Revisiting the Classics of Countertransference and Free Association

As far as I know Heimann was the first to expand countertransference from “transference on the part of the analyst” to include “all the feelings which the analyst experiences towards his patient.” She noted that feelings for another can be both transference feelings and “refer to another person in his own right and not as a parent substitute,” that is, “not everything a patient feels about his analyst is due to transference.” Moreover, Heimann noted, this countertransference was not to be eschewed, but to be used as an important tool to understanding the patient’s unconscious, stating that the analyst’s feelings in response to the patient are “the most dynamic way in which the patient’s voice reaches” the analyst. She evoked Freud and contemporary analyst when she wrote “the analyst’s unconscious understands that of his patient.” Heimann also stressed that the analytic situation is “a relationship between two persons.” [her italics]

Even if contemporary analysts then part ways with Heimann— who interpreted the psychological world through drive and defense and the structural theory, did not see enactments as inevitable, and may have over interpreted the transference and underemphasized attachment needs— we laud her relational use of countertransference and her intimation of its co-creation –here I give the benefit of the doubt that she could not help but see what came from the patient and was received by the analyst was a co-creation though she does not insert the ‘co’: “the analyst's counter-transference is not only part and parcel of the analytic relationship, but it is the patient's creation.”

Forty years later, Aron notes how psychoanalysis, as contemporarily practiced, often neglects the free association method. The classical technique of free association, unlinked from drive and defense and  updated  by a two-person psychology, remains useful, he writes, to avoid the pitfalls of the analyst’s being overly self referential as to transference and projective identification. While Heimann noted that the patient contributes to the analyst’s countertransference, likewise, in its converse, Aron notes, the analyst contributes to the free association of the patient. Aron does not, however, advocate an a priori bias toward interpreting implicit transference resistance nor toward interpreting the interactional impact of the analyst, but says that the analyst must follow the patient’s lead (associations) in deciding when and how to intervene. He concludes with : “The[free association] method presupposes that all that the patient says can be meaningfully tied together and shown to belong to a continuum of psychic life…”

Aron, .L. (1990). Free Association and Changing Models of Mind. J. Amer. Acad. Psychoanal., 18:439-459.

Heimann, P. (1950). On Counter-Transference. Int. J. Psycho-Anal., 31:81-84

Benjamin on Recognition and Regulation

In bringing front and center to psychoanalytic discourse the subjectivity of the mother (not just the mother as object to the infant), Jessica Benjamin, adding to Daniel Stern’s paradigm of play, elaborates the importance, the imperativeness, of mutual recognition in the clinical encounter. What an honor (made possible by a contribution from the Florida Organization for Relational Studies) to have such a gifted and renowned thinker at the December 7, 2013 local Tampa Bay Psychoanalytic Society program meeting.

Attachment and infant-caregiver research have shown that sharing of affective states, where one experiences and understands that another ‘feels the same as I do,’ co-creates a rhythm of interaction—what Benjamin calls the rhythmic third (formerly called the one in the third)—which diminishes existential fear and isolation. The rhythmic third, the up and down orientation of affect in the same direction— which is soothing in its recognition, lets the analyst, as well, know that s/he is not alone in the universe.

It is through recognition, of shared affective states, that affect regulation occurs. Intersubjectivity is the sharing of affective states. It transforms complementarity such that one can feel empowered  with a sense of agency because, not only is one recognized but, one can recognize the other’s feeling in a way that can be shared and creates joy. Mutual recognition can be effected and empowers the self by seeing the self as recognizer, more powerful than simply being mirrored (recognized). Benjamin says recognition and regulation are “twins,” that is, are interdependent. As such, mutuality needs to be in the foreground. Affect regulation is necessary but not sufficient, for we do not want only to keep affects within a tolerable, manageable range. We want additionally to create meaning, acquired within the communion of mutual recognition.

A cornerstone of mutuality is the recognition of impact.  It is the realization by the mother that the child actually needs to discover something about her responses, what it is like for her to be a real human being in a real world. Recognition adds to regulation when the analyst can manifest the impact of the analysand such that the analysand experiences both the analyst and her/himself as a subject with feelings and agency. Sometimes recognition of affects at all from the analyst is a new experience for the patient.

Incumbent on the analyst is survival (Winnicott) so that the analysand does not have confirmation of the fear that her/his feelings can destroy the other. Yet, as Benjamin notes, it is not always easy for the clinician to tolerate and bear the affective state of another, particularly the pull to despair. To help mark (Gergely ) –similar enough to help the patient know you are on the same page, but dissimilar enough so patient does not fear you yourself will be dysregulated and overwhelmed; the mother marks her response to the infant’s distress by showing that she is not distressed in the same way but also that she knows the infant is distressed— affect, Benjamin looks to the third.  By acknowledging what is happening [e.g. ‘Your expectation that I not disappoint you is not unreasonable, you deserve understanding; and yet I am not perfect and so cannot always live up to your expectation.’] creates  a sense of the moral third, a sense of a lawful world where meaning exists and, though expectations can be violated, attachment can be recreated.

