SILENT SCREAM

CHARLES

Silent Scream: The Cost of Crucifixion—Working

With a Patient with an Eating Disorder

Marilyn Charles

Abstract: In working with individuals who have experienced extreme depriva-

tion in early relationships, the pain is often depicted silently and repetitively.
There can be a tension between the need for validation and an avoidance of
growth. The analyst, then, can find herself caught between her empathic reso-
nance to the silent scream and the need to keep in mind the “cost of crucifixion.”
The latter has become my inner way of fixing in my own mind the type of di-
lemma that ensues when the individual truly feels helpless and at the mercy of
outside sources and also resents and fears the other’s power. Marking (and often
magnifying) the distress, then, becomes a way of inviting salvation. The dra-
matic element lends an air of inauthenticity to what is, in fact, very real pain. If
we are unable to note the air of dissonance with which we receive these distress
calls, we miss a crucial healing element: that the self is paying a huge price for de-
fining the other as a source of salvation, and that part of the distress ensues from
the denial of the hostility expressed toward the object for being an insufficient
savior. We find ourselves cast in the role of savior/persecutor, and must find
some means for healing these splits so that we might become a deidealized sup-
port for the other’s emerging attempts toward constructing a more viable self.
This is a dilemma we encounter when working with individuals who
communicate protosymbolically, as is the case with eating disorders.

In our work with those whose early relationships have been marked
by trauma or depression, pain is often depicted silently and repetitively.
These depictions can mark a distress that is both affirmed and ques-
tioned, creating a terrible tension between the need for validation and
the avoidance of growth. The analyst, then, finds herself caught between
her empathic resonance to the “silent scream” and the need to keep in
mind the “cost of crucifixion” for each member of the analytic pair, and
also for the internal object relations that cannot be dichotomized in this
way without hazarding the well–being of the subject herself. This “cost
of crucifixion” has become a way of fixing in my own mind the type of
dilemma that ensues when an individual truly feels helpless and at the
mercy of outside sources but also invites, resents, and fears the other’s

Marilyn Charles, Ph.D., Staff Psychologist, The Austen Riggs Center; Adjunct Professor
of Clinical Psychology, Michigan State University; Training Analyst, Michigan Psychoan-
alytic Council; Private Practice, Stockbridge, Massachusetts.
Journal of The American Academy of Psychoanalysis and Dynamic Psychiatry, 34(2) 261-285, 2006
© 2006 The American Academy of Psychoanalysis and Dynamic Psychiatry
262 CHARLES

power. We can perhaps better understand this dilemma by looking at

some of the constrictions we see in individuals who have experienced in-
sufficient titration of early trauma or, as Lacanians might put it, who
have been caught by the desire of the Other (see, for example, Apollon,
Bergeron, & Cantin, 2002). These are the children Grotstein (1995a,
1995b) refers to so evocatively as “Orphans of the Real,” children who
have been confronted too soon with realities impossible to bear, before
the processes of imagination and symbolization were sufficiently
developed to provide protection.
Overwhelming affect is experienced as traumatic, impeding our abil-
ity to differentiate affective experiences and to make use of affective
cues. Trauma also inhibits the organization and integration of experi-
ence and the consolidation of memories, thereby encouraging splitting
and false dichotomizations (see Krystal, 1988). Any intense affect exac-
erbates this dilemma, resulting in affective storms that make it difficult
for us to obtain sufficient emotional distance from an experience to be
able to even think about it (see Matte–Blanco, 1975), much less derive
verbal language through which to express the pain. The information as-
sociated with traumatic experience and overwhelming affect, then,
tends to be expressed to self through “memories in feeling,” as Klein
(1957/1975) terms them, and communicated to others through what I
have called the “language of the body” (Charles, 2002). Understanding
this type of language helps us to work more effectively with those who
have not learned to read and utilize their own affective symbols
adaptively, but rather communicate protosymbolically through the
body.
Symptoms and enactments enable us to dramatize and externally rep-
resent internal experiences that cannot be symbolized through verbal
language (McDougall, 1985, 1989). This type of nonverbal representa-
tional system provides an avenue for interchanging unconscious or
unelaborated meanings (Charles, 2002), but can also subvert develop-
ment by circumventing the domain of language (Apollon, Bergeron, &
Cantin, 2002). Through symptoms and enactments, patients call atten-
tion to wherever they are stuck, demanding that the analyst attune to the
protosymbolic elements of the communications. This attunement can
provide reassurance that we are truly reading them, a precarious issue
when there is no internal assurance of a self who can own or be the
subject of her own experience.
When the subject herself is in question, the analyst who is not aware of
this tension can over–ride and obscure the essential dilemma in her at-
tempts to “be helpful.” There is a part of us that longs to respond to the
call to fill the emptiness, which makes it critical that we hear the call and
accept its poignancy, its tragedy, and its integrity, without short–circuit-
SILENT SCREAM 263

ing the patient’s development by trying to fill the space. When the parent
has been sufficiently fragile that the question of survival has been at is-
sue, the primary identification is with an injured object. These factors
pose particular challenges for us when working with eating–disordered
individuals, for example, who tend to experience themselves as objects
in relation to their mothers and play out their dilemma explicitly, using
their bodies as dissociated objects, out of touch with internal needs,
desires, or feelings (Farrell, 1995).
When there is a fundamental confusion between self and other, the ex-
perience of symbiosis may provide the only assurance of contact.
Words, themselves, may have little meaning, but rather, as Farrell notes
regarding an anorexic patient: “For her, the only satisfactory state of
communication was two people feeling intensely and identically, in
phantasy a state of fusion, of nondifferentiation. Difference has implic-
itly to be acknowledged when words are used to attempt communica-
tion” (p. xiv). When the experience of self with other is that of an unlink-
ing (Bion, 1977) or “falling into bits” (Klein, 1946/1975, p. 4), we are
confronted with the dilemma of how one might form meaningful links
between two separate beings without becoming submerged or other-
wise destroying self or other. As Farrell puts it: “the problem for both
anorexics and bulimics is how to make a gainful and durable link—an
internal link to an object that can in some way be allowed to be good”
(1995, p. xiv).
When words are not seen as a viable mode of communication, and sal-
vation seems possible only from external sources, one resolution to this
absence of linking is to invite the other in by marking (and often magni-
fying) the distress. This magnification lends an air of inauthenticity to
what is, in fact, very real pain. If the analyst is unable to note the air of
dissonance in these distress calls, we miss a crucial healing element: that
the self is paying a huge price for defining the other as a source of salva-
tion, and that part of the distress ensues from the denial of the hostility
toward the object for being an insufficient savior. This is an arena that
Lacan (1977; Apollon, Bergeron, & Cantin, 2002) points to in his depic-
tion of the self held captive by the desire of the Other. The anorexic de-
picts for us this captivity quite poignantly, as we find ourselves cast in
the equally untenable roles of savior and persecutor.
The abdication of agency by the patient imprisons the analyst, who
cannot take either role offered, and thereby becomes a persecutor by re-
fusing to offer salvation. Grotstein (2000) conceptualizes this dilemma in
terms of not only an ongoing crucifixion, but also in terms of a pietà, in
which the analyst stands accused of crimes for which she is at once inno-
cent and guilty. Grotstein describes the “pietà covenant” in terms of a
container–contained relationship predicated on redemption through
264 CHARLES

