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Intensive work with severely disturbed patients is not easy. Paul Williams warns us of this early in his report. “Any post hoc coherence this paper might convey should not minimize the perplexities and confusions that suffused the analysis.” Unrelenting emotional strain, affective assaults, and feelings of disorientation and deadness are only some of the experiences discouraging analysts from making long-term commitments to this kind of clinical work. Within the group of clinicians who have survived these challenges, Wilfred Bion has been a highly influential presence and with good reason. Placing disturbing mental content in some separate and identifiable place—imagery evoked by Bion's useful concepts of projective identification and containment—is deeply resonant with the subjective experiences of patient and analyst embarking on these challenging journeys. Patients feel “inhabitated”; analysts can come to value the ward key as guaranteeing a reassuring ritual of “locking in” the insanity at the end of the day.
Williams's work with Miss A reflects a personal amalgam of theoretical and clinical contributions drawn from the Kleinian tradition and enriched by currents from the British Middle School. My own thinking, also a personal amalgam, draws as well on British Middle School contributions, but incorporates, in addition, facets of the American traditions of self psychology, intersubjectivity theory and contemporary relational/interpersonal psychoanalysis.