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Psychoanalytic Work with Children and Adults

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This volume is a collection of seminars and lectures Donald Meltzer gave to the Psychoanalytic Group of Barcelona under Dr Leon Grinberg, and later Dr Benito Lopez, during his visit to Barcelona. The clinical case studies outlined in the book address with typical variety Meltzer's thoughts on clinical work with children and adults, and the numerous issues involved therein, including depression, jealousy, delusional omnipotence and perversion.'The content of the book, in which all of the stable core of the group has participated, covers everything I know, think I know or wish I knew. The clinical seminars, punctuated by small off-the-cuff lectures, and coupled with a very receptive atmosphere, allowed me to expand and learn a lot.'- Donald Meltzer.

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1. Casimiro: life in the rectum—flight towards delusion

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THERAPIST: The patient is a 36-year-old bachelor, the youngest of four brothers and sisters who are, respectively, four, five, and six years older than him. The second sister was diagnosed as schizophrenic and required hospital treatment. The mother, suffering from severe hypochondria, was hardly capable of attending to him as a baby as her hypochondriac state had been very much aggravated by the pregnancy. During the five years that followed his birth, she underwent several operations for cholecystectomy, laparotomy, and hysterectomy, all of which were attributed to the act of giving birth to Casimiro. As a baby he was looked after by his grandparents, with whom his parents had lived since their marriage. When the patient was 1 year old, the grandparents forced the parents to go and live elsewhere; from then on he was looked after by a woman to whose house his mother took him in the mornings and from where she collected him after work late in the evening. He didn’t play with other children. At school he often hid from the other children and the teacher, or ran away complaining that the others said or did things to annoy him. He learned things by himself and on his own, rather than in the classroom. At age 12, he was sent to the city to live with an aunt and uncle and was put to work in a bar. However, he found fault with everything and changed jobs frequently, going from one bar or restaurant to another. He completed his national service, doing kitchen work. He then returned home and found employment in a textile factory. This is when he began to consult a variety of doctors, at frequent intervals and for a great diversity of physical ailments. At the hospital clinic he was diagnosed and treated for “psychasthenic syndrome”. It was during the following months that delusional ideas of a self-referential and persecutory nature appeared along with the exacerbation of bodily symptoms. At the age of 24, he was admitted to hospital for a period of two months, where he was diagnosed as suffering from schizophrenia. He then continued his treatment as an outpatient, although on an irregular basis. Later, and of his own accord, he consulted other doctors, whom he afterwards accused of not wanting to cure him, and at the same time he became very aggressive, especially towards his parents. At the age of 28, he was once again admitted to a mental hospital; after that he lived at home periodically, but on very bad terms with the rest of the family. For the last six years he has been permanently in hospital.

 

2. Victor: mental pain—anger and silence

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THERAPIST: I shall present two sessions in the course of the treatment of a child of age 4 years and 8 months. The paediatrician referred him as an urgent case because he had gone mute, as well as very quiet and serious, since October when he first started school. Two months prior to this, the mother had had a baby, at which time she was diagnosed as suffering from a kidney disorder and was sent to hospital. The baby had to be kept in an incubator since it was premature; the mother was admitted to a different hospital from that of the baby.

MELTZER We have a pretty tragic situation before us,

T: Yes. Meanwhile, the child and his father moved into the paternal grandmother’s house and a paternal uncle with whom he had had a lot of contact died.

MELTZER HOW far in the therapy is this session?

T: It’s the first session. I was asked to see the child urgently in order to see whether he could be helped to verbalize something or at least to have someone verbalize the situation to him.

MELTZER Could you describe the child a little?

 

3. Jordi: from bi- to tridimensionality

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THERAPIST: At present this boy is 15 years old; he began having treatment when he was 11, at a frequency of two sessions a week. He lives in an industrial town near Barcelona, where the medical centre in which he is being attended to is also situated. His father is 46 and his mother is 43. He has a brother, who is 13 years old, and a baby sister aged 6 months. His mother has had two miscarriages, the first before Jordi was bom and the second just before she got pregnant with the baby girl. The parents’ main worry revolves around Jordi’s exaggerated shyness, inhibition, and fears, while they consider his limited learning capacity to be a secondary problem. It appears that one of the main reasons for which they sought treatment was that they felt ashamed at the thought that other people should think he was not normal. The family in question belong to the middle class and are well known in the town as they run a rather prestigious business there, in which both parents as well as the maternal grandparents work. According to them, their lives are very much conditioned by this business, since they are always surrounded by people; this set of circumstances is what they put forth as the explanation for having difficulty in controlling the child, above all as regards his eating habits. “He eats what he likes—which is nearly always the same thing—and won’t accept any changes.” Whenever they try giving him something different, he kicks up a row, and, so as not to make a scene, they end up giving in to him.

