Sons of Hubbard’ was being founded. The analysis of the process in that session indicates that the experience of re-establishing a positive contact with me was also followed by incoherence towards the end of the session. In the subsequent session this process was more explicit. Karl was, at that point in his analysis, able to have dreams which provided markers of his experiences in the analysis. His conflict between his wish to explore his mind and his experiences in the relationship with his analyst, on the one hand, and his fear of his destructive self and the devouring analyst, on the other, gain symbolic representation in the shape of the piranha that he found during his trip to the wilderness of the Andes. In the following session he found refuge from his conflict in his account of violence between men. The multiple functions of his violence and the core phantasy attached to it are, nevertheless, accessible for our joint understanding: (a) violence creates an emotional distance from the analyst as the pre-Oedipal mother, as illustrated by the scientologists or the piranha; (b) it allows him to project outwards his destructive self; (c)

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it is an attempt to create a distance between him and the potentially violent patient— analyst couple as represented by the two piranhas; (d) it allows him to experience himself as being the creator of another ‘movement’, after the death of the father, which does not require a father. The ‘sons of Hubbard’ thus become an alternative to the movement founded by the father. I understand this experience as derivative of his phantasy of the primal scene, where there is only himself and his mother, and from which the father was excluded. An aspect which is important to note in relation to these sessions is the pace of the interpretations, that is, the way in which the analyst periodically formulates interpretations after short segments of the patient’s material. I have found that an important aspect of Karl’s analysis is that long silences have tended not to be productive and are followed by more disorganised material. I thus find myself being more active in the session than I usually tend to be, making short interpretations at short intervals of time. A segment of another session illustrates a transformation of the phantasy of a primal scene from which men are excluded. The following material became more completely understood only one year later. Karl had missed two sessions. When he came back he told me that it had taken him a few days to realise what had been happening in his mind. On Sunday he had read in the newspaper about a movement organised by women, from which men were excluded and in which women participated in sado-masochistic relationships which involved beatings and mutual torturing. The article had terrified him, and he had not realised why. It was only two days later that he suddenly realised that he was making a connection between that women’s movement, me and the analysis. Then he had had a dream: he had followed a woman into the toilet and he suddenly realised that she had a nose in the shape of the penis. Nevertheless, he tried to get close to her, but was terrified and woke up. One of the aspects we discussed in that session was his terror of this ‘all women’ sadomasochistic world, the analysis, where men did not have a place. At this point in the analysis the images and the terrifying experiences have been brought to the centre of the transference relationship. It is important to observe too that Karl’s insight into the process had to take place while he was absent from a number of sessions. He had needed distance from me in order to be able to think, although this, at the same time created a sense of omnipotence that ‘he could do it on his own’. The phantasies underlying these dreams refer to a world that preceded any division between the sexes and where the dominant character is the ‘primal parent’ as representing the pre-Oedipal relationship to the mother, before the child has solved the riddle of the distinction between the parents (Shengold, 1991).3

Clinical material: Maria The second example, which I will present more briefly, is derived from the analysis of a woman, whom I have discussed in another paper (Perelberg, 1997). Maria is in her late fifties, and has been in analysis with me for several years. She is the oldest of two sisters and a brother and she feels that her younger sister was always her parents’ favourite. She

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feels that throughout her childhood her mother was never available to her, being a withdrawn and cold woman, unable to show affection either emotionally or physically. Progressively in her analysis we have gained access to a deep terror of her mother. She has vague memories of her mother leaning towards her, screaming at her and trying to throttle her. Maria turned to her father from very early on, seeking his love and support, but was bitterly hurt by the realisation that her mother always came first for him. Her attempts to leave home when she was 18 years old failed, and she returned to live with her parents. She fell in love with Alex, a Frenchman on holiday in Britain and told me that although she felt very attracted to him sexually, she could not let him touch her. She describes herself as ‘being turned on in a way from which there was no relief’. She ‘turned herself inside out’, feeling ‘raw’. At the time she read in the newspaper about a man in the States who had raped and killed several women and said that she could well understand that someone could feel like raping and killing. She remembers feeling that the only way out for her was to cut her genitals. Progressively in her analysis her terror emerged that she might have done something to this man she loved, and it became clear that her breakdown was also a way of protecting him. In the following years she reached such a state of anxiety and neglect of herself that colleagues at college felt she might need psychiatric help. She cut 3 The material being presented, crystallised in the dream of the woman with the nose in the shape of a penis may be related to several frames of reference in the literature, such as that of a ‘combined object’, i.e., the bad parents constantly fused in a dangerous intercourse, a terrifying persecutory fusion of man/woman (Klein, 1945) or the phallic woman (see especially Chasseguet-Smirgel, 1964).

her hair herself very short and walked about the campus unwashed and dressed in rags. She was given Valium but soon rebelled against the idea that she needed it. She finished college and embarked on a successful career. She did not get involved in a romantic relationship again. She came to analysis because of her inability to form relationships but also presented several hypochondriac symptoms in various parts of her body which indicated failures in her capacity to mentalise (see Fonagy, 1991). During our sessions together, Maria embarked on long and repetitive monologues about the various pains in the parts of her body. On the first two anniversaries of the beginning of her analysis she suffered two major accidents, each of which might have killed her. These two accidents and the damage she believes they did to her body, along with the misunderstanding and cruelty with which she has felt treated by the various professionals who came in contact with her, constituted the manifest content of her analysis. The repetitive quality of her interactions with me was also relentless. My patient’s sense of being misunderstood and not heard was profound. She spent most sessions on a raging crusade against almost everybody. The atmosphere in the sessions throughout the period of several months following each accident was of absolute terror and despair. We both felt for some time in her analysis that she was capable of violent behaviour either against me or herself. My experience was of profound precariousness. If I said too much, the risk was that she would actually attack me; if I left her too much on her own she might feel so despairing and abandoned that she could kill herself.

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It was only gradually that we came to understand how this material contained the externalisation of the violence of her internal world. This violence, which she consistently turned against herself in the battering of her body with her many hypochondriac ailments and which was externalised in the two accidents she suffered, was frequently close to being enacted in the consulting room against me. Slowly Maria was able to put into words her wish to smash my head whenever I said something she felt she could not agree with. We have been able to understand these violent thoughts and impulses as her attempts to regulate a distance in relation to me, whenever she felt I was too close (being kind to her) or too distant (being cold and unloving). These thoughts have also expressed her belief that this is what a sexual relationship between a couple is about. In the second dream she brought to analysis, a month into treatment, a huge block of concrete suddenly fell on top of three women. The women were completely flattened and then started to rush about crazily. Maria said it looked like a cartoon. She said it was a dream but it did not feel like a dream. She then said that perhaps this was what had happened to her when she was 18. In this session we talked about her experience that this had not felt like a dream because it was so integral to the way she felt—that she had lost her feelings and her three-dimensionality and had become flattened. It was also her experience of feeling disconnected from herself in the present, and of her way of relating to me, of flattening me in the sessions. This dream which ‘had not felt like a dream’ took on another layer of meaning, expressing a terror that she was going to be ‘hit’ by the analysis and would not be able to cope. Perhaps, too, the three women represented herself, her mother and the analyst, all flattened out of recognition. Another example of her experience that relationships between people were bound to be violent encounters is derived from a dream she brought some four years into her analysis. In this dream, she had stuck a knife into an adder, which she explained was the only poisonous snake in Britain. She remembered that she saw one when she went to the zoo with her parents and they had spent some time together in the snake house. Other associations led me to interpret her fear of the poisonous strength of her rage and her capacity to provoke other people to attack her; she was terrified of what she might provoke in me. This was an image of a primal couple, who were both lethal. I then said that this was what she believed happened in the consulting room between us, that it was like the snake house. In the course of Maria’s analysis I have been able to understand that the two accidents she suffered during her treatment were concrete representations of the damage that can happen in the encounter between two people, of the destructive violence of the couple. As the analysis progressed, however, it also became clear that this was her belief about her early relationship with her mother. My suggestion is that these different time dimensions—the pre-genital relationship with the mother and the primal scene—not only became condensed into one in her mind in terms of après coup, but later became reenacted in other relationships. As we have come to understand in her transference to me, she has had to distance herself from people she loves because of her terror that she might have to murder them.

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Discussion In the analysis of my patients it has been possible to identify the specific points in the transference where violent thoughts and behaviour occurred. They were, each time, attempts to create an emotional distance in the relationship with the analyst. My hypothesis is that they relate to a core phantasy both about their primary relationships with their mothers and about their phantasies about the primal scene, that is, the original act which created them as individuals.

The oscillations in the primal scene phantasies In a session when he had started to talk more about his childhood Karl made a slip and said: ‘The problem with my stepfather is that he cannot bear the thought that he was not present when I was conceived. There were only me and my mother, he was not there.’ Karl is thus expressing a phantasy of being present at his own conception, from which his (step)father was excluded. This leaves him experiencing himself as living in a world where only he and his mother existed from the beginning, a world in which he feels treated as an extension of her desires. After all, he felt that she would have wanted him to be a little girl or gay, because gay people, she felt, never left their mothers. Karl believes that his mother supported his beliefs and that she too stressed his biological father’s absence from his conception. Although Karl acknowledged his slip about the absence of his father from his conception at the time he made it, it was only a few months later when a dream allowed us to bring that belief fully into the transference that he understood the implication of his beliefs. In that subsequent session, we had fuller material in the transference and I was able to point out to him again that he experienced himself as having had no father. In a dream he presented at that session he was searching for his father, but was again presented with his mother. He felt enclosed in a world created by his mother or by his analyst, where he experienced any questions about his father as being blocked. Karl stated that it was such a powerful thought, that it was odd but he indeed had never really thought of himself as having a biological father. He said that he was in contact with his paternal grandmother, but he had never linked her to his biological father. It was as if she was on the side of his mother’s family too. She had told Karl that his father had been violent towards her and that he had turned her off men for ever. In that same session Karl said that he felt that he had just reached an understanding that was going to change his life. I think that he was right because it marked an important turning point in his analysis and he has since been able to come to his sessions more consistently. In the next phase of his analysis, Karl was able to tell me about something unbearable that he felt he had had to carry in his mind throughout his life. This was his belief that his mother engaged in violent sexual activities. He had a ‘memory’ that he had never told anyone before of seeing her spanking his sister. He had come home unexpectedly one day and had ‘heard the spanking noises’. He felt that he had surprised his mother spanking his sister in a sexual way and that they both had looked guiltily at him. They had never mentioned the incident again but he remembers still the ‘look’ in his mother’s face when she saw him. He became very frightened of his mother, especially as she had told him

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that she wished he would never leave home. His account of the look reminded me of the wolf man, and I understood this ‘look’ as the expression of Karl’s projections of his own desires and identifications. As Freud said in relation to the attentive looking of the wolves in the dream: ‘The attentive looking, which in the dream was ascribed to the wolves, should rather be shifted on to him’ (1918, p. 34). In subsequent sessions Karl’s account seemed to oscillate between referring to this as a memory and also feeling confused about what he had actually seen. The ‘look’ became the clearest evidence he had for this account. Wollheim has pointed out the connection between imagination and desire. In discussing Freud’s paper ‘A child is being beaten’ he points out Freud’s suggestion that the problem patients may have in describing what they have imagined is a difficulty in recognising their desires (1984, p. 96). Thus one can identify the oscillation in Karl’s different phantasies in this period of his analysis between an image of a sado-masochistic interaction between his mother and father, brought to the analysis at the very first consultation, a sadistic interaction between him and his father, and a sadistic interaction between his mother and his sister. I think their order of appearance in the analysis may be a reversal of their chronological order, from a phantasy of an exclusive relationship with his mother, homosexual phantasies towards mother but identifying himself with a little girl, to a more potentially heterosexual phantasy. In the transference these phantasies oscillated and the oscillations seem to me to be transformations which express different desires for heterosexuality and for a homosexual encounter in the primal scene. They also indicate contradictory beliefs. Thus the belief that his father was not present in his conception exists side by side with the belief that the intercourse between his mother and father was violent. Having tracked this observation in the transference, I turned to the literature to look for further definitions on the theme of violence. As discussed in my review of the literature (chapter 1), I identified that Freud did not seem to be aware that he used the word Violence’ mainly in connection with the primal scene.

The function of violence: hypothesis In the course of his analysis, we have been able to reconstruct Karl’s terror of his mother. Throughout his late adolescence and young adulthood Karl engaged in violent sexual interactions with women, where penetration was absent, but where he enacted a sense of power and control. This violence, as we have come to understand, represented an attempt to create a shield against his terror of women. These violent encounters became progressively out of control when he was at university. He ended up spanking his girlfriend in such a way that they both became frightened and ran away from each other, which led Karl to come back to London. Another example of this experience of a shield, now in interactions with men, was present in a session when he told me how, after being involved in a violent scene with other young men he had experienced himself as immune to everything. He described the way in which he was wearing just a tee-shirt in freezing weather, when everybody else around him was wearing jumpers. He had felt completely immune to the cold and to the three youths whom he had defied.

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As we have also been able to reconstruct in Maria’s analysis, she too experiences her father as having abandoned her, but to a cold, cruel and sadistic mother who was unable to relate to her. She also believes that her father raped her mother, and that this was how she was conceived. Maria’s first and only sexual relationship with a man is described by her as a rape in which she went out with a boyfriend but ‘froze up’ when they had intercourse and ended up being forced to submit to him. Both these patients believe that their parents, specially their mothers, supported their beliefs in the violence of sexual intercourse. Karl feels that his mother has consistently stressed to him, in ways which he often experienced as enticing and seducing, the violence in her sexual relationships, whereas Maria thinks her mother led her to believe that sexual relationships were about men raping women. Maria’s first dream at the beginning of her analysis—the block of cement which fell on top of three women who were flattened and started to run around crazily like cartoon characters—became paradigmatic in her analysis, also indicating the violent homosexual configuration of her pre-Oedipal experience. Both these patients enacted their beliefs in the violence of the primal scene in the violence of their own sexual interactions and both felt that they had to retreat from sexual relationships. Recently Karl had what he called the ‘first penetrative intercourse’ in his life. Both their analyses were characterised by the ways in which they retreated from the analytic encounter: Karl in his consistent absence at the beginning, Maria in the endless monologues, and the various professionals she sought to help her with her numerous bodily pains. The analytical task, which involved a great deal of frustration, anguish and fear was to attempt to carry on interpreting the process, as I understood it, to my patients, that is, to try to put into words what was for them still so much in the domain of action. Glasser has suggested the notion of a ‘core complex’ to indicate a conflict between on the one hand an intense longing for indissoluble union with the object, which, however, leaves the individual with a fear of being merged and annihilated on the other. In the pervert, Glasser adds, the father is emotionally, if not geographically, absent. Glasser has also distinguished between self-preservative violence and sadism or malicious violence (1985). Meloy (1992) has also suggested a distinction between ‘predatory violence’ and ‘affective violence’. The former is encountered in psychopathic characters, and is violence that is planned, purposeful and emotionless. The latter is a reaction to a specific threat, closer to Glasser’s ‘self-preservative violence’. What is implied in both ‘selfpreservative violence’ and ‘affective violence’ is the phantasy attached to the violence, which is the issue I explore in this chapter. I think that Karl’s violence can be subsumed under both these categories of ‘self-preservative violence’ and ‘affective violence’. I have suggested that the core phantasy in violence for both my patients is that the primal scene is an act of violence and that the relationship to the pre-Oedipal mother is also engulf-ing and violent.4 These phantasies have been developed in a context where their beliefs seemed to correspond to their actual parents to some extent. This idea links with what Wollheim designates as a ‘disposition’. Wollheim suggests that when certain events occur in a person’s life, the experience of these events establishes a mental disposition, a mnemic disposition, which has a psychic force (1984, p. 131). The effect is the obtrusion of the past into the present, which at times can become tyrannical. Thus I think that for both these patients, their phantasies about their primary relationships with their mothers and about the primal scene reverberate in their actual experiences of their primary relationships.

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I would like to discuss the alternation between maternal and paternal functions in the transference. Conceptually, I understand my patients’ violence as a defence against an object which is experienced as terrifying and dangerous, and as an attempt to create an equilibrium where they do not feel either too separate from or too overwhelmed by this object. I feel, however, that when the analyst formulates interpretations—of whatever kind—she is inaugurating something for the patient, independently of the content of the interpretation. The analyst introduces differentiations and separations into a territory previously more chaotic and undifferentiated. The theories present in the analyst’s formulations are thus not there, present in the mind of the patient, available to be uncovered, but become constructions made by both the analyst and the patient in the analytic process. In this process, the analyst is by definition creating the paternal function and breaking up the phantasy of a fusion with the mother. When the patients reject these interpretations, in the process of 4 A recurrent connection between aggressive behaviour and primal scene phantasies is found in the literature about children, adolescents and young adults. In his analysis of the Rat Man, Freud interpreted the violence of the patient’s dreams as defensive attempts to cope with his sexual wishes and castration fears within an Oedipal framework (see also Crocker, 1955; Bonnet, 1986; Shengold, 1989; Grotstein, 1982). Anthi (1982) has suggested that the theme of murder in detective novels is unconsciously motivated by traumatic primal scene experiences. Quoting from a personal communication by Dr Anna Katan, Greenacre (1950) suggests that children who have repeatedly witnessed primal scenes may be drawn into participating in them by the parents. This may increase the scopophilic-exhibitionistic elements of their character (p. 461). In a moving account of the analytic treatment of a violent adolescent, Letarte (1987) indicates how the violence was understood in terms of the patient’s phantasies about her origins. She emphasises the relevance of reconstructive interpretations in the analysis of this adolescent. Harris and Pontius (1975) point out that acts of dismemberment attempt to disintegrate a primary object representation in order to reconstitute it in a more meaningful way Their paper is derived from written documents and interviews with two men who had been committed to prison for violent murders. Biven (1994) suggests the idea of a ‘tableau’ as a scene left by some murderers after their murder. Biven suggests that these are coded screen events, ‘nonverbal inanimate communications, largely unconscious’ expressing a massive perversion compromise formation and attempting to mask childhood trauma. The tableau expresses the dehumanising principle by obliterating any humanity in both the self and the object.

working through, are they then not, by definition, attempting to reinstate the fusion with his mother? Thus the paradox is that if violence, on the one hand, is an attempt to create a separate space where the patient can survive, it at the same time reinforces the experience of being locked up in a chaotic world with their mothers. I am aware that an important difference between these two patients is that Karl has actually been violent towards other people, whereas Maria has not. Nevertheless, she differs from many other patients I have had in analysis who have either had violent dreams or expressed violent conscious thoughts against me in that at a specific period in her analysis both Maria and I knew that she was close to actually attacking me in the consulting room. Since the beginning of his analysis, Karl has not been as involved in violence as he had been previously. When Karl is locked up in dreamless states of sleep and does not come to the sessions, is it not the paternal function performed by the analytic process itself, independently of

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anything I say, that Karl is rejecting? When he gets into violent fights with his male friends, could these fights be understood as attempts to eliminate the males, and in the transference, the paternal function of the analytic process itself? His longing—and also his terror—is of fulfilling the phantasy of being in a special and unique relationship with an idealised mother. I emphasise the idea of fulfilling a phantasy and not of regression because the phantasy was never a reality. The father as a ‘given’ was, after all, present from the beginning. The other aspect involved in his fights, however, is that of reaching a special relationship with these men, and in that sense it is a homosexual phantasy that is being enacted. When Maria is locked up in her endless monologues about the state of her body and the many symptoms she experiences, is it not the engulfing relationship with her mother that she too is expressing? In Maria’s internal world men and women had stereotyped representations: the women—like herself—seemed to be lifeless and frozen, unable to relate and produce warmth, leading lives in which men were non-existent or worthless and violent towards women. In the analysis the alternative has been either to keep me as a dead object, frozen and unable to think, or as an object that contains passion, but would be experienced as violent in my attempt to get close (in parallel with her alternating between coldness and violence). Any aliveness seemed to represent an inauguration of a violent relationship with me. In her analysis Maria has relentlessly and sadistically projected on to me her rage at feeling unloved as well as her terror of me. At the same time, she cannot experience differentiation because this means being in touch with an inner reality where the stress is on violence and murderous encounters between two separate people. I would either be experienced as unloving and cruel, in which case she would feel like murdering me, or as kind, in which case she would be possessed by thoughts of violence against me because she feared I would take her over. She has attempted either to contain these contradictory experiences in a relationship with her own body which has thus been characterised by violence and fragmentation, or to project them outside, as in her experience of the two accidents, which were also violent encounters. She has persisted in encountering an external world that she experienced as dangerous and violent towards her. Her analysis has consisted of a slow process through which we have attempted to understand her profound terror of both fusion with and differentiation from me since she feared she could only find in me a mirror of herself. Both these patients feel unable to enter a three-dimensional world, which is experienced as violent and dangerous, and they attempt to retreat into a two-person relationship, which in turn is also dangerous and engulfing. Both found it difficult to differentiate between their state of mind and that of the other person, and to think about other people as having separate minds (see Fonagy, 1991, Fonagy and Target, 1994). This led, in both cases, to a dehumanisation of the other and of themselves. Both retreat into a dehumanised and robotic world. Karl’s initial dreams in his analysis pointed to his experiencing himself as a machine or a computer involved in dangerous and violent games. Maria experienced herself as possessing a psychotic body, full of bits that attacked and ached. She attempted to hold herself together by becoming a piece of concrete, which she then attempted to drop on her analyst and herself. I would suggest that it is ultimately the phantasy of the mother’s body which both Karl and Maria attempt to get rid of in their violent attacks, a mother who is experienced as not only in possession of my patients’ bodies, but also of their intellectual and affective

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experiences. The violent act is, ultimately, an attempt to destroy the obstacle imposed by the other’s existence. Thus violence, for my patients, has had the function of allowing them to believe that they have created a space in which they can survive in the face of an object who is experienced as terrifying. There is a pattern in which violence is exercised, a plot or narrative, which allows the underlying phantasy to be identified. This condensed unconscious narrative functions as a screen memory for a childhood ‘event’ (actual or phantasised) and an explanation formulated by the individual about his existence. Violence is, thus, a communication about these patients’ belief systems about themselves, about their relationships with others and, I think, about their origins. The violent act or phantasy tells a story, which is their personal myth of creation and contains both preOedipal and distorted Oedipal theories. The function of the analytic process is to follow the chains of associations as manifested and enacted in the transference and to construct this narrative of origins.

