Containment, affirmation and structural deficiency – revisiting an issue in psychoanalytic method

ABSTRACT The aim of Freudian analysis was to recover repressed memories, phantasies and wishes and make them conscious. This was the basic principle of analytic cure, and the means was interpretation. During the last 5–6 decades, analytic method has been supplemented by types of interventions addressing the relationship between therapist and patient. New kinds of intervention aim at adapting to the patient’s developmental level and capacity to profit from interpretations. These interventions seek to establish (new) meaning, not to uncover hidden meaning. A special point concerns a combined type, where an interpretation is wrapped in an affirmative form. The authors discuss this development and focus on the concepts of containment (Bion) and affirmation (Killingmo). They are developed from different models, but in spite of this, their aims seem to be similar; to remove doubts about the experience of reality and establish new meaning, thus preparing the way for interpretation of unconscious material. Two clinical vignettes illustrate some of the challenges facing the analyst in dealing with these dynamics.


Introduction
From the start, the main psychoanalytical intervention was interpretation of unconscious psychic material.Developing during the last five to six decades, this method has been supplemented.In an overview of this development, Gabbard and Westen (2003) separate three types of intervention: those fostering insight, those addressing aspects of the treatment relationship, and secondary strategies appearing to be useful.So, qualities of the relationship have become an important element in the analytic cure, and interventions concerning the relationship have supplemented interpretation as therapeutic action.A special point concerns the combination of interpretation and relational intervention with a view to the patient's type and level of pathology.Our point is that the patient's state often consists of a combination of relational (developmental) failure and intrapsychic, neurotic conflicts, calling for combined forms of intervention.
In previous discussions of these questions, different related concepts have been used for this extension of analytic technique.Steiner (1994) has discussed a kind of interpretation that addresses the patient's thoughts and feelings about the therapist's state of mind.For instance: You are afraid that I will, or you think that I will, interrupt the treatment without notice.Such interpretations are analyst-centred in Steiner's sense.They communicate an understanding of the patient's feelings and thoughts about the therapist and the treatment situation.Levine (2011), in his paper on Freud's Constructions in analysis, discusses aspects of this development.One of his points is that where Freud aimed at construction of past events and repressed memories, contemporary analysis, in addition, attempts to construct 'aspects of the patient's affective experience of the here-and-now interaction in the analytic relationship' (Levine, 2011, p. 94).The aim is to help the patient mentally to represent and to symbolize inchoate proto-emotions and intolerable states.Levine notes that this is central in treatment of non-neurotic patients with reduced capacity to represent mental states.So, the work of construction is extended to include un-represented states in addition to repressed states.
Feldman, in his paper on reassurance (Feldman, 1993), is touching upon closely related treatment problems.He notes that attempts to reassure the patient easily turn to countertransference enactments, making the patient anxious about the analyst's ability to tolerate the activated emotional state.Referring to an example of this reported by Melanie Klein, where she tries to reassure a patient, he states: . . .what the patient would actually have found reassuring would have been to encounter an analyst who was able to understand and to bear the patient's and her own anxiety and pain without trying to give an apparent reassurance to her young patient or to herself . ... (Feldman, 1993, p. 279) Here, Feldman describes an attitude quite similar to containment and gives a precise formulation of what in our opinion is the very essence of the extension of method that we are going to discuss.
We will base our reflections primarily on two concepts, containment (Bion, 1962a(Bion, , 1962b)), and affirmation (Killingmo, 1989(Killingmo, , 1995(Killingmo, , 2006)).We note the similarity between the conceptions we find there and in Steiner's and Levine's discussions, and also the similarity between Feldman's and Bion's formulations.However, first we turn to the question of varying levels of pathology.

Developmental structural failure -intrapsychic conflict
We will base our understanding of the patient's mind on the distinction between developmental failure -also named deficit pathology -on the one hand, and neurotic pathology -also named conflict pathology -on the other.In a seminal paper, Killingmo (1989) gives a comprehensive presentation of differences, experiential and functional, embedded in this distinction.
