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Dr. Karme is to be congratulated for her frank and effective paper as well as on her analytic work. The sequence of events described is believable and clear, in the sense of “I know what she means.” Clearly conceptualizing what happened, however, is a different problem. The comments I am going to make should not be construed as criticisms of Dr. Karme or her work; I have the impression of a well-conducted analysis, one which is successful to this point and apparently approaching termination. There are many limitations on the data available, however, brought about by the conflicting demands of, on the one hand, the nature of our work and, on the other hand, the requirements of a public presentation with time constraints. It is unfortunate that time and considerations of confidentiality have not allowed us the opportunity of hearing detailed process notes of several sessions. I think that only that kind of material can provide a firm enough basis of clinical evidence to measure the appropriateness of different approaches against one another.
While we learn something of the background of the patient and somewhat more about her analysis, we do not know very much, certainly not a significant fraction of what Dr. Karme must know. The details that we have are:
At age two the patient's mother died of cancer on the East Coast, and the patient was sent to live with her paternal grandparents on the West Coast. As a result, she seldom saw her father.
At age four years and five months her father remarried and she was taken to live with him and her new stepmother; she remembers the stepmother as angry and demanding.
Over the next period of years—we do not know how many years—three male half-siblings were born; the patient remembered
certain details, which we are not told, that caused the patient or the analyst or both to infer that the father became depressed and passive, the stepmother felt overwhelmed, the patient was unhappy, and two of the three half-brothers were unhappy as we