References Anthi, P.R. (1982) ‘The primal scene in Sandemose’s murder mysteries’, Scandinavian Pyschoanalytic Review 5(1):91–104. Biven, B.M. (1994) ‘Sadists and serial killers: the role of the dehumanising principle’, paper presented to the Association of Child Psychotherapists Annual Conference. Bonnet, G. (1986) ‘En proie aux affrès du remords: psychanalyse d’un meurtrier’, Psychanalyse à L’Université 11(42):309–332. Crocker, D. (1955) ‘The study of a problem of aggression’, Psychoanalytic Study of the Child 10:300–335. Fonagy, P. (1991) ‘Thinking about thinking: some clinical and theoretical considerations in the analysis of borderline patients’, International Journal of Psycho-Analysis 72(4): 639–656. Fonagy, P. and Target, M. (1995) ‘Understanding the violent patient: the use of the body and the role of the father’, International Journal of Psycho-Analysis 76(3): pp. 487–501. Freud, S. (1918[1914]) ‘From the history of an infantile neurosis’, Standard Edition, 17. Freud, S. (1919) ‘A child is being beaten: a contribution to the study of the origin of the sexual perversions’, Standard Edition 17, pp. 177–204. Glasser, M. (1985) ‘Aspects of violence’, paper given to the Applied Section of the British Society. Greenacre, P. (1950) ‘General problems of acting out’, Psychoanalytic Quarterly 19:455–467. Grotstein, J.S. (1982) ‘The spectrum of aggression’, Psychoanalytic Inquiry 2(2): 193–212. Harris, J.E. and Pontius, A.A. (1975) ‘Dismemberment murder: in search of the object’, Journal of Psychiatry and Law 3(1):7–24. Letarte, P. (1987) ‘Des caves de la Sorbonne a la Drague Rotative’, Revue Française de Psychanalyse 51(2):737–749. Meloy, J.R. (1992) Violent Attachments. Northvale, NJ: Jason Aronson. Perelberg, R.J. (1995) ‘The psychoanalytic understanding and treatment of violence: a review of the literature’, Bulletin of the Anna Freud Centre 18(2). (In this volume, chapter 1. ) Sandler, J. (1959) ‘The background of safety’, in From Safety to Superego. London: Karnac, 1987. Shengold, L. (1989) Soul Murder: The Effects of Childhood Abuse and Deprivations. New Haven and London: Yale University Press. Shengold, L. (1991) ‘Father, Don’t You See I’m Burning?’ Reflections on Sex, Narcissism, Symbolism and Murder: From Everything to Nothing. New Haven and London: Yale University Press.

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Shengold, L. (1993) ‘The Boy Will Come to Nothing’: Freud’s Ego Ideal and Freud as Ego Ideal. New Haven and London: Yale University Press. Walker, N. (1968) Crime and Punishment in Britain. Edinburgh: Edinburgh University Press. Wollheim, R. (1984) The Thread of Life. Cambridge: Cambridge University Press.

Introduction to chapter 5

In ‘Narcissism and its relation to violence and suicide’ Anthony Bateman suggests that thin-skinned and thick-skinned narcissistic states as described by Rosenfeld (1987) may be associated with self-destructive and violent impulses respectively. In Bateman’s view these are dynamic rather than fixed states although both facilitate temporary stability. Patients may oscillate between the two states, and it is at the point of such movement that enactments of violence and suicide become more likely, since such oscillation results in identity diffusion, which in turn may lead to suicide or violence in an attempt to regain the self and/or to separate from the other. Bateman also believes that interpretation is most likely to be effective at moments of transition from one state of narcissism to the other. He is in agreement with Perelberg’s formulation that violence (and, he adds, suicide) are attempts to create a space in the relationship with an object which is experienced as intrusive and terrifying. Violence is more likely if an individual tries to regain stability and separateness through refuge in a thick-skinned state; suicide occurs if the individual seeks solace through a thin-skinned state. In agreement with Campbell, Fonagy and Target, and Perelberg, Bateman suggests that the underlying phantasy of both actions may be the same, namely, an attack in phantasy on the body of the mother. These attacks are possible because the self or the body becomes identified with a hated other. In his formulation, as in the other chapters in this collection, the role of the father is also emphasised as fundamental in enabling the creation of a triangular space in the relationship with the mother. Bateman discusses a woman patient in whom a thin-skinned state incorporated selfdestructive impulses which were held at bay only so long as the analyst was believed in phantasy to be meeting all her desires and needs. Breakdown of the thin-skinned state after an analytic holiday led to recognition of the underlying thick-skinned state which harboured violence. The patient became defensively identified with the powerful aspect of her mother, attempting to tyrannise over the analyst as the helpless, needy mother, through verbal abuse and by threatening herself and the analyst with a knife. Simple, decisive, reality-based speech and action by the analyst gave the patient an outside perspective on the pathological aspects of her view of the analyst-patient relationship, and proved to be calming and mutative.

5 Narcissism and its relation to violence and suicide1

ANTHONY BATEMAN Recently psychoanalysts have begun to consider violence from a perspective of mental representation, thereby placing a focus on internal processes which may result in violent acts. This emphasis has allowed a distinction to be made between different types of violence (see Perelberg, 1995a for review) such as self-preservative violence, malicious violence, predatory violence and affective violence (Glasser, 1985; Meloy, 1992). In essence it is the use of and the experience of an object both in phantasy and reality that are crucial in characterising the different types of violence. For example in selfpreservative violence the experience of the object is as a threat which must be either avoided or destroyed whereas in malicious violence the object is controlled and tormented for the subject’s gratification. Yet the nature of the object needs further definition as there is often confusion about whether the object referred to is either an internal or an external object. This is particularly important in any consideration of violence since someone may be attacked because he or she has become identified with an internal phantasy object. Thus an attack on another person may be driven by an impulse to destroy someone inside oneself. Contrastingly a suicide attempt or act of selfmutilation may occur if the self or the body becomes identified with a hated other. There is therefore a close relationship between violence and suicide yet little is known about why one should occur rather than the other. This chapter addresses that question and develops Rosenfeld’s ideas of narcissism. My thesis draws on the distinction proposed by Rosenfeld (1987) between two types of narcissism, namely, thick- and thin-skinned narcissists. In essence thick-skinned narcissists are inaccessible and defensively aggressive whilst thin-skinned narcissists are fragile and vulnerable. I consider Rosenfeld’s division 1 A fuller version of this paper was published in the International Journal of Psycho-Analysis 79 (1998):13–25.

helpful in clinical practice and yet too schematic. It is my view that narcissistic and borderline patients mostly move between thick- and thin-skinned positions and are rarely fixed in one or the other. This movement gives an unstable clinical picture which is both

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a danger to and yet an opportunity for analytic treatment. On the one hand the movement increases the likelihood of enactment either in the form of violence to others or in the form of self-destructive acts; yet, on the other hand, it is only when a patient is moving between positions that interpretation becomes therapeutically effective, allowing progress in treatment. The determining factor in either violence or suicide as an outcome of the unstable movement is the relative contribution of thick-skinned and thin-skinned elements at any given moment. If thick-skinned elements are to the fore, violence occurs whereas if thin-skinned processes are uppermost suicide may result.

Narcissistic/borderline organisation Rosenfeld (1987) clarified two aspects of narcissism identifying thick-skinned and thinskinned narcissists. Both groups use their psychological structure to maintain a feeling of safety (Joffe and Sandler, 1967). In ‘thick-skinned’ narcissists, the survival of an idealised self is paramount. The analyst is experienced as someone who wishes to dismantle the patient’s self, to effect a cure and to engender dependence. As a result analytic sessions become dominated by defensiveness, a devaluation of external relationships, and a wish to destroy the analyst as an object who can be a source of goodness and personal growth. In short, thick-skinned narcissists become prone to selfpreservative violence as they struggle to retain psychological equilibrium. The thick-skinned narcissist is difficult to keep in treatment, remains unmoved by breaks in the analytic process, sneers at interpretation directed towards need and dependency, rejects before being rejected, and maintains an impenetrable superiority. His whole self becomes identified with a destructive self whose sole purpose is to survive by triumphing over life and creativity. Losing an external object not only leaves this destructive self unmoved but also stimulates a feeling of excitement and triumph as the destructive self is further empowered. Similarly, personal achievement fuels feelings of supremacy and self-importance. Interpretation of envy is necessary and frequent confrontation is unavoidable. In contrast, the thin-skinned narcissist is more vulnerable. He is ashamed of himself, feels sensitive to rejection and persistently judges himself as inferior to others. Achievements at home or at work are a stabilising element in his personality rather than a source of power, increasing self-regard rather than feeding a triumphant, arrogant self. As a consequence, Rosenfeld warns against interpreting destructive narcissistic elements in these patients. Interpretation may both inhibit their ability to build up satisfactory object relationships and puncture their vulnerable sense of self. Rosenfeld’s division is, I think, too schematic and categorical, albeit for clarity, since in many patients a division between thick-skinned and thin-skinned elements is unclear. The psychological processes change even during a session, sometimes from moment to moment, as different narcissistic aspects ebb and flow. This leads to difficulties in knowing when interpretation during a session is appropriate and when it is ill-advised since interpretive analytic work is hampered in both aspects of narcissism. However, in my view, such patients are especially available for analytic work as they move between thin- and thick-skinned positions. Further I suggest that during a shift between thick- and thin-skinned states of mind the likelihood of enactments is increased. In their static and

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rigid form both narcissistic positions are stable but a shift between them exposes a dangerous instability during which both violence and self-destruction are possible depending on the balance of introjective and projective processes. There is therefore an intrinsic opposition between the uncovering, interpretive work of the analyst, which in itself destabilises the patient’s equilibrium, and the survival of the patient. The experience of fear in the analyst is critical in this process. Fear of both suicide and violence prevents effective analytic work and, unwittingly, leads to collusion and to the development of ‘blind spots’ in treatment. The analyst avoids crucial affective experience and meaningful exploration because uncovering aggression may overwhelm appropriate analytic distance between patient and analyst, swamp objectivity, conflate thinking and feeling, and, if accompanied by a collapse in counter-transference processing by the analyst, lead to sudden suicidal or violent enactment on the part of the patient. There may be a gradual analytic suicide in which an empty narcissistic self is protected by immobilising a perceived, destabilising threat from the analyst, since it is better for the narcissistic patient to die than to experience the humiliating need of an identity through someone else. This may become represented in the analysis by a flight from treatment which is precipitately broken off without notice. Yet, if the patient remains in treatment, uncovering through interpretation his or her need of vicarious selfcoherence leads covert aggression to become manifest as a final, desperate defence. At this point the aggression may not be represented by an ending of the analysis but find form in overt suicide becoming either directed at the patient’s own body since, for narcissistic and borderline patients, the easiest and commonest outlet for affective expression is within the physical domain, or alternatively aimed at destroying the threat posed by the analyst and the analytic process through direct attack. In the female patient I am going to discuss how thin-skinned elements form part of a defensive self protecting a powerful thick-skinned self. Her thin-skinned self provided a stable state and she was not suicidal. Similarly her thick-skinned state protected her from abject need of another. However, when she began to shift between thick and thin-skinned positions she was in danger of either attacking me as her thick-skinned state came to the fore or of committing suicide as her thin-skinned self no longer formed a safe haven. Thus there are three components leading to a development of suicide or overt violence. First there is a psychological shift which destabilises the patient, second there is an attempt on the part of the patient to re-establish an equilibrium by either regaining a thin-skinned state or finding a powerful thick-skinned position and, third, depending on the balance at the time of thin- or thick-skinned elements, there is recourse to suicide or an attack on the threatening object which has not only to be immobilised but also destroyed. Such movements introduce formidable technical problems for the analyst. The rapidity of events may leave him bewildered, fearful and anxious. It is only if the analyst can retrieve an analytic position that events can be contained and brought under control. To do this the analyst needs to interpose himself between the confused thin- and thickskinned positions of the patient and intervene from the point of view of a third object (Bateman, 1995).

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Clinical material Jane is a 37-year-old woman, formerly in a successful career. At the age of 34 she took time out from her work to do some research. On her return to work, her colleagues informed her they did not want her back. Bewildered, she accepted their decision and cleared her desk. She experienced their rejection as a crushing, personal blow. It substantiated her terror of never being able to do anything well. Her pre-existing view of herself was of someone who was a fake, someone who was always on the edge of being found out, and someone who struggled to cover over her inferiority. In a similar vein, she felt there was nothing attractive about her. She had never had sexual intercourse, believing her closest friend, a man, visited her only because she conned him with a false liveliness. Her life had been a question of surviving and of not getting caught out. Indeed she likened it to walking across a battlefield littered with landmines which might explode at the slightest vibration. Jane came from a middle-class background, the third child and only daughter of professional parents both of whom were successful. Her father was a powerful, dominating man, bombastic, incisively intelligent, and critical. Hard on his children, he had little time for their problems or difficulties which he believed should be ignored. He himself had struggled as a child with a physical deformity. Never giving in to the limitations this imposed, he excelled at sport for the disabled and achieved highly academically, gaining a double first at university. He expected his children to do the same, to overcome adversity without a whimper, and to develop a self-sufficiency that could only arise out of paternal neglect. ‘Pull yourself together gal’ was his phrase when faced with childhood emotional expression. He drank excessively, often not returning home until late evening. His return from work each day was awaited with dread by the whole family. Jane remembers lying awake in bed listening for his key in the door, fearful that he would come up to her bedroom and, in his drunkenness, inexplicably start shouting at her after an altercation with her mother. Her mother, a successful writer, was quiet and long-suffering, always complaining that her only support came from Jane. Jane reported at the beginning of her treatment that her relationship with her mother was close and intimate. Ever since early childhood she had felt she was her mother’s favourite. They spent many hours together whilst her siblings played together. Thus Jane described her relationship with her mother as the best friendship she had ever had. However as her first few sessions progressed it became clear that there was another side to their relationship. Mother persistently complained to Jane about her ‘lost love’, saying that it was only Jane that stopped her from ending her life. Indeed Jane was her mother’s only confidante and carer, used by her mother to fill her own emotional void. Gradually Jane became locked into looking after her mother, hardly able to go out and frightened to go away from home, even to children’s parties, for fear that her mother would kill herself. By adolescence Jane rarely went out with school friends, spending most of her time at home working at her desk. By the time she gained a place at university she was able to leave home but returned every weekend. This historical material was related in a desperate, piteous manner during the early part of her analysis. Jane attributed her depression to the loss of her job and to rejection

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by colleagues rather than to her past life. There was no sense of bitterness or anger, rather a desolation, gloom and an overwhelming sense of emptiness. My remarks were, on the whole, limited to empathic statements such as ‘you certainly feel very let down’ to which she eagerly but defensively agreed. Two years At the time of a break, two years into analysis, Jane talked about having left home to attend university and how she had felt it was cruel to leave her mother alone, unsupported. Taking this up as her feeling that I was cruelly and selfishly abandoning her, leaving her struggling on her own, resulted in a barrage of questions about whether I cared for her or not. Jane portrayed me either as someone who should feel sorry about her harsh treatment or as someone who was cruel, heartless and cold, contributing to her misery. She felt betrayed. She told me that taking breaks was a selfish act, did not take account of her needs and that it didn’t seem to matter whether she felt she could manage. On return from my break Jane seemed quite different. In place of a sorrowful, compliant and vulnerable patient was an arrogant, tense and disdainful woman. During the first session she told me that she had managed well and hadn’t given her analysis much thought. I told her she seemed proud to have been unaffected by the break. She responded by asking if she was supposed to have been bothered? My lack of response to her question made her anxious. She demanded an answer. There was no doubt that she was in a combative mood and so I said that she seemed to have come back from the break determined that her analysis should have no meaning and yet the break had left her feeling unwanted and uncared for, abandoned by me as I followed my own selfish requirements. Haughtily, she laughed, telling me that I was clearly deaf. She had already told me that no thought had been given to the analysis during my absence. On the contrary, it had shown her that her need for treatment was less than she had believed. She wanted to know if I had given her any thought. I said that the thought I was giving her now was that her response to our break had changed her feelings of sorrow and of betrayal into hostility and dismissiveness. Again she laughed derisively. Jane continually asked me if she should stop analysis whilst also telling me that there was nothing left in life for her. She was a failure. She asked me if I liked her, if I would be relieved if she left, whether I hoped she would not come to her sessions so that I could have some free time. The tone of her questions changed. Far from being desperate, they were fired like bullets, insistent, threatening, and frightening. On some occasions she would taunt me with my uselessness, laughing at my comments. Her ambivalence towards me escalated and her oscillations between a nasty thick-skinned state and a vulnerable thin-skinned state increased both in intensity and in frequency. Yet she attended promptly and without fail. Sessions were never missed. Her personal torment was obvious, exampled by conflict in all aspects of her life. Nevertheless, like her former work colleagues, I found myself wishing she would clear her desk and not return to analytic work. Powerful wishes to cease treatment on both our parts represent suicide under such circumstances, as the analytic process represents life and developmental hope for the future. If this collaborative hope is destroyed and lost by the analyst and his suicidal patient, both give up and attack the process that appears to be causing such pain. In

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borderline and narcissistic patients the origin of the pain is often identified as the physical body, symbolised in analysis by the analytic relationship. Thus the relationship is destroyed in an attempt to save a threatened self although the underlying problem remains unaddressed and actual suicide remains a future possibility. My wish to stop treatment was a suicidal equivalent based on my own feeling of failure since the analytic relationship became imbued with hopelessness created by Jane’s own sense of futility. Although I recognised this as Jane’s own projected sense of failure, my interventions seemed futile, only leading to an orgy of self-abasement by Jane. In exasperation I told her that I thought she felt she had defeated analysis, triumphed over my ability to help her, and that now she wanted me to watch whilst she gradually committed suicide. She didn’t know whether she wanted to clear me out of her mind and never return or to get me to clear her out so she could continue to feel sorry for herself. Her response was to tell me that she had been right all along and that I was fed up with her. I told her that she was doing her best to make me fed up with her by conducting her analysis under a persistent threat of suicide. At this point she left the session without saying a word. After a few minutes I followed her outside but her car was gone. The next session began with a dream. Jane was sitting in a house. Her body was on either side of a window, half in and half outside the house. Outside there was violence. Her head was banging against the window, oozing blood. She was dying. Inside the house no-one was noticing her gradual physical destruction outside. She experienced a feeling of desperation. People in the room looked warm and cosy but it wasn’t the place for her. Eventually a black-hooded figure came and took her away. She was relieved. She told me that she felt dreadful. She didn’t know where she was, whether she should have come to her session, stayed in bed, or gone to stay with a friend. The dream frightened her. I said that she seemed half in and half out of our analytic house and that she didn’t know how violent her actions needed to become to ensure that I noticed her desperation. She felt she was banging her head against a closed window which offered sight of warmth and yet also shut her out. She agreed with this telling me that individuals who had a clear physical injury, like her father, could evoke sympathy and care whereas from the outside she looked normal. She had seen someone the day before with a broken leg and found herself wishing she had broken something. Everyone would then have to take notice of her. She would be unable to get out of her top floor flat and people would have to bring her food. It was clear to me that Jane felt I ought to be doing more than I was—bringing food to her top floor flat, understanding to her mind—and I felt, too, that I had to do more than interpret or offer empathic statements. Neither felt as if they were adequate to deal with her increasing desperation. Furthermore Jane’s degree of distress had begun to give me images of a wounded, frightened animal. Returning to the dream, I said that I thought she was beginning to feel that suicide was her only solution, bringing relief from her desperation. The black-hooded figure, partly signifying death, was leading her away. At times she thought I was the black-hooded figure but she didn’t know whether I was death or life since the black-hooded figure may also have been Batman (a play on my name, Bateman) who himself is a force for good

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rather than evil. However, I suggested that, as she felt that she might harm herself, I would like to admit her to hospital, especially as I thought that her bleeding head was worse than a broken leg. She seemed relieved at my suggestion but refused to consider it further on the grounds that no one at a hospital would admit her. Jane presumed that they would think there was nothing wrong with her. She felt that she had to pull herself together, do it on her own, and no one else was going to do anything for her. I said that she now felt that I was not going to do enough for her in the session to sustain her until the following day. She started to reassure me that things would be all right, suggesting that perhaps she was being melodramatic. ‘I am OK really.’ I did not feel reassured and said that I still felt that we should consider hospital admission. She became calm and quiet saying she would be all right in a minute. My interpretation of Jane’s dream was accepted, reflected upon, and thought about, leading to moments of calm in this part of the session. In my view, interpretation was useful at this point because once again Jane was between her thick- and thin-skinned states, represented in the dream by her being half inside and half outside the house. However a few moments later she returned fully to the outside of the house by taking up a dangerous, violent, thick-skinned position in which interpretation was futile. On the couch she turned on her side, opened her handbag which she always kept beside her, and pulled out a kitchen knife. Startled I watched as she started to bang it on her wrists and the palm of her hand, drawing small amounts of blood. She told me that she had found that the knife made her feel better if she carried it around with her—‘I don’t die if I’ve got this.’ ‘I told you I will be all right.’ Initially I made a fumbled attempt at interpretation at which point she told me to ‘fuck off’. In desperation I told her that her knife made me feel worse and that unless she put it away I would not be able to think and to consider how to help her not to turn her dream into reality. Such a statement of truth about the analyst’s reality has been recommended by Kernberg et al. (1990) to stabilise borderline and narcissistic patients, especially when paranoid reactions intensify. However, Jane sprang off the couch like a predatory cat, saying she would do what she wanted. As she paced up and down the room waving the knife I asked her to sit down whilst we considered what was happening. She refused, pointing the knife at me; I stood up and asked her to give me the knife which, to my surprise, she did. I placed it in my desk drawer where it was to remain for over a year until she asked for it back; by that time it had become an innocuous object, offering little for her in excitement and security. For the rest of the session I talked to Jane about admission to hospital. Initially she told me I only wanted her to go into hospital because I was scared. To some extent this was clearly correct and I told her that I was scared that she was going to destroy either herself or me in an attempt to rid herself of something ineffective she believed she had inside her. Eventually she agreed to hospital admission and this was arranged. Her admission was short and her analysis continued whilst she was in hospital. After discharge from hospital Jane initially appeared sensitive and wary during her sessions but gradually she became more reflective about what had happened and it became apparent that hospital admission had had a beneficial effect. Although she felt that I had let her down, accusing me of betrayal and failing to understand her, there was the beginning of an embryonic capacity to consider the evolution of the dramatic events and what she now wanted from analysis. For example she talked about renewing her entry ticket to a reference library and her concern that her application would be refused

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because of her demands on the librarian’s time over the previous two years. She asked me for a letter in support of her application for renewal. I interpreted her anxiety that I would not renew her analytic ticket since she felt her behaviour had been so demanding throughout her two years of analysis. Instead of the dismissive response or self-pitying tone that this would have elicited hitherto, she talked of her other concern that, even if the ticket was re-issued, the desk on which she placed her reference books would be taken by someone else. Linking this to her analytic sessions and her place on my couch for her own analytic research opened up a recognition of the importance of analysis to her. This was a more constructive and fruitful dialogue than had occurred prior to her hospital admission. Hospital admission may have a beneficial effect on analysis for many reasons, not least of which is the safety under which analysis may be conducted, leaving both patient and therapist able to explore difficult issues without becoming dangerously anxious. Nevertheless, in Jane’s situation I think it was both my decisiveness and truthfulness that was important in stimulating change and decreasing the threat of both suicide and violence.

