Primitive Experiences of Loss: Working with the Paranoid-Schizoid Patient (Book Review)

Author:  Waska, Robert
Publisher: London: Karnac, 2002
Reviewed By: Andrew Eig, Summer 2005, pp. 68-69

Students from both the doctoral and postdoctoral programs in which I teach, often ask me how a modern Kleinian works. In other words, do Kleinians still plaster their patients with deep part-object interpretations, such as “You want to steal my babies”? I often reply simply that it depends. Every self-proclaimed Kleinian has a different way of using and understanding the theory. Waska’s Primitive Experiences of Loss gives us glimpse into how one modern day Kleinian thinks and practices. With the inclusion of many verbatim patient-analyst exchanges, the reader is treated to a rare glimpse into a senior analyst’s consulting room.

Waska’s book investigates “…the ego’s experience of loss in the paranoid-schizoid position and the way projective identification is then used to cope with overwhelming anxieties of annihilation and separation.” (p.1). For Waska, this experience of loss can come both from intrapsychic causes in the form of excessive envy and aggression as well as external sources such as trauma, abandonment, and neglect. Patients in the paranoid position have a rather “…fragile hold on an idealized, intrapsychic object that they crave union with, for safety and emotional nutrition.” (p. 189). Loss of unity with the object is experienced as persecutory. Instead of tolerating the absence, loss turns good gratifying objects into attacking bad objects. Through projective identification, these patients turn this intrapsychic reality into an interpersonal nightmare. A vicious cycle then ensues where bad object begets loss, which begets another bad object.

Primitive Experiences of Loss is divided up into two main parts. The first part entitled “The contributions of projective identification and symbolization.” encapsulates several small chapters that illustrate various theoretical and technical issues that surround clinical situations where projective identification is excessive and symbolization is sparse. Projective identification (PI) for Waska, following from Klein’s early description, rids the ego of unwanted, intolerable, and disavowed aspects of the self. Because the primitive ego cannot tolerate loss or separation, PI becomes excessive, leaving the ego in a state of further fragmentation. Symbolization, on the other hand, is seen as ameliorative to loss as it allows the experience of loss and dread to be tolerated. Waska does a masterful job in clearly and concisely reviewing Hannah Segal’s important work on the different levels and aspects of symbolization.

The writing is elegant in delineating how different patients experience the loss of or separation from an idealized object whether it be from internal or external sources of reality. Instead of describing each chapter, I will leave the interested reader with a few choice morsels of Waska’s work.

In chapter three entitled “Idealization, Devaluation, and the Narcissistic Stance” Waska illustrates how these patients transform loss of their trusted objects into bad objects. He writes with both precision and beauty: “Some patients are always on the alert, fearful that their objects are about to betray, reject, and hurt them. They want to trust their objects and look up to them, but they cannot get past the tremendous anxiety that what is good will become bad and what is stable will shatter. Again, this phantasy has dual elements that feed off each other. Loss of the trusted object is felt as a critical rejection and abandonment. Due to the subsequent projection of rage, greed, and envy, the object then becomes transformed into a venomous monster, returning for revenge” (p. 43).

I think every psychodynamic clinician can relate to the experience of suddenly becoming the transferential monster after a loss or separation is felt in the analytic relationship.

The latter part of this section discusses difficulties in the clinical encounter when loss is experienced as betrayal, symbolization is minimal and PI is excessive. The patient is guarded and cannot tolerate feelings of vulnerability or pain. Waska’s approach is that of a traditional Kleinian. He seeks to interpret the here-and-now relationship focusing specifically on how the patient is using the analyst. Waska stays within the psychic reality of the patient without appealing to a corrective authoritarian approach of pointing out what reality actually is. Enactments are seen as inevitable and useful but coming mainly from the patient.

Part two, “Primitive Loss and the Masochistic Defense,” addresses how loss is turned against the self. Waska describes how patients whose experience is within the primitive realm use masochistic compromises to ward off paranoid anxieties rather than depressive ones. In other words, masochism is used to defend against annihilation rather than loss of the object. Perhaps the central distinction between masochism in the depressive position versus masochism in the paranoid schizoid position is the ability to maintain hope.

Discussions on the different vicissitudes of the masochistic defense are fascinating. We learn about the self-righteous pleaser whose slavish devotion to the object he or she fears most can be viewed as an attack on that object. We learn among many other things about how the self identifies with a broken down (or watered down) object to defend against the cruel persecutory object. The case material in this section again is evocative. We see how the session ebbs and flows, how the patient and analyst interact with each other. Again, Waska showcases the traditional Kleinian style of staying close to the transference through interpretation while also using some metaphoric language to illustrate the psychic prisons his patients are in.

In the last chapter of the book, Waska calls upon modern Kleinians to look more closely how to resolve the technical problems of working clinically with excessive PI. He believes that we lack the theoretical insight and therefore the interpretations to move these patients effectively to the depressive position. Perhaps the curative factor is something more than the interpretation. As I am sure Waska would agree, recent work such as Stern (2004), and fellow Kleinian, Symington (1990), illustrate how the therapeutic relationship and the act of interpreting may be more curative than the actual content of the interpretations themselves especially when dealing with more primitive patients. The emphasis should be more on the relationship than the exactness of the interpretation. Waska’s theories may be enhanced by looking more towards the therapeutic relationship. The quest for the ideal technique or interpretation may be a psychoanalytic red herring.

Although I found this book interesting and enlightening in many respects, I do have some differences with it. We get to see Waska’s eloquent and sensitive interpretations. He clearly cares about his patients. Nonetheless, perhaps quite ironically in a book about loss, I found myself missing the author. I could not get a sense of him as a person through his writing and his technical interpretations.

My other departure from Waska’s work lies with a conceptual difference in the use of Klein’s paranoid-schizoid and depressive positions. Although he views many less disturbed patients as able to move back and forth from one position to the other, Waska sees certain patients as “stuck” in the paranoid position with little if any movement towards the depressive position. Bion (1965) has illustrated several examples of how the most primitive patients move back and forth from one position to the other. In Bion’s view, experience is more fluid. This experience is captured from moment to moment in the session in sometimes quite subtle ways. Symbolization or the ability to symbolize coheres then breaks down and then reconfigures only to break down again.

Finally, Primitive Experiences of Loss is a book worth reading. Waska takes a different turn by looking at how primitive personalities experience detachment from an idealized object. While this work may seem a bit too theoretical or intellectual for the clinician hungry for pragmatic suggestions, it is replete with rich clinical examples that illustrate Waska’s technique and bring his theoretical ideas to light. I recommend this book for anyone looking for an insightful and challenging work that brings Klein to the current day consulting room.

References

Bion, W.R. (1965). Transformations. London: Heinemann. Reprinted in Seven Servants: Four works by Wilfred R. Bion. New York: Aronson (1977).
Stern, D.N. (2004). The present moment in psychotherapy and everyday life. London: W.W. Norton and Company.
Symington, N. (1990). The possibility of human freedom and its transmission (with particular reference to the thought of Bion). International Journal of Psychoanalysis, 71, 95-106.

Reviewer Note

Andrew Eig is Assistant Clinical Professor at The Derner Institute of Advanced Psychological Studies where he teaches and supervises in both the doctoral and postdoctoral programs. He is also the former Treasurer and Representative to the Board of Section VII of Division 39. Dr. Eig is currently in private practice in New York City.

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