the analyst’s absorption and transmutation of the guilt. Hopkins (1989)

usefully locates this type of transformational relationship in terms of the
mythic and fundamental need of the developing individual to encoun-
ter the other who can survive one’s own destructiveness and thereby af-
firm one’s potential for survival as a separate and yet connected human
being.
The analyst’s refusal to offer “salvation” is fundamental to the treat-
ment, affirming that salvation is not ours to offer. Being mindful that we
cannot substitute our self or our knowledge for that of the patient helps
us to tolerate with them the terrible not–knowing. As Winnicott (1971)
puts it: “the patient’s creativity can be only too easily stolen by a thera-
pist who knows too much” (p. 57). For Lacan (1977) the stakes are even
higher: it is one’s very subjectivity that is at issue, a subjectivity that can
only be defined in terms of “his identity to himself” (p. 296). Ultimately,
the analyst’s refusal to offer an illusory salvation and his or her tolerance
of the despair of the patient affirms that renunciation of the illusion of
“having it all” is not only necessary, but also survivable. (See, for exam-
ple, Lacan’s 1977, pp. 56–77, view of the “lack,” Klein’s, 1940/1975, de-
scription of the depressive position, and Winnicott’s, 1971, depiction of
the “use of an object.”) In refusing to accept a dichotomized split be-
tween self and other, we affirm the importance of finding a means for re-
lating as separate and yet connected beings, and thereby engender the
possibility of becoming a deidealized support for the other’s emerging
attempts at constructing a more viable self. In this article, I will use the
case of “Alice” to illustrate the dilemma of analyst and analysand in
finding themselves caught in this type of snare.
Alice is a lovely and extremely bright 24-year-old woman whose de-
meanor is that of a girl far younger than her actual age. Her apparent
competence and buoyancy mask a very fragile and undefined self. She is
one of many young women I have encountered, very different in initial
appearance and yet having in common, at closer look, similar life dilem-
mas. Most particularly, they describe their mothers in similar fashion: as
devouring and relentless objects, who seem to fill all the depictions we
term “borderline.” Each of these young women seemed to be caught be-
tween an arrested internal development and a pseudo–mature external
facade. Each characterized herself as the victim and rescuer of her own
mother. For each, the father had been unavailable as a resource; for sev-
eral the father had also been actively abusive in some way. Each woman
had had extended periods of disordered eating; several (including Al-
ice) had been hospitalized for eating issues and also for suicide attempts.
The question seemed to be whether these children could be fed without
being destroyed, and whether they could exist as a separate self.
The intense distress and intractability to treatment of these young
SILENT SCREAM 265

women has led me to ponder the need to sacrifice the self as a way of cre-
ating one’s life. This would seem to be the dilemma Hopkins (1989) de-
scribes in Winnicottian (1971) terms of the infant who has not been able
to sufficiently “use” the object to establish his or her own agency. In the
absence of this fundamental developmental milestone, there is insuffi-
cient containment of either love or destructiveness, which gives rise to
an experience of profound emptiness that Grotstein (1990, 1991) and
others have characterized in terms of a “black hole.” The struggle with
emptiness represents a particular dilemma for women versus men
(Charles, 2000a, 2000b), characterized by the type of active un–knowing
Bion (1967) describes in his depictions of attacks on linking. Emptiness
can reflect the desire to not be full of the internal inadequacy/badness
interpolated from a lack of parental care. At the extreme, this state of
emptying out the unacceptable may take the form of an abstinent refusal
of life, a drama we see being played out by the anorexic, as she tries to
find a way to survive without sustenance.
In some sense, we have before us the story, not only of an ongoing cru-
cifixion, but also of an immaculate conception: Can one become a self
without having to take in the seed of another? Can one deny what one
takes from the other? Can one learn to accept the gifts while refusing the
toxins? These vital issues seem to be played out in the desire to abstain
from eating altogether or, failing that, to disgorge whatever becomes
toxic within the self when taken in. We can see in these enactments (op-
posing the desire to be taken and transformed, as in Grotstein’s, 2000,
depiction of the more positive aspects of the pietà constellation) the des-
perate need to be able to be given to by the other without being taken
over, the terrible fear of becoming lost in the taking, and the rage at being
so dependent on depriving or intrusively satiating objects. This was a di-
lemma that Alice had not been able to work through on her own or in
previous therapy attempts. This failure left her frightened and alone,
isolated behind a facade that had become a deadly pretense at being a
self.
These women describe mothers who were so caught by their own in-
ternal demands that they seemed unable to attune to or attend to the
daughter’s needs. The daughter, then, attempted to attune herself to the
mother sufficiently to provide the experience of being together, in an at-
tempt to self–soothe via the other in the absence of being able to more di-
rectly soothe one’s self. We can conjecture that these mothers were not
sufficiently available to their daughters in the early years to set in motion
the titration of affect so crucial to the development of the young child.
We also see in these families an inability on the part of the father to inter-
cede effectively on the child’s behalf. Often, as seems to be the case in Al-
ice’s family, the energies of the family are focused on the mother’s equi-
266 CHARLES