Breakdowns in mutuality occur when complementarity prevails. It is as if only one can survive. It is the belief that only one subjectivity is in the room, as if the other is not allowed to have thoughts, or as if one is making the other feel something. This is a breakdown of the moral third where it seems the other can only submit or resist. Benjamin advocates the need for parents to implicitly communicate to their children (or analysts to their analysands) that there is a lawful world in which other subjectivities can exist, a world of mutual understanding where everyone has a right to live, called a moral third. Sharing of affect allows us a way out of an impasse.

[The third, an unfelicitous term which has not ‘jumped’ to common psychoanalytic  parlance, seeks, noted Benjamin, another word to capture that area where negotiation can occur, where two are united to transcend destruction, where the analyst is not under the sway of projective identification and can retain the capacity to think, and where the analyst can tolerate greater degrees of vulnerability. At dinner last night, Paulina Robalina suggested “intermedium.”]

Nelson Mandela has died

              Nelson Mandela     July 18, 1918-December 5, 2013

Peace and reconciliation, not revenge.

He defeated the enemy with forgiveness, 

A Differing Perspective on the Irma Dream

The hall—numerous guests, whom we were receiving

He becomes aware of himself as a multiple self .Different parts of himself are gathering together unconsciously to negotiate their existence .He is dissociated though therefore he cannot experience this multiple existence of his parts as owned by himself therefore he alleviates himself from accompanied anxiety by projecting the ownership to familiar persons with whom there are ‘unfinished businesses’.

I reproached Irma for not having accepted my solution; I said: ‘If you still get pains, it's your own fault,

He approaches first the internal saboteur self-state. The pains are substitutes of cocaine. He is aware of taking cocaine as a self -attacking procedure and is afraid of recognizing the devastating power of such a self state .He comes aware of the Winnicotian anxiety of self-fragmentation and tries to renegotiate this relationship in himself.

Irma's complaint: pains in her throat and abdomen and stomach; it was choking her

The survivor self state is taking the lead now. It complaints to himself that he was not listening to it so far. This part of himself was warning him by physical symptoms (the pain in his nose) that something was going on, it was calling for his attention and action.Throat ,abdomen and stomach are somatic areas that are used for digestion. His survivor self state warns him of not being able to digest his theory thoroughly; his theory is incomplete, in pain. He starts to feel guilty of having constituted a theory that is inadequate (this is a disguised occurrence of a narcissistic injury).

She looked pale and puffy

By visual representations he becomes aware of his vulnerable (narcissistically wounded) self. He still cannot own this part as his and he needs to project it on a wounded woman (Irma) as way to feel superior to his injury.

I was alarmed at the idea that I had missed an organic illness

He is becoming alerted on his inability to reflect properly on himself. He is becoming gradually aware that his grandiosity made him blind to experience his vulnerability. He is unconsciously aware that his internal saboteur would be able to create a physical illness that he could not cope with or/and eliminate its origins.He starts to understand that his physical problem with his nose and his solution to it(taking cocaine)could bring him into psychological death ,implying he was aware of his ‘deadly’ addiction to cocaine.

I took her to the window to look down her throat. She showed some recalcitrance, like women with false teeth. I thought to myself that really there was no need for her to do that

His addicted part of himself receives finally more attention and consequently there is a more careful glance to it. The internal saboteur initially resists such a closer relationship. The false teeth are representing the oral aggression of the internal saboteur ,the false self that is disguised under the narcissistic cocoon. He understands the vanity of his narcissistic defences though he is not ready to explore them deeper.

What I saw in her throat: a white patch and turbinal bones with scabs on them

He moves more deeply to understand his wounded self. He can now contain some pain of his traumatized self and the wounded self’s image becomes clearer.

I at once called in Dr. M., and he repeated the examination

He doubts his self image is accurate and calls for an external representation of himself . Dr.M is his disguised Mother .His mother is being put in authoritarian position, although he is in need of his mother’s representation he becomes aware of his rage against her of putting him in an inferior position. On another level Dr M is really his superior colleague and he painfully questions him of the way he represents Froyd as a medical professional.Froyd becomes aware of his dependent positioning around authoritative figures. The cocaine dependency is a self-attacking manifestation of his grandiose self-rage attacking the self of himself that is need of external mirroring.

Dr. M. was pale, had a clean-shaven chin and walked with a limp

He is fighting against the external object .His maternal representation of him cannot be internalized without pain. He is becoming furious of such a procedure and he unconsciously realizes the nature of his narcissistic injury. On another level he is aware that the closer his relationships get the more his narcissistic vulnerability (his fear of how other people perceive him) is expressed.

