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Introduction

                  This paper explores questions about the nature of psychoanalysis that arose during a three-decade span of work with a psychotic woman. She presented a difficult clinical problem, that of keeping open a place for speech, for someone who cannot yet speak. Winnicott's concept of the "holding environment" provided me with a theoretical foundation to this difficult task, for during long dark periods there was simply nothing to be said, and 'holding on" seemed to constitute the whole of the treatment. Actually, the patient did speak right from the start, but her words did not touch the agony that coursed through her and erupted into actions, whose evocative impact pushed me to the limit.
                  And so, this case illuminates the tensions of trying to sustain an analytic position, while dealing both with the patient's anguish and ones countertransference. One major obstacle to attempting the "talking cure" was her destructiveness. One manifestation, scratching her wrists to the point of drawing blood, moved me to select "wading through blood" for part of my title.
                  Destructiveness had been generated within a family climate where aggression and selfishness was concealed behind a facade of righteous gentility. Her mother, a dedicated to Christian Scientist, used that ideology to explain her daughter's wrong-doings, as failures to "declare the truth" about her sinful nature.
                  My efforts to help her verbalize her unbearable chaos, took us "to the signifier" to confront the traumas that had generated it. The word "signifier" also indicates my effort to weave a Lacanian perspective into my practice - the result of several years' study. Lets consider a signifier to be a word, a phrase, and, in this case, even a sound that circulates in a given culture. A family uses these elements in a unique way, bathing their offspring in signifiers that lay down primary repression. The signifiers then mark the infant as a nascent subject, and he, in turn constructs a world in which he structures himself.
                  The conundrum, "could this be psychoanalysis?" refers to aspects of the treatment that some would say are not analytic. I do not want to argue about whether these aspects are preconditions for or prerequisites to analysis, but I will rather, assert that this treatment is analytic. To this end I employ a "lean definition" of psychoanalysis: namely that psychoanalysis is constituted by the intersection of the analyst's desire to know and the analysand's urge to speak. And the analyst is responsible for creating the conditions necessary for this.
                  This concept of psychoanalysis rests entirely upon the motivation of the practitioner to hear the patient out, and advantageously locates its essence where it belongs ­ on the speech of the analysand. While this statement seems straightforward, matters are more complex, for we have to take into account the unconscious as the source of signifiers and the effect of repressions and transferences. The analysand ever avoids saying what he does not want to know or, as in this case, simply cannot capture in speech what lies beyond words. The analyst's attention is diverted, by the analysand's misleading speech, and then by what the analysand's words and actions evoke in him.
                  My commentary comes from a "worked over" practitioner, looking back over a span of thirty years upon that self-assured and scrappy newcomer to the field, who waded into treatment with this patient. I was armed then with the works of Winnicott and Searles, and supported by mentors who considered psychoanalysis to be the treatment of choice for psychotic patients. My later exposure to Lacan has had the effect of shifting the emphasis of my thinking from the "holding environment" toward the pursuit of signifiers. To be sure Winnicott clearly sets out an analytic sequence of "holding ­ handling ­ interpretation." But concerned that I had under-emphasized the importance of speech, it was with no little trepidation that I opened the pages of decades old notes, there to find that I had been in hot pursuit of signifiers even before I knew what a signifier was.
                  Those signifiers that most shaped the patient's experience were the words, rats garbage "the black stuff" and kill, the pronouns, her and me, and the sound of a siren. I consciously chose for my patient, the pseudonym, "Karen Adams" on the basis of its phonetic resonance with another of her signifiers. After the fact, I was unsettled by the discovery that I had unwittingly selected the name, Karen, because of a personal experience of no little significance to this case. This will be woven into the story.
                  The broad outlines of the case are as follows: At the point we began our work together, Mrs. Adams had spent half of the previous two years confined four times in a psychiatric hospital. The pain of the chaos that raged through her, moved her to frequently drink herself into a stupor by mid-morning. Her idea of obliterating her agony by drowning herself hovered ominously in the background. Despite being subject to sudden but transient psychotic episodes, she was never again hospitalized. How I was able to manage her regressions in an office setting forms another theme of the story.
                  After many months she stated that I had helped her to enjoy time spent alone, and this sharply contrasted with her need to anesthetize herself with alcohol. This affirmation of my work quite moved me, yet at the same time evoked an ominous dread. She seemed fragile and likely to fall to pieces, or to kill herself to prevent this. This admixture reflects the way progression alternated with regression. And as the relentless waves but slowly reshape the shore they expend themselves upon, change for her was slow and but partial, for to this day a residual chaos continues to exert itself.