Developmental failures come to the fore as structural disturbances and deficits that are intrasystemic, mainly affecting the ego.Often, we refer to these states as more severely disturbed functioning.When this is a dominating state, it corresponds roughly to personality disorders.These patients suffer from various degrees of basic existential problems, like feelings of emptiness and meaninglessness, amorphous feelings of shame and guilt, and feelings of confusion and loss of identity.They often use what we call primitive defences, like splitting, denial and projective identification, and they may suffer from anxiety of fragmentation and loss of control.This can be experienced as fear of becoming psychotic.
Neurotic pathology refers to states dominated by structural, intrapsychic conflicts.Contradictory feelings are experienced as ambivalence, that is they are allowed to exist side by side.Thus, feelings of love and anger for the same person may be present at the same time.This is in contrast to splitting, where one of the opposed feelings is denied and the one that remains conscious often is exaggerated.The defence mechanisms are more advanced; repression, isolation and reaction formation prevail in neurotic states, and anxiety often concerns guilt, loss of love and castration.The person's basic feeling state is rather marked by frustrations and unhappiness than by emptiness and meaninglessness.
On a neurotic level, patients usually wish to understand themselves.They are curious about their own experiences, and want to see and understand their own role in what happens to them.They experience themselves as acting and responsible agents in their own life.In Bion's language (1962aBion's language ( , 1962b)), they are curious and want to learn from their experiences.These states roughly correspond to Klein's (1940) depressive position.The patients are ready to accept, and profit from, interpretations uncovering hidden and repressed meaning, and to extend and deepen their self-knowledge.
All patients have a need to be understood.However, if this need dominates and is not combined with willingness to take an active part in the process of understanding, it gives little space for curiosity and readiness to learn from experience.The patient will to a lesser degree experience himself as an acting agent in his own life, and tends to consider himself as a victim to unfortunate events and circumstances.The responsibility for his pain and suffering lies outside himself.These states roughly correspond to Klein's (1946) paranoid-schizoid position connoting more severely disturbed mental functioning such as personality disorders.
These patients have problems to represent feeling states meaningfully in symbols and words and have reduced curiosity about their situation with weaker capacity to learn from their experiences.They may not seem interested in discovering things about themselves and to deepen their self-knowledge.
Therefore, interpretations aiming at uncovering meaning will miss the target and leave the patient unaffected.These patients are using their therapy for other reasons than to gain insight into their problems.Their main concern may be to obtain relief and security, not to understand themselves (Killingmo, 1989;Steiner, 1994).
A third type of patients, outside of this conflict-deficit scheme, do not even want to be understood.In Steiner's words (1994), they seem to hate the very idea of being understood.But, if so, why do they seek psychotherapy at all? Steiner notes that even if they reject the meaning of therapy and deny the need to be understood, it seems that they need the therapist to register their misery; to have it recognized by him.An additional reflection may be that we have to do with a reduced capacity for containment combined with massive denial of misery and psychic pain.These patients seldom seek analysis or psychotherapy.If they do, however, a reason could be that they, in spite of the denial, feel their deep misery and lonelinessand their need for understanding and help.
The distinction between developmental failure on one side and conflict or neurotic pathology on the other is, of course, an abstraction, facilitating the formulation of a model for therapeutic action.It is just one dimension in the complex landscape of mental problems and disturbances.In reality, the picture is more diverse.In addition, severe developmental failure and neurosis may be considered as poles on one dimension of mental development, and the patient's position on this dimension is not fixed.It is dynamic, dependent on the interplay of inner and external forces (Killingmo, 1989).In the clinical situation there are several possibilities to have in mind: (1) A variation between individuals concerning the structural level of personality organization.Here, we have to do with traditional diagnostics: neurosis?personality disorder?psychosis?(2) A variation between different areas of the personality of an individual.This requires subtler diagnostics; personality as a profile of varying levels of organization, a case formulation.
(3) Fluctuation from moment to moment, in the patient, of what is prevalent in the transference.
The therapist has to adapt his therapeutic strategy to the dominating quality of transference.(4) The most frequent case is perhaps a weaving together of different levels of structural organization in the same mental material; pre-oedipal elements are entering the weft of oedipality, or dyadic and triadic relations are mixed in the same emotional state.