My friend Otto was now standing beside the patient and my friend Leopold was examining her and indicated that there was a dull area low down on the left

.

He is still questioning his representation in other significant authoritarian people of his circle. Leopold is one of his self-states that can see clearly his narcissistic wound. The underlying friendship with Otto and leopeold (his self-states) indicates his self becomes more cohesive.

A portion of the skin on the left shoulder was infiltrated

He understands his death anxiety issue as another narcissistic wound. He understands he is not immortal and he is connected more with the physical pain that is his disguised  pain of realizing he is getting older .

In spite of her dress

The dress is the narcissistic defenses that although there are still there they cannot longer hide the narcissistic wound. However he is afraid of a possible collapse without his defences therefore the dress cannot be taken away.

Dr. M. said: ‘It's an infection, but no matter. Dysentery will supervene and the toxin will be eliminated

Dr.M becomes familiar with his injury but cannot offer more empathy. Froyd becomes aware that his theory although significant in understanding the symptom lacks proper interpersonalization and here there is another narcissistic injury  .On another route his mother was able to understand his vulnerabilities though her understanding was not expressed properly for him.

We were directly aware of the origin of the infection.

The self states party reveal a coherent self. He understands now the psychodynamics of his injury and has a clearer opinion of what went wrong.

When she was feeling unwell, my friend Otto had given her an injection

He understands he needs his friends to overcome his injury; he can now let them become closer to him.  On another level he understands there are parts of himself that are healthy and can really help him if he sustain  a better internal relationship with them.

A preparation of propyl… propyls … propionic acid

He needs to smell the perfume of closer relationships but still he gets in the paranoid position .The perfume is perceived as contaminating acid, that is closeness is still threatening. He is shimmering between close and distant. 

Injections of that sort ought not to be made so thoughtlessly

He understands the paradox of taking care of himself with cocaine a way that is revealing his self-attacking mechanisms. On another level the injection could be an interpersonal injection that is necessary to be done thought anxiety provoking if not regulated in proper dose of proximity.

And probably the syringe had not been clean

Here there is indication of phantasies of being contaminated by close relationships (indication that his mother was scary for him).

by Stavros Charalambides

We Hardly Knew Ye

fifty years ago today

Frequency and the Frame

Stern considers the argument over frequency when analysts try to define what psychoanalysis is. He advocates that intrinsic criteria (not extrinsic criteria such as frequency) ought to define what analysis is, and does not think interpretation of transference is such an intrinsic, defining criterion. What is intrinsic to the process emerges from the dyad within the ‘analytic third’ and requires “freedom to find their way into” the process. Frequency does not distinguish psychoanalytic psychotherapy from psychoanalysis, but rather it is the training of the clinician, and her willingness to engage in such a process with each particular patient, which delineates therapy from analysis. This willingness includes an openness to negotiation.

Because some things the analyst imposes “unilaterally,”Goldberg also does not think that everything in the clinical situation is co-created or negotiable. [Here I think he may have a too narrow definition of negotiation. Negotiation requires that we put our desires on the table, but does not guarantee that we get to have what we want. Negotiation means it can be talked about in a welcoming way, and is not the same as compromise or submission.]  Goldberg agrees that analysis cannot be defined simply by external criteria such as frequency, but notes that certain external criteria – a place of meeting, an agreed upon meeting time, for example—and an understanding not to physically harm each other, are required for the process and for a sense of safety. He asks us to consider the purpose of the frame and what is its mechanism of action. It is not enough that frequency be negotiable, rather we must investigate what effect increased or decreased frequency has on psychic reality and self regulation.  But what is intrinsic to analysis? Goldberg cautions against but notes that what we believe intrinsic often cannot be separated from our theoretical point of view.

Goldberg, P. (2009). With Respect to the Analytic Frame: Commentary on Paper by Steven Stern. Psa. Dial., 19:669-674.

Stern, S. (2009). Session Frequency and the Definition of Psychoanalysis. Psychoanal. Dial., 19:639-655

Responding to Patients

There is no formula for what to say or when to say it. Rather, in a moment to moment appreciation of the effect our words have had on a patient, we will perpetually fumble and tweak our utterances. Attention to detail in communication will guide us as we attempt to proceed in a meaningful way. After we speak, patients may say nothing; they may quietly consider our words; they may sigh in relief or exasperation; they may weep silently; they may appear as if slapped in the face. We strive to be attuned to minute changes— in face, posture, breath, tone, prosody, and so on, as well as in narrative—for the effect we may have had. We do well to be able to admit when we have made a mistake. Often, a response from the patient with confirmatory material, or new material, means we have said something of meaning to the patient.