Clinical material

                  Now let me introduce Karen Adams to you as she was introduced to me by her attending psychiatrist, Dr. G., who had asked me to care for her during her last hospitalization, while he had to be away. Dr. G. led me into her hospital room where I was confronted with the sight of Karen seated on the floor, back against the wall, legs spread apart, screaming out, «Rats! Rats!» while she methodically smashed both fists into her face.
                  Dr. G. quickly knelt down before her and grasped both her wrists. He addressed her as «Baby Karen,» attempting to soothe her as he restrained her. As I looked upon this scene with a jaded eye, I recall thinking, «I'd never treat a patient this way,» that is, in an infantilizing manner. Within the year Dr. G. moved to another part of the country and referred Mrs. Adams to me. My easy hubris would be sorely tested. Now, it was my turn to confront and grapple with this very difficulty.
                  At the start, Mrs. Adams regarded me as a judgmental presence ­ a kind of Christian Science god. Because it was important to her that I know about her relation to Christian Scientism, she gave me a brief note, written in a neat hand. It read: "Man was created in the image and spiritual likeness of God. Except for errors, man would be God-like. No matter how hard you try you never succeed. The struggle never ends because you are always plagued by your own human errors. Christian Science creates in you the desire to be perfect, but actually it makes you feel inferior and evil."
                  As a little girl, she endured the pain of a broken ankle, a middle ear infection, and an ulcerated tooth, while her mother prayed over her. "She ignored my pain, "Karen said. "She told me I had 'bad thoughts and had not 'declared the truth.' She was right, I must have been at fault. Better not to exist, better yet never to have been born."
                  Later Karen would voice much hatred of her mother. "My mother makes me sick! She kept saying, 'control your mind ­ why are you always running off to that doctor?' My god-damn mother made me bad; my god damn mother killed me." On another occasion she wept bitterly and exclaimed, "I keep killing my mother over and over again, but she keeps coming back."
                  But in the beginning she could only desperately ask me, «Is it all right?» My attempts to find out what might not be "all right" were ignored and met with more plaintive questioning. Her obsessive quest would collapse and she plunged in another scene from which I was excluded and whose horror I could only infer from her desperate activity. Her eyes tightly shut, she would edge from her chair to the floor and scoot across the room searching for a door to exit through. Once she located a window and moved to open it to climb out. On another occasion she tried to bang her head against the corner of my desk.                   Now, it is just not good form to have a mad woman wander the halls of your office building, break her head open on your desk, or plunge twenty floors to the pavement. Verbal intervention had absolutely no effect and her actions were potentially harmful. And as I could see nothing else to do, I simply restrained her.
                  I made this decision rapidly, but not lightly, out of concern that once I did something this intrusive, I would be committed to keeping it up for as long as necessary. The risk of suicide, injury and drunkenness certainly raised the question of hospitalization, but was mitigated by the fact that her regressions were always brief and reversible ­ and she always emerged from them quite engaged with me. Also, at the end of each hour she uttered an obsessive formula, "time to go to the train," which echoed the instructions of her most supportive and tolerant husband: "At the end of the session you go to the train." She obeyed and this meant that she would not go on past the station entrance, walk the length of the street and wade into Lake Michigan.
                  Physically restraining her felt to be the most natural thing to do for three reasons. My medical training - which at that point was not that far behind me - included a literal hands-on approach to the patient. In the ordinary conduct of examining and treating ill patients one must repeatedly touch them. Secondly I had wrestled competitively in high school and college - and so "holding on" was engraved in my somatic memory. But, most important was Winnicott's work. He repeatedly states how the analyst imaginatively holds the patient. But in addition he also wrote (1963), "Occasionally holding must take a physical form . . . because there is a delay in the analyst's understanding which he can use for verbalizing. Probably there are times when a psychotic patient needs physical holding, but eventually it will be understanding and empathy that will be necessary."
                  In her dissociated state Mrs. Adams seemed to be caught in the grips of a monster that was smothering her. She at last spoke of the mad world she was immersed in, "How do you stop splinters and angry shooting noises like thunder? The lightening bolts come like spears and rip my head apart, all is blackness, I go around and around, and I fall into no being."
                  During the first phase of therapy, dealing with this terror comprised the whole of our work, and it determined a particular pattern. After restraining her she would collapse and lie motionless, as if she had fallen just as she said, and then hit bottom. I remained sitting nearby on the floor. After a few moments she would rouse herself, reach about, and brush against me. Suddenly relieved to discover another person, she would clutch at me in desperation. Next, she insisted that we feel each other's pulses. Satisfied that her heart was beating, she was relieved to feel my pulse, too. But instantly the pulsation terrified her and she abruptly drew her hand away.