Suicide or violence Jane was, within her own self-structure, stuck between pathological aspects of both her mother and father. She could not develop psychically unless she handed over the care of her mother to someone else. Her father would not take responsibility, failing to protect his daughter from a depressed, unfulfilled mother. There was no one to whom Jane could hand over her duties. As a result Jane never developed a capacity to leave her mother and reappraise her relationship with her from a different perspective. She remained bound up with her mother, fighting for her own as well as her mother’s survival, but primarily identified with her mother as a tyrannical aggressor (A. Freud, 1936). Her mother was only able to see life from her own point of view and not from her daughter’s. Jane was stuck in a dyadic confusion, unable to triangulate her relationship and only able to separate temporarily by adopting pathological thin- or thick-skinned positions. She desperately needed to keep her mother alive but in so doing she lost herself, trapped half in and half outside her mother’s body, caught between thin- and thick-skinned positions as represented in her dream by being half in and half out of a house. It was this that led her to attack her own body in the session. Her thin-skinned position through which she maintained distance between herself and her mother (analyst) through a reversal of transference roles (King, 1980) in which she was her weak, piteous mother and I her protector and mentor, had collapsed. At this point I think she has to attack her mother within both her mind and her body, trying to separate from her or trying to obliterate her by banging her head against the window. In a further attempt to regain psychic equilibrium thick-skinned elements came to the fore—Jane pointed the knife at me, and violence became more likely for at that moment I, rather than her body, was identified within her mind as her mother from whom she needed to separate. Carrying the knife is a pathological solution, making her feel more secure because she feels she can protect herself from disappearing either through violence or suicide. Giving her knife over to me, and thus symbolically giving herself, necessitated hospital admission since it left her

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defenceless. My decisive demand for her knife and my honesty about my own fear demonstrated to Jane that a different role was possible for me in her analysis. First, analysis was not a place where confusion reigned and anything could happen and, second, I had demonstrated that I had a mind of my own. I had acted in a manner that she had longed for from her father in the hope that he would interrupt the tyrannical mother/daughter dyad by retrieving his mind from alcoholic despair. Only when I again possessed a mind of my own, was it likely that Jane would begin to separate out herself from her mother. I had survived a murderous attack by demanding and removing her knife and placing it in my drawer where I was to look after it, thereby retaining a space for thinking (Britton, 1989). Analysis could then represent a place of safety whereas hitherto it had been a threat. In the dream, analysis was represented by a warm room which could not be experienced as the right place for her; it was a place where she would disappear in a sea of confusion and her only protection was either a hostile, violent, thick-skinned self or a suicidal thin-skinned self. The warm room represented a collapse of separation and loss of difference which was to be avoided at all costs. By retaining a space for thinking in my own mind I had triangulated our relationship, maintaining a space in which I could stand and look at our relationship without falling into it. Hospital admission was this psychological state made manifest since it separated Jane and me, allowing her a safe haven from which to reflect on our relationship and giving me some respite from a dominating fearfulness. Through active intervention I had interposed myself between her and her mother, acting as a third object and preventing a collapse into dyadic, unseparated confusion. At the same time I had pulled her towards a different solution by arranging her admission to hospital from where her analysis continued uninterrupted. This intervention interposes from a point of view of a third object by observing the primary relationship between the self and other and intervening decisively. Jane’s original solution of adopting a thick- or thin-skinned psychological state had given her a lifelong illusion that she had created a space for herself which protected her from an obliterating, suffocating mother. It was the collapse of this space through analysis that led to her attempts to retrieve it through violence or suicide. Perelberg (1995a, 1995b and chapter 4 in this book) has also described violence as serving a similar function in a male patient who repetitively got into violent fights with his male friends.

Technique and the role of the father According to received wisdom, a psychiatrist must not show a patient that he is frightened of him. This escalates the fear of violence within the patient himself, increasing the likelihood of aggression. The doctor must stand his ground resorting neither to counter-attack nor to retreat. In the case of Jane I think it was important for me neither to counter-attack nor to retreat despite Jane’s attempt to control her own terror by terrorising me through her threat of suicide but to maintain a space in which to think and, when necessary, take decisions. Initially the tendency can be to increase transference interpretation especially if a patient is controlling powerful affects by projection and if analyst-derived countertransference responses (A.Reich, 1951) are evoked. In these circumstances, interpretation

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itself can be used as a counter-attack (Gabbard, 1991). Further, I suggest that, in borderline/narcissistic patients like Jane, interpretation alone is ineffective if thickskinned or thin-skinned elements are to the fore. To this extent I partially disagree, as I have said, with Rosenfeld who believed that interpretation was effective with thickskinned patients. I think it only becomes so at the point at which a patient is moving between thick- and thin-skinned elements. Only then is the patient’s mind capable of understanding the thinking within the analyst’s mind as formulated in an interpretation. Thus an important aspect of technique with borderline and narcissistic patients is to develop a shared sense of reality through constructions made by both patient and analyst in the analytical process rather than to uncover the past (Perelberg, 1995a). This has to be done through the constant demonstration by the analyst of his capacity to think about the patient’s experience thereby nurturing an experience of a secondary level of mental representation (Fonagy, 1991) which is so strikingly lacking in borderline patients. Initially, this may require a constant dialogue between patient and analyst which by necessity lacks the complexity of interpretation if the patient is to recognise that the analyst’s thoughts are different from his own (Fonagy and Target, 1995). Complex interpretation is a weak intervention when a patient is overwhelmed by impulses to cut her body. Simple, clear, analyst-based statements may be necessary at such times if both analyst-centred and patient-centred interpretations (Steiner, 1994) are to be effective later. In Jane’s treatment I think my truthful, reality-based intervention, that is my demand for and removal of her knife and her subsequent admission to hospital, took place outside the pathological relationship that had developed, giving her an experience of a simple secondary level of mental representation and it was this that was calming and mutative. Reliance on complex interpretation alone endangers treatment since it bewilders a patient who is already perplexed and precipitates defensive recourse to thick- or thinskinned responses. Continual exploration by the analyst of the patient’s experience with the judicious use of reality-oriented statements allows the development of a secondary level of mental representation on which both patient and analyst can find a common ground for effective interpretation.

Conclusion It is my hypothesis that thin-skinned and thick-skinned narcissistic states may be associated with self-destructive and violent impulses respectively. The underlying phantasy of both actions may be the same, namely an attack in phantasy on the body of the mother (see Fonagy and Target, 1995; Perelberg, 1995a). A thin-skinned state incorporates self-destructive impulses which are held at bay only so long as there is someone to enact a phantasy in which all desires and needs are experienced as being met. Conversely a thick-skinned state harbours violence, smouldering beneath the surface, ready to be activated by stimulation of need. The predominant mode of interaction in a thin-skinned state is empathic, protective and enveloped in pity whilst that in a thickskinned state is combative, argumentative, intellectual and shrouded in detachment. If either state is punctured, a collapse of self and other results in identity diffusion (Erikson, 1968), which in turn may lead to suicide or violence in an attempt to regain the self and

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separate from the other. In Jane’s thick-skinned state I was experienced as a needy mother from whom she was detached, hence her asking if I had thought about her during my break, and of whom she was violently dismissive, giving herself an illusory sense of power through an absence of need. It was this that led Jane to threaten me later with a knife, a shift from psychological to physical violence, because I was momentarily identified as a needy, demanding mother threatening to envelop her. Within her thinskinned state, Jane held power through weakness. Yet a failure of responsiveness, for example when taking a holiday break, once more threatens a conflation of self and other which in a thin-skinned state can only be dealt with through suicide since the body rather than another person becomes the demanding greedy mother who has to be attacked for survival. In this way both suicide and violence become an attempt to regain a space between self and object, a space in which thinking may take place, and a place in which a third object can operate allowing emotional subjectivity to inter-mingle with understanding and objectivity.

References Bateman, A. (1995) ‘The treatment of borderline patients in a day hospital setting’, Psycho-analytic Psychotherapy 9:3–16. Britton, R. (1989) ‘The missing link: parental sexuality in the Oedipus complex’, in R.Britton, M.Feldman and E.O’Shaughnessy (eds) The Oedipus Complex Today. London: Karnac. Erikson, E. (1968) Identity, Youth and Crisis. New York: Norton. Fonagy, P. (1991) ‘Thinking about thinking: some clinical and theoretical considerations in the treatment of a borderline patient’, International Journal of Psycho-Analysis 72:639–656. Fonagy, P. and Target, M. (1995) ‘Understanding the violent patient: the use of the body and the role of the father’, International Journal of Psycho-Analysis 76:487–501. (In this volume, chapter 2.) Freud, A. (1936) The Ego and Mechanisms of Defence. London: Hogarth. Gabbard, G.O. (1991) ‘Technical approaches to transference hate in the analysis of borderline patients’, International Journal of Psycho-Analysis 72:625–637. Glasser, M. (1985) ‘Aspects of violence’, paper given to the Applied Section, British PsychoAnalytic Society. Joffe, W.G. and Sandler, J. (1967) ‘On some conceptual problems involved in the consideration of disorders of narcissism’, Journal of Child Psychotherapy 2:56–66. Kernberg, O.F., Selzer, M.A., Koenigsberg, H.W. et al. (1990) Psychodynamic Psychotherapy of Borderline Patients. New York: Basic Books. King, P. (1980) ‘The life cycle as indicated by the nature of transference in the psychoanalysis of the middle-aged and elderly’, International Journal of Psycho-Analysis 61:153–160. Meloy, J.R. (1992) Violent Attachments, Northvale, NJ: Jason Aronson. Perelberg, R.J. (1995a) ‘Violence in children and young adults’, Bulletin of the Anna Freud Centre 18:89–122. (In this volume, chapter 1.) Perelberg, R.J. (1995b) ‘A core phantasy in violence’, International Journal of Psycho-Analysis 76:1215–1231. (In this volume, chapter 4.) Rosenfeld, H. (1987) ‘Afterthought: changing theories and changing techniques in psychoanalysis’, in Impasse and Interpretation. London: Tavistock, New Library of Psychoanalysis. Steiner, J. (1994) ‘Problems of psychoanalytic technique: patient-centred and analyst-centred interpretations’, in Psychic Retreats. London: Routledge.

Introduction to chapter 6

In the following chapter the author focuses on the technical challenge of working with a borderline patient who displayed verbally aggressive behaviour in the consulting room and presented violent phantasies. She indicates that her patient alternated between a state of mind where he experienced the analyst as a reflective, dangerous object that he needed to eliminate and his need to preserve her alive for sadistic attack. In this formulation one can perceive the influence of the works presented in the previous chapters of this book, i.e. Glasser’s distinction between self-preservative violence and sadism, Fonagy and Target’s stress on the breakdown in the capacity to mentalise in such patients, Perelberg’s hypothesis of a core phantasy in violence and Bateman’s suggestion that these patients are more accessible to interpretations when moving between thin- and thick-skinned narcissistic states. Davies stresses that it is an error of technique to return projected parts of the patient prematurely via interpretation. The patient attempts to control the analyst’s mind as a vehicle for his projections in order to deny the object’s separateness. Davies draws attention to the intensity of hate that is experienced in the transference and countertransference and argues that perhaps it is the patient’s observation of the analyst’s attempt to deal with these highly charged hateful moments which are mutative. In the discussion of her clinical material and the description of two sessions six months apart, Davies demonstrates how focusing on the intense affective experience of narcissistic anxiety, using analyst-centred interpretations or recognising the informative experience as described in the second session, seems to be more mutative than the interpretation of the manifest attack on the analyst in the first session.

6 Technique in the interpretation of the manifest attack on the analyst

ROSEMARY DAVIES In the affective frenzy that characterises the analysis of borderline patients, we are hard pressed to gather our analytic resources, to experience the moment, to steady ourselves and to interpret. In this chapter I focus on the technical difficulties I encountered in the treatment of a borderline young adult who relentlessly attacked the analysis and the analyst in the early years of treatment. Detailing analytic material, I compare a session where the manifest attack was interpreted, and a later session where paying attention to the affective content behind the assault before interpretation proved more mutative.

Theory of technique with the borderline patient The borderline patient inhabits a psychic world of idealised and denigrated others, a world where no cohesive model of an ordinarily satisfying and at the same time disappointing object can be conceived.1 The manifestations of these characteristics become present within the transference with a rapidity and precipitateness of considerable intensity. There is an acute sensitivity to proximity or distance from the object and the analyst has to be constantly monitoring this, leaving the patient neither overwhelmed by claustrophobic nor by agoraphobic anxiety, where he can begin to imagine the existence of another mind 1 Fonagy (1991) notes, ‘Among the most commonly shared characteristics of individuals considered to be borderline is an impairment of object relations, internal as well as external…relationships appear to be short-lived, sound chaotic yet extremely intense. They manifest an interpersonal hypersensitivity which leads to dramatic alterations in their relationships, a fragmentation of their sense of identity, an overwhelming affective response and mental disorganisation’ (p. 639).

which it is not necessary to destroy (Glasser, 1979; Rey, 1994). The resulting need for tight control over the object, the ‘lasso’ as Symington (1983) describes it, often manifests itself in persistent attacks on the analysis and the analyst which present substantial

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technical difficulties. One’s existence as a separate, autonomous functioning analyst is constantly under threat. A number of analytic authors, aware of the technical demands inherent in such a predicament have been exercised by how in the heat of the assault we can also heed the vulnerability, the defensiveness and the narcissistic fear of the borderline patient. Rosenfeld (1987) describes ways in which moment-by-moment interpretive technique requires modification in work with borderline states. He concludes that what he called the thin-skinned narcissistic patients may be brought to collapse if aggressive and destructive elements are interpreted too precipitately and forcefully. This has been elaborated by Bateman (1998) who argues that interpretation was only useful with his narcissistic, borderline patient when she moved between her thick- and thin-skinned narcissistic states. Only at this point could the patient develop ‘a shared sense of reality, forming a base for interpretation’ (p. 23). Bateman observes that interpretation, based as it is on a shared, empathic, cognitive process between patient and analyst, may be insufficient for the borderline patient, for they require some clear recognition of their intense affective state. The vehicle for addressing these powerful and threatening affects may not be normal interpretation as this can be experienced as too affectively distant from the terror. This shared sense of reality requires a way of communicating or experiencing an affective moment with the patient that is not overloaded with superego elements that may render interpretations intolerable. Sandler and Sandler (1983) in their model of psychic conflict, although not addressing the specifics of analytic work with the borderline patient, offer important technical guidelines to the management of the patient’s narcissism in the interpretive moment. They suggest that interpretation should take place when the material is hot, alive and felt by the patient in the here and now. The analyst should formulate interpretations in a manner which provides an environment within which previously unacceptable parts of the self can be thought about. Interpretations need to sustain an affective impact through addressing the current conflict that is being censored. They cite the example of interpreting the patient’s conflict in terms of what he fears is going on in the analyst’s mind. They suggest: a patient who is struggling against the emergence of affectionate feelings should not be told ‘You are fighting against loving or affectionate feelings towards me’, but rather the motive for the conflict must be interpreted in the form, perhaps, of ‘You must find it very difficult to let yourself feel your loving feelings towards me because you are afraid I will laugh at you.’ (P. 423) Steiner (1994) elaborates these technical issues in his differentiation between patientcentred and analyst-centred interpretations. He argues that in borderline psychopathology separateness from the object cannot be tolerated. The patient is always alert to the analyst’s state of mind in his omnipotent need to control such endangering states of separateness. In the initial work with borderline patients, the analyst-centred interpretations can take into account the patient’s need for the projected elements to reside in the analyst and be tentatively understood in their projected state. Spillius (1992)

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writes that the patient-centred interpretation may be misinterpreted by the borderline patient as blame, whereas working descriptively through the analyst-centred interpretation, the borderline patient may experience a world less blaming, more responsive to curiosity and to an awareness that ‘other people are separate from oneself but have minds fundamentally similar to one’s own even if they may have different thoughts’. The importance of the shared experience between analyst and analysand which forms the basis of the mutative interpretation is described by Joseph (1983). She highlights, ‘a point, which in a sense is only too obvious, that analysis to be useful must be an experience in contrast, for example, to the giving of understanding or explaining’ (p. 293). Chused (1996) has recently elaborated what she calls the informative experience, that is an affective, sometimes non-verbal communication is made which lays the foundations for an interpretation. She describes informative experiences as arising out of interactions where the expected reaction is not forthcoming. The resulting emotional dissonance between expectation and experience leads to a shift in the patient’s perception. The experience informs and may provide an impetus for psychic change. This allows for the hearing of interpretations which before might have been misconstrued and refuted. She argues that where cognition is limited, it may only be through such informative, affectively shared analytical experience that interpretive communication can penetrate. Chused cites the example of the patient who becomes enraged, but the analyst does not retaliate, rather he notes the rage and stays engaged to explore its determinants. Thus he challenges the patient’s mental representation of the analytic object and can then use interpretive work in a more fertile ground. The borderline patient may well be more prone to hearing another’s words as severely contaminated by superego projections and thus before he can use an interpretation he must experience the possibility of alternative understandings: ‘learning is always easier from experience than from explanation, which can feel critical to the onewho-didn’t-know’(p. 1069). The general consensus in theory of technique appears to be that interpretive interventions require different timing from those with the neurotic patient. It is technically a mistake to rush to interpret projected parts of the patient. The patient has projected these elements precisely because his need is for them to continue to reside in the analyst where they are required to be tolerated, detoxified and understood. As a result of the projection the analyst is felt to be that much more threatening and the patient may resort to all sorts of psychic manoeuvres to thwart analytic contact. Fonagy and Target (1995) argue that the patient is trying to control the analyst’s mind for use as a vehicle for their projections in order to deny the separateness and the possibility of the object’s loss. Technically, they suggest that the interpretation of aggression towards the analyst as attacks on the analysis is futile and go on to pose the following technical conundrum: ‘How can a pathological organisation focused on the destruction of empathy and compassion be changed using a technique based on just these qualities?’ (p. 489). They, like other authors, argue that experiencing the affective content behind the manifest attack is required before interpretation. I would like to describe something of the early years of analytic treatment of Paulo and describe detailed material from two sessions six months apart. The clinical material illustrates how focusing on the intense affective experience, using analyst-centred references or recognising the informative experience as described in the later session

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seems to have been more mutative than the interpretation of the manifest attack on the analyst in the earlier session.