So, interventions have to be adapted to changes from moment to moment in the patient's state, and to intermediate states, where elements of structural failure and psychic conflict coexist.This call for interventions combining elements of interpretation in Freudian and affirmation in Killingmo's form; interventions given in an affirmative form.
In two short vignettes, we will illustrate our way of thinking.The first patient mainly functions on deficit level.The second functions more on a conflict level, but mixed with elements of deficit pathology, i.e., oedipal (triadic) and pre-oedipal (dyadic) dynamics are intertwined and the interventions are formulated to communicate with the patient's combined level of function.

Mr J
The patient, a young Chinese, spent his first years with a depressed mother.We have reasons to believe that her capacity for reverie was reduced, leaving her son without support to develop a secure identity and without protection against his infantile anxiety.The result was a partial developmental failure, deficit pathology in Killingmo's terminology.
Mr. J was referred to psychotherapy for his mental problems in his first term at the university and was offered analytic psychotherapy, two sessions a week.The sessions are from his third month of therapy.He surprised his therapist (T) by insisting to talk English instead of Chinese.J reported constant feelings of meaninglessness and loss of contact with reality, and he was unable to mobilize motivation, interest and energy in his daily life.He had been diagnosed with depression but anti-depressant medication did not help him.He was convinced that nobody could love him and he could not feel real love for anybody.
J was born in an English-speaking city and his mother suffered from postpartum depression.When he was 7, his parents moved back to their home town.Soon after, the parents got divorced and his mother became depressed again.Meanwhile, J was bullied at school but his parents were not informed about this.A year or two later he moved to his father in another city.
T could feel the deep anger underneath J's emotionless poker face, an anger about being misplaced!She said I can understand that you are angry and feel misplaced.This is not your choice and you feel stuck.After a short silence, J talked about his anger towards his father, who did not support his wish to study abroad.It was such a disappointment.He thought that he would feel renewed in an English-speaking environment.He was angry at the university, claiming to use English as teaching language, when in fact his classmates used Chinese all the time.I am stuck here for four years.It is total waste of time!I will learn nothing here.It is totally meaningless, he complained.T reflected Yes, you are angry because you feel that both your father and the university have failed you.
We may wonder whether this strong insistence to use English language has to do with some English talking person, a nurse or domestic help, who gave him love and attention very early, when his mother was depressed and absent; a good object who suddenly disappeared, leaving him alone and desperate.
J repeatedly dreamt about being surrounded by skeletons and zombies, and he angrily stabbed them in the eyes.However, he was not curious about the meaning of his dreams.He suffered in silence.T tried to connect the dreams with his experience of his depressive mother: Obviously someone is dead, and you are angry, but also terrified that dead eyes can't see you.J rejected this, and we note that interpretations do not seem to help him unless T first contains his pain.She has to find a way to connect to him, getting in contact with his suffering.
They talked English; J insisted that he could not speak Chinese and that his pronunciation was funny.Besides the identity issue and the protest expressed this way, there is something more related to the question of language.None of them has English as their mother tongue, and T noticed how the words could feel different from Chinese in describing inner states.This makes it hard really to own your feelings.At one point, J complained that language -Chinese and English alike, we have reason to believe -created difficulties for him.He was convinced that it was impossible and meaningless to try to connect to others.Then he added that he was weak, uninteresting and completely incapable.He was desperate; all he could do was to wait for death to find him.T tried to capture the essence of this desperation, sharing her empathy directly: It is painful when we can't find the right language.We feel our experiences remain unnamed, and thus unknown, not owned.And it is a great pain to be unnamed and unseen.J looked up, there were tears in his eyes.In that moment, T felt that she had reached him for the first time.
In her wording, T directly shared J's experience; 'we can't find . ..' and 'we feel . ..'.If the therapist is able to impart her own experience of despair and her capability to endure it, and the patient to receive the full message, we may perhaps have an example of containment in Bion's sense.J's response points in that direction.

