Psychotherapy

I decided to review this book because its predecessor,¹ which I found intriguing and very useful, is highly regarded and frequently cited in the contemporary psychoanalytic literature. John Steiner provides a lengthy introduction summarizing each chapter, preparing the reader well for what follows, and engaging the reader. He repeats this format in each chapter, outlining in more detail what he wants to convey.

Steiner discusses clinical situations where patients feel stuck, and where failure to develop impedes the progress of the analysis. He observes that defences are sometimes held onto with great tenacity, and are most resistant to change when they form an organized and coordinated structure. He describes these systems of defences as pathological organizations of personality, which give rise to structures he calls psychic retreats. This book is divided into 3 parts. Part 1 deals with embarrassment, shame, and humiliation. Part 2 deals with helplessness, power, and dominance. Part 3 deals with mourning, melancholia, and repetition compulsion.

Part 1 starts with “The Anxiety of Being Seen: Narcissistic Pride and Narcissistic Humiliation.” Steiner describes a patient whose defences were based on fantasies of superiority and admiration, who was very sensitive to being observed. The analytic setting made him feel exposed; he was prone to feeling inferior and persecuted. In “Gaze, Domination and Humiliation in the Schreber Case,” Steiner suggests that the subject of Freud’s famous study failed to find anyone who could understand and contain his distress, leaving him unable to face the humiliation and emerge from his paranoia. Steiner believes that containment requires the analyst to be open to the patient’s projections, and to understand the experience evoked in him (the analyst) in a way that retains a relationship with reality. In “Improvement and the Embarrassment of Tenderness,” Steiner illustrates the narcissistic organization the patient turns to for protection, and his fear that this would be seen through and exposed. In “Transference to the Analyst as an Excluded Observer,” Steiner describes how the analyst can sometimes be provoked to make judgmental interpretations in response to being excluded and looked down on. Steiner provides an excellent summary of the relation between transference and projective identification, and between splitting and the internal world. Steiner highlights Klein’s discovery that what is transferred is not so much an object from the past, but one that exists in the present, as an internal object that is then projected onto the analytic situation. Steiner does not aggrandize himself as a therapist. At the end of a treatment he describes, he clearly entertains doubts about to what extent his patient was helped.

Part 2 begins with “The Struggle for Dominance in the Oedipus Situation.” Steiner describes the conflict over power and dominance that can occur in the Oedipal situation, and distinguishes between paranoid and depressive solutions to the Oedipus complex. Steiner argues that Freud’s classical resolution to the Oedipus complex was a paranoid solution, giving rise to a psychic retreat dominated by resentment and the wish for revenge. He suggests a possible depressive outcome in which the child initially dominates in fantasy, but eventually recognizes that in fantasy he has destroyed both parents, with feelings of triumph turning into despair and guilt, which can move toward remorse and reparation. In “Helplessness and the Exercise of Power in the Analytic Session,” Steiner relates the importance of power in the patient’s relationship with the analyst to the development of a narcissistic superiority as a reaction to helplessness. Helplessness is connected with an inability to find an available figure who is able to perceive and cope with the patient’s true situation. In “Revenge and Resentment in the Oedipus Situation,” Steiner, using an extract from Robert Louis Stevenson’s Kidnapped,² argues that if resentment can be expressed as hatred and a wish for revenge, this may bring about a shift to the depressive solution to the Oedipus complex, where resentment can be relinquished and replaced with forgiveness.

Part 3 begins with “The Conflict Between Mourning and Melancholia.” Steiner discusses the importance of mourning in relation to the task of letting go of omnipotence in facing the reality of loss. Development and change can lead to mourning, while resistance to change leads to melancholia. When the depressive position begins to be faced, there is a conflict between mourning and melancholia. To mourn, the patient must emerge from a psychic retreat and face the anxieties of seeing and being seen. In “Repetition Compulsion, Envy and the Death Instinct,” Steiner focuses on the place of envy and the role of the death instinct in creating obstacles to psychic change. He believes that the repetition compulsion expresses a hatred of change related to the difficulty in both sexes of tolerating a receptive position, which is often viewed as feminine and inferior. Envying and being envied are related to the experience of seeing and being seen.

Steiner is an unusually lucid writer who speaks clearly to his readers and offers an unvarnished account of his struggles in helping patients escape from their psychic retreats. This text, although relatively short, provides much theoretical and clinical material to ponder. It is recommended for all clinicians practising or interested in psychodynamic psychotherapy and psychoanalysis.