At times her urgency would become sexually tinged and she would rub herself against my leg. When she discovered my foot, she often would slip her finger between my shoe and heel. As she became calmer, I insisted that she describe her experience to me. She would try to respond, but could find no words and would become frustrated.
                  One day as I again pressed her to tell me what had happened, she gestured for pen and paper which I provided her. This proved to be the fulcrum on which the treatment took a turn toward words. Over many months she made sketches, crudely lettered with words and phrases. Once she held the pencil like a dagger and practically carved the word, "kill" into the paper. Thus the paper could become the target of assaults formerly visited upon her body.
                  This is what she spoke of in association to these sketches: "I feel encased in a steel shell. Inside I am filled with garbage and I would scratch at my wrists to get it out ­ I'd draw blood and my mother was always after me about doing this. Inside I had a heartbeat, and I feared it, because I did not know what it was to be alive. Why didn't they kill me instead of making me live in death? I was a baby that fell; I had to suck my fingers ­ that was the only way I could survive the fall." To be killed moves her to kill, as she demonstrated by drawing an ominous black figure, that she quickly ripped apart exclaiming, "me kills everything it touches ­ I suck my fingers ­ the baby cries and kills everything ­ I want to kill my sister. My body is bad ­ I have to hide my whole body. They said I'd bankrupt them because my sucking gave me buck teeth." This last statement arose from her mother's warning that she would need expensive orthodontic treatment.
                  One day she put a question to me, "Dr. Turk, do you kill?" The tone of her voice was paradoxically most loving, as if she were appealing to me to perform a mercy killing. This made her query all the more jarring,
                  Immediately two thoughts flitted through my mind, first: "How did she find out?" and second: "How could she possibly consider that? ­ After all, I'm a dedicated physician!" When I recovered my composure, I asked her why she wanted to know this.
                  "So you could cut into my head and kill off the part of my brain that gets me into all this trouble," she replied.
                  Trying to seize an opportunity I responded, "I'd say that you want to reveal to me what is on your mind ­ but we can't do that by cutting into your head, we can only deal with this by talking, not by surgery." My explanation fell upon uncomprehending ears, for she still regarded words as concrete objects. "Dr. Turk," she once said to me with some urgency, "Words can kill, you know that, don't you? Words can kill. My parents killed me with words and then 'me' killed them. 'Me' doesn't want to kill anyone else, so 'me' will go away. I should be strong and not come here ­ I should follow the divine direction of Christian Science truth. It is a divine concept and 'me' always failed. That is why 'me' is bad."
                  She was unable to bring the good and the bad together, so she imagined that she was split into a black part, associated with her mother and a white part that she saved from the bad by projecting it onto the person of her paternal grandmother. The latter lived with the family, along with a hated sister, one year her junior, and a year older brother, she often called "King George."
                  One day she wrote the word "me" and then crossed it out and printed the number 12. When she was 12 years old, her parents vacationed in Europe and left their children in the care of a housekeeper. Her grandmother suddenly collapsed, and soon an ambulance arrived with its siren wailing. Two men took her grandmother away in it. No one ever talked to her about what had happened, but from what she overheard she learned that grandmother had died of a heart attack.
                  At the moment that her grandmother collapsed, Karen was putting on lipstick for the first time. Thus her budding femininity is linked up with terrible loss, moreover she felt that her body betrayed her. She exclaimed, " My blood is black, decayed and worm infested." Worms refers to her menarche, for which she was unprepared. She tried to deal with menstrual bleeding by tearing up strips of cloth, and wadding them into her underwear. She then hid these blood-soaked strips in her closet where they became infested with maggots. On discovering them her mother became furious, and screamed at her, "You stink!" Mrs. Adams later wove this into the delusion that she was filled with worm infested garbage.
                  In the fifth year she reported the following dream: "We are in a barn or a store. I bring you seeds and flowers and plants. You are pleased with what I bring you. But then rats came and started eating the garbage that's in me." She explained, "I'm garbage because once I felt love for my mother and just as I was about to tell her that I loved her she slapped me in the face. Me is garbage and vomit ­ that is why rats come and eat it up ­ garbage is the badness of daring to want ­ no, to even think - of the word 'love.' To say, 'I love you' is to say, 'me' hates you.