We ask ourselves: When do I feel compelled to speak up? Am I aware of at least some of my motivations to speak? Do they include the wish to know more, or only to correct or inform the patient? Can I apply an experience-near, emotional, and cognitive context to my remarks? Am I more or less attuned or empathically immersed in this moment? Am I involved or distracted? Is something in my own physical state or personal life having an effect on my level of attunement? Is something in my visceral or fantasy experience in the moment intimating unspoken information about the patient’s experience? What might it being trying to tell us?Does something about the patient’s demeanor, affect, voice, or the content of the material lead me to dissociate from it? What do I find so disturbing, and why? Do I want to invite the patient to help me in exploring answers to these questions?

Buirski and Haglund, from a Self psychology perspective, move us into the area of how we respond to or what we say to patients. They note interpretations that provide new cognitive knowledge when made with empathic attunement –resonating both cognitively and affectively—serve the selfobject function of promoting self cohesion through self understanding.  They go so far as to say that “for  verbal interpretations to generate meaningful cognitive and emotional understanding, they must be given within the context of a primary selfobject relationship” [italics mine]. An interpretation, constructed from the experience of both patient and analyst, is meant to help organize the patient’s experience. While their paper is about how verbal interpretation can serve as a selfobject function, they nevertheless recognize the function of procedural and perceptual communication in making meaning. Haim, while from a more traditional perspective, nonetheless asks, “When the analyst talks, is he working to regulate the patient’s tension level, or her or his own?” Haim is forthright about her uncertainties of when to respond and what to say.  She decides that “the best time to make an intervention is when the patients asks for one” [Spotnitz’s ‘contact functioning’]. Both authors seem aware of the relational and intersubjective component of experience between patient and analyst.

Buirski, P., Haglund, P. (1999). Chapter 3 The Selfobject Function of Interpretation. Progress in Self Psychology, 15:31-49.

Haim, R.J. (1990). The Timing of Interventions: A Countertransference Dilemma, when to Talk and When Not to Talk. Mod. Psychoanal., 15:79-87.

Benjamin elaborates the Third

The Tampa Bay psychoanalytic community will be enriched on December 7, 2013 by “A Day with Jessica Benjamin” hosted by the Tampa Bay Psychoanalytic Society. Psychoanalyst, philosopher, feminist, and a remarkable theoretician and author, Benjamin has reminded developmental psychoanalysts that mother is not simply an object to baby but a subject in her own right who—along with soothing, mutual regulation, reverie, and developmental impetus—also brings language, law, and thirdness to the dyad. When the mother identifies with her baby (because she was once a baby) and she experiences herself as the adult mother holding her baby, thirdness (of baby, mother once baby, and present mother) ensues, that is, mother’s ability to hold two positions simultaneously adds to the dyad the third vertex of a triangle, creating potential space for new things between both members of the dyad.  Thirdness, says Benjamin, orients the intersubjective analytic work, both as communion experience (one in the third) and symbolic experience toward differentiation (third in the one dyad). When thirdness breaks down in the therapeutic situation, complementarity leads to impasses and enactments.

Benjamin defines intersubjectivity as a developmental achievement of mutual recognition, as when the baby—much like the effect, described by Winnicott, of the mother’s survival creating for the infant externality—sees the mother as a separate other no longer under his omnipotent control. While there is some sadness with the loss of fantasized omnipotent control over the other, there is joy that the other as a subject is now worthy to recognize in turn, and greater joy still that this separate other sometimes shares like-mindedness, choosing communion and not simply united by subjugation of will. Now each subject in the dyad can recognize the other as a subject, not merely an object to serve the needs of the self.  This subject to subject interacting is highly precarious, for each subject keeps falling to the side of treating the other as if an object. “Holding the tension” then becomes the Herculean task of the analyst as she tries to refrain from oppressing the analysand with her expectations, her theories, and her will and strives instead to keep thirdness viable.

Benjamin, J. (2004). Beyond Doer and Done to: An Intersubjective View of Thirdness. Psychoanal Q., 73:5-46.

Negotiating a deepening of the treatment

The negotiation between analyst and potential analysand, says Wilson, includes facilitating an unending process of “mutual adaptation” toward “a ‘thought community.’”  He writes, “A thought community works to bring into existence new objects, or so modifies old objects that they appear in a new way…”  I surmise that, here, there may be an interpenetration of subjectivities, a ‘hive mind’ where, as Freud noted, one’s unconscious speaks to the unconscious of another. Both patient and analyst participate in many thought communities at a given time, and the analyst facilitates the awareness of the tensions that exist between them as they approximate a closer and closer shared reality and come to terms with differences. One such difference might include the fury at the not good-enough mother clashing with the new found and mitigating recognition that mother had also been deprived as a child. It is the perturbations that make for fruitful moments of negotiation.