Mr B
The weaving together of different levels of structural organization is prominent in the next vignette that we will present.The patient basically functions on a neurotic level.Simultaneously, symbiotic, dyadic elements from his early mother relationship are activated beside his complex oedipal triangle.The interventions presented try to take this complexity into consideration.
Mr B, a young man, was passionately involved with his family members (mother, father, and younger brother).He felt that his father was devoted to his sons, but he could also be rough and condescending.B was very fond of him.Mother was an active and busy person, and he was tortured by the suspicion that she loved his brother deeper than she loved him.To counteract this feeling of abandonment, he developed a false self and tried to be a kind, clever, trustworthy boy that his parents really could rely on.
Separation anxiety and inhibition of aggression are central elements in B's character.The vignette is from his second year in four sessions a week analysis.
At this time, his ex-girlfriend, (K), had become pregnant with her new partner and thought of abortion.She and B had separated 2 years ago, but they still stayed in touch.B was beside himself.He was to blame for this.He had ruined her life.Now he had only one thing to do: marry her!He is the only man who can make her happy.And he added: The thought that she gives birth to that child makes me mad.I can make anything to prevent it.I hate that child.The thought of the child activated his separation trauma, when his brother was born and stole his place in his mother's arms.We can see how this situation disturbs him.He loses his sense of reality.What K herself thinks about her pregnancy or the prospective father's role, is irrelevant to him.Facts are drowned by the catastrophe he experiences.
In the following weeks he was tortured by fear of dying.He dreamed that his heart started beating slower and slower, and that he was really dying.He tried to call his mother, but nobody answered and he died.He woke up, in deep anxiety.
In one of these sessions, a young colleague of T (the analyst) overlooked the 'occupied' sign on the door and entered the room.He immediately realized his mistake and withdrew.B's reaction was very strong.His face was white with rage.He could kill that man!His death-wishes towards his rivals; his brother, his ex-girlfriend's expected child, this man invading the room in his session, were close to consciousness, and T tried an interpretation: Even if you have nothing to do with her pregnancy and abortion, it feels like your own unforgivable crime.The reason can be that it activates your reactions when your mother gave birth to your brother.You love your brother, but at the same time he took your mother from you.Your anxiety and rage over losing her made you wish him dead and gone with the same violent rage you felt yesterday, when this man entered the room during your session.
B was moved.He first tried to hold back his tears.Then he cried from his heart, and T could after a while hear a release in his weeping.T added and you have been totally alone with these feelings, thinking that they were unforgivable, mortally sinful.He went on crying and calmed down only slowly.By the end of the session, he said that for the first time that he wished that he could have stayed longer; what he experienced in the session was terrible, but it was also a release to be given words to this inner state and to share these feelings with T.
The interpretation of his death wishes towards his brother is formulated in a supportive and affirming way.It helps him to experience his despair and his grief.The aggression is only partly experienced, and it has not fully entered the transference relationship.Also, his submissive attitude towards T is not yet worked through.
B reported that his obsession with K's pregnancy disappeared after this session; so did his fear of dying.The agony followed a pattern.When his rage was activated, it was first turned against himself -in the form of death anxiety.When he managed to feel that the rage was his own anger, his fear of dying disappeared, sometimes quite suddenly.
In one session he thought of a scene at the hospital, when his brother was born.He remembered his mother: She was so happy, with his brother lying there, a small rosy lump.He could see the scene.Full of enthusiasm, he had jumped into the bed, and his mother shouted No, you are not allowed!His father pulled him out of the bed.He had described the incident before, but now it was clearer to him.He remembered not only that his father pulled him out of the bed, but also his mother's strong No!He started crying in despair, losing his breath, tugging his sleeve.After a while, T said You can feel the pain in your heart.He responded: Yes, and there is anger too, anger at my mother, at my father, at my brother . . .I could beat him, kill him . . .and at you, sitting there looking down at me in my misery.
He was really beside himself, and T said: It is this anger that you connect with malice.But today we have seen how your anger has a direct connection to your intense disappointment and despair about losing your place in your mother's bed.This is another example of an affirmative interpretation, where his feelings are interpreted and acknowledged and his death wishes are placed in a meaningful context.