The Transference

                  Let us see how this splitting entered into the transference. In regarding me as a version of the Christian Science God, she could no more placate me than she could her mother, whom she identified with this persecutory God. Nor could she be in touch with me anymore than she could touch her yearned for grandmother. All her yearnings for her beloved grandmother had gone unexpressed. These were centered upon an urge to touch her earlobe. Terrified of her "lethal touch," Karen begged me to believe that she never touched her.
                  Once, after having emerged from a dissociated state, she looked at me directly - something she felt was forbidden ­ and with an awe-struck expression, reached out and touched my earlobe. "There are cats inside me fighting," she said, "and they will scratch my eyes out; cats can give you babies, too. You do not scratch my eyes out. This is what I get killed for, to dare to think someone would love me."
                  Although her father provided well for the family, it could be said that he was absent. He often feigned headaches to avoid social situations, and when he came down with pulmonary tuberculosis and had to go to a sanitarium, he became a source of distress to her mother in her dealings with the public health authorities.
                  While she remarked how he never intervened on her behalf, my presence was a source of conflict. For example she once stated, "Me is free here, I don't have to prove anything. I don't have to have the right answers ­ I don't have to be good ­ it is because of you; but you should stop me from being, then Mrs. Adams' life would be better." As if of two minds, she sketched her head separating into two pieces. "One part goes far away ­ way back far away. I'm afraid you will make me go away because I want to be inside you so I do not lose you."
                  Her solution was that I must only be a figment of her imagination, because then, if she had no real contact with me, she could not lose me. As she put it, "I get the idea that you don't think 'Me' is bad ­ but no one else ever thought that about me, and I can't really believe that you do; maybe I just made you up." To make sure of this she always avoided looking at me.
                  Wanting to make some in-road into this, I asked her ­ with a bit of stuffy humor, "Madame, as far as I'm concerned you can keep your eyes closed forever, I don't care if you ever look at me, but I am curious. If you did look at me what would you see?"
                  "A gorilla!" she immediately exclaimed.
                  She was half-serious and I was amused to think that she had transformed her grappler-analyst into King Kong, gently holding this little beauty in the palm of his hand.
                  Then she interjected, "And don't call me 'madam'."
                  I was ever alert for opportunities to say "madam," to convey its full resonance as both an adult woman, and as the proprietress of a whorehouse. This role referred to a racy joke she had told me that made a rare link to sexuality. Otherwise she steadfastly disavowed being female. "I'm an it," she would say. I was to learn months after the event, that she had sexual fantasies about me and this had led to an orgasm. She had never experienced this before and far from being enjoyable, it went on and on reproducing the agonies of the "black stuff," that coursed through her.
                  Although much of what transpired was agonizing and marked with the "black stuff," our work was also leavened with a good bit of humor. She often began a session with a playful overtures, and I would join with her in the punning or in some absurd talk. My reservations about this quickly dissipated, when I discovered that inevitably some key word or phrase would emerge out of this play, and lead us to discuss the kind of experiences mentioned previously.
                  One day she teased me, "Dr. Turk, are you a rat?" In the next moment she exclaimed, "Oh, I didn't say that - I want to take it back ­ just forget what I said. Oh, it's no use, I know you; you don't forget anything ­ you've got the memory of an elephant." I recalled her having told me that as a schoolgirl she had read that on Christopher Columbus' voyage of discovery, conditions had become so extreme that his sailors had been reduced to eating rats in order to survive.
                  So, I didn't pursue the matter. She had forbidden me to say "rat" because the sound of that word would plunge her into a terrible hallucinated scene of rats swarming around her. Only she could say the word, "rat." I just took note that she had now cast me in the role of consuming her "garbage."
                  This theme was recast in a dream that she related with considerable embarrassment. "I was in the company of a French Chef. We were making hors d'oeuvres out of my feces." Because she could speak no more, and not wanting to lose the opportunity she had presented, I quickly said, "Yes what you think is revolting, I find palatable. That is what I've been saying to you all along, that the way out of this is by talking our way through it."

