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Dr Horowitz's case presents us with what must be the ultimate problem in psychoanalytic treatment - the analysand who does not talk and does not come to his sessions. Dr Horowitz struggles courageously with these difficulties. As the narrative ends the treatment seems to have taken hold. The patient is able to resume a medical
career interrupted long ago. He experiences an improved working alliance with his analyst and enhanced empathy for others. Dr Horowitz conceptualizes these improvements as occurring through the interpretation of the mutually constructed analytic relationship.
As a self psychologist, my way of accounting for the changes in the patient is somewhat different from Dr Horowitz's. Mr L presented in a fragmenting state. The course of the treatment led to the reconstitution of a positive paternal selfobject transference which had merger and idealizing elements. Mr L's initial state of devitalization was also converted to a condition of incompletely modulated grandiosity. I would expect this primitive form of grandiosity to continue to be modified and integrated in an increasingly realistic fashion as the treatment progresses. In short, a healthy growth process involving analyst and patient has replaced a pathologically stunted one. One might say that Mr L is having a ‘corrective emotional experience’.
Initially, the demands of treatment were almost too much for Mr L. The analyst's neutrality felt so much like his father's neglect that Mr L could barely speak, or even come to his sessions. To Mr L, temporary withdrawal must have seemed the only way he could regulate the repetition of his childhood trauma. Yet there was hope, based on the fact that Mr L had been able to form a usable positive transference to Dr P in the past. I suspect that Mr L must have perceived that Dr Horowitz was trying very hard on his behalf. This preconscious awareness saved the day and enabled them both to survive the rage, paranoia and re-enactment of abuse and abandonment of