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In this clinical report, Dr Balsamo reports in detail his state of mind and fantasies and reveals the way he thinks while listening to his depressed patient, Sabina. He describes the arduous task of engaging her in an analytic process in the face of what might be called primitive narcissistic defenses and the repetition of a stereotyped relationship with an affectively absent mother. I imagine that his description will be familiar to many psychoanalysts. There is not a great deal of verbatim material quoted, but only a few key moments are presented to illustrate the clinical dilemma. I read the report primarily as an account of Dr Balsamo's attempt to grapple with a difficult transference-countertransference entanglement, a kind of stalemate that obstructs a potentially transformational analytic process. In my comments to follow, I will not directly address the interesting theoretical discussion he offers, but will focus mainly on the questions raised in the report about transformative possibilities in psychoanalytic treatment, arguing that the concepts of figuration of psychic experience and of the intersubjective engagement that brings it about can help us understand this case.
The analyst experiences himself initially as caught in a situation of emptiness and non-communication, a description reminiscent of Arnold Modell's concept of the defense of non-communication of affect, which he observed especially in narcissistic formations (1980). The patient in this formulation strives to avoid acknowledgement of a transferential relationship, in favor of establishment of what Modell termed a ‘cocoon’. Of course communication and transference are inevitably present in such cases, even if not explicitly spoken of. Modell (1973, p. 121) wrote that in the absence of affect: “Transference begins to occupy exclusively the center of the analytic process” and countertransference becomes the analyst's principal “perceptual instrument”. In Dr Balsamo's example, the patient's prese