 

4. Yolanda; vicissitudes and failures of symbolism

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THERAPIST: This is a case that has been presented at previous meetings. On this occasion, one of the sessions had to be reconstructed at a later date; as regards the other, I shall limit myself to making only a few comments.

The patient has been undergoing treatment for two and a half years at a frequency of two sessions a week. The diagnosis was basically that of a borderline patient. More recently, starting about ten months ago, she struck up a relationship with a young English man, William, and this relationship has become quite stable. Every so often, one of the two travels and spends approximately one week in the town where the other one lives.

MELTZER For those people in whom projective identification forms an important part of their character, entering and leaving the country is of great importance. At times they feel claustrophobic when they leave their country, and sometimes even when they are in their own country they feel so, which is when they are impelled to leave it There was something of this kind in the previous patient, in connection with the New York subway. Go on, please.

 

5. Herbert: a vocation for perversity

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THERAPIST: Herbert is a 35-year-old man of Central European origin who has been living in Spain since he was 11 years old. He is tall, blond, with a rugged complexion, and his physical appearance could be pleasant if he were more careful with his grooming and personal toilet. He consulted around four years ago because he was unable to reach a sexual climax. He had previously consulted several specialists who had found no relevant cause as far as a somatic disorder was concerned, and they suggested he should look for psychotherapeutic assistance. Since the age of 20 he has experienced the need to urinate frequently, and he complains of a more or less permanent itching sensation in his urethra. These disorders come to their height during sexual intercourse, in such a way that the more excited he gets, the stronger the itching sensation becomes and the greater the need to urinate, which prevents him from obtaining any kind of satisfaction when ejaculation occurs. He also complains of “nerves in his stomach”, has trouble digesting, and frequently suffers from diarrhoea. There is also a serious tendency towards bulimia. He often feels depressed, irascible, on the verge of blowing up, and it is then that he thinks of suicide. He is afraid of himself and that one day his impulses could lead him to losing control and carrying his thoughts through into action.

 

6. Cecilia: the end of analysis

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THERAPIST: The patient, whom I shall call Cecilia L., is 33 years of age and works in the administration department of a firm. She belongs to a traditional middle-class family from the south of Catalonia. Her father, aged 72, has a violent and domineering character but is extremely hardworking and reliable. The mother, aged 69, is a housewife. She also is aggressive but more of the passive type. This is the description the patient draws of her family, in which moral and religious principles ruled over demonstrations of affection. Her only brother, approximately three years her junior, had serious psychological problems of a depressive type during adolescence.

She has been undergoing treatment for about ten years, at a frequency of four sessions a week. The motives for which she consulted were panic when faced with going out into the street and relating to strangers, extreme shyness, and depression. She also had hallucinatory episodes in which she believed she saw the devil,

Initially, she was treated by a colleague psychiatrist, and once she began to improve clinically he recommended a psychoanalytic treatment. At present the analysis is developing quite satisfactorily: she has progressed in her insight, and the quality of her link with me is satisfactory as well. She has also successfully finished her studies in business management. Her financial situation is good, thanks to the fact that she has been promoted at work. However, she still has not been successful in finding a partner, which obsesses and distresses her; at times, she gives the feeling that she reproaches me for this as if the analysis had helped her mainly to earn her living and to be more efficient and pragmatic with her father, whereas she still has difficulty being successful with men.

 

7. David: sucked into projective identification

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THERAPIST: At the age of 5i years David was referred to me, by an institution, for treatment. He is the second child of a couple who also have a girl two years older than him.

David is extremely demanding and tyrannical with his parents and constantly blackmails and contradicts them. He has had serious problems with his eyesight—he was born with a squint, which apparently developed into near-sightedness, and at the age of 1 year and 5 months he had to wear a patch on his eye, prescribed by a doctor. It was an extremely difficult situation because he was unable to tolerate this. The parents were very inflexible and fear that this may have affected their relationship with him. At the age of 4 years and 9 months he had an operation and now wears nine-dioptre glasses.

MELTZER HOW many operations has he had?

T: One operation. As far as this operation is concerned, the parents seem very insecure and they don’t seem to have much information. It could be that they felt very guilty for not having detected this defect in time. It is not known exactly when all of this appeared—whether it was something very primitive or not. The parents don’t know and feel very much overwhelmed by this.

 

8. Montse: delusional omnipotence

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THERAPIST: The patient is 30 years old and married, without children. She has one session of psychotherapy a week and has been in treatment for nine years.