The countertransference

                  As I wrote this paper I was again and again disconcerted to identify in my own experience what Mrs. Adams presented as starkly mad. It was as if I harbored within myself an animated miniature version of her that I had constructed over the long course of our work. These inevitable evocations bring us to the topic of countertransference, where we may distinguish between evocations that disrupt and those employed as a defensive countertransference. It is important to define our terms ­ and to get quickly to the heart of the matter ­ I advance Winnicott's operational definition. He states that, "the true meaning of the word countertransference can only be the neurotic features [of the analyst] which spoil [his] professional attitude and disturb the course of the analytic process as determined by the patient."
                  Earlier I stated that I had chosen the pseudonym, Karen, to rhyme with a specific utterance. At first I could not make out a phrase that she quickly blurted out, when excited. When I was at last able to get her to speak slowly the words were, "Karie, Karie, coo, coo," the cruel schoolyard taunts her classmates hurled at her because of how crazy she appeared to them.
                  But something else entered into this choice of "Karen." I suddenly remembered that I had a playmate named "Karen" who died when I was five years old. My mother, looking rather distracted announced to me softly, "Did you know that Karen died?" I found out little more, for then my mother drifted off into some inaccessible place.
                  I implicated myself in the illness of which my playmate died, because of a bit of innocent misbehavior that touched upon fantasies of sexual transgressions. In this midst of our play my usually taciturn mother broke in upon us and bellowed, "What are you doing!"
                  To sum up ­ it turns out that I am no stranger to the fantasy that one touch can be lethal; nor am I unfamiliar with someone who drifts off to inaccessible places, so that death remains unspeakable, just as it had been for Mrs. Adams. But for me there was a crucial new ingredient, while my mother's interior life remained enigmatic, I was privileged to learn a great deal about what erupted up out of Mrs. Adams; that is, to find out what happens "in there."
                  Being with her as I have described was as if I were immersed in a churning stew, a kind of alphabet soup whose letters spelled out "killing" and "touching" upon me: it had its impact. While Mrs. Adams was subject to the unspeakable chaos that coursed through her body, its effects extended beyond to evoke in me something akin to it.
                  Searles (1973) explicates this kind of impact, pointing out that, "the symbiotic instability of [the psychotic patient's] ego boundaries makes it impossible to know whether the anger or depression, for instance, that one suddenly experiences, is one's "own," or whether one is empathically sensing the patient's "own" feeling against which he has successfully defended [and] projected [onto the analyst]. . . . It is often impossible to know, and it feels urgently important to ascertain, whence and to whom these communications are coming."
                  Let me focus upon a single event where aggression erupted in me. One day she was especially terrified and I found restraining her to be particularly strenuous. At last she collapsed in a heap on the floor. Rather tired out I sat back, and thinking myself to be "neutral," I was shocked by a feeling of fury accompanied by an urge to hit her, and the thought, "Why don't I just screw her and get it over with?"
                  I am explicit here, in order to turn an analytic eye upon what erupted in me. Consider, first of all, that we were engaged in a situation of struggle, she with her monster and I with her. There was nothing that could be said. Moreover this was the most recent of a series of similar events, the accumulation of which had pushed me to my limit. It was this confrontation with what seemed to be her unremitting madness that propelled me to want to precipitate a limit ­ and to this, I had dedicated my aggression. Here I had identified with her notion of "killing," contained in her question, "Dr. Turk, do you kill?" Of course, I did not act in response to this kind of transposed madness, for, to "get it over with" at one stroke, would mean that everything we had been trying to weave together would have been torn asunder.
                  Winnicott (1968) states that in the treatment of certain very ill patient, the most critical thing is that the analyst survives. He writes: "[The patient] will find that after [the idea] "subject relates to object: comes [the idea] "subject destroys object" (The object then becomes external.) Then [there] may come [the idea] "object survives destruction by the subject." But there may or may not be survival. [But if there is], the subject says, "Hello, object! ­ I destroyed you. ­ I love you. ­ You have value for me because of your survival of my destruction of you. ­ While I am loving you I am all the time destroying you in (unconscious) fantasy. . . "
                  So if there is survival it is because the analyst survives in the mind of the patient who imaginatively kills the analyst. And the analyst survives by not retaliating and by keeping enough of his technique from "being spoiled" to sustain a place for speech. To this she responded with such phrases as, "You let me be ­ I do not have to be good ­ you don't make me do anything. She often in her confusion would plead, "Where can me be?" indicating just how tenuous her sense of having a place was.
                  Now what of the sexual content of my de-repressed thoughts, the idea: "screw her?" The first image that crossed my mind was that of a photo essay about elephants in an old issue of Life Magazine. Elephants, I learned from this essay, not only never forget ­ as Karen regretted - but also dedicate themselves to one mate for life. A series of photos depicted a male elephant's reaction to its mate's death. He tried one thing and another to rouse her back to life. All this failing, he, at last, attempted to mount her. This little death succumbed to the greater one; and he lumbered off, grieving ­ so it seemed to me.
                  Carried to the extreme such "dedication" amounts to a desperate attempt to cure at any cost - to spare nothing ­ to throw oneself into the void. And if I thought that the elephant in the photo sequence felt grief, it was because I had projected my own long buried grief from that little girl, Karen onto this contemporary Karen, and had the sudden impulse to attempt a cure by coupling. But this impulse also contained contempt directed at the object of temptation, that little girl, Karen colored by my mother's critical exclamation, "What are you doing?" ­ now conflated with my patient, Karen. In my urge to attack the contemporary Karen I was also trying to obliterate my playmate, Karen, as an object of sexual temptation. Then she would not have been subject to my touch and she would have survived.