The patient Paulo came to analysis aged 20. I know little more of his history than he presented in the first assessment. He is the younger son of lower middle-class parents who moved to this country from southern Europe when the patient was an infant. The referrer surmised Paulo’s violent presentation to be a defensive structure of an isolated, tough, unfeeling, cynical and menacing young man, aimed at warding off overwhelming feelings of anxiety and despair. This defensive manoeuvre had been reinforced by two crucial life events. First, aged 10, he had been sent away to boarding school on a scholarship. Paulo tenaciously holds the view that this is the root of his problems for he was bullied for being different in terms of class, ethnic origin and talent. In retaliation he became the cruel bully. Second, aged 15, he bore witness to his father having taken a near fatal overdose. On finding his father comatose, Paulo alerted the emergency services, but felt enraged by his father and remained extremely hostile and diminishing of him.

The analysis In my initial interview with him, Paulo presented himself with some bravado but also was strikingly compliant and showed a certain degree of insight. He was, for example, able to see how threatening treatment might be to his defensive structure when he thought about how analysis might ‘touch him’, for he had initially sought help after fleeing in a narcissistic panic when literally touched in a movement class at the commencement of his training at drama school. He was also aware that the specialness afforded by being part of a research group evoked anxieties about a link with being the scholarship boy at school and all his subsequent difficulties. At this early stage he was able to articulate that he had managed these troubles on his own at school by violence and smug complacency. He described many incidents of ferocious attack on other children at school, including one episode of rendering a fellow pupil unconscious. This initial use of violence seems to have been aimed at preservation of the self in the face of his intense need and despair in response to his parents’ abandonment. It was a sign of weakness to seek help: it meant he was weak, like his suicidal, depressed father. Both the referrer and his putative analyst believed that the task of the analysis might be to unravel the narcissistic problems expressed in his grandiosity and contempt, and gain access to the underlying anxiety behind these defences which seemed to be expressed in an extreme vulnerability about any exposure of his difficulties. However, within a month of the analysis commencing, I found myself on the receiving end of relentless and brutal posturing, an unbreachable ring-fence of violent and contemptuous fantasies that only hardened as I tried interpretive work. During the first six months of Paulo’s analysis he and I struggled with his terror of letting anyone get close to him. He felt anxious lest any knowing of him would be like ‘getting right inside my head’ and if I did affectively connect with him he feared his own

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pull to retaliate violently against me. His emotional range was extremely limited and I think he was convinced that his object had the same limited capacity. There seemed to be but two psychic positions. On the one hand he could identify with his diminished, suicidal father and express vulnerable feelings which left him feminised and humiliated. For example, he described the encouragement many of his teachers were giving him to go into classical theatre: ‘They just want me to be a faggot in tights.’ On the other hand, he could identify with his idealised ancestry who, he claimed, had been active members of a terrorist organisation and express his violent, manic grandiosity in various tyrannical postures, He resorted to provocation and attack. He dismissed me as ‘a fucking idiot …this is just psychobabble bollocks…it’s a fucking disaster…stupid ignorant analyst with such a love of yourself’. He talked about wishing someone would mug him so that he could attack them. He would threaten me with revealing my incompetence: ‘They all know now that my violence is all your fault. I’m going to reveal you as a spectacular failure to all the college staff.’ Paulo’s world was characterised by vengeful, hateful fantasies. He told me again and again that all he could do was hate, indeed that was, he claimed, his only way of relating to people. ‘When hate’s gone, I’ll kill myself,’ he declaimed. He also spoke of his need to wreak revenge on all women, and often detailed horrific fantasies about fellow students. For example he told me, ‘I would like to hold her by the hair, slit her throat from ear to ear, as I come inside her arse.’ He exposed me relentlessly to this kind of material and there were many times when I considered terminating treatment, for bearing the affective onslaught was so taxing.2 He left me feeling exasperated and very much at the mercy of his clever, controlling manipulations. I often felt as though I were negotiating a series of psychic traps set for me, which Paulo described as a familiar technique. He told me in the initial interview how at the beginning of the academic year he put on his usual facade of presenting himself as what he describes as ‘a stupid pillock’ with some fellow fresher students and then he was asked to perform. He could see the girls giggling as he rose to speak, but then they were shocked by the quality of his performance. He described the pleasure he derived from seeing their shocked faces and this illustrated how he invites people over a long period of time into a hole which he digs for them. He then triumphs contemptuously when they fall in as the giggling girls had done. He was able to verbalise this projective mechanism as ‘I put feelings on to others and then I control them to deaden the possibility of them being anything other than what I ascribe to them.’ Paulo asked very early in his analysis, ‘I’d like to know if what you think is the same as what I think.’ This intense need for sameness did allow for some affective contact early on. Despite the bravado which on the whole characterised this period there were sessions in which he had neither felt compelled to attack me in the closeness nor to flee in a narcissistic panic. After one such session, when he revealed to me how taxing he found the weekends and the idea of a holiday break, he seemed to feel able to reveal more of his internal struggle. Thus towards the beginning of the first analytic break he could rail against me and the analysis being a problem because, ‘I’m not allowed to treat people just as frigging arseholes.’ Then he asked me at the end of a silence, ‘What’s up, are you faking sleep?’ and he was able to consider that this might be a real longing, perhaps an erotic longing, that he wished to be lying asleep with me, a sleep that could deny the forthcoming separation of the analytic break. His painful psychic dilemma was perfectly

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articulated in a thought about his mother: ‘I want to be looked after and wrapped up in cotton wool, but on the other hand I want to get away.’ He revealed to me in a very moving way that he had controlled any wish for affection and contact with his mother or his father. He explained this was caused by the extent of his father’s disturbance during Paulo’s teenage years. He felt his father to be completely beyond control. He remembered how, on one occasion, it had required five hefty policeman to contain his father, giving us a glimpse of the vast amount of psychic energy it 2 I often felt overwhelmed and on occasion frightened by this patient and it was crucial that I was part of a research group where these kinds of issues could be examined. It may be that the introduction of this ‘third’ dimension enabled me to think more clearly about the patient in a way that he and I were facilitated by the ‘third’ perspective provided through the analyst-centred interpretation or the informative experience.

involved to maintain the illusory control of me. But behind this manipulation and control I felt there lurked intense, unspoken and terrifying needs. During the first six months of analysis, I felt that some very fragmentary psychic contact may have been achieved. However, the price that a patient such as Paulo pays for such contact has subsequently been revealed as enormous and the result was an increase in threats of violence to others and to himself. In the face of this, I often lost track of the capacity to bear the onslaught and focus on the affective content behind the sadistic attack, and found myself resorting to an all too easy interpretation of the attack on the analysis. A Friday session one year into his analysis illustrates the problems of this approach. Friday He telephoned me just before his session leaving a message saying that he wouldn’t be able to come to his session, ‘I’m caught up with things, I might phone later, I’m not sure, we’ll take it from there. Sorry.’ Then during his session time he telephoned again, asking if he could see me later. I was concerned about him with the weekend ahead and decided, as this was an unprecedented request to agree and offered him a session later in the day. He arrived on time in a somewhat dishevelled state and said facetiously that he’d proved what he’d been telling me that everything is just boring. He went on to tell me about being rude to the secretary at work who is just ‘a failed actress’ and he said he’d tell me later about the missed session, ‘but I’ll tell you first about an amazing day yesterday’. He talked about going into college where he was rude to senior members of staff and waiting 50 minutes for his tutor to mark his essay for which he got ‘an average to crap mark’. He had gone in to his tutor who had said that he was sorry for keeping him waiting but Paulo

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had said ‘Well, we’ll let the girls go first because I despise them’ and his tutor had laughed at that. He talked about how the person who had got the top mark for her essay was particularly objectionable when she said she couldn’t believe she had got the top mark because she thought Paulo really had deserved it. He went on to tell me how he had lain down on the floor where various teachers had had to step over him and doubtless they had thought he was a nutcase, or tired. He returned to talking about his fellow student who had got the best mark who was so arrogant. He told another teacher that the college is just a ‘load of crap’ and how he loathed all the students, they’re just ‘no good idiots’. His tutor had asked him if he had any friends and he had responded that he doesn’t ‘give a fuck about anything’, just his degree. He told his tutor that of course his analysis is making everything worse, ten times worse. He’s no longer violent but he feels ten times worse and he broke off his discourse suddenly seeming to remember that I was there and said emphatically, ‘And you know that.’ This continued for the first half of the session and then he told me that after all this he had gone home and burst into tears with his father, telling him everything and saying that he was now going to kill himself. His father had suggested that it would not help ‘to nut himself’ so he had told his father that in fact what he was going to do was go off and hurt people and his father didn’t seem to mind this. Paulo continued that he’d have to wait to do this until he’s got the power and of course he wouldn’t kill himself until his mother dies for he despises all women except his mother. He’d woken up suicidal and depressed, ‘as I do every morning’, he said, and he described again being rude to members of staff. He had then got on a bus to Hampstead and went to King’s Cross instead. He had some time to kill so he’d had a few drinks and then he’d gone to a prostitute and ‘had a blow job’. ‘So’, he said, ‘I’ve gambled, I’ve smoked, I’ve been violent and now I’ve had sex and I’ve shown it’s all boring, it’s all nothing.’ I intervened saying he seemed to be showing me how he wished to worry everyone—his tutor, his father and me. He seemed to be saying how contemptible and despicable I am, in his mind, for not helping him with that which he takes to his father and his teacher and the prostitute. He responded contemptuously, ‘As if you would be concerned, have any worries. If you were worried you’d be a social worker not an analyst.’ He went on to describe the prostitute as ‘quite sweet, very professional, soft, and for

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the first time I didn’t really feel anything. I felt confident when I took my clothes off.’ He continued in this vein for some time about the prostitute and I commented that it seemed to me there was a sense in which he needed to tell me that I was not available to relieve him, to be professional, to offer him something, but he has to take it all to others. He ignored this comment and carried on with his diatribe of how he despises all women except his mother and told me that that’s very Freudian and he aggressively said, ‘What do you make of that after wasting five years of your life being a doctor to study that?’ I commented that I thought he was wanting to put something in my mouth to silence me or perhaps to excite and worry me as he had been doing by making me wait whilst he was with the prostitute. He said he wouldn’t do such a thing to a woman, ‘don’t be ridiculous, of course you don’t worry.’ Then he went on to tell me again that he had proved that everything was boring, although he had liked the prostitute, she was honest because he feels ‘all women are whores but at least she said she was one.’ He had ‘wanted to bugger her, but she was too nice.’ I took this up in a relationship to him attacking or buggering what I have to say, not feeling able to receive my comments. He commented very contemptuously, ‘Oh, you’re getting angry now, yes you are’, and then got up from the couch and said, ‘I’ve got to go for a piss.’

On reflection, I consider my interpretation of the attack on me, the wish to humiliate me via the prostitute he visited at the same time as his analytic session, was theoretically correct. However, I think my verbalising the inter-pretation was counter-productive, for his aggressive attack on me seemed then to bear fruit: he felt gratified as I was drawn into an excited battle with him in a way that quite clearly ‘the professional prostitute’ had not been excited and had therefore left him ungratified and humiliated. In the affective frenzy of the session it may have been a more effective strategy to acknowledge the narcissistic anxiety expressed in for example, his having to ‘wait 50 minutes’ or of his being ‘stepped over’, rather than gratifying his wish to obliterate my analytic functioning in so contemptuous an attack. Detailing material from a session six months later, I would like to illustrate how using the informative experience and an analyst-centred focus broke the vicious circle and challenged the omipotence Paulo had experienced after the session described above.

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Tuesday Paulo had arrived for his session the day before 10 minutes early. It had been a very silent session broken at one point by his commenting, ‘If I don’t come here I can’t slag you off, and if I stop coming people will just say I didn’t try.’ Gradually through this session he indulged in his characteristic rocking which certainly had strong elements of auto-erotic comforting. I interpreted his need to show me how he could comfort himself and his response was, ‘No, I’m just practising my fucking technique.’ The session continued in a contemptuous manner. That evening he telephoned me to tell me that he would not be coming for the following session. I was somewhat perplexed by this phone call and taken off my guard. I wondered if he was actually saying he was going to stop his analysis. After my silence he said that he wasn’t able to come tomorrow because he hadn’t got any money and he wouldn’t be able to afford the bus fare. I found myself drawn into a conversation with him about finding the money for the bus fare including a mention that perhaps his parents could help. As soon as I said this I regretted it. One of the main aspects of this patient’s analysis is how humiliated he feels about remaining in the family home. He finished the phone call saying he would get there if the weather was good because he could walk. He arrived on time and told me that he was just tired, lonely, overworked, depressed, and that’s why he had telephoned me. I acknowledged that state but commented on the conflict between making a telephone call in order to seek me out, at the same time as telling me that he didn’t want to see me. He seemed to ignore this comment and went on to describe the afternoon he’d had in which he had worked in the library, gone drinking, gone home and felt very alone. After a while he said something about the comment I had made about his parents, that he might be able to borrow the money for his fare from them. He said, ‘I thought you must have gone nuts.’ I was extremely struck by this comment and considered that it actually altered the rest of his session and allowed him to make contact with me. He returned to saying how tired he was, how he was smoking and drinking heavily and yet still working. I reminded him about how worried he must have been if he felt I had gone nuts and that I felt we had an opportunity to think about this together since something

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had happened between us in the telephone call which we could both see and discuss rather than us relying on something he felt very wary of reporting to me and ended up reporting in a rather one-dimensional way. At this point the session moved into a different gear. He told me how frightened he is about a girl at college and how they used to tease each other and she would say how deep he was and how shallow she is, he was academic and she wasn’t, but overall he felt scared of something in her and this was worrying him yesterday. He said he knows he frightens people but he’s so frightened of whether he’s attracted to women or not. I wondered whether he was frightened by the girl because of his desire for her, as he had felt frightened here by his need for me which had led to the telephone call. He continued talking about this feeling whether he was frightening or whether he was frightened and said again that he was attracted to women but also he felt attracted to men and he said he wished he’d done something about it at school when he had the opportunity. He went on to describe how he feels that the girl would just be using him so he ends up having to frighten her. I said he seemed to be telling me that this attempt to frighten her ends up being a bit of an empty victory, similar to when he attacks me as he had done yesterday, verbally, and then is frightened by what he’s done to me and thinks I might have ‘gone nuts’. Unusually he agreed saying, ‘Yes, it is an empty victory. When I withdraw from people I feel constantly angry so I bury myself in my work. It’s killing me. I’ve never been so upset.’ He went on to say, ‘I haven’t got a clue what to do. What shall I do?’ and then he talked about how depressed he felt and how confused about men and women, perhaps that’s why he didn’t sleep with the woman. He described crying the day before and how he doesn’t feel he has any fight left in him any more and how he hates himself for not being strong. He wants to be invincible, untouchable, and he couldn’t understand how in some ways everything is going right, he ought to be happy but he’s never been so miserable and he can’t see himself getting out of this hole, he has no optimism, there’s no way out. I commented that perhaps he had seen a way out of his despair yesterday when he had telephoned me but then he had felt worried about how I, as he had put it, had gone nuts and hadn’t been able to withstand him telling me how bad he felt. And in his feelings of humiliation and weakness in relationship

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to the young woman at college he feels similarly in his need for me between the sessions. He responded that he couldn’t bear to feel things for he would be like his father, weak and humiliated, who he blames for his current state of mind. This was the end of the session but Paulo seemed able to sustain a thread between this and his next session in which he allowed himself some self-reflection.

I do not wish to elevate technical errors to the level of good technique, but this material clearly demonstrates the utility of being able to focus on the here and now in the session, the ‘Petri dish’ of sessional material which we both can observe and verify rather than being dependent on the patient’s report which in the case of a borderline patient may be contorted through grandiosity and contempt. Here the informative experience may have provided us with a commonly held affective encounter upon which an interpretation based on his concern about what was happening to his analyst, the analyst-centred focus, could be mutative. This then led momentarily to a shared transitional space in which psychic reality could be explored rather than obliterated.3

Discussion In the presentation of two pieces of clinical material I have wanted to show how Paulo’s response to my interventions bore out what the theory of technique predicts. In the first session described, as I struggled with the intensity of the acting out through the visit to the prostitute and my intense counter-transference responses to such a provocative assault, I quickly interpreted the manifest attack. As a result Paulo remained in the same psychic state of omnipotent and triumphant defiance. In the second example, despite what might be considered a technical error I felt sufficiently robust for us to be able to tussle with the question ‘has she gone nuts?’ which led to us being able to experience the affect behind the sadistic trickery. The outcome of this approach seemed to be that Paulo could reflect somewhat on his internal conflict and narcissistic injury. I would like to consider a number of factors that influenced the effectiveness of these differing technical approaches. First, the location of affective meaning requires careful attention to the countertransference. Heimann (1950) in her well-known work on counter-transference, bears out the view that sustaining the affective experience is required before interpretation. She writes of the analytic relationship: what distinguishes this relationship from others is not the presence of feelings in one partner, the patient, and their absence in the other, the analyst, but the degree of feeling the analyst experiences and the use he makes of these feelings…. [and his ability]…to sustain his feelings as opposed to discharging them… (p. 152)

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3 Winnicott (1951) describes the transitional space as a prerequisite for the development of the child’s capacity to play, relate and have their being. With the very disturbed patient one of the analyst’s primary functions may be to locate such a space for the adult. Bollas(1989) for example comments on the disturbance of the transitional space for the drug abuser whose omnipotence represents a futile attempt to return to the transitional space he was unable to use in early life.

I consider this sustaining of the affective experience and the resulting dissonance between what the patient expected and what he received was central. In the first session I had little time for reflection but knew an assault had taken place. I interpreted precipitately on the basis of what I considered to be transferential and counter-transferential issues, but I failed to observe the notion of sustaining the moment as Heimann describes. I think discharge prevailed over thought. As a result there was no space for attention to the underlying anxiety which had led to the acting out, thereby leaving him with a sense of blame against which he defended himself using familiar techniques: nothing moved. In the second example, I had time for reflection. As a result I felt able to consider the meaning of his telephone call and my response to it. I felt foolish but perhaps in forgiving myself the slip, I felt more able to forgive and thereby understand Paulo’s need to invoke this response in me. With hindsight, tracing my counter-transference, I felt on the receiving end of Paulo’s wish to dig a hole for me and sadistically triumph over me: a familiar move which he had described early in his analysis. By responding as I did I may have, as Sandler (1976) describes, been nudged into a ‘role responsive act’. Technically, the crucial feature of the role responsive act is the righting of oneself, the observation and reflection post hoc. In the act of righting myself I felt able to engage with Paulo, share the affective experience, and interpret with an analyst-centred focus. It seems to me that Paulo could experience me as less censorious when he heard me describe that which he thought might be going on in my head. As Spillius (1992) comments, a less blaming world can be more responsive to curiosity which is a crucial ingredient if analysis is to be helpful. Second, Paulo’s relationships with his objects were suffused with sadism. The sadism binds the perpetrator to the victim, for the perceived suffering of the object is central (Glasser, 1979; Fonagy et al. 1993). My interpretive technique in the first session failed to break that bind. I was drawn into a battle with Paulo and thereby failed to sustain myself as the separate, functioning analyst who could help him. In some ways I participated and gratified his violent attack by retaliation. Kernberg (1989) alerts us to this when he suggests that the patient’s relentless attack on the therapist may gratify sadistic needs to an extent that provides more gratification than any understanding or resolution might provide. The borderline patient’s need to gratify sadistic wishes can defeat even the firmest of analyst’s steady resolve and on many occasions I found myself so compromised by Paulo. He would often tell me that he would prefer a fight rather than experience the humiliation of my concern. This was then vividly enacted in the transference where my analytic concern was experienced as a castration and he resorted to repeated attempts to draw me into a fight, culminating in a spoken wish to place a bomb near the Institute of Psycho-Analysis so that not only would the dangerous analysts be killed, but their baby analysts in training would perish too. Alongside threats of violent attack, he also used the threat of suicide. ‘That’s what the clever ones do, leaving the dross swimming in the shit’, he told me. His threats of suicide were aimed at me and he would tell me that if he