Tensions as well exist between differing theories held by the analyst. While theories may serve to ‘hold’ the analyst in times of inevitable uncertainty, adherence to theory may also generate tensions. To which theories we adhere is multifactorially, and unconsciously, determined. Wilson notes the pressure “to adhere and yet not to adhere...” to our theories. Both patient and analyst must adapt not only to each other but to their shared or disparate theories. Wilson expects that analysis will take on a stability “constituted by more than the individual inputs of analysis and patient” [the analytic third], and that the analyst will move “from the realm of precepts to the realm of understanding” and both participants will move toward “understanding how to understand” as they develop together an analytic space where the work of analysis can be fruitfully done.

Wilson, A. (2004). Analytic preparation: The creation of an analytic climate with patients not yet in analysis …

         J. Amer. Psychoanal. Assn., 52:1041-1073.

Listening

Bohm reminds us that we are, as we listen to patients,  influenced by our theories and training; and while theories may help us organize and make sense of what we hear, we must be careful not to fit the patient into the Procrustean bed of our theories, but instead be open to surprise and  learning anew. We must tolerate uncertainty and accept that we cannot always know what is going on in every moment of the therapeutic encounter. I am reminded of a visit to Tampa in Sept 2010  from Sandor Shapiro  [see post 9-12-10] when he noted that theory helps mitigate the analyst’s anxiety and not to underestimate the value of lessening the analyst’s anxiety!  Bohm suggests we “work with mixtures of exploring and applying attitudes” and he favors “more pluralistic thought systems.”

Meissner, while accepting as fact objectivity and neutrality, nonetheless reminds us to listen at “multiple levels of discourse simultaneously.” He writes, “The analyst listens not merely to the words…but also to the tone, pace, affective coloring, nuances of expression, and …  other behavioral factors…” and he believes (re: reading the patient) that “there is no reading at all without a previously accepted framework.”

Ideas about listening analytically are on my mind not just because they are being discussed by candidates and students in the introductory series, but also because attorneys, among others, have recently inquired about how psychoanalytic listening differs from that done by a psychiatrist. I can’t help but think that my psychiatry training taught me to listen from a statistical point of view with the aim of fitting what I heard into columns A and B of a Chinese menu of diagnoses, whereas my psychoanalytic training thought me to listen from the unique and singular POV of one patient’s experience, to listen for not just what the patient says, but for what s/he intends, and even to read between the lines for intentions that the patient may not yet be aware that s/he has.  All the while we cannot be completely sure of the other's subjectivity, except, as candidate Dimitris Tsiakos, points out, we are the while participating (co-creating) our subjectivities. If you don't mind the mixed metaphor, it is a tough nut to juggle so many balls in the air simultaneously .

Yes to aggression

For Winnicott, aggression is the infant’s natural exuberance and assertion, its motor activity, a ruthlessness without the intention of destruction, and it fuels creativity and the self’s coming into being (becoming alive, having a sense of self).  Aggressiveness, as such, is part of who the infant is, a necessary part—and by implication, should be a welcomed part if the infant is to come into being without dissociating or distorting part of himself as a Not-me [Bromberg’s dissociated not-me]. Freud and Klein saw aggression as innate, as part and parcel of the death instinct. Winnicott sees destruction, infant ruthlessness, not as essentially hostile, but rather as a necessary part of the developmental struggle, much like Phyllis Greenacre’s analogy of a chick ‘hatching’ -breaking out of its shell. Winnicott disagreed with Klein (and Freud) about the innateness of aggression (the kind with hostility) , seeing hostile aggression instead as a natural consequence of frustration, and, as such, its intensity and fate dependent on the environment’s ability to adapt to the infant’s needs without creating undue frustration. With this understanding of the consequence and interplay of the infant’s aggression with the environment of objects, Winnicott provides us with the relational aspect. He recognizes that an infant’s development is always in relation to its mother (there is no such thing as a baby)  and that a reliable relationship is essential to healthy development. Afterall, it was the mother’s reliable response to the needs of the infant which allowed him in the first place the illusion of a sense of omnipotence.

The sense of self coming into being is central to Winnicott. Because the infant’s sense of self comes into being in relation to its mother, and because her attitude –including the contents of her mind—toward her infant and his aggression greatly impact his sense of self, it is imperative that the mother [and the analyst] accept and allow for expression of his aggression, and survive it, so that aggression can be integrated into his whole self, the Me, so he can become, so he can become whole. The mental health and contents of the mother’s mind are as important, maybe more so, to the infant’s development as is the intrapsychic life of the baby that Klein and Freud so privileged. 