The next session, in a second thought, he reflected on what he had been through; how impossible it is to develop your self-knowledge by reading.This wish to get rid of his brother now he could feel it was real.If this had not taken place in T's room, he would have thought about it as something supernatural.He saw the scene at the hospital so clearly -in details, colours, shades.He could still feel the scent of the grapes on the table.

Interpretation
In Freud's psychoanalysis, neurotic symptoms were rooted in repressed memories, feelings and wishes.The cure consisted in lifting the repressed from repression, making it available to consciousness, and the means were interpretation and construction (Freud, 1937).Construction referred to the presentation of a piece of forgotten history to the patient, e.g., the complex reactions to the birth of a sibling.Interpretation referred to the handling of a single element in the material; the meaning of a dream, a repressed memory, a peculiar action, a strange feeling state or an exaggerated reaction.Today, this conceptual distinction has more or less been lost, and we use interpretation for both cases.
Interpretations are usually preceded by preparatory steps before they are formulated to the patient.Confrontation, demonstration and clarification usually are such preceding steps.However, as we can see from the clinical vignettes, the field has been extended.Also, empathy and our efforts to understand what is going on prepare for the interpretation together with affirmation and reflection.In such ways we try to pave the way for the interpretation and assist the patient in the efforts necessary to overcome the repression.When the repression is lifted, the ego has moved a mental element from unconsciousness and made it available for conscious work.

Containment
Bion's introduction of the concept container/contained came in steps.In his theory of thinking (1962b), he made a distinction between frustrations that were tolerated and those that were not.Such a distinction was first made by Freud (1917) in his discussion of mourning and melancholia as reactions to loss.Only when reality, the loss of the loved object, is accepted and tolerated, the individual can transform his experience into a symbolic, or mental, state.Only then, he can start a work of mourning or thinking about it.If the experience is not tolerated, these mental elaborations will not take place and the state is denied or projected.In Freud's words, the individual enters a state of self-condemnation and melancholia instead of working himself back to his earlier life through a work of mourning.
Freud did not develop this thought, but Bion does.He chooses the hungry infant as an example to describe what may happen.If the child tolerates the absence of the breast, the experience can be transformed to a thought, and the formation of an apparatus for thinking can begin.If the frustration is not tolerated, the result is projection or externalization instead of thinking.This is close to Bion's later conceptualization of mother's reverie as a response to the child's anxiety, and to container/contained in the analytic relationship, but he does not introduce the terms in this paper.
Bion's second point of departure is Klein's concept projective identification.In his reference to this (1962a, p. 90), he says that Klein described an aspect that was concerned with the modification of infantile fears.The infant projects its bad feelings into a good breast.There they are modified, becoming tolerable to the infant's psyche, and can be re-introjected.Bion does not give a specific reference to Klein, and we have not been able to find this formulation in her texts.However, Bion here gives a precise description of the model of container/contained, the way he himself developed it.And he does it in a way that is highly relevant for psychoanalytic technique as a complement to interpretation.
The way Bion discusses his ideas and models, his extensive use of abstractions and symbols, makes it necessary for readers to develop their own understanding of his thoughts.This gives space for disagreements and also for diversity -and richness.After all, nobody can make use of concepts that he himself does not understand.Here, we present our interpretation of Bion's container/contained model for analytic treatment.
Containment refers to sharing and tolerating the patient's pain in a way that helps him or her to tolerate and experience his own (painful) states.Empathizing with and understanding the patient's feeling states, maybe even combined with a 'test-identification', are elements in the container/contained process.The containing function presupposes an inner work of the therapist, a kind of mental metabolisation, the result of which is transmitted to the patient.It can be described as a process with the following steps: • The patient projects into the therapist a state that is intolerable.
• The therapist experiences the state as exactly that, intolerable.• The therapist does not evade the discomfort, but tolerates this painful state; it is recognized, accepted and shared with the patient.(Here, to share means to feel the patient's pain as if it were one's own; deep empathy.)• By being tolerated, the painful state is modified (or metabolized) and may become tolerable.• The patient can re-introject the split off, projected part of the self and extend his self-knowledge.
