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Dr. Kemper has presented a vivid and clinically pertinent paper. He has addressed a topic that most psychoanalysts confront when they treat patients with serious, and seemingly intractable, psychopathology. He has done so with candor and forthrightness, and without distance or intellectualization. He has raised questions from his own experience, and given clinical illustrations to let us know from where his experiences and questions emerge. He raises questions that are loaded. For example, what does psychoanalysis do for us, and what does it do to us? By what criteria do we judge our own work and the progress of our patients, in particular, when our patients do not seem to get better? If they are not getting better, do we continue our work? If we continue, how do we proceed? If we proceed, by what standards and methods do we chart our lonely path? In this regard, Dr. Kemper is writing from the perspectives of Bion (1967), Meltzer (1967), Winnicott (1974), Khan (1974), Klauber (1981), and Little (1981).
He has presented a case of a seriously disturbed man with experiences of depersonalization and imminent disintegration, a man whom I consider to be more schizoid and “as if” than borderline, as Kemper has diagnosed him. After six years of psychoanalysis, the man has shown no apparent structural changes, no improvement in his capacity to use dialogue, and in particular, what is of concern is that Dr. Kemper has had many insights into the man's psychodynamics, while the patient himself has had few, and those which he has had do not endure. The man has two additional striking qualities: (i) he