The defense countertransference

                  If we characterize the disruptive countertransference by the phrase: "I'm finding out more than I can bear to know," we can contrast the defense countertransference as: "I don't want to know anything about it." The sound of a siren precipitated many of Karen's violent regressions. She was convinced that they indicated trouble, and trouble for us meant that at any moment a group of white-coated men would break into the office and carry one of us off to a "QR." This referred to the quiet room or seclusion room where she had frequently been taken, when she had become disturbed while hospitalized. There she spent immeasurable spans of time, isolated and alone, without her wrist-watch, taken lest she harm herself with it ­ not knowing if anyone would ever come to remove her or allow her have access to a toilet when she needed one. Thus this form of "standard medical treatment" filled her with agonizing tension.
                  She once exclaimed, "'Me' is not human; this world is not for me ­ it is your world, not mine. That is why they put me in the quiet room in the hospital, the quiet room is for dogs." At that moment she was making a drawing of what she termed, "me." She suddenly became certain that she was driving me crazy, and repeatedly stabbed at the drawing with her pencil, to kill and then to bury this evil self. "I should be put into a hole -a hole is bad, the baddest - but you are good to me. I fall into a hole, and then I find a ladder you put there, and then I can climb out."
                  She again manifested such idealization at the end of another session, when she printed something on a scrap of paper, rolled it up, opened a drawer my desk, dropped it in, shut the drawer and affectionately patted it as she left. On opening the drawer and unfolding the tiny mote, I was greeted by the crudely printed word, "Me." She expressed the hope that in the treatment she might find a place where her lively potential ­ whose workings she feared were lethal ­ might develop.
                  These are examples of how she engendered in me most poignant feelings - that whatever the travail, it was all worth it ­ that nowhere could I ever have found such an affirmation of my value not only as an analyst, but also as a human being. Let us now discuss the problems that arise when one comes to feel this way in response to a patient.