The analyst’s attitude, likewise, becomes important in her interactions with her patient and his aggression.  Aggression, for Winnicott, is what facilitates a creative life, a life lived by a spontaneous and authentic self. If the mother grossly impinges on the baby’s sense of self and his becoming, she disrupts his continuity of being, his going on being. If the analyst derails the patient, she too impinges. Because I include Winnicott’s theory of aggression as aiding the creative potential in becoming the self, as well as in separating the self (Me) from the other (Not-me), I do not theoretically want to dispense with the patient's aggression, even though in reality at times it is very difficult to both bear and survive.

Beginning a treatment and use, or not, of the couch

Beginning an analytic treatment can be stressful for the candidate -analyst, too. How does one understand what has brought the patient to treatment and what does one do with what is learned? How does one negotiate with the analysand an environment which facilitates the analytic process? Does one use the couch or not?

Meadow reminds us that the initial phase of treatment focuses on “avoid[ing] injury to the ego” …and to help them to talk.” She and patients decide together whether they are a fit and, if she thinks so, she conveys her “willingness to work with him.” She uses three guides: diagnosis, “contact function” and “ego insulation” or protection to help her discern “what attitudes the patient can comfortably have me take” and “[w]hat quantity of stimulation will help the patient to be in the room with me and to talk.” Meadow states that “change takes place within the doctor-patient relationship” and so for “patients who have given up hope of getting what they need from others” we must figure out “how to bring them into a relationship with the analyst.” In the initial phase, she keeps a reign on her subjectivity, stating “The projector does not need a contradictory perception…”

Geist, too, reminds us to hold our subjectivity in check when doing so benefits the patient. He cautions against trying to fit the patient into the Procrustean bed of our theories and recommends co-creating experiences “that facilitate mutual growth and healing.” This is most easily achieved by empathic immersion which also allows “the analyst to use his or her subjectivity and authenticity in the service of the patient’s growth.” Geist delineates three modes of empathy:

1.      Vicarious introspection, where “we sense in ourselves the feeling states of the analysand”

2.      Empathic resonance, where “[w]e react unselfconsciously to the patient’s associations…with qualities of spontaneity, humor, metaphor, creativity…playfulness and meditation…in a mutual act of giving and receiving”.

3.      Somatic empathy, where we use our “physical feelings  that reflect a visceral communication” such as “a sinking feeling in the pit of my stomach”.

The empathic stance, says Geist, keeps us experience near, “ facilitates the patient feeling deeply understood…[which]creates a …powerful bond between patient and therapist”. It also “enables the analyst to become acutely attuned to the multiplicity of his own internal states”.

Working as such requires a frame. Is the couch a necessary component of that frame? Aruffo, despite his traditional roots, acknowledges that sometimes the analytic process is better facilitated by the patient’s sitting up. Lying on the couch is not the goal, whereas exploration of the patient’s refusal to do so is as worthy of exploration as any other. He also recognizes that interpretation of intrapsychic processes is sometimes superseded by the need for the “interactive” touch. He writes that “at times, spontaneity increases the effectiveness of an intervention” and that “mutative moments…always involve a personal interaction”. While his clinical examples show no danger of ‘wearing the attributions’ or of query of ‘the patient’s experience of the analyst’s subjectivity’, we can be heartened by Aruffo’s advocacy for maintaining “rapport” even if I was hard pressed to discern in his clinical examples how exactly that was maintained. Forrest is much more unequivocal. After a brief history of the ideas about use of the couch, he states its many pros and cons.  The cons include “errors of affect appraisal”; the absence of the analyst’s facial expressions to communicate care, empathy, sadness, etc; the ability of the reclining analysand to hide one’s shame; a loss of a sense of the egalitarian; regression beyond what is therapeutic; infantilization; and possibly a sense of torment akin to torture with its restricted vision, unanticipated startle, and sense of submission.

Re: Aruffo, candidate Stavros Charalambides noted:

the couch has become rather an inheritance of the orthodox movement and is faced with serious skepticism under contemporary thought… I consider the face to face treatment essential for those clients with serious developmental traumas(personality disordered) as the interplay with significant others has created the basis for their trauma …[which can be] repaired via …an analytic third …co-created in the space between them, something I think the couch seriously eliminates. ..[E]specially with borderline clients facial expressions of the analytic dyad is essential for linking internal self states with facial gestures. In my recent training with Beatrice Beebe she explained that having done her research with mother-infant attunement led her to deny the couch as a mean to offer curative care to patients that have experienced their mother as sadistic or depressive.

The candidate disagreed with Afuffo’s:

If the rules tell us an intervention is wrong but it produces a desirable effect, then the rules must change.