In this process, the patient's capacity to tolerate psychic pain and frustrations is strengthened.
The result is that an inaccessible state can be moved into consciousness, and become subject to mental work.This is Bion's α-function, transforming β-elements (somatic, undigested states) into α-elements (mental, symbolised states).This strengthens the patient's capacity to learn from experience and makes development and growth possible.
The containment function demands that the therapist endures the patient's dissatisfactions, anger, projections and misconceptions, however unreasonable, unjust and unwarranted they may be.He also has to contain his own counter-transference reactions and resist his wish to retaliate.When this works well, the patient can feel contained.He can feel relief and becomes able to identify with the therapist's capacity to think, and he can apply it in his own life.So, we can see the crucial part played by containment in the therapeutic process, when conceived in this way.We can also see the fatal effects if the therapist does not endure (and contain) the projections; the patient will feel misunderstood and attacked, and the effect may be more extended splitting and stronger projections.
Containment brings relief, a feeling of being understood and respected, of not being alone in one's misery.However, it does not necessarily result in growth and development (Steiner, 1994).The patient needs to integrate the therapist's capacity for containment into his own way of handling mental pain; eventually managing his life without the support of the therapist.Perhaps this is what structural change in analytic therapy means: the ability to make the analytic process continue after the termination of the therapy; to apply more adequate ways of handling new challenges, whenever they may arise after termination of the treatment.In line with this thinking, Stänicke and Killingmo (2013) have described a specific qualitative changethey called it object trust -as a product of the patient's experience of being contained, and not primarily having his repressed material interpreted.For the patient, part of this process is of course concerned with the termination of therapy and the separation from the therapist.This means to be able to handle the loss of the therapeutic relationship and to be able to mourn this loss.

Affirmation
Affirmation, in Killingmo's conception (1995Killingmo's conception ( , 2006)), has the same aim as containment; to strengthen the patients access to and comprehension of unmentalised and unsymbolised states.This may be promoted when the patient feels that he is seen, understood and respected by the analyst, and when his doubts about reality are accepted.So, the intervention aims at making the patient feel secure and inspires him to take a step forward and become interested in understanding himself.To be able to become curious about himself, he has to tolerate the mental pain that is often connected to insight.This tolerance of mental pain and frustration approaches the meaning of Bion's containment.
The analyst can express an affirmation by stating: Yes, I understand that this made you confused, or This situation is really not possible to understand, at least not for a child.Killingmo notes that the tone of the analyst's voice may be as important as the wording.Affirmation may also work as a silent background, where the analyst's presence and way of listening are validating and supporting.Again, we can see the affinity of this attitude to containment, where the analyst's silent, inner work with the patient's projections is emphasized.
When we try to describe this attitude, similar words come to mind for affirmation and containment; emotional presence and listening, empathy, attempt to identify with the patient's state.With respectful accept we try to come close to the patient's state.
Affirmation aims at weakening the patient's doubt about how to understand situation or a state.Thereby, the patient can strengthen his feeling of identity.We try to help the patient to feel more secure in his understanding of reality, and be inspired to understand himself, not just passively be understood by others.Also, Bion says that containment aims at removing doubt about our life conditions, opening ourselves to curiosity and capacity to learn from experience.
In Killingmo's second paper on affirmation ( 2006), the affinity to containment is still more obvious.He discusses the same phenomena as Bion, psychosomatic states marked by deficient mentalization.Somatically based affects do not get into contact with meaningful, emotional self-representations.The patient does not experience feeling states as his own.Therefore, interpretations remain meaningless.Bion could have said the same thing, in somewhat different words.Both containment and affirmation aim at helping the patient to create a meaningful relation to unmentalised, somatically based affects.