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killed himself this would reveal me as having spectacularly failed. He described a thought of blowing his brains out into other people’s laps and said, ‘If I hurt myself it will be all down to you.’ His and my autonomy was to be expunged for we would die together in the explosive moment. He could exhibit his potency in the grandiose contempt but the real pain lay in the humiliating impotence as he attempted to negotiate intimacy. In the second session described, Paulo let me know something of this conflict which was elaborated in thinking about the shame experienced in wanting to contact me by the telephone call, disguised quickly by telling me in an indifferent manner that he could not get to his session. Another aspect of his sadism lay in his assertion that he could only relate through hatred. In analysis this hatred is often expressed through the sadistic use of the object. The management of hate in the transference and counter-transference is particularly problematic when one is exposed to relentless attack. Winnicott (1949) argues that the borderline patient cannot be expected to tolerate his hate if the analyst cannot hate him. Gabbard (1991) reiterates the bind that hate secures, ‘to hate is to hold on to an internal object in an unforgiving way…’ (p. 626). He argues that the analyst is required to walk a fine line between blasting the patient with his own hatred and denying its very existence. It may be that the patient’s observation of the analyst’s attempt to deal with these highly charged hateful moments is mutative. Like other writers on technique with the borderline patient, Gabbard recommends the postponement of interpretation because there is a need for the patient to have an experience that is other than expected. In the first session cited I do not think I blasted Paulo with my hatred but I do consider I engaged in a fight with him in the guise of an interpretation of the manifest attack which left the patient feeling I too related through hate. Although the second session may have been presaged by a moment of sadistic trickery, I think a more measured approach protected him from the sense of isolation in the bleak omnipotent desert of hatred. Breaking this bind of Paulo’s sadistic control of his analytic object pushed him to the limits of his mental functioning. This influenced the efficacy or otherwise of my analytic technique. For example, in the first session when I interpreted his wish to stuff something in my mouth to excite or silence me as he had with the prostitute, he may have felt threatened by my assumption of a more sophisticated psychic range. The borderline patient often finds himself identifying with the concrete content of the interpretation, not its symbolic meaning. They lack the capacity for symbolisation, for an ‘as if’ experience, for pretence, or for playing with words. Paulo may have experienced my interpretation in a literal, threatening and critical way. In the second session described, the experience of our engagement in a common analytic investigation, rather than a fight, may have permitted a marginal extension of his limits. He had told me in a very early session about his amazement when he overhead a conversation between his mother and a friend in which she had been describing thinking about him. In the second session I think there was a tentative thought that I might be able to think about him. Fonagy (1992) describes how the borderline patient’s self remains fragile because his capacity for self-reflection has been jeopardised and his capacity for conceiving of himself in the mind of another may have been distorted by the incapacity of the mother to think about the child as an intentional being whose behaviour is driven, by thoughts, feelings, beliefs and desires. He comments that ‘the capacity to envision the object as having a mental state different from

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one’s own was a major developmental achievement that entailed considerable mental pain’. Perhaps Paulo was beginning to venture along that developmental path. Third, the issues of gender and sexuality inevitably influenced the nature of analytic technique with Paulo: here was a young male adult filled with homo-sexual dread engaged in treatment with a female analyst. His sadistic binding of the object was constantly being threatened not only by my presence as a separate other, but also by my presence as a woman. Over the months he revealed some of his sexual fantasies which centred on memories of boys at school and thoughts of oral sexual encounters with older men. His only thoughts of women were of anal intercourse. He felt desperately ashamed of these thoughts and extremely ambivalent about having revealed them to me. He then verbally attacked me for having been there to hear him when he revealed these fantasies. However, it was also striking at this point that there was a momentary reference to what might be happening to me in the course of this onslaught. He referred to how he thought I was getting ‘a bum deal’ and he was ‘giving you a gobful today’. All this seemed to illustrate his dilemma in the transference about me as a woman: how much he feels he is abusing me/I am abusing him in getting to know him from behind, but on the other hand he feels relieved that I can bear to hear the worst. His perverse sexual fantasies represent a wish to deny separateness and difference inherent in adult genital heterosexuality (Chasseguet-Smirgel, 1985). In this context Paulo bears out Perelberg’s thesis of the ‘core phantasy’ of the violent patient (1995a, 1995b): that is the violent thoughts and enactments are a response to the fear of the violence inherent in the primal scene.4 Whenever contact between the analyst and patient is experienced the patient flees for fear of the inevitability of the violent encounter. I consider that Paulo’s fantasies and threats of violence against self or other were indeed exacerbated by the anxiety that two can only come together in a violent and endangering way. He articulated this in the transference in the oscillations between fear of merger 4 The link between anality, which clearly characterised Paulo’s psychic functioning, and the primal scene is central in Freud’s development of the primal scene. In the Wolf Man’s dream there is an assumption of terrifying, violent anal penetration in the child’s witnessing of the primal scene (Freud, 1917).

and fear of abandonment. He also demonstrated this in his beginnings of relationships with women when he told me that he could not sustain his relationship with his girlfriend for she was not interested in terrorism and violence. He felt abandoned to the thrall of the violent encounter and yet dependent on it as a protection from the engulfing other. This was vividly depicted when he was eventually able to consummate his relationship with his girlfriend. He fled from the experience, found himself unable to speak in his sessions and then enacted the terror in an anonymous, fleeting homosexual encounter. Paradoxically his flight from the terror of the heterosexual coupling led him to express his sense of risk in a more self-destructive, endangering moment. Paulo’s aggressive dismissal of his female analyst’s view; his crude and cruel attack on girls at college; and his description of ways in which he would take revenge on all women when he becomes rich and famous, seemed to illustrate a need to obliterate one part of the creative couple. Furthermore, his insistence against some of the evidence that he was special and picked on for being special seems to present a defence against the

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reality of his ordinariness: conceived of two humans, man and woman, rather than the self-appointed star of his college or as he put it once, ‘star of the Institute of PsychoAnalysis’. In fact, he had to deal with not being special. His fantasies about the primal scene I think were also borne out when I agreed with him to talk to his general practitioner who is a man. He then insisted that his doctor and I would inevitably be in disagreement and he set up a battle between the Prozac prescribed and the analysis. At one point he said, ‘the two of you could only collide’. The idea of our being creatively involved in helping a patient seemed unthinkable. Paulo reveals little of his history other than a personal myth of being borne of the union of ‘exceptional’ parents, a ‘happy-golucky kid’ of unique talent, suddenly broken in adolescence by the cruelty of his envious peers. Thus he denies both the origins of his own primal scene and the origins of his pathology. In his humiliating and contemptuous visit to the prostitute at the same time as his analytic session he may have had in mind a couple bound together in undifferentiated morass of sadistic hatred: himself and the indifferent prostitute, himself and the provoked and retaliating analyst. In the second session cited, I understood him to be more able to tolerate the notion of a couple, differentiated in part by gender and, ironically, in that differentiation, able to come together in something of a creative analytic dialogue. Fourth, I think Paulo had a sense of something I might be able to offer him which in part accounted for his dedication to treatment.5 When I failed him in my over-zealous interpretation of the destructiveness I think his sense of deprivation left him vulnerable to malign envy which may have accounted 5 Abraham (1921) delineates the conscious conflict for the anal-sadistic patient between compliance and vengeance. Paulo exhibits this compliance in his zealous attendance which contrasts with a cruel vengefulness which characterises his discourse.

for the risk of the negative therapeutic reactions which we regularly encountered. As Paulo allowed himself a tentative acknowledgment of my value to him: that is in my role as a separate, analysing object, not an object subjected to his violent omnipotent attack, he was more at risk for he could now see the consequences of his own destructiveness. My counter-transference responses were often intense and immobilising and I was exercised by the nature of these negative therapeutic reactions. In the analysis of the acting-out patient the negative therapeutic reactions can feel more difficult to bear because of the real risk of violent and life-threatening enactment. This may leave both patient and analyst at real physical risk of a concrete manifestation of defence through violent enactments within the session or violent acting out outside the session (Campbell, 1995; Perelberg, 1995a; Bateman 1998). In her discussion of the negative therapeutic reaction, Riviere (1936) reiterates the need for caution when she writes: ‘Nothing will lead more surely to a negative therapeutic reaction in the patient than failure to recognise anything but aggression in his material.’ Kernberg (1992) notes that in work with the borderline patient one encounters the negative therapeutic reaction not as a result of primitive superego functions as in Freud’s (1923) original view, but rather as a result of the envious attack on the possibility of analytic help. Thus when Paulo could allow a momentary sighting of my having something good to offer him he would retreat to an envious attack fearing that whatever there was would be withheld or destroyed. After the second session described we did not immediately face the negative therapeutic reaction,

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as we had on previous occasions, and he managed to sustain his capacity for selfreflection into the following session.

Conclusion Bearing in mind the intensity of the counter-transference, the binding of the sadism, the thrall of the ‘core phantasy’ and the risk of the negative therapeutic reactions, it is hardly surprising that we are counselled to be cautious in the analysis of the borderline patient. It is my view that this caution informs a technique which allows the patient to feel less isolated and blamed. The tools of such a technique include the analyst-centred interpretations and the informative experience which when used with Paulo provided therapeutic clarification rather than illusory gratification.

References Abraham, K. (1921) ‘Contributions to the theory of the anal character’, in Selected Papers. London: Hogarth Press, 1953. Bateman, A. (1998) ‘Thick- and thin-skinned organisations and enactment in borderline and narcissistic disorders’. International Journal of Psycho-Analysis 79:13–25. (In this volume, chapter 5.) Bollas, C. (1989) Forces of Destiny. London: Free Association. Campbell, D. (1995) ‘The role of the father in the pre-suicide state’, International Journal of Psycho-Analysis 76:315–323. Chasseguet-Smirgel, J. (1985) Creativity and Perversion. London: Free Association Books. Chasseguet-Smirgel, J. (1985) The Ego Ideal. London: Free Association. Chused, J. (1996) ‘The therapeutic action of psychoanalysis: abstinence and informative experiences’, Journal of the American Psycho-Analysis Association 44:1047–1071. Fonagy, P. (1991) ‘Thinking about thinking: some clinical and theoretical considerations in the treatment of a borderline patient’, International Journal of Psycho-Analysis 72: 639–656. Fonagy, P. (1992) ‘Discussion of Kernberg’s paper’, UCL Psychoanalysis Unit Conference, London. Fonagy, P., Moran, G. and Target, M. (1993) ‘Aggression and the psychological self’, International Journal of Psycho-Analysis 74:471–485. Fonagy, P. and Target, M. (1995) ‘Understanding the violent patient: the use of the body and the role of the father’, International Journal of Psycho-Analysis 76:487–501. (In this volume, chapter 2.) Freud, S. (1917) ‘From the history of an infantile neurosis’, Standard Edition, 17, pp. 3–123. Freud, S. (1923) ‘The Ego and the Id’, Standard Edition, 19, pp. 3–66. Gabbard, G.O. (1991) ‘Technical approaches to transference hate in the analysis of borderline patients’, International Journal of Psycho-Analysis 72:625–637. Glasser, M. (1979) ‘Some aspects of the role of aggression in the perversions’, in Ismond Rosen (ed.) Sexual Deviation. Oxford: Oxford University Press. Heimann, P. (1950) ‘Counter-transference’, in International Journal of Psycho-Analysis 31. Also in

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M.Tonnesmann (ed.) About Children and Children-No-Longer. London and New York: Routledge, New Library of Psycho-Analysis, 1989, vol. 10, pp. 73–79. Joseph, B. (1983) ‘On understanding and not understanding: some technical issues’, International Journal of Psycho-Analysis 64:291–298. Kernberg, O., et al. (1989) Psychodynamic Psychotherapy of Borderline Patients. New York: Basic Books. Kernberg, O. (1992) ‘Psychoanalytic psychotherapy with borderline patients’, paper presented at UCL Psychoanalysis Unit Conference, London. Perelberg, R.J.(1995a) ‘A core phantasy in violence’, International Journal of Psycho-Analysis 76:1215–1231. (In this volume, chapter 4.) Perelberg, R.J. (1995b) ‘The psychoanalytic understanding and treatment of violence: a review of the literature and some new formulations’, Bulletin of the Anna Freud Centre 18(2):87–122. (In this volume, chapter 1.) Rey, H. (1994) Universals of Psychoanalysis in the Treatment of Psychotic and Borderline States. London: Free Association. Riviere, J. (1936) ‘A contribution to the analysis of the negative therapeutic reaction’, International Journal of Psycho-Analysis 17:304–320. Rosenfeld, H. (1987) ‘Afterthought: changing theories and changing techniques in psychoanalysis’, in Impasse and Interpretation. London: Routledge and the Institute of Psycho-Analysis, The New Library of Psychoanalysis. Sandler, J.(1976) Counter-transference and role-responsiveness. International Review of Psy-choAnalysis 3:43–47. Sandler, J. and Sandler, A.-M. (1983) ‘The second censorship, the three-box model and some technical implications’, International Journal of Psycho-Analysis 64:413–425. Spillius, E. (1992) ‘Discussion of Steiner’s paper’, paper presented at UCL Psychoanalysis Unit Conference, London. Steiner, J. (1994) ‘Problems of psychoanalytic technique: patient-centred and analyst-centred interpretations’, in Psychic Retreats. London: Routledge. Symington, N. (1983) ‘The analyst’s act of freedom as agent of therapeutic change’, International Review of Psycho-Analysis 10:283–291. Winnicott, D.W. (1951) ‘Transitional objects and transitional phenomena’, International Journal of Psycho-Analysis 34:89. (Also in Playing and Reality. London: Tavistock, 1971:1–25.) Winnicott, D.W. (1949) ‘Hate in the counter-transference’, International Journal of PsychoAnalysis 30:69–74. (Also in Through paediatrics to psycho-analysis. London: The Hogarth Press and the Institute of Psycho-Analysis, 1975:194–203.)

Introduction to chapter 7

In her chapter ‘The paradox of suicide: issues of identity and separateness’ Joan Schachter discusses the analysis of a man in his early twenties who had made several serious suicidal attempts prior to his starting analysis. Like in the other papers in this collection, the analyst understands the suicide attempts as expressing the patient’s failure to negotiate and establish an adequate sense of separateness from his primary objects, especially the mother. The attacks on his body became the pathway for the expression of intense affects. The author understands the suicidal acts as representing in phantasy a solution to the developmental impasse in adolescence of being unable to resolve his conflictual sense of personal and sexual identity. The analyst understands, in her analysis of the transference and the counter-transference, the powerful sense of entrapment this patient experienced in relation to his internal mother coupled with an absence of a strong internal paternal figure. The author also discusses the importance of the analyst’s relationship with the research group, within which the analysis was conducted, in that it enabled the analyst to remain in touch with the patient’s suicidal potential, a point that has contact with Donald Campbell’s discussion in the third chapter of this book about the relevance of the father as a third object in suicidal states.

7 The paradox of suicide: issues of identity and separateness

JOAN SCHACHTER

Introduction In this chapter I will discuss aspects of the analysis of a suicidally depressed borderline young man. From the start of the analysis, Robert linked his suicidal feelings to his experience of his body as a hateful, alien object, frighteningly out of his control. Analytic work revealed that his hatred of his body (in fact, particular aspects of his body and its functioning) expressed his unconscious fear and hatred of his parents, whom he unconsciously experienced as engulfing and murderous. His suicidal phantasies represented his attempt to free himself from these hostile internal objects, and in so doing to take his revenge on them. His suicidal impulses arose in the context of intense feelings of helplessness, anxiety and fear. These feeling states, and his suicidal state of mind, were predicated upon his inability to negotiate a secure sense of separateness within which he could develop a coherent sense of self. The emotional unavailability of his father as a third object, facilitating separation from his mother, played an important part in Robert’s remaining trapped and stuck within his omnipotent attempts to fulfil his mother’s phantasies and expectations. The essential role of the father in the separation-individuation phase of development has been discussed by many analysts. Campbell (1995), Fonagy and Target (1995) and Perelberg (1995a, 1995b) have emphasised the relative absence of the father as playing an important part in their patients’ propensity for violent acts towards the self or others. Maltsberger and Buie (1980) in their paper ‘The devices of suicide’ state: ‘It is the paradox of suicide that the victim, finding inner death in life, seeks inner life in dying.’ In ‘Mourning and melancholia’ (1917) Freud discussed suicide in terms of aggression initially directed towards the object becoming turned against the self, with a part of the ego ‘altered by identification’ (p. 249). Freud described a process of regression to identification with the object and to sadism ‘under the influence of the conflict due to ambivalence’ (pp. 251–252). Implicit in this is a splitting of the ego in which one part of the self, identified with the hated and longed for object, is attacked and in retaliation attacks the dependent part of the self. The suicidal person is both victim and murderer.

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Since it is the body which defines us as separate individuals, the suicidal attack on the body can also be understood as a wish to rid the self of an unbearable experience of separateness. The high incidence of suicidal acts in adolescents and young adults attests to the developmental crises which may arise in individuals in whom the earlier process of negotiating separateness from the primary objects has failed. The bodily changes in adolescence frequently become the focus of fears of losing control of aggressive and sexual impulses. Hatred of the changing body in the face of intense anxieties and conflicts evoked by an uncertain sense of identity may intensify regressive fears of merging, and provoke the desperate defensive manoeuvre of a suicidal attack on the body. The suicide phantasy is a psychotic phantasy in that the individual believes that the attack on their body will not end in death, a part of the self will survive (Campbell, 1995). The self which is envisaged as surviving is an ideal self in a fusional relationship with an idealised mother, a phantasy of eternal peace with no frustration and pain. This unconscious scenario also expresses a primitive Oedipal phantasy in which the mother of infancy is possessed completely and the father is excluded totally. Predicated upon the failed negotiation of separateness from the primary objects, suicide as a solution may be seen as failed mourning of the infantile relationship with mother, which leads to a profound sense of emptiness and despair. Various defensive manoeuvres develop as attempts to cover up this central absence, in particular the denial of separateness with consequent distortions of reality testing.

Clinical illustration Robert made his first suicide attempt after taking his university finals. The prospect of leaving, being faced with functioning independently, evoked intense fears and conflicts to which he responded by retreating into a state of suicidal despair. He took an overdose and on waking, cut his wrist. He later described how in a rather macabre way, he had wanted to dissect out his vein. His parents were in the process of divorcing at this time, which undoubtedly exacerbated his sense of having nowhere to go. I first saw Robert when he was 22, a year after he had left university, during which time he had made two further suicide attempts. He had tried to swallow bleach, and had tried to hang himself in his mother’s house. These suicidal enactments were further evidence of the violent solution he sought to his difficulties in living his own life. He was intensely depressed and extremely angry with his parents who he felt had let him down. He described feeling controlled by his mother’s emotional demands for submission to her views, and by her depression. He felt terrified of his father’s bullying and critical attacks. In his description of his childhood relationships with his parents he clearly allied himself with his mother against his father. He portrayed his mother as a god-like omniscient figure whom he tried to please. He was desperate to be her special child, remaining within her orbit throughout adolescence, when he anxiously retreated from peer relationships. Early on in the analysis he gave a picture of his family in which mother was at the top of the house in her study, with the door closed, whilst father was in the basement messily cooking a huge meal. Robert saw himself as somewhere in-between. I thought this gave an important insight into his unconscious relationships with his primary

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objects. Mother is idealised and tantalisingly unavailable in her ivory tower. Father is denigrated in his paternal role, while his nurturing capacities are portrayed as dangerous and disgusting. Robert’s dilemma is apparent: he cannot securely identify with either parent, defensively oscillating in between. Robert felt that from early on ‘things were not right’ between his parents, which made him feel ‘If I lean against my mother that would destroy her, if I lean against my father, he would destroy me.’ In this way he vividly conveyed his view of his parents as damaged and damaging objects who have to be kept apart. Robert consciously experienced his father as a threat to his existence, however at an unconscious level he also experienced his mother as murderous towards his adult masculine self. From this perspective his suicidal phantasies are both revengeful attacks on and a submission to the murderous parents. Robert was dependent on a variety of obsessional routines of exercise and diet to control his anxiety and fear of collapse. He felt extremely self-conscious, feeling that people could see through him and see into him, thereby seeing how helpless he felt. He experienced others as humiliating and threatening. The intensity of his anxiety and terror of breakdown, and the aggression in his routine of excercise, all had a violent quality. He was imprisoned by his anxiety and fear of life, and his obsessional and narcissistic defences imposed a tyrannical form of control.

