Clinical Commentary XV

[This section is a regular feature. In this case the two sessions and the therapist's prefacing notes were sent ‘blind’ to three contributors who were asked to comment in a way that would bring out differences between ways of working and of thinking about this particular patient.

Although contributors were asked to give their analytic orientation, according to the house style of the journal, two felt quite independently that such a label would be misleading or an oversimplification - Ed]

The Patient

Miss X comes to see me once a week. She is in her mid-twenties but looks almost childlike. Her whole appearance conveys a state of deprivation, exacerbated by looking undernourished and thin. Her pale face expresses two things simultaneously: an appeal to be cared for and yet at the same time a withdrawn emptiness which seems to be beyond reach. Terrified of speaking and afraid of taking anything in, she has been a silent patient, sitting in her chair and avoiding eye-contact most of the time. Her silence speaks to me in various ways: sometimes it feels like despair, at other times it has a sullen and angry quality, very often, however, it feels tantalising as if she is involved in some cruel game-playing with me. My countertransference feelings are very strong and can range from acute worries to despair and, in more darker moments, to sheer exasperation.

She was referred by her GP who was worried about her. Miss X went to see him because she felt emotionally dead, at the point of disintegration and frightened that she was losing control of her life. Her GP described her as being in a state of mental and physical retardation and having a very diminished ability to concentrate on anything. Due to her mental state she had been unable to continue her studies and had deferred for twelve months taking her third and final year. A subsequent psychiatrist's assessment confirmed the GP's view of retardation. She was diagnosed as being depressed with no evidence o