I am not sure this is always  the case .Sometimes being attuned to the rules and deciding not to follow them enlight[en]s the therapist with the freedom to create something new, sometimes with the analysand's help in this. This does not mean necessarily that we have to change the rules (framework) but rather [we have] to be aware when not to follow them. Techniques that are products of spontaneity or/and authenticity within [one] analytic dyad [do not] necessarily constitute a new framework for another analytic dyad.

Aruffo, R.N. (1995). The Couch: Reflections from an Interactional View of Analysis. Psa. Inq., 15:369-385.

Forrest, D.V. (2004). Elements of Dynamics III: The Face and the Couch. J. Amer. Acad. Psychoanal., 32:551-564.

Geist, R. (2007). Who are You, Who am I, and Where are We Going: Sustained Empathic Immersion in the Opening Phase of Psychoanalytic Treatment. Int. J. Psa. Self Psychol., 2:1-26.

Meadow, P.W. (1990). Treatment Beginnings*. Mod. Psa., 15:3-10. 

Expanding the Frame

The Introduction to Psychoanalytic Concepts I and the Practical Analytic Subjectivity I courses dovetail nicely this week for both address the fee aspect of the analytic frame. Bass advocates for flexibility

Because analysts work within different frames over the course of a day's work…a notion of the analytic frame is misleading… Rather, analytic frames come in many different shapes … constructed out of a variety of materials, varying in intent …understanding and articulating the particular ways in which the frame doesn't fit inevitably becomes an integral aspect of an evolving therapeutic process.

flexibility in negotiation of each dyad’s unique frame, paying “attention to the vicissitudes of the ongoing negotiation”, a negotiation that is ongoing as both patient and therapist  change over the course of treatment.  [Levine, too notes that  “[t]he frame is established and re-established daily From his relational perspective, Bass recognizes that the analytic frame is co-created and contextual. He may actively enjoin the participation of the patient, even inquiring about her experience of him in negotiating the fee so as to invite in possibly disavowed aspects of his subjectivity. He writes “My unconscious life with any given patient is implicated”.  Furthermore, 

the establishment of the frame serves both as a relatively fixed, clearly defined container for the therapeutic work and as a point of departure for the negotiation of transference-countertransference elements, and enactments, and the working through of such enactments in an intersubjective field.

Bass reminds us (from Mitchell, 1993)

what is most important is not what the analyst does, as long as he struggles to do what seems, at the moment, to be the right thing; what is most important is the way in which analyst and analysand come to understand what has happened.

In class, we discuss again the fee, including an easy to read, brief paper by Allen which, despite it’s use of the meta-psychological language such as strengthening of the ego and superego, and more importantly, the not yet considered (in 1971) importance of including the patient in the negotiation of the analyst’s dilemma (such as: ‘I charge for missed appointments and need to make a living but worry I will be re-enacting your “rigid overly demanding mother who never gave an inch” ‘-case 4; or conversely, ‘I am of two minds about charging for missed appointments when you were so ill, but worry I will be failing to expect you to be the responsible adult that you are just as your laissez faire parents failed to see you as capable‘ –case 5), it makes several helpful points:  

when a therapist ignores or fails to properly deal with the whole area of payment or nonpayment of his patient's bills, he too is violating an explicit and agreed upon responsibility—namely, that of effectively functioning as his patient's therapist

Gedo states: 'When a patient in psychotherapy fails to pay his bill he has violated an explicit and agreed upon responsibility'. I would like to add that, conversely, …as I understand it, is that the withholding of payment for psychotherapy is best explained in the conceptual framework of the transitional phenomenon of Winnicott (6): when the withholding of payment is an attempt by the patient to deny his separateness from the therapist, the retained money represents a transitional object.

And the long arc of the analytic attitude where the patient is

being recognized by the analyst as something more than he is at present

Expanding [see post March 10, 2011] the idea of the frame is my favourite of the class papers this week, by Miller and Twomey, not because of its ideas about salary and fee for service, but because it brings in the idea of the Third as an essential component of the frame.

In the analytic situation, this third element is supplied by the analytic setting…[and]“triangular space” in analytic work is the therapist's symbolic thinking… both influenced by and independent of the patient's mind. … [T]he Third keeps the analytic situation from degenerating into nothing but a personal encounter… Without the Third to structure the relationship between patient and therapist the dyad falls prey to the danger of merger and incoherence in which everything outside its relationship is excluded and denied.

Allen, A. (1971). The Fee as a Therapeutic Tool. Psychoanal Q., 40:132-140.

Bass, A. (2007). When the Frame Doesn't Fit the Picture. Psychoanal. Dial., 17:1-27.

Levine, A.R. (2009). Bending the Frame and Judgment Calls in Everyday Practice. JAPsA., 57:1209-1215.

Miller, L., Twomey, J.E. (2000). Incoherence Incognito: The Collapse Of The Third In A Fee... Contemp. Psa., 36:427-456.