The analysis The analysis was conducted within a research group at the Anna Freud Centre which was set up to study breakdown in young adults. In the initial months Robert spoke with a sense of great pressure and urgency. There were very few silences in the ceaseless flow of talk. I felt he needed to keep me at a safe distance to protect himself from humiliation of a devastating nature. His sense of fragility created an atmosphere in which I felt I had to tread carefully, as suicide seemed an everpresent danger. His predominant response to interpretations was to feel humiliated, to experience me as forcing him into a frighteningly helpless position of dependence. In the counter-transference I at times felt forced into a passive role, or pushed into an active rescuing role. Whilst he longed for relief from his suffering, he experienced my understanding as a threatening engulfment. I was then living inside his head scrutinising all his thoughts like his mother. He defensively resorted to repetitive intellectualised thinking, or to a grandiose and violent phantasy of self-sufficiency in which he rid himself of the dangerous analyst. It took some time before I became more clearly aware of the erotisation of his talking and his use of his intellect. His words were felt to be concrete links with me, intended to keep me enthralled and excited, in a phantasied state of non-separateness. He avidly read psychoanalytic books. He described how he felt his words were ‘banked up’ inside me. He was very watchful, he needed to feel one step ahead to try to make my actions predictable. His anxious need for control of the relationship was based on his intense dependence on me and on the setting. He was unconsciously extremely fearful of what was going on in my mind, what I was thinking and feeling about him. He was unable to

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tolerate another point of view, experiencing this as non-validating of him, and seeing it as my attempt to exert my superiority arrogantly and sadistically over him. Weekend and holiday breaks were felt as neglectful and cruel abandonments, leaving him vulnerable and exposed to overwhelming anxiety and suicidal feelings. During the first treatment break Robert took an overdose and then took himself to hospital. He remained an in-patient during the holiday and then attended a day hospital for a further six months. In this way he was able to obtain a sense of control and to create additional support and structure. He thus modulated his experience of the analytic relationship which he found both intensely exciting and frightening. The role of the body: representations of the body In Robert’s analysis anxieties about his body predominated. The intensity of his gaze, the stiffness of his body movements, conveyed his conflictual feelings about his body. His anxieties arose from all developmental levels. He was fearful of his oral greed, his anal messiness and sadism, and his phallic strivings. His body represented the hated part of himself, in which his incestuous and aggressive feelings and phantasies were barely distinguished from the objects who elicited them. Robert’s obsessive exercising and dieting had become his way of trying to maintain control over his affects which threatened to overwhelm him. He attempted to create a kind of muscular body armour to protect himself from his father and others he perceived as threatening. Robert used exercise and his muscular body to create a thick-skinned experience of self (Bateman, chapter 5 in this book). When he felt threatened by my interpretations he resorted to talking about exercising or intellectual achievements in order to distance himself. He would then quickly become anxious about losing contact and return to a position of idealisation: ‘You are so important to me, I love you so much.’ His body was also used to express his primitive phallic narcissism. He would describe in detail the results of his exercise in terms of achieving the perfect ‘muscle definition’ which he would admire in front of the mirror. I was supposed to be admiring and excited, although the threat that I would become the engulfing mother was always evident. He talked in one session of his anxieties about moving into a shared flat with peers. He wanted his own space, in particular his own toilet. He went on to speak of his sensitivity to smells with a mixture of disgust and excitement. He described how he looks at his own faeces to see whether ‘what I have produced matches my experience’. I said I thought his concerns about smells expressed his anxieties about emotional contact with others, since emotions like smells cannot be seen, but get inside him and others. I added that his concerns about damage to himself and others intensified his wish and fear to know what is going on inside where he cannot see (Shengold, 1985). Fonagy and Target (1995) discuss a patient whose attacks on his body represented attempts to make a distinction between his own sense of himself and that of his mother. They suggest that the patient has an unconscious phantasy that ideas reside in the body. Robert’s actions to control and manipulate his body can also be understood in this way. Another recurring theme in his discourse about his body was his hatred of his hair growing. He felt it had a life of its own which made him feel he wanted to ‘hack it back’. His fear of this uncontrollable part of himself seemed matched by his excitement at cutting his hair very short. He linked this with his mother’s control, forbidding him to cut

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his hair short when he was a young adolescent. He also complained that she would not let him touch her hair. I wondered at times whose hair he was cutting, whose mind and body he was attacking when he cut his hair. He felt that having very short hair made him look hard and aggressive, as if making him invulnerable to his threatening father and engulfing mother. The role of the father Discussions with the research group in the third year of the analysis were particularly important in enabling me to recognise the extent to which I was caught up in a dyadic relationship with Robert, interpreting too exclusively in the maternal transference. This stance on my part reflected to some extent the impact on me of the violent intensity of Robert’s primitive affects. Of course his reporting suicidal feelings and impulses evoked my anxiety, but it was more often the intensity of his narcissistic rage which provoked defensive reactions on my part. In a week in which he had become increasingly depressed and anxious, he had telephoned and left a message on Thursday evening, asking me to phone him. We had been talking about his conflict between the wish to be separate and independent which evoked his fears of being isolated, abandoned and seen as arrogant, and his angry, revengeful wishes to destroy himself, his parents and his analyst. I had returned late and decided not to phone him. The following day I was aware of a feeling of anxious anticipation about the session. He arrived a couple of minutes late and went to the toilet as usual. I was surprised by my fantasy on hearing a clicking noise, that Robert had a knife. He began talking about his anger and disappointment with me for not phoning him back, he felt my concern was all ‘just talk’. He had felt like not coming to the session. I thought I needed to be careful in how I took this up. I felt wary about interpreting his wishes to intrude in a controlling way into my life, anticipating that he would be unable to hear this as other than a humiliation. I took up his fear and rage at feeling left with his feelings after the session yesterday, and his desire to have contact with me as a way of fulfilling his wish for me not to be separate. He replied angrily that I was telling him that I had chosen not to phone him back. He went on to say he had written letters of resignation to his professor. I said he was telling me how he felt when he could not get me to respond in the way he wanted, he felt filled up with feelings of rage and revengefulness, wanting to destroy himself, and also me and the analysis. He seemed to acknowledge this and went on to talk of how he thought of himself as a kind of tragic case, having so much potential which he cannot fulfil. I suggested that his fantasy of being a tragic case, or tragic hero, was his way of remaining firmly tied to his mother and me, insisting that he needed to be taken care of forever. He denied this but then talked of his need to be held physically which I do not do. In retrospect I thought this was an example of my being initially immobilised by my counter-transference feelings of anxiety, hostility and guilt. Though it was an uncommon event for Robert to telephone between sessions, he frequently complained that I did not do enough to help him, I ‘just talked’. This session took place a few weeks before the summer break, which undoubtedly intensified his anxious demands, and my anxiety

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about the possibility of a suicide attempt. My fantasy that Robert had a knife shocked me into realising the violent nature of his phantasies of intrusion, which felt so dangerous to speak about, as if in that moment, in the absence of a protective internal father, the fear of not surviving the violent attack, was very intense (Campbell, 1995). I was unable to maintain a third perspective, instead identifying with Robert’s use of me as a hated, but needed controlling superego. Faced with evidence of his violent hostility he and I retreated onto the ‘safer’ ground of his narcissistic fragility. After the break Robert reluctantly recognised his wish to ‘monopolise’ people, which evoked feelings of helpless rage. He was more painfully aware of his dependence on me to provide a sense of control and of boundaries which reassured him and acted as a protection against suicide. His awareness elicited fear and hatred, and a need to distance himself. He said he felt so bad that if it were possible to have a gun he would not be alive. He could understand why people went out and shot others. I suggested that in this way he imagines he can rid himself of his painful and murderous feelings and rid himself of his analyst who he feels creates these feelings in him. Throughout this session Robert repeated that he did not know how I could help him. He talked of his feelings of jealousy towards the wife of his boss whose attention and admiration he wanted so desperately. I said that he was aware that he feels particularly excluded and envious when the person he needs, like his boss and myself, is involved in a relationship with someone else, rather like he felt yesterday when he was aware of someone else in my house. This made him feel that he was losing his contact with me. Some months later he began a session saying he felt depressed about a woman he liked who seemed uninterested in him. He went on to speak of feeling obligated to fancy another woman who had been supportive to him around the time of his first suicide attempt. I suggested that his sense of obligation was a way of repeating his relationship with his mother but with himself in control. He appeared to ignore this and said yesterday’s session had been good, he had worked hard. He recalled my talking of his not being able to bear separateness and clinging on to an illusion of a relationship with an unavailable woman. He went on to say he creates a bond in his mind, like he did with his mother. He feels he has to be loyal and finds it very difficult to let go of the bond. I said the bond expresses his wish for the other person to feel the same as he does, for there to be no difference. He said it did not feel safe to be different. He then talked about his father’s bullying and controlling behaviour with food and how he had felt much too frightened as a child to protest. He had taken up judo in adolescence, which he described now as a technique with which he tried to face or fight the world which he found so threatening. Robert describes the wished for and feared bond with a woman that evokes the phantasied bondage with mother from which he cannot extricate himself without the help of his father. However he is so terrified of his father’s hostility towards him that he cannot allow a relationship which could offer a route out of the bondage. In the previous session he had been able to accept my paternal function of creating a space in which he could gain a new perspective on his experience, his acknowledgement of clinging on to an illusory relationship. This shift inevitably stirred up his anxiety about moving away from mother, and his uncertainty about existing without her, which for him meant being confronted with a world full of violence and annihilatory threats.

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Robert’s bondage with his mother can be understood in terms of Glasser’s concept of the ‘core-complex’ (1992). In the core-complex the phantasy of fusion with the idealised mother is envisaged as the means of meeting the desire for complete satiety and security. The mother, however, is a split figure. She is conceived of as both engulfing and indifferent. The consequent annihilation anxiety provokes two concurrent defensive responses: narcissistic withdrawal and aggression with the aim of destroying the dangerous annihilating mother. The role of the father is of vital importance in the resolution of the core-complex. Robert’s fear of his father and the collusive relationship with his mother undermined his capacity to form a positive relationship with his father. Instead of identifying with his father, Robert attempted to dis-identify with him, further intensifying his dependence on his mother. He remained completely dependent on his mother/analyst for approval and more fundamentally for a sense of existence which was totally conditional on complying with her wishes and phantasies. His hostility towards his mother had to be split off and projected into his father. The primal scene phantasy and the search for a sense of masculine identity Early in the analysis Robert asserted that he was a feminist and not an aggressive male rapist. This statement, which at the time I was not supposed to question, reflected his compliance with what he believed to be his mother’s views, and mine, since he believed that all women thought the same. It expressed a central aspect of his dilemma—what kind of a man could he be in mother’s world. He frequently voiced his love and admiration for women. However, this apparently idealising view could easily shift into his complaint and grievance that women had all the power. Whilst Robert endlessly talked of his wish for a loving relationship with a woman he frequently felt intensely angry with women he encountered. Particularly in relation to weekend and holiday breaks when he felt rejected, and humiliated by his feelings of dependence, he spoke of his angry wishes to ‘turn the tables’. He wanted to feel in total control, to pick up a woman, ejaculate into her and discard her. This led to visits to prostitutes over the weekend. He began to report these encounters with a sense of excitement, he felt he was doing something concretely to me, of an exciting and rejecting nature. I attempted to point out the repetition of his attempt to transform the unavailable mother/analyst into his exclusive partner. I also took up his fears of closeness with a woman, to which he responded by reporting a fantasy of chopping off his hand with a meat cleaver, then ‘that would be it’. In this way he turns his hostility against himself, in an attempt to get rid of his hatred and sadism, thereby making himself into the apparently helpless victim. The child’s phantasy construction of the primal scene is inevitably affected by the mother’s conscious and unconscious attitudes towards her husband and her own parents. Robert’s need and desire to maintain an exclusive relationship with his mother meant that he also had to take on her views, as he perceived and wished them to be, of his father as a feared and denigrated sadistic man. Perelberg (1995a and chapter 4 in this book, 1995b); discusses a violent patient who ‘felt trapped in a world created by his mother/analyst, where he experienced any questions about his father as being blocked’. She describes the

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oscillating phantasies in the transference that expressed her patient’s different desires in regard to the primal scene, his ‘contradictory but simultaneous beliefs and identifications’. Gaddini (1974) emphasises the presence of the father capable of ‘generating extremely dramatic responses in the child’. He sees the primal scene as indicative of a crucial phase of development: ‘during the course of this process, the gradual recognition of the second object appears to be experienced by the child as an unexpected and bewildering series of changes in the mother’. The woman with all the power, the sexual/Oedipal mother is suffused by the shadow of the pre-Oedipal mother, the life-giver and death-dealer. Robert’s primal scene phantasies as evidenced in his views and feelings about women and sexual relationships were of destructive, sadomasochistic object relationships. The fear of the self being destroyed in a violent encounter is ever present as an intense bodily experience. Robert is the possessor of the dangerous sexual power and in danger of being obliterated by it. His inability to imagine a creative and satisfying adult relationship with a woman was most vividly expressed in his fantasy of finding a girl who had similar feelings of deprivation and grievance towards her parents, and then deciding to commit suicide together. In his masturbation phantasies Robert imagined ejaculating over a woman to demonstrate his power and elicit her excited admiration; his reporting these phantasies to me at times had the quality of an enactment of them. He clung to his defensive idealisation of a relationship with a woman in order to counteract his fears of castration, of passive submission and engulfment, and his fears of his hostility. There has been some lessening of the intensely sadistic nature of his sexual phantasies, which has enabled him to approach the real possibility of a sexual relationship. His first experiences, in the fifth year of his analysis, were brief encounters with unavailable women. The in-between character of his relating, with the implicit or explicit presence of the threatening third person was very evident in these fleeting events. Subsequently he has developed a relationship with an older woman who he is drawn to because she is not critical of him. Initially he felt very excited about this relationship but soon he came to experience her as trapping him, as being too much like his mother. This relationship, though clearly a transference displacement, seems to be both a partial working through of his incestuous attachment, as well as a defensive holding on. For Robert, being sexually active with a woman threatens him with being overwhelmed by his hostile feelings towards the engulfing preOedipal mother. He then experiences his penis as undifferentiated from his father’s penis which he believes his mother hated, he has then to retreat into a passive position linked with his feminine indentification.

Concluding comments: some issues about technique and termination In the first years of the analysis the focus was primarily on Robert’s destructive attacks on his body and his mind. As these have become modified through his developing capacity to understand and accept his affects, his violent, hostile feelings and phantasies towards women have emerged. His defensive need for control and his consequent difficulty in allowing a more sustained emotional engagement became the focus of analytic enquiry. Though there is now more space for thinking in the sessions, and he can risk being critical of me, a significant degree of restriction remained. He rarely brought

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dreams and he could barely allow any consideration of their unconscious meaning. Quick to pick up my interest in dreams he tended to use them to tantalise me. His fear of humiliation continued to be a major issue, consistently part of his response to interpretations. The threat of humiliation evokes violent fantasies towards himself and his objects, which we have understood as having the function of restoring his sense of omnipotent control. He has articulated his fear that any move towards independence will bring a catastrophe. The seductive excitement of his suicidal fantasies has become clear, his ‘ultimate weapon’. His use of suicidal fantasies as a threat when he felt confronted in the analysis with aspects of himself he found difficult to accept, has led to an increased understanding of his terror of change. His passivity and sense of narcissistic entitlement which underlie his fears are expressed in his defensive ‘freezing’ of himself and his objects, his wish for there to be no difference. More recently he has responded to feeling confronted by me through missing sessions; earlier he could not contemplate missing a session. To some extent this can be seen as a development in his capacity to experience himself as separate, as having an identity away from the analysis and his analyst. However it is also an expression of a fundamental resistance. As Fonagy and Target (1995) pointed out, violent patients who rely on using the analyst’s mind to deny separateness can only make progress when this ‘bondage’ is abandoned and mourning of the illusory omnipotence is achieved. For Robert this process constitutes a struggle in which the absence of his phantasied omnipotent control appears like a void of terrifying proportions. In a paper on termination in the analysis of severely disturbed adolescents, Burgner (1988) suggests that analytic progress with such patients may be characterised as ‘lessening the pressure of primitive anxieties, phantasies and enactments, and to facilitate a psychic organisation that has a more Oedipal emphasis; an organisation in which the terror of and overwhelming wish for the mother have receded and the father is recognised as having a more active yet protective role’. An implication of this movement would be the development of more differentiated gender identifications. It is in this area that Robert faces his fundamental ambivalence. He has not yet been able to find a way to safely integrate his masculine sexual identity and his feminine identifications. Whilst Robert describes himself now (in the seventh year of his analysis) as feeling fuller and rounder as a person, less estranged from other people and pleased to be a man, he remains vulnerable to anxious and violent reactions to disappointments. He has with difficulty made changes in his life, each occasion of making a decision facing him with his fear of not being perfect and the need to give up other options. His relationships still lack depth, being dominated by his narcissistic needs, thus he remains fearful of true intimacy. He vividly expressed this in his reactions to moving into a new flat, in the house of an older woman. He described his anxiety about what would happen between them; what would she expect from him, and his fear of himself: ‘How can she trust me? I might be an axe murderer.’ This paradoxical relation to his objects, his clinging attachment and his defensive hostile distancing, underpins all his relationships and inevitably functions as a central resistance to the analytic work. His reluctance to relinquish his incestuous attachments and his difficulty in mourning his infantile omnipotence raises issues about the possible interminability of analysis with young adults, who, like Robert, use the analysis to some extent as a refuge from life, as a kind of narcissistic cocoon.

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Summary The analysis of a suicidal young man is discussed from the viewpoint of the underlying failure to negotiate and establish an adequate sense of separateness from his primary objects. The suicidal acts represented a phantasy solution to the developmental impasse in adolescence of being unable to resolve his conflictual sense of personal and sexual identity, which had been built around the trap of fulfilling maternal phantasies. The compelling nature of his suicidal phantasies reflected his rigid dependence on omnipotent control. The analyst’s relationship with the research group, within which the analysis was conducted, was important in enabling the analyst to remain in touch with the patient’s suicidal potential, and to confront his omnipotence and resulting narcissistic rage. This relationship also highlighted the role of the father in the patient’s pathology, and the importance of primitive Oedipal phantasies in his suicidal enactments.

References Bateman, A. (1998a) ‘Thick- and thin-skinned organisations and enactment in borderline and narcissistic disorders’, International Journal of Psycho-Analysis 79(1):pp 13–25. Bateman, A. (1998b) ‘Narcissism and its relation to violence and suicide’, chapter 5 in this book. Burgner, M. (1988) ‘Issues of termination in the psychoanalysis of the severely disturbed adolescent’, in International Journal of Psycho-Analysis 69(2):179–187. Campbell, D.(1995) ‘The role of the father in a pre-suicide state’, International Journal of PsychoAnalysis 76:315–324. (In this volume, chapter 3.) Fonagy, P. and Target, M. (1995) ‘Understanding the violent patient: the use of the body and the role of the father’, International Journal of Psycho-Analysis 76(3), 487–501. (In this volume, chapter 2.) Freud, S. (1917) ‘Mourning and Melancholia’, Standard Edition, 14, pp. 239–260. Gaddini, E. (1974) ‘Formation of the father and the primal scene’, in A Psychoanalytic Theory of Infantile Experience. London: Routledge and The Institute of Psychoanalysis, New Library of Psychoanalysis, 1992. Glasser, M. (1992) ‘Problems in the psychoanalysis of certain narcissistic disorders’, International Journal of Psycho-Analysis 73:493–503. Maltsberger, J.G. and Buie, D.H. (1980) ‘The devices of suicide’, International Review of PsychoAnalysis 7:61–72. Perelberg, R.J. (1995a) ‘A core phantasy in violence’, International Journal of Psycho-Analysis 76:1215–1232. (In this volume, chapter 4.) Perelberg, R.J. (1995b) ‘Violence in children and young adults’, Bulletin of the Anna Freud Centre 18:89–122. (In this volume, chapter 1.) Shengold, L.(1985) ‘Defensive anality and anal narcissism’, International Journal of PsychoAnalysis 66:47–73.

Introduction to final remarks

This brief presentation by Peter Fonagy was given in September 1997 at the Conference on ‘Violence and Sexuality in Borderline Young Men’ at the Psychoanalysis Unit, UCL in association with the Anna Freud Centre. This Conference presented some preliminary results of the research carried out by the Young Adults Research Scheme (described above, p. xix), a subsidised scheme offering analysis to young adults and under which several of the patients in this collection have been analysed. The papers presented were by Rosemary Davies, Joan Schachter, both included in this collection and another by myself (1997, on the patient discussed in chapter four). In his concluding remarks Peter Fonagy discussed three main themes which he derived from the analysis of these patients: the issue of separation and separateness; the emphasis on the body, which accompanies an absence of mentalisation and is rooted in these patients’ experiences with their primary objects; and finally the common features of the analytic processes in which acting-out behaviour is consistently present. Peter Fonagy highlights the fact that in each case the analyst emphasised the importance of keeping contact with the patient’s anxieties. There was also enormous pressure on the analysts to monitor their counter-transference in order to be able to reach in their own mind formulations about their patients’ mental states. This was especially important in the cases of the three female analysts analysing three violent male patients, where the possibility of violence in the consulting room was constantly present.

Final remarks1

PETER FONAGY In looking at case studies it is notoriously easy to arrive at an understanding of a case on the basis of rich analytic material and be tempted into the false epistemic move of overgeneralisation. Of course, we all know that understanding a case is not the same as understanding a more general clinical problem. There are several potential pitfalls. It is necessarily the case that certain aspects of our psycho-analytic observations will directly relate to the causes of the disturbance on which we are focusing—in this case violence and abnormal sexuality—a relationship which is a particularly disturbing problem for society at large as well as for all of us individually. However, it is a non-trivial task to separate these aspects of the material from abnormalities that we are liable to observe in other clinical contexts and which cannot therefore be considered specific causes; for example, an uncertain sense of sexual identity evidently characterised all the three patients discussed here. Yet all of us have seen many patients with profound difficulties in this area who were not prone to violence against others. Nevertheless, some features of the mental world of these patients, whilst not unique to the problems of violence, may be necessary (although not sufficient conditions for its emergence). Thus the mere fact that a problem such as severe separation-individuation difficulties is common to a range of disturbances does not necessarily eliminate it from consideration as an important factor in cases of violence. A second, somewhat more subtle, conceptual issue arises in separating the unconscious mechanisms which may legitimately be regarded as causing the problems from ones which may more appropriately be treated as consequences of the patient’s manifest difficulties. For example, take Rosine Perelberg’s fascinating suggestion that a violent primal scene image underpins acts of violence. 1 Final remarks from the Young Adults Conference at the Psychoanalysis Unit, University College London, September 1997.

She offers compelling and striking clinical material, here and elsewhere (1995a and in this book, 1995b, 1997), which confirms the prominence of such fantasies in violent patients. This may, however, also be seen as a distortion of a ubiquitous mental representation by a mind focused on destructiveness, rather than the cause of such a predisposition.