The work of interpretation is to make conscious that which is unconscious.The work of containment and affirmation is to change a state that is unmentalised, and therefore meaningless, into something that has a meaning and therefore can be part of the consciousness.This transformation is in our view necessary to make interpretations useful to the patient.Only what is mentally represented can be subject to interpretation.Some patients are capable of performing this transformation themselves, others need the help of the analyst.Somewhat simplified, we can say that containment and affirmation transform bodily states into mental states, thus making them open to interpretation.In this view, the cure of psychoanalysis is a result of the combined work of these two functions.

Affirmation and containment. Related phenomena, different theoretical bases
Obviously, affirmation and containment refer to related phenomena.But how are they related conceptually?
Killingmo does not refer to Bion in his two papers on affirmation, but he does so in Conflict and deficit (1989).There he suggests that containment is subsumed under the heading of affirmative interventions.One of us (Zachrisson, 2021) has proposed the opposite view, that affirmation can be considered an element, a precursor, of the containment process.In this paper, we consider them to be equal, but based on different personality models.This has to be explained.
Shortly, and running the risk of making complex things too simple: Bion's background is Klein's object relation model in combination with clinical work with psychotic patients.The concepts of projective identification, evacuation of psychic pain, somatic anchoring of unmentalised states are central in his thinking, together with his developing central Freudian concepts.His model is based more on dynamic than structural elements.Containment is more expression of an attitude, a way of listening and a quality of presence, than how we formulate our interventions.
Killingmo has come to object relation theory from ego psychology and from character analysis, the way it was developed in Norway, inspired by Wilhelm Reich.As a result, the concept of structure has a central place in his thinking.Intentionality, self and object representations, agency, inter-and intrasystemic conflicts and structural differentiation are elements in his model.Like Bion, Killingmo is solidly anchored in Freud's thinking.Also, affirmation is expression of an attitude, a quality of listening and being present.And Killingmo underlines the importance of the analyst's tone of voice.Nevertheless, it is easier to give examples of how to formulate an affirmation than to transmit containment.

A challenge
Let us return to the question of how to adapt the intervention to the patient's inner state and kind of pathology.How do we find a form that the patient can profit from?
For severely disturbed patients, functioning at more primitive levels, the therapist's containment is necessary.With them, need for affirmation and being understood often takes priority over their wish to understand themselves, and our treatment methods have to take this into consideration.Less disturbed patients may be able to handle interpretations and use them without further support from the analyst.Often, the response to the intervention may inform us of the effect, and help us to adapt to the patient's level of functioning.
However, we cannot settle down with a definitive diagnosis, and so offer a determined or manualised treatment.Often, the patient's state is not fixed or stable; it can change from one session to the next, depending on which conditions and relationships that are activated in the process.Furthermore, some patients are in an in-between state, where interpretation of forbidden and repressed wishes has to be presented in an affirmative way, and containment has to precede interpretation.
It is a challenge to handle this complexity.To keep a productive relation to the patient, a working alliance, we try to be in contact with the actualized state that is marking the transference for the moment.In the clinical vignettes, we presented some examples of such combined interventions.In this task, we have to rely on our therapeutic experience, scrutiny of countertransference feelings, empathic listening, perhaps also supervision.And do the best we can.

Disclosure statement
No potential conflict of interest was reported by the author(s).

Anders
Zachrisson is training and child psychoanalyst in the Norwegian Psychoanalytic Society, and associate professor emeritus, Psychological department, University of Oslo.He was editor-in-chief of The Scandinavian Psychoanalytic Review 1993-1997, and president of the Norwegian Psychoanalytic Society 2002-2006.He has been lecturing and supervising at the School for child and adolescent psychoanalysis in the Psychoanalytic Institute for Eastern Europe and in psychotherapy and psychoanalysis training programmes in Beijing and Wuhan.He was also member, first of the Sponsoring, and then of the Liaison Committee for Moscow Psychoanalytic Society Study Group, and is author of 25 articles on psycho¬analysis.A selection of these were published in 2021 in the book Psychoanalysis my way.Complex Oedipus and other issues.Mek Wong is PhD and clinical psychologist, University of Macao, the student psychiatric clinic.She has been in the staff of the Sino Norwegian training program in psychanalytic psychotherapy for several years.