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There is something rather disconcerting about the sequence in which the material is presented. After a brief description of the patient's subjective experience, a clear statement of the therapist's position is made: ‘I came to a diagnosis of paranoid-schizoid anxiety with manic defence’. This seems to tell us as much about the therapist as the client, situating her firmly in the Kleinian tradition, and one wonders if the diagnosis was made as early in the therapy as in the paper. There follows a certain amount of historical background which very sympathetically stresses the elements of early deprivation and specific trauma. This, and selected elements of her current reality (the difficulties with colleagues), are woven together with transference aspects to form a strand that traces the vicissitudes of the patient's aggression: her ‘feeling thoroughly persecuted by her bad objects’.
It is easy enough to speculate about alternative theoretical frameworks, especially when, unlike the therapist, one does not have the direct experience of the relationship with the client. But as the patient's history and preoccupations came to be elaborated, I found myself wondering if a formulation of the source of her paralysing anxiety might not be made in terms derived from Fairbaim's ideas about schizoid mechanisms. The therapeutic task would then revolve around exploring the patient's fear, not that her hate had killed her mother, but that her love was bad. For in spite of the Kleinian terminology, there is much in the material, including some of the therapist's interventions, to suggest that the patient fears her constructive and loving impulses have been and still are unavailing; and the assumption that the enemy here is the patient's projected hate, as opposed to an environment that cannot receive her love, is not necessarily borne out.
The elaborated version of the pin and bow incident, in which she finds her mother ‘sitting cross-legged in bed in a mad state’, speaks of a terror