librium—her distress being so toxic that it is avoided at all costs—even if

this means sacrificing the well–being of others in the family. This is the
type of disequilibrium that Lacanian clinicians point to that becomes so
precarious for the developing subject. The child needs the “father” as the
agency of the Law and logic of language to constrain the needs and de-
sires of the mother sufficiently that the subject can learn to tolerate limit
and discover her own needs and desire (Apollon, Bergeron, & Cantin,
2002).
From an object–relations standpoint, early deprivation in the par-
ent–child bond leaves the child in an impossible dilemma. The lack of
attunement becomes an unfathomable hole through which the nascent
self falls. Optimally, in our early years we begin to develop our ideas of
self and other through relationships that are sufficiently attuned that we
can learn to recognize self and other with some reliability. The early
prosodies of communication and of relationship become the foundation
on which knowledge, self–regulation, and meaning itself are built
(Beebe & Lachmann, 1998; Fonagy, Gergely, Jurist, & Target, 2002; Stern,
1985), based on our ability to read and interpret pattern across sensory
modalities, through touch, gesture, and intonation (see Charles, 2002).
These prosodies underlie our relations to our selves, our defenses, and
our symptoms (see Apollon, Bergeron, & Cantin, 2002) and form the
templates for relational patterns in adulthood (see, for example, Charles,
1999).
With sufficient parental attunement, the child learns to differentiate
self from other and also learns that each can survive the absence and the
aggression of the other (see Winnicott, 1971). When parental attunement
has been insufficient, however, it is more difficult to build consensual
meanings, to clearly and adaptively distinguish self from other, or to
distinguish one’s own desires from that of the Other. The child then ex-
periences the demand to accommodate to parental standards without
having internalized the means for being effective in achieving these
goals. This can result in an impossible bind in which goodness (mother)
is equated with self–annihilation (as not–mother and therefore as bad)
and psychic survival depends on preserving self from mother (preserv-
ing difference). The resolution of this dilemma, for Alice, has been a des-
perate and hostilely reactive self–denial that at times has brought her
very near her own death.
As analysts, we build our clinical understanding from our experience
in conjunction with our theory, mindful that each both informs and ob-
scures the other. Relational models derived from parent–child interac-
tions highlight some of the subtleties of the prosodies of nonverbal com-
munication between analyst and analysand, as well (Charles, 2006).
Although we tend to privilege the word, elements of nonverbal commu-
SILENT SCREAM 267

nication fundamentally inform our work, most particularly when depri-

vation or trauma have impeded the integration of experience at the ver-
bal–symbolic level. This makes it important, when working with indi-
viduals such as Alice, to have in mind not only an awareness of these
models of primary interactions, but also ideas as to how internal
fantasies are configured and played out when the self is at risk.
Seligman (1999) notes the strong resonance between contemporary
psychoanalytic observations regarding child–parent interactions and
Kleinian (1952/1975) notions regarding the potent force of phantasies
(based on these early interactions) in organizing conceptions of self and
world. This resonance, in my experience, makes Kleinian conceptualiza-
tions vital tools to have in mind as conceptual maps to guide us in our in-
terventions with individuals whose early lives have gone so terribly
awry. Klein had an uncanny ability to track the primary emotional reali-
ties we face in that dire realm in which survival itself is at issue. The fear
of annihilation brings us into what she terms the “paranoid–schizoid”
reality, in which we are residing in a world that is “in a state of dissolu-
tion—in bits” (Klein, 1935/1975, p. 269). This dissolution—this “unlink-
ing” (Bion, 1977) and unknowing—titrates the underlying anxiety, but
then we are inevitably persecuted by whatever it is we are not–knowing.
The enforced blindness of projection and expulsion does not eliminate
the feared objects, but only dislocates them, so that the impossibly bad
object coexists with the fantasied perfect object in a lie that continually
yearns to right itself. The wish for perfection further vilifies the
imperfect self who cannot attain the longed–for perfect object, and the
hope of perfection keeps us hooked.
In this disjunctive world, where the stakes are high and reality is un-
fixed and ephemeral, Klein (1935/1975) helps us to locate ourselves
through her descriptions of dichotomized disjunctions of good and bad;
persecutor and victim. This type of splitting entails a dislocation of parts
of self and other, such that the identification with the other often takes
the form of an aggressive object–relation (Feldman, 1997; Rosenfeld,
1971). In projective identification, whatever is vilified is not seen within
the bounds of self, but only outside, in the other. Aggressive impulses
are then externalized and experienced as retaliatory and persecutory,
whereas excessive projection of good aspects of self becomes an elusive
ego–ideal, resulting in an overdependence on the other and a reciprocal
weakening and impoverishment of the self. In the absence of effective
self–soothing, intense affect becomes a signal for avoidance rather than
reparative efforts, and vigilance becomes the salient means of
self–protection.
Alice finds herself caught in this type of mire, in which it is the other’s
affect she is tracking, never her own. Her own distress surfaces in acts of
268 CHARLES

desperation that she experiences as inchoate feelings of “panic” or “fall-

ing.” She looks to others as sources of salvation, but her difficulties in in-
tegrating good and bad aspects of self and other leave her caught in rela-
tionships in which she is inevitably persecuted, whether by the
withholding good or the actively bad object. It is difficult to tell which of
these is more dangerous, making it important that I not accept willingly
the role of the ideal “good” mother, who could “know” her without
words. I find myself in the paradoxical situation of needing to try to read
her silent communications and yet to also affirm that I will, inevitably, at
times be wrong.
When Alice is feeling less vulnerable, she gives me information so that
I might “read” her more accurately in those other moments when being
hidden seems so important. She tells me, quite urgently, of the mask that
she wears and how potently it hides her from view. Seeing her caught
between her despair, her arrogance, and also her hope of perhaps being
known without annihilation, I tell her quite pointedly that I am fallible,
and try to avoid rescuing and preempting her by finding words for her.
Rather, I invite her to put her experience into words, to choose her own
words, so that she can be in charge of the communication in a way that
she has avoided quite actively in the past. This avoidance seems to be an
integral part of the passive–aggressive enactments through which she
plays out the pretense of engagement without having to take the risks
entailed in actual contact with another human being.
In a session in the ninth month of the treatment, Alice relates a dream
in which we can see the displaced aggression lurking behind its mask,
waiting to destroy her and the treatment unless we can recognize it and
contain both good and bad aspects of self and other. Her recounting is
elusive, the dream a means of revealing and obfuscating split–off as-
pects of self she needs me to be able to integrate without destroying her
in the process.

Alice tells me that for some time she had been unable to dream, al-
though at times she would take a nap and dream, though she cannot al-
ways distinguish between the dream and the reality. On this occasion
she had had a dream; one of a series of dreams that have gone on for
some time, not exactly the same, but having this theme of cats. She is not
sure why she would dream of cats, as she doesn’t particularly like them.
In her dream, she realized that she had a cat, but that she had forgotten
that she had had it, and now realized that the cat would be needing
things; things she had failed to provide. She went into the room where
the cat was, and there was all this fur and then she realized that there
were lots of little kittens and she thought “Oh God the cat was pregnant
SILENT SCREAM 269

and had had kittens” and then she saw two big cats staring at her and
they seemed menacing. This theme of menacing seemed to link back to
the other cat dreams she had had as an adolescent, in one of which she
had left a cat unattended in the bathroom, because there was a party in
the house and she needed to keep it away. But then she needed to go see
to it and she was afraid to; again the sense of menace.
Alice’s associations go to her brother, who was allergic to cats, and to
her father, who didn’t like cats, but maybe it wasn’t that he didn’t like
them—she remembered him painting a room and needing to keep all the
windows open because of the smell of the cat and her father being very
angry over this. Alice seemed to think that the anger toward the
“damned” cat was displaced, but did not expand on this, but rather
floated away.
Her associations also went to the room and the sense of place; she had
never had a secure place in her home. Everyone else had had a room, a
place, but if someone was going to be displaced, it would be her. She de-
scribed in a great deal of detail the walls of her previous rooms and how
they had been painted. She said that when she came in to our sessions
she felt as though she painted a painting each time. There was always a
new canvas, she said, and it depended on how she felt. Sometimes she
had only three colors; sometimes she might have twenty.
She was telling me that she felt free to paint in her own way and con-
trasting this with her experience of her parents coming to town and try-
ing to paint her apartment. Alice had mentioned wanting to paint one of
the walls in her apartment, and her mother had wanted to know “which
color?” Alice explained that she didn’t want to paint it a color; she
wanted to paint on it. Her mother refused to understand this and kept
searching for a color.