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A similar but even more difficult problem arises when we try to distinguish aspects of functioning that are clearly associated with a tendency towards violence—not in a causal way but rather because both violence and the phenomena in question are consequences of the same underlying process. I believe that this may be somewhat relevant to our consideration of the role of the father in the mental life of these patients. The absence of a father imago was noted in both Dr Schachter’s and Dr Perelberg’s presentation. Yet, does this imply the absence of a controlling influence (a cause) or is it that the primitive mental functioning of these patients precludes the simultaneous representation of two minds (mother’s and father’s) so that it is the absence of representational capacity specific to mental states which is responsible for permitting violence and precluding a full representation of father in the Oedipal context? Thus the absence of a paternal representation is associated with, but does not cause or permit, violence. I have included this brief introduction as a warning as much to myself as to anyone else. Ultimately we do not know what causes violent behaviour. What we are trying to do is identify those unconscious factors which help us work with these patients: some of these factors are unique to violent patients, other factors are the consequence of a violent disposition; and still others have very complex relations to the problem of violence. Let me now turn to some elements which seem to me to characterise in all the presentations.

1. Separation and separateness A striking aspect of all the analyses described here is the prominence of problems of separation and separateness. Rosemary Davies’ patient Paulo was terrified of letting anyone get close to him and appeared to use violence, at least verbally, to create a distance between himself and others. Rosine Perelberg’s patient Karl obtained a gun with bullets to keep at bay his unconscious terrifying fantasy of being buried inside his analyst, expressing his deep but deadly attachment to his mother/girlfriend/analyst. Robert directed the violence at himself to kill his mother’s emotional demands, which he felt to be alive inside his head. (I used to have a patient who came into his sessions daily and placed a knife on the table, both announcing his peaceful intent and also indicating that one of us was in mortal danger should the closeness become overwhelming.) Yet, paradoxically these patients also manifest a great and even puzzling dependency on their objects. Robert was much troubled by analytic breaks. Karl and Paulo were terrified of losing their girlfriend/analyst. It may be tempting to understand such ‘object hunger’ as part of a split off, idealised identificatory process or some expression of a perhaps sadistic need for another. The striking aspect of the dependency we can see in all these cases is that, unlike the primitive infantile object relations they mimic, the physical and continuous presence of the object is essential because without it the patient’s internal states became overwhelming. The object perhaps fulfils a peculiar symbolic function in providing an interpersonal situation within which the experiencing of the self as a mental entity becomes possible. An important aspect of the identity disturbance of all three men may have been rooted in their self representation, which was contaminated by the other having been internalised into the self. Edith Jacobson (1954) and Donald Winnicott (1967) independently noted that the internalisation of the representation of another before the boundaries of the self

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are fully formed undermines the creation of a coherent sense of self because the infant is forced to internalise the other not as an internal object but as a core part of his self. If the caregiver fails to contain the infant’s anxieties, metabolise them and mirror the self state, the infant, rather than gradually constructing a representation of his internal states, is forced to accommodate the object, an alien being, within his selfrepresentation. This suggestion was perhaps most clearly portrayed in Dr Perelberg’s presentation of Karl, who at one level experienced his mind as quite separate from himself, almost as a separate head, a piranha monster or a computer. I do not believe that such images are simply indications of ordinary splitting of affect from cognition but rather express the very real experience of the presence of another mind within the self. Rosine Perelberg’s concept of absence of an organising identity relates to this observation (1997): identity may be impossible to achieve if within the self-representation there exists an alien other. Robert, Joan Schachter’s patient, was perhaps most keenly aware of this: ‘He felt his parents were living inside his head.’ Paulo revealed a similar sense of feeling ‘infiltrated’ in his persistent wish to externalise versions of himself (like the stupid pillock) which felt real and not real at the same time. In the discussion after the papers, Anne-Marie Sandler was quick to point to the probable damage to Paulo’s mind from a psychiatrically ill father and Joan Schachter pointed out the ubiquity of such histories in violent patients. Of course these introjections are coloured by the traumatic context in which they occur. What is internalised as part of the self is a caregiver with frankly hostile terrifying intentions. In the discussion, Jim Rose drew our attention to the re-experiencing of these traumata within the transference. What I think the papers were depicting was a specific rather than a general problem of identity. The child of a non-reflective caregiver is at risk for two related, but separate, reasons: first, because the representation-building function of the experience of having been mirrored is compromised, so that the child fails to develop coherent representations of its own internal states; second, in place of this symbolic function, the child carries an additional burden, that of the representation of a series of alien, hostile mental states lodged within the self structure. These are not representations of the other. They are experienced as representations of the self. Yet the representations are those of thoughts and feelings associated with the introjected object rather than representations of internal states within the child. The two related deficits are: inadequate symbolisation of mental states and a self-representation disrupted by non-reflective introjection. Rosemary Davies notes clear deficits in the symbolic function of her patient. Joan Schachter draws our attention to Robert’s incoherent sense of identity. Rosine Perelberg identifies both problems when she talks of understanding violence: ‘the understanding of phenomena which are potentially at the limits of self-representation…because they relate to something profoundly destructive in the psychic sphere that breaks through the capacity of the mind to contain it’ (Introduction, p. 7). The suggestion here may be that the child comes to externalise habitually alien aspects of the self-representation on to the real object in order to achieve a measure of coherence of identity. While this may lead to massive external conflict in relationships, it works, in that the individual experiences himself in a more authentic way. However, since reflectiveness, or mentalising, is experienced by such damaged patients as primarily being a property of the object rather than the self, the depleted self comes desperately to depend upon an object to mirror its internal states. This gives rise to

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a two-fold and desperate need to ensure the continued physical presence of the object: first to ensure the continued possibility of externalisation; and second to provide the essential auxiliary ego function for self preservation. Of course, side-by-side with this need for the other is the unconscious fantasy that by killing, annihilating, terrorising or murdering the other, the self would remain forever free of the alien object. Thus arises the peculiar alternation of life and death, love and hate, presence and absence, noted by Rosine Perelberg (1997).

2. The use of the body A second feature noted in particular by Rosine Perelberg and Joan Schachter was the peculiar use of the body which created massively abnormal sexual experiences for all three young men. Robert exercised obsessionally, worried about his hair. Paulo had perverted sadistic fantasies that may have caused him to be impotent with his girlfriend. Karl’s violence was linked by Rosine Perelberg to his omnipotent phallic identity. In all three cases there is always the background threat that the analytic relationship might become physical, the real thing as opposed to a thought, a feeling, an idea. Paulo’s account of his murderous fantasy of anal penetration is so vivid that it frightens his analyst and frightened me in reading it. The other two case reports contain similar experiences. Dr Schachter notes how Robert attempts to control his affects through creating a muscular body armour. In all three cases the impact of the absence of mentalisation is clear. The intention must remain in the bodily realm of real anxiety, real anger and real confusion because the patients are unable to describe these as current internal states. We may imagine that the need for bodily action rather than verbal exchange may be rooted in experiences with the primary objects where changes in the objects’ mental states could not be brought about by the patient addressing the object’s and their own desires, wishes or beliefs. Rather the object behaved in a way that conveyed that only physical acts could be expected to modify the object’s or the patient’s internal stance. But as a consequence the patient’s experience of minds comes to be a bodily one. Robert’s attempts at perfecting his physical body are expressions of his intuition of there being something (mentally) wrong which he needed to address. The bodily ego antedates the psychological self. Unable to control the mind of the caregiver as well as his own, the child attempts to achieve control through the body and the body becomes, by default, the vehicle for mental states. Mental states, unable to achieve representations as ideas or feelings, become symbolised in the bodily domain. As Eglé Laufer has emphasised in the discussion (and also in Laufer and Laufer 1989), the bodily changes of adolescence threaten the continuity of the person. This is especially so if identity is predominantly experienced physically. Little wonder then that all three young men had profound difficulties in integrating adult genital sexuality into their representational world. There is an additional problem, particularly clear in Robert’s case. If the individual is unable to externalise the alien affect and belief states into a physical other, the body may serve as a vehicle. Joan Schachter pointed out that Robert’s suicidal acts were murderous acts on the other lodged within the self. The critical point is that for Robert the attacks could not be on the other qua other because the other was experienced

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as part of the self. When he dissected his veins, when he attempted to asphyxiate himself by hanging, he was hoping to destroy the alien part of the self which in turn threatened to destroy his self-coherence. Hurting or destroying his body helped him by leaving his mind feeling more coherent and bounded, belonging more clearly to the self. His objects could not be genuinely attacked mentally because they resided within the self. This was depicted in the imagery of the early analytic process as a house with mother in the study, father in the basement. Thus paradoxically, suicide, particularly violent suicide, may be a way of generating a sense of reflection which would normally be intrapsychic but which has to be established for some people through physical attacks on the body. The process is less subtle in the case of physical violence and the reasons for the choice between these two modes of expressions of violence are often not clear. In cases of physical violence against a therapist, the unwanted mental state is simply attacked. The threat of its destructive return to the self-representation is avoided through its mindless destruction. There is no genuine representation of the victim as a mental entity. The other is not experienced as suffering. A fundamental biological barrier against violence has been removed and what is experienced is what Rosemary Davies aptly terms ‘affective frenzy’. All three analysts were in actual physical danger while they were vehicles of the patient’s projected mental states. But they were all trapped by their therapeutic task, by what Anthony Bateman called in the discussion the push and pull of the analytic relationship. Unless they could become what their patients wished them to be they could be of no assistance to their patients. However, as soon as they were felt by their patients to have become what their patients wanted them to be, they became legitimate targets of destruction, pathways for their patients to achieve an illusion of sanity. The analysts’ continued survival was dependent upon their capacity to draw their patient’s attention to their independent mental existence. They had to demonstrate constantly that they were minds capable of thinking thoughts, and experiencing feelings which their patients did not place there. This process was beautifully illustrated by Rosemary Davies in her second reported session with Paulo. She reports that she had made an error in suggesting that the patient should borrow money from his parents. Yet, paradoxically, this mistake enabled Paulo to bring to the session his central conscious concern about his relationship to women and he was able to reflect on his habitual stance of externalising the terrified and terrifying self state as an ‘empty victory’. In sharing Rosemary’s mental state, he came to think about his analyst as thinking about him, which is ultimately the process which needs to be rehabilitated in his mind. It is not just the analyst-centred nature of this work which is critical, it is the patient’s finding himself, in this case as a nutty individual, in the mind of the analyst. It is as if the analyst, in reflecting on her own nuttiness assisted the patient in understanding his own. He learns from the analysis what a moment of psychic relief feels like.

3. The analytic process This takes me to the third and final point. How can we formulate simply the common features of the analytic processes we have heard about? In different ways, all three presenters pointed to the absence of symbolic content in the patients’ material. In the

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analytic process, the patients equated their state of mind with a physical reality. There was no representational process mediating their pathology. Rosine Perelberg refers to fleeting thoughts coming to have the status of reality. Joan Schachter implicitly identified this ambiguity when she described Robert’s anxieties about his body in terms of roles rather than representations. Robert’s or Karl’s body or the bodies of their victims were not symbolic of a state of mind but rather they were equivalent to a state of mind and were reacted to accordingly. The analyst becomes the state of mind and has to reflect on it, to mentalise it, so that the patient can simultaneously own, but also distance himself from, this state. This may be important in Rosine Perelberg’s plea that intellectualisation should be allowed to happen in the analytic work with these patients. It is important to be aware, however, of a counter-therapeutic tendency inherent in such analytic relationships. Whereas with many patients it is possible to interpret the pressure towards role responsiveness, Karl, Paulo and Robert were all invested in externalisation in a much more malignant way. They were not just trying to push their analysts into representing parts of themselves; they wished to destroy that part of their self representation. If their analyst is to reject the projection, the patient is then forced to find an actual violent solution. If the analyst accepts this role, the analyst can be of no more value to their patients than the original objects which were too destructive to be introjected as separate internal objects. There is a constant paradox in the analysis of such patients: for the analytic relationship to serve a function and to be tolerable, the analyst has to become what the patient wishes him to be; but at the same time to be an analyst and help the patient overcome such primitive modes of relating, the analyst must be anything but what is projected on to her. What we have been shown in these cases were analysts able to adopt an attitude analogous to that of the parent engaged in pretend play with the child, constantly juggling responses to these opposing pressures. These considerations imply a shift of emphasis in technique. The focus of technique in all three analyses was maintaining contact with the patient rather than making conscious what was unconscious. Making contact means retaining a coherent identity or, more specifically, preserving a clear and complete picture of the patient’s mental state in the analyst’s mind. This is analysis rather than any other therapy because in no other relationship are such individuals likely to experience their own mind in their relationship with another person. The temptation we need to grapple with is the wish to avoid unbearable mental contents because in so doing we destroy the possibility of enabling our patients to identify themselves as people. I believe one of the hurdles in the counter-transference, which affected all three analyses, was each of the analysts’ reluctance to see themselves as they were being seen. Rosemary Davies, in the first session she reports, insisted on interpreting the patient’s need to take over and totally possess her mind as an aggressive attack. She reassured herself by asserting her sanity; she could see that being forced into the role of a prostitute could destroy her analytic capacity and understandably wished to protect this. However, when later in the analysis she reflected on her own uncomfortable experience, she retained a mentalising stance both for herself and for her patient and permitted what Judy Chused (1996) called ‘an informative experience’ where experiencing oneself in the mind of the other becomes possible. There are some other common problems with such patients: crediting the patient’s material with more meaning than it really contains; entering into historical dialogue or a

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dialogue about the unconscious; withdrawing from the patient’s destructiveness into silence or passivity; confronting the patient’s version of psychic reality; and, as Anthony Bateman pointed out, assuming that the patient you are describing is the patient to whom you are giving the interpretation. When the analyst adopts a non-pragmatic elaborative, mentalistic stance, he places a demand on the patient to focus on the mental state of a benevolent other. This stance in itself enhances or disinhibits the patient’s propensity for reflection and self-reflection (mentalising). Perhaps more important, the patient is then able to find himself in the mind of the analyst as a thinking and feeling being, the representation that never fully developed in early childhood and was probably further undermined by subsequent painful interpersonal experience. In this way the patient’s core self-structure is strengthened and sufficient control may be acquired over mental representations of internal states for relationships to become more understandable, meaningful and predictable. The internalisation of the analyst’s concern with mental states enhances the patient’s capacity for similar concern towards his own experience and enables him to protect fragile mental structures in ways other than by violence.

References Chused, J. (1996) ‘The therapeutic action in psychoanalysis: abstinence and informative experiences’, Journal of the American Psychoanalytic Association 44:1047–1071. Jacobson, E. (1954) ‘The self and the object world: vicissitudes of their infantile cathexes and their influence on ideational affective development’, Psychoanalytic Study of the Child 9:75–127. Laufer, M. and Laufer, M.E. (1989) Developmental Breakdown and Psychoanalytic Treatment in Adolescence: Clinical Studies. New Haven and London: Yale University Press. Perelberg, R.J. (1995a) ‘A core phantasy in violence’, International Journal of Psycho-Analysis 76:1215–1231 (in this volume, chapter 4.). Perelberg, R.J. (1995b) ‘Violence in children and young adults’, Bulletin of the Anna Freud Centre 18:89–122. Perelberg, R.J. (1997) ‘The interplay between identifications and identity in the analysis of a violent young man: issues of technique’, paper presented to the University College London Conference ‘Violence and Sexuality in Borderline Young Men’, September. Winnicott, D.W. (1967) ‘Mirror-role of the mother and family in child development’, in P. Lomas (ed.) The Predicament of the Family: A Psycho-Analytical Symposium. London: Hogarth, pp. 26–33.

Name index

Abelin, E.L. 65, 66, 82, 85 Abraham, K. xiv, xvi, 19, 23, 141 Abrams, S. xv Adams, Mr (patient) 10, 77–9, 81–5 Adler, A. 35 Aichorn, A. xvii Akbar, M. 20 America see North America Anthi, P.R. 105 Arendt, H. xii Asch, S. 80 Balint, M. 26 Baranes, J.J. 36 Bateman, A. 4, 5, 8, 9, 11, 12, 13, 109, 111–23, 125, 128, 142, 151, 166, 168 Bergeret, J. 36 Bion, W.R. 24, 62 Biven, B.M. 105 Blackman, N. 54 Blakeslee, S. 66 Blos, P. 42 Blumenthal, M.D. 19 Bollas, C. 24, 26, 137 Bonnet, G. 105 Brenner, C. 33 Britain 20, 23–9 British Psycho-Analytical Society 11, 24, 26 Britton, R. xviii, 6, 8, 12, 24, 42, 53, 67, 120 Buie, D.H. 20, 34, 63, 64, 76, 77, 147 Burgner, M. 8, 42, 66, 157 Burlingham, D. 65 Campbell, D. 1, 2, 3, 4, 6, 8, 10, 13, 37, 42, 51, 63, 66, 73, 75–86, 109, 142, 145, 147, 148, 152 Chasseguet-Smirgel, J. 8, 36, 42, 99, 140 Chused, J. 129, 168 Clancier, A. 22, 35 Cohen, P. 37

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Cooper, A.M. 32 Cordess, C. 25, 39 Cox, M. 25, 39 Crocker, D. 105 cummings, e.e. xii Davidson, D. 62 Davies, R. 4, 5, 7, 8, 9, 10, 11, 12, 13, 25, 125, 127–44, 159, 162, 164, 166, 167 De Zulueta, F. 39 Deutsch, H. 42 Diatkine, R. 35, 36 Early Childhood Development Project 31 Edgecumbe, R. 28 Einstein, A. 40 Elberhart-Wright, A. 19 Enriquez, M. 36 Erikson, E. 122 Faimberg, H. 36 Fairbairn, W.R.D. 19, 25, 27, 62 Ferenczi, S. 19, 38 Fonagy, P. 4–13, 19, 24, 25, 28, 39, 42, 51, 53–72, 89, 100, 107, 109, 121–2, 125, 127, 130, 138, 140, 147, 151, 156, 159, 161–8 France 20, 34–7 Frank, A. xiv Freud, A. xii; Centre xviii, 2, 27, 93, 119, 149, 159 Freud, S. xii, xiii, xiv, 3, 4, 20–23, 24, 27, 28, 33, 35, 38, 39–42, 43, 45, 46, 75, 82, 87, 102, 103, 140, 142, 147, 148 Frith, U. 54 Gabbard, G.O. 121, 139 Gaddini, E. 8, 42, 155 Gardiner, M. 19 Gedo, J.E. 31 Gillespie, W. 27 Gillibert, J. 35 Glasser, M. 3, 5, 29, 37, 42, 54, 77, 89, 104, 111, 125, 128, 138, 154 Glover, E. 26 Gosliner, B.J. 65, 82 Green, A. 7, 35, 36, 67 Greenacre, P. 65, 105 Greenberg, J.R. 24 Greenson, R. 81 Grotstein, J.S. 31, 105 Grunberger, B. 35, 36, 67 Hale, R. 77 Harris, J.E. 105

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Hartmann, H. 22, 30, 31 Hegel, G. 62 Heimann, P. 137, 138 Heimann, R. 11 Herzog, J. 42, 66 Hobbes, T. xiii Homer xi International Psycho-Analytical Association Congress 33 Irigaray, L. 8 Isaacs, S. 23 Jacobson, E. 163 Jane (patient) 5, 11, 114–22 Joffe, W.G. 112 Jones, E. 23 Joseph, B. 129 Joyce, J. xiii Kaës, R. 36 Karl (patient) 5, 10, 13, 90–99, 101, 102, 104, 106, 162, 164, 167 Katan, A. 105 Kernberg, O.F. 12, 19, 34, 35, 42, 53, 118, 138, 142 Kestemberg, E. 33 King, P. 78, 119 Klein, M. xiv, 19, 23, 24, 27, 42, 99 Kohut, H. 19, 32, 34, 35 Kris, E. 30 Lacan, J. 7, 8 Laplanche, J. 21, 22 Laufer, M. and M.E. 29, 80, 165 Lebovici, S. 24, 35 Lester, D. 20 Letarte, P. 105 Lévi-Strauss, C. 7, 41, 42 Lichtenberg, J.D. 31 Limentani, A. 8, 37, 38, 42 Lindner, R. 31 Loewald, H.W. 33, 65, 82 Lowenstein, R.M. 30 Lussier, A. 28, 35 McDougall, J. 64 Mahler, M.S. 65, 82 Main, M. 67 Malcolm, R.R. 24 Maltsberger, J.G. 20, 63, 64, 76, 77, 147 Marcovitz, E. 19 Maria (patient) 99–101, 104, 106

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Meers, D. 34 Meissner, W.W. 34 Meloy, J.R. 5, 38, 39, 55, 104, 111 Menninger, K.A. 30, 31 Menninger Clinic 30 Milton xi Mitchell, S.A. 19, 24, 34, 53 Moran, G. 65 Morton, J. 54 Neubauer, P. xv, 66 North America 20, 30–34 Ortmeyer, D.H. 19 O’Shaughnessy, E. 24 Osofsky, J.D. 19 Parens, H. 19, 31, 32 Pasche, F. 35 Paulo (patient) 5, 10, 130–42, 162–4, 166–7 Perelberg, R.J. xiii, xviii, 1–15, 19, 42, 89–108, 109, 111, 120–22, 125, 140, 142, 147, 155, 161–4, 166–7 Petot, J.-M. 24 Piaget, J. 66 Pontalis, J.-B. 21, 22 Pontius, A.A. 105 Portman Clinic 37 Premack, D. 54 Psychoanalysis Unit, UCL 159 Reich, A. 121 Reichard, S. 20 Rey, H. 128 Riviere, J. 142 Robert (patient) 6, 10, 147–57, 162, 164, 165, 167 Rochlin, G. 36 Rose, J. 163 Rosenfeld, H. 25, 109, 111, 112, 113, 121, 128 Rousseau, J.J. xiii Sander, L. 31 Sandler. A.-M. xv, 11, 12, 27, 28, 79, 80, 92, 128, 163 Sandler. J. xv, 11, 12, 27, 28, 79, 80, 92, 112, 128, 138 Satan xi Schachter, J. 5–12, 13, 42, 145, 147–58, 159, 162–5, 167 Segal, H. 6, 24, 25 Shane, M. and E. 32 Shengold, L. xi–xvii, xviii, 1, 19, 38, 39, 42, 89, 99, 105, 151 Sohn, L. 6, 25 Solnit, A.J. 19, 33