The patient was referred by a psychiatrist in order to be treated for sexual dysfunction. She had previously been treated unsuccessfully by a psychologist using behaviourist techniques.

T: As a matter of fact, the treatment wasn’t terminated. It seems that the psychologist who was treating her used relaxation techniques, and what happened is that this professional left her job. The psychiatrist told me that she had “left him in the lurch”. He was therefore referring the patient to me to see what I could do with her because he felt rather awkward, as the psychologist in question had worked with him.

The patient related this experience with a smile, as if it hadn’t affected her in the slightest.

The psychiatrist informed me that Montse takes 15 mgs. of Valium as she suffers from a state of psychomotor agitation. (She persistently moves her left arm, carrying out the same movement non-stop.)

 

9. Felipe: analytic work on the threshold of the depressive position

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THERAPIST: The idea of presenting this case arose as a result of an internal seminar carried out on projective identification. I referred to this case when we were speaking about the clinical material that we had presented, and my colleagues suggested I should bring it to this Seminar, as they found it interesting, in order to develop this concept. I have brought some notes from the first interview, one week of the patient’s treatment (three sessions), and yesterday’s session, in which there is a dream that I found interesting and illustrative.

At the time of his first interview with me, Felipe was around 30 years of age. He had seen a psychoanalyst, who had referred him to me.

P: Are you Argentinean? I wanted a Catalan so as to integrate.

X. told me that what I wanted to “integrate” was my head. I left my country many years ago. I was in Venezuela and California before I came here…; . But I am mistrustful of Argentinean psychology. He made several references to other attempts to receive psychotherapeutic assistance in his own country, which all led to interruptions.

 

10. Julio: unborn parts of the personality?

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THERAPIST: Today I am presenting a child whom I have named Julio, and who is at present 8 years old. He first came for consultation at the age of 5 years and 2 months.

He is receiving treatment in an institution where a colleague of mine is in charge of the case, while I have been in charge of his psychotherapy for the last two years, at a frequency of once a week. It was suggested to his mother that it would be advisable for him to have two sessions a week, but she did not want this. When he first came, he was sent by the school and not through any concern of the family’s. His mother says that what’s wrong with the child is that he is “as stubborn as a mule”, that he doesn’t know the names of the colours, and that he doesn’t talk as he should at his age. It is the father who brings up the fact that the child wakes up terrified at night and goes to his parents’ bedroom with his eyes wide open. After this, the father begins speaking about a whole series of fears that haunt the youngster. Outside the home, Julio has learnt one route only and he will not go by any other; he has a jacket that is the only one he will wear; if he ever happens to see a worm in a particular place, he will never again pass by that place.

 

11. Sylvia: the exciting servitude of jealousy

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THERAPIST; At the time that Sylvia seeks help, she is approximately 40 years old. She consults on account of obsessional jealousy as a result of her husband’s extramarital affairs and intimate relationships. For many years, this couple had led an “open” marriage, both having affairs with different people. There came a point when she became aware of the fact that her husband was truly interested in another woman, and she felt her marriage to be threatened. As a result, she says that she feels intensely jealous and fears going totally mad, as this intense jealousy has completely invaded her.

She was the first to have extramarital affairs, although she always made sure that these did not interfere with her life with her husband. He, on the contrary, has never been discreet and has not even avoided telephone calls from his lovers to the couple’s home, or avoided having her meet them, and soon.

MELTZER; The fact that her husband isn’t jealous is a problem. This part of the story in which she says that she was the first one to have extramarital affairs is probably not true. There are usually two different versions of the marriage, given by each member of the couple. When one of the two organizes the marriage around the idea of a contract and the other does so with a romantic expectation, the former does not adjust to the latter and the latter enters a form of sadomasochistic “romantic agony”. Go on, please.

 

12. Paula: the fascination of the esoteric world

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THERAPIST I shall first of all present the first interview with the mother. The text reproduces the mother’s account as literally as possible.

Paula was born in October 1982. The preliminary interviews take place in March 1991. The mother comes to the first interview alone. She tells me that she is expecting a baby (which is obvious) and that it is due in May. In January of the previous year she had had a miscarriage, but Paula was not told that they had lost her little brother; instead, she was told that he would come a bit later.

MELTZER HOW could they have known it was a little brother and not a little sister?

T: This is their fantasy; they didn’t know.

MELTZER Okay. Go on, please.

The mother says that Paula saw how her cousins were born, but that her little brother didn’t show up.

In March of the previous year the father developed a cancer. Paula “cried and became depressed", and, when asked what was wrong, she answered that she was sad. When the mother became pregnant again, Paula said, “I don’t want it.” When the parents asked her why, she answered: I’m bad and I don’t want to have it.”

 

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