Alice contrasted this with her experience of me, saying that this is the
first time anyone has ever really listened to her. In the past, therapists
had had some protocol they seemed to be going through and it was like
they could only see the tip of the iceberg and did not want her to look be-
neath. I wondered what I was not seeing, and referred to the kittens,
wondering whether the kittens were a part of her she was not willing to
see and if I was colluding in ignoring important issues.
We can see how Alice’s hostility becomes displaced and masked by
the “forgotten” cats whose needs make them “menacing,” and how I be-
come responsible for marking the place of whatever is not being seen.
Alice abdicates her agency and her understanding, wondering why she
would be dreaming of things she doesn’t like and presuming the inevita-
bility of misunderstanding. When persecutory anxieties are extreme, de-
270 CHARLES

fensive withdrawal can provide the illusion of safety, for a time, but life
and its instincts for survival resurface and we are faced, once again, with
desire, hunger, and need. Abstention from eating ostensibly denies Al-
ice’s dependence—much as she denies her interest in or understanding
of antipathies between herself and others—but also keeps her at the
mercy of abusive others who might not be so abusive if Alice were able to
define her own needs and set limits in her relationships. In denying her
needs, Alice becomes complicit in her own persecution, leaving even the
idea of need for the other to hold, so that saving her life becomes some-
thing she must be forced into, against her will. This becomes one more
crazy game in which she can only lose.
The abstention of the anorexic is an untenable resolution to an impos-
sible dilemma. The desire to have no needs is inextricably intertwined
with a desire to have no words, no way in which to symbolize—and
thereby make more palpable—thoughts that seem too distressing to
think about. These are children whose early object relations provided no
means by which the self might be soothed. They tend to be incapable of
more direct paths toward self–soothing, but rather achieve this end indi-
rectly by escalating tensions until it is the respite from the tension that
provides a feeling of relief. This type of enactment can be seen in exces-
sive exercising and also in the rhythms of the bulimic cycle, through
which the dilemma of need, internalization, toxicity, and repugnance is
played out over and over again, exacerbated by the altered states of con-
sciousness that characterize fasting or the successful resolution of the
bulimic cycle (Reiser, 1990).
For those caught between the need for food and the need to abstain or
evacuate, there is also a tension being played out between the need for
the words that might make the experience tolerable (and digestible) and
the fear of knowing. The analyst finds herself in danger of swinging
from one side to the other of this pendulum, seeking sufficient equilib-
rium to titrate the unmanageable experience. In her attempts to speak to
what is missing as well as whatever is present, the analyst may find her-
self quite alone, opposing the patient’s fear, and yet our attunement can
help our patients to verbalize and thereby detoxify those very feelings
that had seemed impossible to know together. Finding words helps to
cast some light into the darkness, and to titrate this terrible fear of know-
ing. Even when our words become twisted and distorted beyond recog-
nition, recognizing the distortion affirms that one might know
impossible things without imminent annihilation (see Charles, 2004).
We see how Alice’s willingness to “paint a new picture” also reflects
an unlinking from one experience to the next. For the individual who
splits in this kind of way, reality may be highly changeable, depending
on the affect of the moment. Many colours may be needed to obfuscate
SILENT SCREAM 271

and paper over the walls of a room that has become untenable, and win-
dows opened to eradicate the smell of cat within. Our task is then to re-
position ourselves such that we can accept these disparate or difficult re-
alities, so that we might work our way toward a more stable and
tolerable representation without splitting off the messier, more prob-
lematic aspects. In this process, we are marking the power of feelings
and the extent to which intense feelings can alter our perceptions,
thereby also affirming that one means for self–care is to recognize the in-
tensity of the affect as a flag for possibly distorted perceptions. This rec-
ognition helps us to use the distortion as a cue, encouraging greater af-
fective equilibrium rather than continuing the disruption, startle, and
panic sequence that is in play (Beebe & Lachmann, 1994). These experi-
ences of disregulation and repair, in the context of a reliable enough rela-
tionship, not only help us learn that we can survive disregulation, they
also help us to utilize the reparative functions of the analytic
relationship in ways that build resilience rather than dependence.
For individuals such as Alice, who experience such profound difficul-
ties in regulating their own affect, our interpretations and our ways of
being can help to redefine reality in ways that are more tolerable and
adaptive. Ultimately, we hope to offer the patient a space in which she
might think her own thoughts and dream her own dreams, in which the
palimpsest can both hide and reveal the layerings in such a way that we
can contain and integrate them over time. We see an example of the re-
parative function of the analytic work in Alice’s initial discomfort and
reactive hostility when I reflect my view of her as a complicit subject
rather than merely a persecuted object. Her initial reaction is to go un-
derground: to present to me her benign victim stance, while seething
with rage underneath. We had, however, built sufficient resilience
through our previous work that this time Alice is able to acknowledge
her anger and to reposition herself and integrate the split–off parts of self
and other, rather than demonizing one and diminishing the other. In re-
fusing to play the victim in relation to my persecutor, Alice acknowl-
edges her own potency in relationships, not an easy position for her to
take. It causes her a great deal of anxiety and discomfort, and she worries
lest this stance be a mirage built upon my illusions of her capacities. It
also, however, helps her to tell me of her fears rather than hiding them
behind the mask of apparent acceptance that leaves no way of
integrating the split or working through the very real problems she
encounters.
At times, I am painfully aware of the utter emptiness Alice experi-
ences. The extremes of projection and introjection leave her with a terri-
ble sense of depletion. We see her caught by the desire of the Other and
by her identification with the injured object. She privileges the other’s
272 CHARLES

