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Dear Editor
In her paper on suicide (BJP 20(3), ), Marguerite Valentine says that her patient experienced his parents as living in his head. He said that he ‘felt truly colonized by an occupying, alien force, over which he had little control’. Valentine quotes Searles' 1959 paper in which he says that this type of internal alienation is difficult to resolve because the therapist becomes caught up in a reconstituted patient-parent symbiotic relatedness in the transference. Searles makes the point that this is not simply a matter of countertransference but arises also because psychotherapists may choose this profession in reaction formation to their own unconscious propensity for symbiotic relating. In consequence, in the hot seat of the therapeutic encounter it is easy for patterns of interaction to occur that can only be understood in retrospect. When Valentine's patient expressed a desire to ‘come off’ medication it presented an opportunity for the therapist to make it a condition of further psychotherapy that the patient consent to her having direct contact with the psychiatric team. In 1976 Searles wrote: ‘I had to develop respect for the limit-setting function as being an inherent part of the analyst's work and, in fact, fundamental to all his “higher” analytic functions.’ He argues that this is needed because the therapist can otherwise become ‘isolated and threatened, singled out from colleagues, in relation to whom, the patient contrasts the therapist negatively’.
It may have been because the patient felt increasingly paranoid about the claustrophobic symbiotic transference relationship that he took up the offer of an appointment for NHS psychotherapy assessment. Eventually, he shouted at the therapist that she should not talk or listen to him and should contact the doctor who would tell her to stop the sessions. However,