Chapter 2 Interminably a Patient: A Discussion of ‘Expiation as a Defense,’ by Ruth Riesenberg Malcolm

As the clinical record shows, the analysis of Mr K was conducted by Mrs Riesenberg Malcolm with courage and persistence, ending painfully when, still very ill, Mr K could no longer use it beneficially. The author’s main purpose in reporting the case was to focus on the handicapping effect of a particular type of masochistic defence, which she names ‘expiation’. She shows, too, how Mr K’s mode of functioning makes termination hazardous, since his defences lead either to disintegration or to suicide. I think her paper throws light also on another problem, since there is another possible outcome for him: if Mr K is neither to deteriorate nor to become suicidal, he must perpetually be, if not Mrs Riesenberg Malcolm’s patient, then somebody else’s. It is this contingency that I should like briefly to discuss.

Mr K, and patients like him, must of necessity continue to depend on therapeutic care because of the specific direction and disposition of their activity and passivity. Mr K is actively destructive and sadistic but only passively connected to help and care. His ego is in alliance with his destructive forces while his constructive functioning is delegated to his object. This is his abnormal resolution of the primary instinctual conflict between his life instincts and his destructive instincts. In this short commentary, ignoring the complex and unfortunate interaction of innate impulses, infantile anxieties and inadequate nurture that created such a resolution, I shall only try to describe in broadest outline Mr K’s active and passive functioning.

Mr K has not been able to confront and deploy his instincts in the normal manner. In ‘The economic problem of masochism’, Freud (1924a) postulated that in the service of the life instincts the essential first step must be the deflection of the death instinct outward. Later, Klein (1932) postulated further that fear of annihilation from the death instinct within is the factor that initiates this outward deflection. This origi