satisfaction at the price of her own and is not able to reposition herself as
the subject of her experience. In affirming the mother’s destructive fanta-
sies and the father’s collusion, Alice preserves the pattern of her di-
lemma so that it can be observed. My task then is to focus on her experi-
ence, to attempt to vivify it and bring it to life, and then to bring into
focus Alice and her perspective as the only legitimate focus of inquiry. I
cannot be willing to accept the dramatization of Alice’s crucifixion—the
story in which others’ demands organize and structure her experience
such that she is merely a puppet on a stage and can have no agency.
Recognition of the splitting helps to contain the ambivalence and to
fuel our refusal to be a willing accomplice in accepting the role of Other
in counterpoint to the patient’s abdication of the role of Subject. We can
then begin to illuminate more usefully the patterns, not only of relation-
ships or characteristics, but also of modes of being and of defense, reac-
tivity, and adaptation that are being repeated. For example, much as in-
ternal and external locuses of aggression feed the persecutory anxiety,
the projection and introjection of loving feelings serve to strengthen one
another and to decrease persecutory anxiety. This containment helps to
build ego resiliency and thereby enhances perception and reality testing,
further highlighting the prosodies through which the person abdicates
her subjectivity and offers herself up as the crucified victim in the drama
she replays. We are then confronted more directly with the question of
the person’s relationship with herself and whether we can focus our in-
quiry in such a way that she can take greater ownership of her own
thoughts and feelings. This position would entail giving up the safety of
the silence and of the cross, and repositioning herself as a subject in her
own right.
Without adequate resources, defenses tend to be primitive, leading to
denial of feelings or connecting links, even to the extent of disavowing
any care for the object. This may be seen as a manic defense that pre-
cludes relatedness and pulls away from acceptance of the inevitable du-
ality of being, back toward the paranoid–schizoid position in which Al-
ice remains isolated within her armor—the menacing and forgotten
kitten. The fear of being the deprecated object makes it difficult for Alice
to even seek less destructive relationships. Her ambivalence comes to
the fore as she invites me to read the affect in her face without providing
any words of her own through which we might anchor her experience.
My conjectures, then, when stated aloud, tend to define her experience
rather than acknowledging it. This is hazardous ground, as we do need
to define our terrain, but we need to define it in her terms; to position her
as the subject of her experience rather than losing her once again in the
very act of trying to find her. In the analyst’s dilemma here, we catch
glimpses of Alice’s dilemma, which helps us to locate ourselves and
SILENT SCREAM 273

better find our way. In this realm, it is not safe to make an affirmative
self–statement, nor to have any power or agency.
I try to articulate this dilemma to Alice so that we might perhaps con-
sider it rather than merely becoming lost in the enactment. I tell her of
my conjectures that she is caught in a perilous predicament. I wonder
aloud whether she is afraid that if she acknowledges any attenuation of
her pain, I will abandon her; if she fears that if she shows any signs of be-
coming more adept at managing her life, I will no longer be willing to
work with her. “There seems to be a fear that if you take any power for
yourself, you will be attacked or abandoned,” I say: “Both, perhaps,” I
add, and see the spark of recognition in her eyes and the merest nod of
affirmation.
At times I can engage Alice in pursuing these avenues of exploration
and she seems to be able to use my words constructively, whereas at
other times she accepts my words blindly, seemingly annihilating her-
self with them. At these latter times, she can be painfully silent or tortur-
ously glib and facile, hiding her anger behind her angelic smile. Either
way, I sense she is using me in the service of self–destruction and I find
myself in another impossible dilemma. If I try to rescue her, I affirm her
insufficiency and further subjugate her to my authority. If I refuse to ac-
cept her desolation of herself, she will often leave silently angry, unable
to acknowledge the anger out of fear of retaliation. At those times she
tends to experience me as hopelessly persecutory, which evokes the re-
ciprocal fear that it is I who am angry with her. If I can talk to her about
this stalemate without attacking her with it, we can begin to talk about
her own anger. Affirming my awareness that she experiences me as
persecutory helps to anchor us in a consensual reality through which Al-
ice is better able to locate the less persecutory analyst and the less annihi-
lated self. At other times, however, we cannot repair the disconnection
and she responds to my words by merely looking lost: persecuted and
attacked by something she affirms to be true.
At these times, Alice uses an apparent agreement with me to relocate
her dependency and subservience into relationship with an internal
rather than an external object. I become closed out of the loop, used as a
persecutory object through which she flagellates us both. Her tendency
to use others in this type of sadomasochistic enactment has made it im-
portant to acknowledge my impact on her, both good and bad, so that we
can talk about the meanings, for her, of these internalizations. Refusing
to accept an all–good or all–bad position for either of us also helps to
counter Alice’s assumption that anything linked to me must inevitably
be good, and thus ultimately bad when its insufficiency is revealed.
Perhaps the detailing of a session later in the same week of the dream
previously reported will give you a further sense of Alice’s internal
274 CHARLES

world and of the layers in which she both hides and illuminates herself
in our work together. She came in complaining:
“I’m feeling really weird today; people are getting sick. I didn’t sleep
very well last night. I had this really intense dream—two dreams—and I
woke up and wrote down the second one and kind of lost the first one.”
“I had this apartment that was over ‘X’ [a coffee shop near my office],
even though there isn’t anything over X; well, yeah. Anyway, I walked
upstairs and there was this table and two people were at it; one was this
guy from my class, no one I know very well, just this guy, and the other
person was a woman with blonde hair [I have blonde hair] and I didn’t
see her face, I just sort of went by and didn’t really notice and then I went
downstairs, just a few stairs, and I don’t really remember going down
stairs, just going down, and there was like this sea of faces and the sec-
ond time I went by I was in the middle of the sea of faces, but it was
weird, like it wasn’t real, like a picture or something; very
two–dimensional.”
“Then I went downstairs and my parents were there for some reason
and we were outside and it was like 10 o’clock and like all the fraternities
got out and everyone was outside and they were like playing football or
something and they were like playing around us like we weren’t even
there and so I thought we should go inside and we sat down and my par-
ents were like irritated or something and my grandmother was irritated
like I wasn’t doing the right thing or whatever and so they were going to
go and my mother said something like they were going to “Mt. Some-
thing” or something, like they were going to make it a vacation on the
way back.”
“So then I went back upstairs and I went by that table again and there
was that sea of faces—that was the second time, and then I went into my
apartment and there were all these dead flowers lying all over the place
and I started to pick them up, but they like had all these pieces and were
crumbling and it was hard to pick them up and then I heard my parents’
voices and they were coming back and so I was hurrying trying to pick
up all the flowers and get them out of there before they saw them and
then when I went out into the hall my brother was there and he was yell-
ing at me and telling me how selfish I was and how inconsiderate I was
being and he was really yelling and I tried to go back inside but the door
had kind of closed in and it was like a tube I needed to go through and
then I woke up. This apartment was more like mine, but it was empty,
and there was something really scary, and it wasn’t a person, more like
just something.”
Alice’s associations went to her fears of dying: this “thing” that had
frightened her seems to be a fear of the death she had already invoked by
not taking care of herself. The dead flowers—which made me think of
SILENT SCREAM 275

the relationships she had alluded to the previous day, that had seemed
fragmented and disconnected—seemed to signify to her the damage she
has already done to herself that she is afraid to really face.
I asked her if she was frightened: she nodded, quite bleakly. I think
that as she begins to move toward life she has to reckon with this damage
she has done, both in terms of her physical being and also in terms of the
relationships she has not attended to sufficiently. I said that I thought
that she was afraid of showing the world her self. She stared at me: the si-
lent scream; the deer caught in the headlight of my imaginings; under-
neath, perhaps, the menace of the “forgotten” kittens.

