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Publications: Book Reviews
Review of Ordinary People And Extra-Ordinary Protections: A Post-Kleinian Approach To The Treatment Of Primitive Mental States

Title: Ordinary People And Extra-Ordinary Protections: A Post-Kleinian Approach To The Treatment Of Primitive Mental States
Author: Mitrani, Judith
Publisher: Philadelphia, Pa: Brunner-Routledge, 2001
Reviewed By: Sharon Grostephan, Winter 2003, pp. 50-52

I was hardly able to put down the Judith L. Mitrani’s Ordinary People and Extra-Ordinary Protections once I began. Dr. Mitrani is able to express our common humanity, and how primitive mental states and protections are a part of everyone’s personality even in her choice of title for her book. It drew me in by her ability to express extremely difficult concepts in an understandable form and address this very difficult topic in a not only readable but intriguing way. She draws on the work of Klein, Bion, Bick, Meltzer and Winnicott and especially her friend and mentor Francis Tustin. As Dr. Jim Grotstein states in the forward “Out of that analysis emerges a significant new view of very early object relationships. In her writings, Dr. Mitrani shows a crisp, articulate and versatile grasp of the extraordinary masks those who have had early misadventures with objects resort to in order to survive.” (p. x)

The opening lines of her introduction express one of the most touching things about how she views her work and the common humanity we all share, when she begins her book by stating: “This book is about ordinary people–-analysts and patients--who share a common humanity consisting of strength and frailty, triumph and failure, joy and tragedy, agony and ecstasy. We’ve each suffered and avoided experience, behaved with both dignity and hubris, been courageous and cowardly, stupid and wise. We have, at times been lost and have also had the good fortune to be found, we’ve been seen as well as overlooked, often dropped and sometimes up-lifted” (p. 1).

Dr. Mitrani identifies herself as a post-Kleinian, a group of Kleinians who have modified the ideas of Melenie Klein and blended them with the work of Bion, Winnicott, Tustin, Bick and Meltzer. She uses the concepts of intersubjectivity, the mutuality of transference and countertransference in combination with Bion’s concept of container and contained as a way of understanding her clients and framing her extremely thoughtful interpretations, always expressed in the context of the transference in the current moment of the analytic hour, starting with the “first moment of contact”(p. 5).

She believes, as did Klein, that interpreting everything as “indirect reference to the relationship with the analyst” serves to make contact with and “begin to mitigate the early infantile splits in the ego…” and to “lessen the burden upon the patient’s day to day life and his relationships outside the treatment” (p. 6). She emphasizes extreme attention to detail: to verbal and non-verbal communications, as information to inform her interpretations and as attempts at contact from a very young “infant” part of the patient, in the belief that that is where the process of psychic change begins, and the patient can be found and finds herself/himself in the safety of a good, attentive mother. It is her belief that educating clients about analysis is unnecessary, and as the process of being in it, and being “seen” and understood, will bring out their own unconscious needs and wishes for more contact and a deep process of healing, change and understanding.

Her chapter on adhesive identification, starting from the work of Ester Bick and built on by Meltzer, Anzieu, Winnicott, Meltzer and Tustin, describes the early infant’s “lack of psychic boundaries sufficiently capable of holding together their mental and emotional contents, as yet indistinguishable or undifferentiated from their bodily contents” (p.20). Bick “proposed the notion of a psychic skin as a survival function which binds the self together as the infant moves toward an integration of a cohesive sense of self.” Some of the interpretations needed by patients with these needs include words such as “falling-into-space,” “dead-end,” “spilling out into space,” evaporation,” “disintegration,” Nameless dread,” “unintegration.” Although these words seem very foreign to me, I am finding that as I use them with particular clients they indeed do speak to what they are trying to communicate to me and are not experienced, to my surprise, as foreign to them at all.

She speaks to one of my biggest concerns about Kleinian analysis when in attempting to interpret the deepest anxieties of patients she says that “interpreting the defense and its destructiveness without acknowledging the patient’s fear of catastrophe and his conviction that he must hold himself together–risks leaving him feeling uncontained and misunderstood, and often results in silent hurt and increased defensiveness” (p. 25). In my experience it also can lead to premature termination and flight for analysis of patients with early childhood trauma who do not feel understood, but re-traumatized and psychically invaded.

Tustin’s work with autistic and psychotic children details the blocking of awareness of reality that she observed in these children. Tustin “understood the point that without an awareness of space there can be no relationship, and without relationship the process of identification cannot be set in motion.” Adhesive identification “serves to establish a sensation of existence rather than a sense of self and object as separate living entities.” Dr. Mitrani goes on to clarify in great detail to speak about her thoughts about the “term adhesive pseudo-object relations by comparing and contrasting it with normal/narcissistic object relations” (p. 38). She then goes on to use detailed clinical illustrations to illustrate and clarify these concepts and how she worked with and interpreted them, as well as her belief in the importance that those analysts who work with these patients be supported, just as a new mother needs to be supported to insure they not “retreat into their own protective shells” and get discouraged in their efforts to make contact with their patients. Again, her detailed clinical illustrations of working with ordinary patients with great difficulties, she illustrates how she made contact with them through the use of her own countertransference experience, her own daydreaming, struggling with her own sense of inadequacy. One example of how she used all of this and was able to contain her patient’s intensive castigation of her extreme distress after a long break in the work was the following interpretation, “I thought he was letting me know how it felt that I was leaving an absolutely unwanted and broken little-him to die alone in a strange, deserted place, with someone who would merely preside over his death, happy to be rid of him. Or perhaps that he was feeling that he was such a big baby that he had damaged me and I no longer could bear him” (p. 78).

