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Initially, Mr L responded by cancelling. When I encouraged him to come and talk, hecancelled more. In some odd way our communication was becoming more direct; he wasnow cancelling with notice, indirectly agreeing, I thought, that I was not merely an analysis-dispensing machine. He even began to leave his head tissue on the couch! While Mr L didnot engage all the fine points of my comments and interpretations, he began to suggest thatgenerally I had been on target and that this recent period of analysis had renewed his hope.He had been surprised and gratified by my response to his silence, that I hadn't justcontinued to try and out-silence him as before, but had really tried to stay involved with him.

I was very pleased with how all of this was going but didn't have long to elaborate.While Mr L became more engaged with me, he abruptly quit his job and planned his finalattempt at re-entering medical school. It all seemed too quick to me and I felt very torn,believing that he was still too disturbed to get into medical school, last in it, or functionadequately as a physician. I also felt burdened by his explicit expectation that I, the analysis,could carry him through where his intellect was not enough, in the interpersonal realm. Ofcourse, Mr L was challenging me to put up or shut up. Would I support him in this importantventure or was I, as he put it, all talk? - no pun intended, he assured me. What saved us bothat this point, I believe, were the frank, at times seemingly one-way interchanges that we hadrecently experienced. I was able to say to Mr L a number of things at this juncture. I said Ihad mixed feelings about his pursuing this goal now. I told him that if he engaged otherswith even some of the off-putting behaviour he had exhibited with me, he would have nochance. I also acknowledged my awareness of how far he felt we/he had come - to makesuch a major shift in his life now and trust that I and the analysis would carry him through.Clearly this shift in how he viewed me represented a major step forward in his relationalcapacities. I also reminded him of the other abrupt changes in his life, perhaps tooimpulsively and without achieving his intended goals. As usual, Mr L stuck to his position.What was remarkable was the increased awareness he demonstrated of me and apparently ofothers as real people, with their own points of view, needs, wishes, etc.

The following year was a harrowing one as Mr L stabilized himself within the treatment,but unleashed himself more fully on the outside world. In some peculiar way, it surprised usboth and not at all that he made it into medical school, almost in spite of himself. He hascompleted his first year, apparently satisfactorily. While analysis is not a social occasion inthe usual sense, I believe that detailed attention to the social aspects of our relationship wascrucial in making this analysis operative and in creating a useful context for examining andanalysing the patient's troubled and conflictual unconscious.

Michael Horowitz

COMMENTARY FROM THE SELF PSYCHOLOGY POINT OF VIEW

Dr Horowitz's case presents us with what must be the ultimate problem in psychoanalytictreatment - the analysand who does not talk and does not come to his sessions. Dr Horowitzstruggles courageously with these difficulties. As the narrative ends the treatment seems tohave taken hold. The patient is able to resume a medical

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career interrupted long ago. He experiences an improved working alliance with his analystand enhanced empathy for others. Dr Horowitz conceptualizes these improvements asoccurring through the interpretation of the mutually constructed analytic relationship.

As a self psychologist, my way of accounting for the changes in the patient is somewhatdifferent from Dr Horowitz's. Mr L presented in a fragmenting state. The course of thetreatment led to the reconstitution of a positive paternal selfobject transference which hadmerger and idealizing elements. Mr L's initial state of devitalization was also converted to acondition of incompletely modulated grandiosity. I would expect this primitive form ofgrandiosity to continue to be modified and integrated in an increasingly realistic fashion asthe treatment progresses. In short, a healthy growth process involving analyst and patient hasreplaced a pathologically stunted one. One might say that Mr L is having a `correctiveemotional experience'.

Initially, the demands of treatment were almost too much for Mr L. The analyst'sneutrality felt so much like his father's neglect that Mr L could barely speak, or even come tohis sessions. To Mr L, temporary withdrawal must have seemed the only way he couldregulate the repetition of his childhood trauma. Yet there was hope, based on the fact thatMr L had been able to form a usable positive transference to Dr P in the past. I suspect thatMr L must have perceived that Dr Horowitz was trying very hard on his behalf. Thispreconscious awareness saved the day and enabled them both to survive the rage, paranoiaand re-enactment of abuse and abandonment of the early stages of the analysis.