Alice’s dreams tend to be chaotic and confusing. There is so much that

we cannot hold on to, which is also how she depicts herself: as full and
complex, but also empty and vacant. Trying to find Alice is like holding
a Jacob’s ladder and watching it change, ceaselessly. We see the split be-
tween the feared and the fantasied Alice and how easily one becomes the
other, as the grandiose Alice invites the devouring need of the murder-
ous mother, and the empty Alice invites deprecation and abandonment.
Alice relates her dreams in ways that distance herself from the dream
and also from the elements, which always seem to be both her and
not–her, similar to how she depicts herself to me more generally.
The shadow of the toxic mother—emptying her of anything good and
filling her intrusively and toxically—is always at our heels. Alice tells
me how she confuses herself with me, finding herself using words or
phrases that had not been hers, but had been assimilated through her
contact with me. I feel a tension in hearing this revelation, knowing that
she needs to be able to take in what feels digestible, but also to be able to
reject what does not. We struggle, quite actively at times, to talk about
how my ostensible care or concern can be experienced as assaultive, ag-
gressive attempts to take her over and make her into some object I want
her to be. Positioning ourselves in this way helps to counter Alice’s de-
sire to incorporate aspects of me without taking ownership and more
consciously integrating them as aspects of self or discarding them as
other. So, for example, when she returned from a trip disorganized and
not eating, lamenting her inability to care for herself or about her life, I
was struck by the anger that seemed to hide beneath her lack of self–care.
My ability to be interested in her anger at me helped her to acknowledge
it and to also be interested in tracking for herself some of the meanings
for her of this angry hiding.
Alice’s avoidance tends to keep her in an as–if realm in which she can
pretend to be, but cannot actually be, in this way affirming her fears of her
essential incapacity. This type of avoidance presents great difficulties
276 CHARLES

for the analyst. With Alice, for example, agreement might simply be
agreement. Her fragility of self, however, is such that agreement is often
a cover for her fear that disagreement is not acceptable, but rather would
mark her as wrong or as an opponent who must be attacked and de-
stroyed. Ostensible agreement, then, could be seen as a pretence cover-
ing her hostility toward a difference that affirms her worthlessness and
also my reciprocal disdain and lack of regard for her. This absolute
worthlessness is a default position to which she can return when threat-
ened. She can then hide behind either the apparent equilibrium or the si-
lent scream, each of which is both a plea for rescue and an attack on the
other, a reminder of the cost of being crucified in her attempts to appease
the relentless, virulent Other. By taking these positions, she can appear
submissive and nonthreatening while also acting out her hatred of her-
self and of me, and keeping these more dangerous expressions obscured
in the background, where they can be denied and repudiated if
challenged (see, for example, Steiner, 1997).
In these perilous terrains, our theories provide conceptual anchors
that help us to steer between the Scylla of (s)mothering the other and the
Charybdis of abandonment. Lacan (1977, 1978) reminds us to keep in
mind the importance of seeking the subject: noting her absence and at-
tending to it. Klein (1935/1975), then, highlights the desperate and deli-
cate balance between the need to rely upon the other versus the terrible
vacuum that ensues when there is insufficient responsiveness to the
child’s experienced needs. A lack of fit between the child’s needs and the
mother’s capacities exacerbates and amplifies dependency needs, so
that they can feel like a terrible chasm or pit, a deficit within the self that
is almost intolerable to bear (see Charles, 2000a). Fear, frustration, and
rage then loop back into the relationship, further toxifying need, self,
and other, and inviting layers of obfuscation to hide these terrible truths.
Without sufficient grounding, the sense of self is permeable and
ephemeral. Experientially, persecution and annihilation become inter-
changeable (Klein, 1946/1975). We are at the mercy of, not merely exter-
nal forces, but also the internal forces that prescribe ways of “reading” in-
terpersonal interactions such that one is in imminent danger to be
fended off at any cost. In this drama, being known becomes a hazard, lest
the “bad,” angry, dangerous parts of self be recognized or the “good” as-
pects be annihilated. The illusion of omnipotence, as seen in Alice’s ab-
stention from agency and her denial of need or desire, fends off the fear
but also keeps her from working through the very real dilemmas in
which she becomes caught (see O’Shaughnessy, 1981). Being unable to
acknowledge her vulnerabilities keeps her from forming relationships
in which there is any real mutuality or utilizing her strengths in other
SILENT SCREAM 277

adaptive ways, thereby augmenting her isolation and feeding her

anxiety.
We can see in Alice’s predicament the early prosodies of communica-
tion and regulation gone terribly awry. In the absence of the mother’s rev-
erie, toxic feelings cannot be contained, but rather are experienced by each
member of the dyad as an assaultive, intrusive, persecutory presence that
must be expelled. For Alice, the confusion is such that she expels not only
the toxic feelings, but also projects outward more competent aspects of
self. In the transference, I see how wary she is of being seen as competent
in any ongoing or enduring way, and reassures herself by marking her
fragility, dependence, and insufficiency. I become the tyrant mother who
exacts her pound of flesh in exchange for whatever care or concern I might
offer, and Alice becomes the tyrant daughter who will not allow me any
enduring respite. At times she is a master of subterfuge, and I am only
alerted to the extent of her anger when I receive an email apologizing for
“being such a problem” or thanking me for “putting up with her.” At
these times, I try to help her to bring her anger into the sessions so that we
can entertain the possibility of coexisting with it.
Alice also uses her dependency and vulnerability as ways of holding
me hostage: she is so disturbed when I go out of town that it creates in-
creasing tension for me as another departure becomes imminent. At
times such as these, I am helped by Lacanian notions of the inevitability
of the lack, and I can use this awareness as an anchor, affirming to Alice
(and to myself) that I will inevitably fail her, and that grappling with this
fact and its instances will be part of our work together. I can see in Alice’s
face that this affirmation helps to break the stranglehold that the possi-
bility of perfection—and with it the persecution of perfection and the in-
evitability of failure—have on her. She is relieved of the terrible intensity
of her fear sufficiently that we can begin to work again.
With Alice, for whom splitting is a primary mode of defense, and
self–experience can be dislocated and eminently un–known, I find that
my attunement is the fundamental crucible within which the work and
meaning itself are tested (see Charles, 2001). Given the as–if nature of
self, experience, and expression, attunement to the communication and
the affective tone is often my most useful resource in tracking meanings
in the moment, and also helps me to sense how, when, and in what ways
these meanings mi gh t b e o ve r t ly a d d r e sse d . Tr an sf e r-
ence/countertransference experiences are fundamentally tied to con-
structive working through in analysis. As Pick puts it: “I wonder
whether the issue of truly deep versus superficial interpretation resides
not so much in terms of which level has been addressed but to what ex-
tent the analyst has worked the process through internally in the act of
giving the interpretation” (1997, p. 352).
278 CHARLES