As her client concurs, she continues….I thought he was trying to communicate some crucial bit of his experience, perhaps of a little-he who had died long ago, unable to bear the terror and rage over being abandoned. Perhaps his silences now were an attempt to kill of not only these unbearable feelings but that part of his mind that could experience these feelings and fears.” This illustrates the completeness of her interpretations, her very thoughtful use of language, her ability to convey extremely difficult psychic experiences in great detail, as well as the humanity, compassion and non-shaming way she speaks to her patients who are in the midst of such incredible unknown dread. It is a hallmark of her style of working that touches me deeply.

In chapter five she writes about the experience of working with a pregnant patient and her maternal development in analysis. In chapter six she addresses the containing of ecstasy and Tustin’s ideas on the “unbearable ecstasy of “at-one-ment” and the infants experience of the “beautiful mother” and our need to help contain the “gratitude and love, reverence and awe” that patients express and feel toward us, in addition to tolerating the hatred and envy. How important it is for our clients to internalize the analyst and their good positive qualities in order to insure successful analytic treatment, and their ability to love and forgive themselves. In my experience, our ability to bear this part of the patient’s experience is closely linked to their ability to tolerate and express the negative experience of us they also have and trust the relationship will survive. If we undermine their love for us by interpreting the negative transference prematurely we circumvent a vital part of the analytic process.

In Chapter 7, Dr.Mitrani speaks with poignancy of an analytic treatment that was prematurely interrupted and her learning from that experience. She takes into account in her analysis of the premature leaving of the patient “the emergence of the fear of breakdown in this analysis: those inherent in the analytic setting, those connected to the analyst’s failures, and those related to the history and character of the patient” (p. 130). Again, as is a hallmark of her work, she speaks to the shared responsibility and experience of both patient and analyst and each of our contributions to the process.

I was touched by her ability to speak to our limitations as analysts, and our need to “examine our failures to account for our losses, as best we can, and to keep going forward in our work to help our patients to re-experience some portion of their forgotten lives” (p. 146). Sometimes there are external factors that interrupt the process, in this case permanently, and in this case the interruption actually happened in the analytic space itself where voices from another room were overheard. To me this speaks to the issue of timing and its importance in analysis, to the need to stay tuned into the patients process as best we can to not go too deeply into the unconscious without the patients permission, places where the patient is not yet ready to go. Based on my experience, this is a particularly deep concern for patients with early childhood trauma and it takes great skill on the analyst’s part to not have them flee treatment.

Chapter Eight addresses the issue of countertransference. Dr. Mitrani begins with a history of countertransference from Freud who saw it as a need for more analysis in the analyst, to the more current thinking as articulated by Dr. Mitrani as a tool to help us better understand our patients so we can construct more accurate interpretations. In this chapter she particularly emphasizes through clinical material the need to be patient in thinking through our interpretations, and listening quietly, carefully examining and thinking about what the patient is trying to tell us about their experiences of us in as non-defensive a way as possible. Her ability in this clinical vignette to hear a very difficult description of herself from her patient, take it in, examine it for its truthfulness about her and her patient’s experience of her, and to use that to help the patient, speaks to her skill as an analyst. She also speaks to our need to not deny our deficiencies. She is able in this way to see the “patient as an ally rather than an adversary to the process of analytic explorations, and to come to consider all communications coming from the patient as a useful ‘second opinion’” (p.149).

Her concluding thoughts speak poignantly to our need to learn from our mistakes and failures and to see each person as a unique individual. We need to be willing and open to learn and listen to our patients and how they communicate to us both how we are helping them thrive and how we are getting in the way of their healing. She addresses our need to be cautious in our “tendency toward arrogance, pride and omnipotence, [and] fear of failure” (p.159), and about the serious responsibility we take on as analysts with our patients. She speaks about the weight of that responsibility especially when a patient is in the infantile transference, and our need to be responsive to all the developmental levels and needs of our clients… infantile, adolescent and adult.

Dr. Mitrani emphasizes the importance she places on making contact and interpreting the internal world of the patient. She does this extremely skillfully. I worry that in this process the external world of the patient may be shortchanged. Our patients bring to us real life current issues and to ignore those misses something vital. I think it also misses an opportunity to make contact with fragile people in a way that is not so threatening to their need to defend against being known, and seen too deeply, too soon. I believe that deep change occurs only after a long period of establishing trust.

I fell in love with Judith Mitrani the analysts and human being. Not with her perfection or flawless analytic understand, or with my total agreement with her, but with her humanity, spontaneity, incredible compassion and hope, her willingness to use and look at herself in the process and share that so publicly with her readers. I see that as a rare gift and a sign of great humility and humanity.

Sharon Grostephan is a social worker in private practice in Minneapolis, specializing in work with individuals with early childhood trauma. She is completing psychoanalytic training at the Minnesota Institute for Contemporary Analytic Studies.

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