A turning point in the treatment came when Dr Horowitz began to speak more freelyabout what he thought the patient felt and what he himself was feeling. Dr H was speakingMr L's thoughts, in a sense. Technically, Dr Horowitz was enabling a merger transference tobegin to form. A merger transference would stabilize and strengthen Mr L's sense of self. AsDr Horowitz became more active, he was also providing a new experience for Mr L in theform of a father figure who cared and exerted himself overtly. This had been implicit in theanalytic relationship up to this point, but then became explicit as a healthy enactment. Thisis what I consider a `corrective emotional experience'. Another corrective element was DrHorowitz's sharing some of his own feelings about his and Mr L's experience together. Thisopenness countered the secretiveness associated with abuse in Mr L's life.

With disconcerting rapidity, Mr L developed a massive idealizing transference. Thisthrew Dr Horowitz a little off balance. He certainly could not believe that he alone could getMr L through the first year of medical school. When Mr L tells Dr H to 'put up or shut up',something else very remarkable has occurred. Mr L has openly been able to risk havingexpectations of a father figure. He began his analysis with a tremendous sense ofvulnerability. The potential for hurt was so extreme that he had to withdraw to protecthimself from further injury. Now his schizoid defences have been replaced by a usable, ifoverblown, idealization. Optimally, from here on out, Mr L's disappointments in DrHorowitz will occur in the bit-by-bit ways that are healthier developmentally. Eventually, MrL's reconstituted primitive grandiosity and idealization will mature into healthy, modulatedforms.

In sum, I agree with Dr Horowitz that his attention to the interactions between himselfand his patient was crucial to the progress of the treatment. I would not, however,conceptualize this approach as an interpretation of a `social' interaction. His creativetechnique was instead a way of stemming the tide of fragmentation by

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providing a primitive merger experience. It also provided positive new experiences whichMr L had not had. In this sense, Dr Horowitz has produced a `corrective (selfobject)emotional experience. Finally, healthy growth was re-instituted. Though I have a differentway of conceptualizing the case from Dr Horowitz, I commend his persistence, courage andcreativity in the face of seemingly insurmountable difficulty. These traits brought the case tothe significant level of improvement we see here in mid-stream. They provide an examplefor all of us to follow, and remind us that the character of the therapist is as important as hisor her degree of technical skill or particular theoretical orientation.

Paula Fuqua

COMMENTARY FROM THE OBJECT RELATIONS POINT OF VIEW

The case of Mr L demonstrates the value of an object relations perspective on thepsychoanalytic process. Dr Horowitz points out at the outset that what `stands out' for him isconducting an analysis with `someone who deeply wanted to have one [an analysis] butalmost as deeply could not bring himself to have one'. The question for the analyst is: why,given that he wanted an analysis to improve his career and severely restricted social life, didhe have such difficulty `bringing himself to have one'? His initial analytic dream displayedhis fear that the analyst was an `ugly hooker' who would `tear his insides out'. Mr L couldsee even at this early point that beginning analysis led to feelings of `exposure, abuse, desireto make myself more shameful'. What will be exposed? The recounting of his history makesclear that he has borne a painful sense of inadequacy all his life. He suffered ridicule fromthe family members who raised him in addition to the excruciating shame of numerousepisodes of waiting for his father who did not appear. He was humiliated for being a `sissy'as well as for being male. Also important to Mr L's shame is the fact that the whole family isshame-prone. The parents treated their divorce as a defect that must be hidden. The charadethat the parents were still married for years after their divorce reflects the inability of thefamily to accept the reality of their lives and display a realistic sense of themselves to others.Mr L lives in continual fear that his `defect' will be exposed to others. Should they see howdefective he is, their cruelty is akin to `tearing his innards' out.

The anxiety of others seeing his defect is at the root of his paranoia. When Mr L says heis given to `nasty projections', he is referring to his experience of others when he feels they `see inside' him. When Mr L is not perfectly understood, he feels exposed, and this feeling ofexposure accounts for the intensity of his reaction. Mr L's pained response to an imperfectlyattuned analytic intervention forces him into awareness of his need for the analyst'sunderstanding and the shame of this experience is unbearable. Under these conditions, hefears and sometimes believes that the analyst is in collusion with his mother `to plot hisdemise'. From his viewpoint, if the analyst did not have malevolent intentions toward him,he would not force him into such painful awareness. His family humiliated him for hisneeds, so if the analyst forces awareness of his needs upon him, he must be acting in concertwith them. Consequently, he has no reason `to think everything you're saying isn't acalculated attempt to make me angry'. The more painful awareness that he cannot yet cometo is the shame that underlies the anger.