The analyst’s attunement and willingness to be deeply self–reflective

help to build a space in which there is the possibility of real coexistence,
without the need to annihilate aspects of self or other. In my work with
Alice, I am profoundly aware of the hazard of finding myself too far out
on either edge of the split she invites. I attempt to attune to the varied
threads of affect and avoidance as they play out within the sessions, so
that I can better track Alice’s affect through my countertransference and
invite her to speak to whatever threads have become background in a
given moment. Acknowledging her ambivalence and inviting her to
speak to it helps to ground my recognition, so that it might be more use-
ful to her in her attempts to ground her own experiences of self and other
more adaptively.
Over time, if we attend quite pointedly to the subjectivity of the other,
we are better able to play out and thereby to recognize the prosodies of
relationship and the salient themes that organize the other’s object
world. Freud (1914/1971) notes that the tendency to reenact the patterns
experienced in our early years represents important attempts to repair
the damage; to resolve the conflict. With Alice, I have needed to be able
to attune myself to the patterns that are being reenacted in the relation-
ships in which she becomes embroiled. I then see more clearly how the
individuals to whom she finds herself drawn often bear an uncanny and
discomforting resemblance to her descriptions of her mother. In one re-
lationship, in particular, she recreates the diffuse boundaries between
self and other that characterize her relationship with her mother. In this
relationship, however, the “mother” figure is more benign. Alice re-
ceives more sustenance and feels as though she is better cared for. What
also becomes clear, however, is how Alice places herself at the mercy of
this woman in her unwillingness to bring her own distinct voice to the
fore in the relationship. With no clear definition of her own needs or de-
sires, Alice’s wishes become the silent voice in the relationship and her
mounting unmet needs become a silent scream, in re–creation of the es-
sential dilemma of the mother–child bond. We are back inside the dream
in which she searches for home but inevitably finds herself outside, be-
ing found wanting; picking up the fragments of debris of broken dreams
and lost hopes, desperately seeking an impossible rebirth.
Although Alice laments the lack of recognition by the other, she is also
so afraid that recognition would be deprecating that she cannot make
any explicit or direct demands. Her needs then become apparent indi-
rectly, as deficits that are left unfilled. She becomes a characterization of
her complaint: the empty chasm that cannot tolerate the ingestion of
food; the helpless victim of her own inability to sustain her life. In this
way, it is her helplessness that is communicated most directly. Indi-
rectly, however, the underbelly of this communication is like a very
SILENT SCREAM 279

sharp hook that embeds itself, as the assault upon the other hides behind
the assault upon the self. The hostility, thus hidden, is free to fester and
spread, creating its own alternative reality, in which not–eating pro-
vides strength, and refusal to ingest is an act of self–vindication.
In this topsy–turvy universe, Alice has gone through the looking glass
and bad is good and good is bad. I see how difficult it is for her to main-
tain any coherent or adaptive sense of direction in these odd spaces she
has created, and suggest to her that she might need to construct a legend
to her own map of the universe, so that she might be able to locate herself
sufficiently to discern in which direction she is heading. If she would
truly like to have a life, I tell her, she will need to make decisions based
on the values that she chooses to assign, rather than becoming lost in this
treacherous universe that parodies her relationship with her mother, in
which living is achieved through dying.
This type of confusion regarding self and other and living and dying
can be seen as a function of having bonded with an unavailable other.
The defenses and modes of being that are built on this shaky foundation
become a desperate attempt at cocreation of the self through whatever
path has been offered. For Alice, being alone is experienced as a vacuum
that must somehow be filled to titrate the terrible anxiety and despair.
The price of engagement, however, is the abdication of self, at best. At
worst, the prerequisite of being with an other who uses one as a self–ob-
ject becomes the annihilation of self. In quasi–relationships such as
these, there cannot be two people: one must sacrifice one’s separate-
ness—one’s self—as the price of acceptance. One is in an impossible di-
lemma in which one cannot be self, and yet one cannot be other: other-
ness is despised and demonized in recursive projective identifications
that seem to extend toward infinity, in terrible experiences of emptiness
and annihilation. Even if one were to aspire toward the idealized vision
of the other, success becomes failure: one cannot be one’s self and be
valued; one cannot be other and still exist.
Dependence on the other can be deadly if one cannot be valued. With-
out faith in one’s own value, the search for recognition becomes a search
for misrecognition. We become caught in the mires of our own internal
deceits, in which truly discovering one’s self may be the greatest fear.
Caught in that odd universe through the looking glass, we literally can-
not recognize self as self. We are then persecuted not only by the bad as-
pects of self that have been split off, but also by the fear that the good as-
pects of self that have been deposited into the hands of the other for
safekeeping are not really ours at all.
Alice’s foundation seems so ephemeral to her that at times she literally
has no faith in it. My faith in her then too easily becomes a dangerous se-
duction, a function of my demands upon her rather than a real reflection
280 CHARLES