Discussion

                  If the psychotic patient makes a connection to a therapist, he will use that person as scaffolding to construct a new object. Mrs. Adams used me to counterbalance the persecutory figure that attacked the "bad me" which loved and destroyed her only good object, an intolerable act that caused her to disintegrate and fall into a void.
                  Long before words were available, Mrs. Adams was constructing an imaginary object. It served as a template upon which ­ to quote Lacan (1977) - "her basket of desire can be hung up by its four corners and stiffened into a phantasy by the ball object 'a'." Upon this "objet a" ­ Lacan's prototypical object - the "black stuff" of her agony congeals into her fecal mass. Through our discourse, she and I ­ in the guise of the French Chef ­ mold this material, into something she can transform into a zoo. Gorilla, rat, and elephant, each mark in succession the functions of holding, handling, memory.
                  She makes use of me as a new object and so comes to address me anew: "Maybe you make me legal." ­ an interesting comment when one considers that Oedipus, being "illegal," was an outcast. She continues, "You do not cut me apart." ­ again she is right to the point. It is words that cut humans as speaking beings away from their animal origins. For the non-psychotic this is repressed, but Karen felt words to literally cut her apart. These were naked words, stripped away from any discourse that might have confirmed her as a subject. In her next statement she compensates, "You keep me together," but then bows to the transference. "Who do you want to see here, Mrs. Adams or me? Me is a trap and Mrs. Adams is a trap."
                  She stands her ground again and draws a circle, labelling it, "Karen - one in here," next to it she printed the words "youme" run together as one word ­ and then a dash and the word "communication." By communication she clearly meant, "We speak to each other."
                  On one level "youme" represents an imaginary "merger," built up upon the physical sensations of being held by another person, perhaps represented in her fantasy that I am a gorilla. She further imagines holding on to me by putting me inside of her. These fantasies impact upon me to inflate my sense of omnipotence. Now signifiers course through my mind: "Karen" clangs with "caring" and my dedicated elephant picks it up with his trunk and molds it into "curing."
                  Searles' (1967) comments about the physician dedicated to curing are relevant: "paradoxically, the very physician most anxiously concerned to keep [his] patient alive . . tends most vigorously, at an unconscious level, to drive [the patient] to what [now] seems the only autonomous act left to him ­ namely suicide. The therapist's functioning in the spirit of dedication which is the norm among physicians in other branches of medicine, represents . . in the practice of psychoanalysis, an unconscious defense against his seeing clearly many crucial aspects of both the patient and himself . . one . . aspect his dedication tends to blind him to is . . sadism."
                  And I, in turn, create a new object, that animated version of Karen, divided in accord with the disruptive and the defensive countertransference. On one hand I infuse her with distressing feelings arising from loss and react sadistically, due to my sense of being unable to limit her madness. On the other hand as she gives me to feel that I have rescued her, I gain a sense of omnipotent mastery.
                  Gratifications, those accruing to her at being "rescued" and to me at becoming a "savior" create the danger that we will want to enclose themselves in a "narcissistic envelope" and zip it up tight against a world, now made menacing by a mutual projection of "the bad." This happens often enough to have gained a theoretical foothold in the concept of a "two person psychology," where the pair worries, "Is my love good enough for you?," and whose endpoint Lacan (1958) designated as a "terminal narcissistic trance," terminal because the effort to pursue signifiers has succumbed to the seduction of life in the narcissistic envelope.
                  Mrs. Adams proposes from time to time that we should end this long treatment. In preparation we reduce the frequency to weekly sessions. After a few days I receive a plaintive phone call, "Where can me be?" Something keeps working within her and she hallucinates. "They were all here ­ mother, sister, brother-in-law, brother, sister-in-law ­ everyone but my father." The network of signifiers we have woven thus far, can not capture that remainder that insists ­ that chaos that Lacan called "jouissance," and that Freud termed the death drive.
                  A conception of psychoanalysis transcends us and guides us. It leads me to question whether the workings of my repetition-compulsion move me to drive her a little mad, so that I can again rescue her from "our" chaos. But, I should prefer to think that what Mrs. Adams is grateful for is not that I waded in to become her savior, but that I kept her reaching for savoir ­ that "savvy" that comes from "working through." But if - as any of us wade through what we must in our work - we happen to save a few souls along the way; well, nobody is going to object to that.

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References

Freud, S. (1983-5) "Studies in Hysteria ­ the case of Frau Emmy von N." SE II, p. 105.

Lacan, J. (1958) "The Direction of the Treatment and the Principles of its Power" in Ecrits ­ A selection. New York: Norton. 1977.

Lacan, J. (1977) Preface to "Jacques Lacan" by Anika Lemaire. Routledge New York. 1996.

Searles, H.S. (1967) "The 'Dedicated Physician' in the Field of Psychotherapy and Psychoanalysis in Countertransference and Related Subjects. New York: International Universities Press, Inc. 1979.

Searles, H.S. (1973) "Concerning Therapeutic Symbiosis" ibid.

Winnicott, D.W. (1960) "Countertransference" in The Maturational Process and the Facilitating Environment. New York: International Universities Press, Inc. 1965.

Winnicott, D.W. (1963) "Psychiatric Disorder in Terms of Infantile Maturational Processes" ibid.

Winnicott, D.W. (1968) "The Use of an Object and Relating Through Identifications" in Playing and Reality London: Tavistock. 1971.

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