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Soule, M. 24 Spillius, E. 12, 24, 129, 138 Spitz, R.A. 31 Stein, M.H. 19, 24 Steiner, J. 12, 24, 64, 68, 69, 121, 129 Stekel, W. 75 Stern, D.N. 19, 65, 76 Stewart, H. 24, 26 Stoller, R.J. 8, 32, 42, 65, 66 Stolorow, R.D. 34, 53 Stone, L. 19 Symington, N. 128 T, Mr (patient) 5, 10, 11, 55–69 Tahka, V.A. 80 Target, M. 4, 5, 6, 8, 12, 13, 39, 42, 51, 53–72, 89, 107, 109, 121, 122, 125, 130, 147, 151, 156 Temple, N. 25 Tillman, C. 20 Treuniet, N. 25, 26 Usdin, G. 19 Walker, N. 37, 89 Wallerstein, R.S. 66 Weintrobe, S. xvi Weiss, J. 20, 54 West, D.J. 20 Williams, A.H. 6, 25 Winnicott, D.W. 11, 19, 26, 62, 63, 67, 69, 137, 139, 163 Wollheim, R. 103, 105 Woodruff, G. 54 Yorke, C. 24 Young Adults Research Group 1, 2, 9, 12, 13, 90, 159

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Subject Index

abandonment fears 94, 116, 141, 150 abuse see child abuse achievement, need for 112 acting out see enactment activity, aggression as 26, 31 actualisation 11 adolescence, and self-violence 29, 148, 157, 165 affective: content, attending to 125, 127, 128, 130, 137, 138, 139; frenzy 166; response 79; violence 38, 104, 111 affects: expression of 54, 145; negative 19 aggression 3, 5, 19; and anxiety 20, 130, 131, 138; and child abuse 19, 53, 54, 70; defensive 111; definition 20, 37, 38, 40; discharge of 30; as drive xii, xiii, xiv, xv, 3, 19–21, 23, 28, 30, 33–5, 43, 53, 89; free aggressiveness 22; function of 23, 30, 34; and gender 51, 67, 68, 70; healthy 20, 23, 30, 43, 89; in infancy 31; as interaction 54, 68; literature 2, 19–50; modulation of 24, 66; nature of 26, 31; towards object 147; optimal xvi; origins of xiii, 32; pathological 20, 30, 43, 89; primary 24; reactive xv, 3, 19, 20, 23, 27–8, 30, 32, 43; role in clinical work 21;

Name index

147

and sadism 29, 30, 37, 89; as self-expression 54, 145; self-preservative 20, 21, 29, 31, 38, 53, 54, 55, 62–3, 89; theories of 39; verbal xiii, 125; and violence 29, 32, 37–42; see also violence alcohol, use of 55, 56, 61 anality xiv, 35, 140 analysis: in borderline patients 110, 113, 121–2, 127–30, 140; maternal function 105, 106; paternal function 105, 106; in suicidal patients 79, 80, 81, 84, 113, 114, 116, 117; techniques of 11–13, 43, 51, 53, 62, 68–70, 87, 104, 129, 138, 156–7, 166–8; terminating 156–7; violence in 9, 13, 34, 43, 57, 67–8, 87, 92, 94, 100, 101, 106, 110, 113–14, 118, 120, 125, 142, 159, 166 analytic: contact 59–60, 69, 84, 92–3, 98, 130, 132–3, 136, 140, 151–2, 167; process 166; relationship 106, 110, 116, 118, 120–21, 166–7 annihilation, fear of 3, 5, 10–12, 24–5, 29, 58, 65, 68, 73, 76–7, 82, 104, 120, 122, 140–41, 147, 150–51, 154, 156; see also merging anxiety 23, 76, 99, 125, 147, 148, 149, 152; and aggression 20, 130, 131, 138; body 150; depressive 25, 80 associations 12 attachment theory 38 blame, avoiding 129, 138 body: anxiety 150; hatred of 147–8; as object 73, 76, 109, 150, 151, 159, 162, 164–6, 168; representation through 6, 7, 9, 53, 55–6, 61, 63–5, 67–9, 111, 116, 121, 122; see also mentalisation borderline states 5, 24, 34, 38, 51, 53, 63, 112, 116, 118, 121, 125, 127, 137–40, 142, 147; analytical technique in 110, 113, 121–2, 127–30, 140 boundaries: breaching 3, 19; creating 42, 82, 153; of self 163 bullying 130, 148, 153 caregiver, non-reflective see mirroring change, fear of 156–7 childhood 30, 31; abuse, and aggression 19, 53, 54, 70;

Name index

148

deprivation 19, 30, 43, 53; fantasy 30; love 31; murderousness 30; spoiling, in xvii communication: bodily see body representation; non-verbal 83 compassion 13, 55 conflict 11, 21, 25, 30, 58, 76, 80, 98, 104, 128, 137, 139, 148, 164 confusion, body/mind see body representation and mentalisation connection, attacks on 24, 57, 69, 95 consciousness 167 contact, analytic 59, 60, 69, 84, 92, 93, 98, 130, 132, 133, 136, 140, 151, 152, 167; see also reality, shared containment 7, 13, 24, 26, 36, 51, 62, 63, 70, 163 control: need for 56, 58, 130, 150, 151, 153, 156, 165; object 125, 128–30, 132–3, 139; parental 149, 151; see also power core: complex 3, 7, 10, 29, 104, 154; phantasy 20, 87, 89, 101, 125, 140, 142 countertransference 1, 8, 11, 13, 25, 59, 73, 79–81, 87, 89, 92, 121, 125, 137–9, 142, 145, 150, 152, 159, 167 criticism 57, 76, 148 cruelty see sadism death instinct xii, 3, 20–27, 30, 34–7 defence(s), ego xvi, 11, 12, 13, 19, 29, 38, 53, 148, 152, 165; aggression as 111; fantasy as 57; violence as 103, 109, 131, 138 delusions, suicidal see fantasy denial 7, 8, 29, 141; of separation 130, 148, 156 dependency needs 26, 27, 28, 112, 150, 153, 154, 162, 163 depression 3, 4, 25, 55, 56, 80, 87, 115, 149 deprivation see childhood despair 130, 148 destabilisation, of patient 113–14 destructiveness 20, 22, 26, 27, 35; bodily 76, 165; containment of 7 developmental crises see adolescence Devil xi dieting 150 disposition 105 distance, emotional 101, 127 distortion, of reality 29, 30, 67, 69, 76, 148

Name index

149

dreams 58, 60, 63, 64, 91, 95–7, 100–2, 104, 117–20 drive(s): aggression as xii, xiii, xiv, xv, 3, 19, 20, 21, 23, 28, 30, 33, 34, 35, 43, 53, 89; discharge 30, 31; energy of 30, 33, 55; fusion of 33; theory xiii, xiv, xv, xvi, 19, 20, 39 drug abuse 56, 61 ego: autonomous 30; development xvi; psychology 20, 22; splitting 76, 148; see also defence emotions see affects empathy 13, 19, 55, 56, 84, 117, 122, 128, 130 emptiness, sense of 55, 61, 62, 115, 148 enactment 69, 94, 109, 112, 113, 122, 137, 138, 141, 142, 159 engulfment see annihilation and merging environment: mastery of 40; role of 24, 31–4, 37, 53 envy 24, 57, 59, 81, 112, 141–2 Eros instinct 22, 33 eroticism 32 evil xi, xii expectations, fulfilling 147, 157 exploitation 57 failure, feelings of 116 fantasy see phantasy father, role of 2, 7–9, 13, 20, 29, 42–3, 51, 56, 58–9, 61, 65–8, 70, 73, 81–2, 85, 102–4, 109, 114, 121–2, 130, 134, 136, 145, 147, 151–4, 162–3; see also third object and triangular space fear 147–8; of abandonment 94, 116, 141, 150; of analyst 106; of annihilation see annihilation; of breakdown 149; of change 156–7; of intimacy 157; of mother 103, 106; of rejection 56, 59, 61, 112 feelings: of failure 116; of frustration 26, 27, 30, 32, 37, 66, 92, 104; guilt 4, 22, 25, 26, 33, 38, 59, 61, 83, 152; of hopelessness 116; of humiliation 32, 69, 136, 138, 149, 150, 152, 156; of inferiority 112, 114;

Name index

150

persecutory 56, 62; of shame 56; see also affects and hate and love and rage forgiveness 138 free aggressiveness 22 frustration 26, 27, 30, 32, 37, 66, 92, 104 fusion see annihilation and merging gambling 78, 79 gender: and aggression 51, 67, 68, 70; of analyst 43; identity 13, 32, 81, 154, 157, 161; representation 9; see also sexuality God xi grandiosity 131, 137, 150 guilt 4, 22, 25, 26, 33, 38, 59, 61, 83, 152 hate, as ego function 21, 23, 25, 26, 27, 28, 31, 34, 38, 57, 59, 125, 131, 147–8, 155 helplessness 58, 147 homeostatic effector 31 homicide see murderousness hopelessness, feelings of 116 hospitalisation 117, 118, 119, 120, 150 hostility 4, 32, 38, 152 human nature xii humiliation 32, 69, 136, 138, 149, 150, 152, 156 hypochondriasis 100 id 22 idealisation 77, 84, 127, 149, 151 identification 13, 75; gender 13; with hated one 109, 111, 148, 157; with object 148 identity: diffusion 109, 122; disturbance 163, 164; establishing 69, 145, 147–58, 164, 165; gender 32, 81, 154, 157, 161; threats to 38, 61, 62, 68, 93 impulsiveness 57, 59 individuation-separation see separation infant see childhood inferiority feelings 112, 114 informative experience 129, 132, 135, 137, 142, 168 insight 130 instinct see drive intentionality 28 interaction:

Name index

151

aggression as 54, 68; modes of 122; therapeutic nature of 59, 60, 69, 84, 92–3, 98, 130, 132–3, 136, 140, 151–2, 167, see also relationship internalisation 27, 163 interpretation 11, 12, 69; analyst-centered 129, 137; mutative 129, 137, 139; patient-centered 129; timing of 112, 113, 118, 121, 125, 128, 130–42; see also understanding intimacy, fear of 157 introjection 11, 24, 25, 113, 164 kill, urge to see murderousness libido 30, 31, 33, 35 life: force 26; instincts 24 linking see connection and contact, analytic love: curing by xvii; as ego function 23, 25, 26, 27, 28, 54, 57; in infancy 31 malicious violence 37, 54, 89, 104, 111 masochism, primary 21; see also sado- masochism maternal see mother melancholia see depression mentalisation, capacity for 6–8, 9, 20, 28, 36, 51, 53, 54–6, 61, 67–8, 70, 100, 107, 125, 140, 159, 163, 164, 165, 167, 168; see also body representation and symbolism merging: fantasies of 8, 9, 13, 104; longing for 3, 4, 5, 11, 29; with mother 76–7, 80, 84, 85, 104, 105, 106; with other 63, 73, 107, 148; see also annihilation mindless violence 6, 10, 53, 68, 70, 166; see also body representation and mentalisation mirroring 63, 69, 163–4 mother: fear of 103, 106; ideal 77, 84; merging with 76–7, 80, 84, 85, 104, 105, 106; murderousness 36, 83, 99, 103, 147, 149 mother-child relationship 7, 8, 23, 28, 36, 42, 54, 59, 63–7, 90, 93, 101, 104, 115, 122, 149, 152, 163; mourning 148;

Name index

152

pathological 82, 83, 103, 104, 119 motivation, unconscious 38 motivational theory of aggression 34 murderousness xiv, xv, 3, 21, 25, 32, 37–8, 165; in infancy 30; maternal 36, 83, 99, 103, 149; parental 147 myth 7, 41, 43, 87, 89, 107 narcissism 35–6, 43, 62, 67, 109, 111–23; defences 149; management of 128, 131; rage 32; thick-skinned 12, 109, 111–14, 116, 119–22, 125, 128, 151; thin-skinned 12, 109, 111–14, 116, 119–22, 125, 128 needs 133, 163; dependency 26–8, 112, 150, 153–4, 162–3; safety xv, 28, 64, 92, 112 Nirvana Principle 22 object: aggression towards 147; body as 73, 76, 109, 150, 151, 159, 162, 164–6, 168; controlling 125, 128–30, 132–3, 139; external 111, 164, 167; fantasy 111; identification with 148; internal 111; intrusion 109; need for 163; relations xvi, 3, 4, 5, 6, 8, 20, 21, 26, 30, 35, 37, 42, 75, 109, 125, 138, 139, 155, 159; separation from 129, 145, 148; as threat 109, 111, 119, 140; third 122, 145, 147 obsessional states 149, 164 Oedipus complex xiii, 4, 21, 32–3, 39, 40, 41, 43, 61, 66–7, 87, 94, 99, 104, 107, 148, 155–7, 162 oscillation, of states 13, 109, 111–14, 116, 119, 120, 140, 149, 155 other: merging with 63, 73, 107, 148; within the self 163–5, 167 pain, mental 76 panic attacks 58, 64 parental: control 149, 151; murderousness 147; relationship 32, 67, 147 passivity 22 patient(s): Adams, Mr 10, 77–9, 81–5; destabilisation of 113–14;

Name index

153

Jane 5, 11, 114–22; Karl 5, 10, 13, 90–9, 101, 102, 104, 106, 162, 164, 167; Maria 99–101, 104, 106; Paulo 5, 10, 130–42, 162–4, 166–7; Robert 6, 10, 147–57, 162, 164, 165, 167; T, Mr 5, 10, 11, 55–69 persecutory feelings 56, 62 perspective, external see father and third object perversion 3, 8, 29, 32, 36, 37, 104, 140, 164 phantasy 6, 61; core 20, 87, 89, 101, 125, 140, 142; defensive 57; infant 30; maternal 35, 36; of merging 8, 9, 13, 104; object 111; primary relationship 105, 106; psychotic 148; role of 31, 32; sadistic 25, 164; sexual 140, 155; and suicide see suicide; unconscious 11, 23, 24, 64, 83; violent see violence power, wish for 35, 36, 93; see also control predatory violence 38, 104, 111 pre-suicide state 75–6, 79–82, 83, 84; see also suicide primal scene 4, 10, 40–3, 87, 91, 98, 101–5, 140–1, 154–5, 161–2 primary masochism 21 projection 11, 24–6, 57, 63, 107, 113, 121, 125, 129–30, 132, 154, 167 projective identification 11, 24, 57 psychopathy 54 punishment: need for 33; self 56, 75 rage 32, 34, 39, 55, 56, 58, 61, 106, 152, 153 reactive: aggression xv, 3, 19, 20, 23, 27, 28, 30, 32, 43; sadism 32; violence xv reality: distorted 29, 30, 67, 69, 76, 148; shared 118, 121, 128, 162; see also contact, analytic recognition 57, 69; of emotion 125, 128 reflection see mirroring regression xvi, 75, 78, 82, 85, 106, 148

Name index

154

rejection, fear of 56, 59, 61, 112 relationship 57, 93, 100, 101; analytic 106, 110, 116, 118, 120, 121, 166–7; distance 101, 127; through hatred 57, 125, 131, 139; mother-child 7, 8, 23, 28, 36, 42, 54, 59, 63–7, 90, 93, 101, 104, 115, 122, 149, 152, 163; parental 32, 67, 147; primary 105, 106; violence in 101; see also interaction and object relations religion, and violence xi repetition compulsion 22, 84 repression 7, 69 retaliation, in analysis 138 revenge, suicide as 75, 83, 84, 139, 147, 149, 152 role responsiveness 11, 138 sadism 5, 6, 10, 21, 31, 34, 35, 38, 54, 75, 103, 125, 137–9, 142, 148, 155; and aggression 29, 30, 37, 89; fantasies 25, 164; reactive 32; and violence 22, 29, 30, 39 sado-masochism 3, 34, 37, 73, 83, 85, 103 safety needs xv, 28, 64, 92, 112 security 154 self: -assertion 2, 5, 6, 7, 9, 11, 20; boundaries of 163; -consciousness 149; -destructiveness 21, 33, 57, 61, 63, 64, 109, 112, 122, 141; -development 51, 54, 62, 69, 70; -esteem, threats to 38, 61, 112; -expression, aggression as 54, 145; fragile 32, 34, 57, 64, 68, 93, 107, 122, 140, 150, 152, 168; -image 62; -importance 112; -mutilation 30, 64, 70; -reflection 136, 140, 142; -representation 163; sense of 147; -sufficiency 150; surviving 76, 77, 82, 112, 148 self-preservative: aggression 20, 21, 29, 31, 38, 53, 54, 55, 62–3, 89; instinct 23, 28; suicide 109; violence; 5, 37, 39, 54, 55, 89, 104, 109, 111–12, 125, 131, 164 separation 77, 82, 106, 147, 152, 161: achieving 29, 32, 43, 147, 159; and aggression 3, 10, 20, 26, 32, 38, 63, 65; denying 130, 148, 156;

Name index

155

desire for 62, 63, 120, 132; failure of 148, 157, 162–4; from object 129, 145, 148; sense of 145, 147–58 sexuality 90, 140, 161; and hostility 32; fantasy 140, 155; parental 91; and transference 9, 10; and violence 2, 3, 9–11, 29, 30, 37, 41, 42, 102, 103, 104; see also gender shame 56 shared reality 118, 121, 128, 162 somatic displacement 29 soul murder xv, xvii, 38, 39 splitting 7, 11, 27, 29, 76, 148, 154, 163 suicide 3, 13, 25, 38, 77, 78, 145, 148; analytical technique 79, 80, 81, 84, 113, 114, 116, 117; fantasy 6, 10, 63, 66, 73, 75–7, 80, 82–4, 109, 122, 145, 148, 156; function of 6, 30, 63, 64, 68, 76, 120, 122; and murder 20; paradox of 147–58; as revenge 75, 83, 84, 139, 147, 149, 152; as self-assertion 6, 7; self-preserving 109; or violence 111, 119; and withdrawal 80, 84; see also pre-suicide state and surviving self superego: critical 76; development xvi, 22, 33: role 38, 57, 128 surviving self 76, 77, 82, 112, 148 symbolisation, capacity for 139, 164, 166; see also mentalisation tension, build up 55 termination, of analysis 156–7 therapeutic reaction: to interaction 59, 60, 69, 84, 92–3, 98, 130, 132–3, 136, 140, 151–2, 167; to interpretation 129, 137, 139; to love xvii; negative 142 thick-skinned narcissism 12, 109, 111–14, 116, 119–22, 125, 128, 151 thin-skinned narcissism 12, 109, 111–14, 116, 119–22, 125, 128 third object 8, 9, 67, 69, 122, 145, 147; see also father and triangular space thoughts, and violence 6–7, 55, 67, 68; see also body representation transference 1, 11, 13, 25, 57, 68, 85, 89, 93, 99–102, 105, 119, 121, 125, 127, 138–9, 145, 151, 155;

Name index

156

maternal function 105, 106; paternal function 105, 106; sexual 9, 10 transitional space 11, 137 trauma 25 triangular space 12, 67, 109, 119, 120; see also father and third object unconscious: motivation 38; phantasy 11, 23, 24, 64, 83; timelessness of 12 understanding: analytic 13, 56, 57, 60, 61, 64, 68, 69, 91, 93, 100, 101, 107, 118; violence 53–72, 164; see also interpretation union see merging verbal aggression xiii, 125 violence xii, 1, 3, 109, 161; action of xii, xiii, 13; adaptive potential of xvi; affective 38, 104, 111; alternatives to 168; concept of 2, 4, 20, 35, 40; in consultation 9, 13, 34, 43, 57, 67, 68, 87, 92, 94, 100, 101, 106, 110, 113, 114, 118, 120, 125, 142, 159, 166; defences against xvi; as defence 103, 109, 131, 138; definition of 3, 5, 37, 53, 87, 89, 90, 103; function of 6, 42–3, 55, 89, 103–7, 120, 122, 131; increased awareness of xii; malicious 37, 54, 89, 104, 111; meaning of 31, 39, 122; mindless 6, 10, 53, 68, 70, 166; Oedipal xiii, 4; phantasies of xii, 1, 3, 4, 91, 104, 107, 109, 122, 125, 131, 150; pre-Oedipal xiii; predatory 38, 104, 111; presenting 130; reactive xv; reasons for 162–6; in relationships 101; and sadism 22, 29, 30, 39; as self-assertion 2, 5, 6, 9, 11; self-preservative 5, 37, 39, 54, 55, 89, 104, 109, 111–12, 125, 131, 164; and sexuality 2, 3, 9–11, 29–30, 37, 41–2, 102–4; or suicide 111, 119; understanding 53–72, 164; see also aggression and body representation vulnerability 131, 136

Name index

withdrawal: 154; prior to suicide 80, 84

157