of self. In these moments, it is difficult to get our bearings: the world has
turned on end and often I can only point to our position in the conceptual
landscape and affirm that we are, indeed, upside down once again. As I
try to get my own bearings in these moments, I know that I cannot save
her preemptively: the choice must be hers. Any value must be built on her
own foundation. She will have to find her own internal compass, I tell her,
and make her own decision as to where she would like to be; what are to
be her values, her ends. Otherwise, we find ourselves locked in a battle for
psychic survival that is built on fictions so densely warded off that we can-
not even encounter them. They seem, rather, to loom or to intrude upon us
in ways that evoke anger, fear, panic, or other ways of not–seeing.
I speak to Alice of what I do see. There, before me, is the incredibly poi-
gnant and lovely pietà figure with her vast, silent scream. There, in an-
other moment, is the pitiful child who is lost completely in the wilder-
ness. There is also, however, underneath these more ego–syntonic
images, the arrogant Alice who enjoys these portrayals in which the
other is seen to be inevitably lacking; who enjoys being used so that she
can point her finger in accusation. The part of her that affirms herself by
demonizing the other is a deadly ally that leads her further and further
into acts of self–harm and self–annihilation. She acts out the fear that it is
the Alice–who–knows who must be killed, lest the world shift once
again and she becomes the bad object. Yet, clearly she cannot survive
without her own potency, which is tightly entangled with her rage.
Without acknowledging the rage, we cannot find her agency, with
which she might extricate herself from the trap she has set. In any given
moment, I do not know whether she can tolerate the exposure, whether
my faith in her potential can be realized or whether she will have to
de–create it in order to reestablish her own deadly order.
In this moment, my faith in Alice pays off. Her silent scream gives way
to a silent rage that I interpret to her. I cannot afford to turn a blind eye in
our work together, but rather try to accept all aspects of her as integral
parts of a whole and viable being. After one particularly difficult ses-
sion, in which Alice had been at her most desperate and despondent, she
reports back to me of her anger at me that had been raging internally
throughout the session. She had not wanted her anger and hostility to be
known. In reaction to my recognition of her unacknowledged hostility,
she said, she had found herself directing it at me, “the one person to
whom it did not really belong.” This experience was disjunctive and dis-
turbing to her, which provided an opening for a profound shift. This
type of experience of defamiliarization (Miall & Kuiken, 1994) helps us
to look anew at what has become invisible (see, for example, Symington,
1983; Parsons, 1986), helping Alice to see her actions—and her
world—in a new way.
SILENT SCREAM 281

My unwillingness to “buy” the act, while also acknowledging the pain

and the rage, reordered Alice’s reality and gave her an opening, an op-
portunity to do things differently. This opportunity seemed to arise
from an encounter with what Bion (1977) calls “O,” and Lacan (1978)
calls the “trauma of the real,” which provides, paradoxically, a simulta-
neous destabilization of the extant reality while being anchored quite
firmly in the “real.” My recognition of truths that previously could not
be held offered new possibilities of truth and of relationship. Thoughts
that had been occluded from view could now be explicitly known, rather
than being hidden under layers of deception and deceit. Perhaps most
importantly, I had taken a stand regarding the importance of Alice being
“the one who knows,” actively opposing her willingness to abdicate her
own subjectivity.
In the next few days, Alice found herself setting limits in the very re-
lationships in which this had seemed most impossible. Rather than act-
ing out her anger passively by tolerating the abuse and then belittling
the abuser, she is setting limits on the abuse. She feels, she says, as
though she is “in training for the battles to come,” in which she will
have to demand to be treated as a whole and viable human being,
rather than resorting to the submissive victim role to which she tends to
revert. She acknowledges the part of her that still struggles; that
crashes. I accept this part. She will have to accept it as well, and to learn
to live with it in more adaptive ways rather than exacerbating it as a
means toward salvation. She will struggle, I affirm, but she can keep
her struggles more private, rather than allowing them to leak into her
working life and sabotage what she is trying to build. She can be hu-
man and also be viable.

CONCLUSION
Infant observational studies show how the capacity to confront and
engage with the world facilitates development. Our ability to use our
own experience and to moderate our perceptions in line with reality con-
straints in adaptive ways is fundamental to the ability to build a self. In
contrast, excessive anxiety leads to rigidity and a lack of permeability
between conscious and unconscious, impeding coping, symbolization,
and integration. Severe deprivation impedes the ability to effectively
mark or to receive goodness, and to make crucial distinctions between
self and other and between internal and external sources of danger and
disequilibrium. When internal and external sources of danger are con-
fused, real self needs may be abdicated in the hope of repairing the other.
At the extreme, self–denial and injury become the ultimate gift, in hope
of reparation. If the underlying hostility remains split off, self–harm can
282 CHARLES

become a very dangerous manic defense, in which the analyst can

become complicit.
When early objects have been toxic, it is important to be able to come
into contact with a real human being who can tolerate good and bad as-
pects of self and other. In our consulting rooms, we can provide an envi-
ronment in which one might more safely become one’s own frame of ref-
erence without destroying or being destroyed by the other. The analytic
relationship provides a means for coming to terms with one’s own sub-
jectivity, for internalizing a more adaptive sense of self, other, and rela-
tionship, and building a stronger and more resilient self.
The struggles between constructive and destructive impulses can be
quite taxing. As we see with Alice, the potency of the destructive im-
pulses can reach a point such that life–enhancing activities are fore-
closed. The ensuing resolution may then take the form of what contem-
porary Kleinian theorists have termed “narcissistic” (Rosenfeld, 1971),
“defensive” (O’Shaughnessy, 1981), or “pathological” organizations
(Steiner, 1990, 1997). This type of organization may be seen as an interim
state in which the individual is caught between the fragility of the ego
and the intensity of the anxieties, resulting in the type of oscillations be-
tween exposure and restriction found in the symptoms and relation-
ships of individuals with eating disorders (O’Shaughnessy, 1981).
On the one hand, this type of position can be very refractive to treat-
ment, particularly when the destructive aspects are highlighted and
linked with envy. The envy then too easily aligns with the powerful
parts of the destructive other as a means for psychic survival (Rosenfeld,
1971). On the other hand, this type of an interim position may at times of-
fer some respite from the fragmentation and confusion of the para-
noid–schizoid position, and from the anxiety and anguish of the depres-
sive position (Steiner, 1997). Although this defensive organization may
be characterized as a kind of no–man’s land in which no growth can oc-
cur, within the containment provided by the analysis it may also enable
the ego sufficient respite that growth is eventually possible
(O’Shaughnessy, 1981). With individuals such as Alice, there is always a
tension between the terrors of growth and the devastation wrought by
evasion.
“I feel like this is a major problem that I can’t just keep thinking is go-
ing to get better,” Alice tells me. “Every day I get up and swear that it’s
going to be different, and every day I fail. I just don’t know how to make
this any better.”

1. Reprinted with permission, © W.W. Norton.

SILENT SCREAM 283

I take this in and an image comes vividly to mind. “Adrienne Rich

[1981, p. 591] has a poem called ‘Turning the Wheel,” I say. “It begins:

‘The road to the great canyon always feels

Like that road and no other. . .’

but then she goes on:

‘Today I turned the wheel, refused that journey . . .’”

“Sometimes we turn the wheel,” I say. “We take a step sideways, in

another direction. Sometimes it’s almost the same direction, but not
quite. It’s a step.”
In my work with Alice, I am always perched at the edge of the split she
so easily invokes between good and bad, between hopelessness and pos-
sibility, and between what may and may not be known in a given mo-
ment. My task is to acknowledge her current limits while also repudiat-
ing their inevitability and to believe in her viability without leaving her
at the mercy of her incapacity. There is always a choice, I tell her, and it is
important to be able to make a better choice, to mark every success, no
matter how small. For it is the ability to mark meanings, to track experi-
ence, and to celebrate small successes upon which a life is built.

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