Multiplicity of Selves

The TBIPS Relational Study Group meets by conference call at 2:00pm on the second and fourth Friday of the month and welcomes all clinicians to discuss interesting papers on relational subjects. Yesterday was a particularly lively discussion of Donnell Stern’s 2004 paper which asked ‘how is it possible for the analyst to see her unconscious involvement with her patient?’ In this dauntingly lengthy paper the answer was not so clear, but perhaps the answer is found in the concept of the multiplicity of selves where one self state sees another. [One ego psychologist asked, ‘How is this different from the observing ego?’ but Stern did not bridge or contrast the two concepts, perhaps because the structural theory is too differently meta-psychological these days.]

While it seems the paper was to expand and illustrate Bromberg’s ideas on dissociation and how disparate parts must be brought in relation to, in awareness of, each other before conflict can exist, Bromberg’s ideas were somewhat obfuscated by so many other ideas (such as the author’s need to debunk the idea of a core or true self, inviolate and incommunicable, in favour of self as social construction, necessary perhaps as we consider the multiplicity of selves; Stern does make a nice case for countertransference reinforcing  transference). Clinically, the patient and analyst become aware of dissociated self states through enactments understood only in hindsight. Furthermore, “It is only when we can tolerate conflicts between multiple states that we can negotiate [Pizer] the disagreement between them.” (p 210). “Negotiation is an ongoing never-finished weighing of the alternatives…[W]e cannot negotiate until conflict comes about.” (p.211) and “[T]he self is healed by the creation of conflict.” (p.217)

The group argued a bit about whether everything is an enactment (the trope used to be: everything is transference). I leaned toward favoring Stern’s description of enactments as “rigid and unyielding” which leaves open the possibility that there is much unconscious involvement— such as, as Stern noted, mutual regulation— which are yielding and fluid and promote growth in both analyst and patient. Two of my favorite points of the paper had to do with love and with an analytic attitude. Referring to Wolstein, Stern said that a perquisite of love is “the capacity and willingness to know and accept one’s deepest view or sense of the other.” (p. 203) [I was reminded of Natterson’s 2003 paper; see Oct. 1, 2013 post.] Regarding the analytic attitude, Stern noted that for “reparative and facilitative unconscious involvement –accepting, loving, humorous, or playful” the analyst has to ‘mean it’…”it has to be more deeply felt than mere conscious decision…” (p. 205)

My favorite point, perhaps because I am of late preoccupied with Winnicott’s ideas on survival, was on the analytic attitude as it deals with aggression: “The analyst’s role is not defined by invulnerability…but by a special (though inconsistent) willingness, and a practiced (though imperfect) capacity, to accept and deal forthrightly with her vulnerability.” And “If the analyst characteristically denies his own aggressiveness…he is unlikely to feel empathic when the patient is feeling aggressive. Instead, the analyst is likely to identify  with…the patient’s internal objects  that scold or reject the patient  [Racker’s complementary countertransference] for having angry feelings or behaving aggressively.” (p.216)

This dense and rich paper left more to be discussed than one one-hour meeting allowed. I look forward to revisiting it with my generous colleagues.

Stern, D.B. (2004). The Eye Sees Itself: Dissociation, Enactment, and the Achievement of C... Contemp. Psychoanal., 40:197-237.

Teaching Openness and Ethics in Psychoanalytic Training

While Poland uses traditional language and clings to the idea that insight via interpretation is what is mutative, he nonetheless  recognizes the power of the implicit and procedural and its consequent necessity for the analytic attitude to be open, even to explore the analyst’s self. He grapples with this by delineating the “declarative interpretation” (content) and the” procedural interpretive attitude” (process). More than once, Poland notes that psychoanalysis is defined by its belief in the unconscious with its wellspring of hidden motivation and meaning. An interpretation, he writes, must include something new in understanding or experience. His emphasis on exploring new understandings might seem to privilege content over process except that Poland is writing about an interpretive attitude (part of process) which he deems necessary for change to occur. –Poland speaks to process when he “wondered about what was unfolding between us” [p.820]—The interpretive attitude includes caring curiosity, and inquiry, exploration, and revelation, all working toward bulwarking the premise that there is always more to be learned.

What Poland calls the interpretive attitude I might call the implicit welcoming we offer our patients to hear whatever the patient brings, to bear it, to think about it, and, in heights of inspiration, articulate new meaning. I disagree with Poland that experience can always eventually be put into words or even that putting experience into words is a necessary component for change to occur. Sometimes, the procedural experience of openness, without interpretation, is sufficient.

More than the willingness to explore and interpret, an analytic attitude includes behaving ethically. Allphin says that qualities of an analytic attitude strive to:

          hold the needs of the patient as the priority;

          [be] devoted  to the growth and development of the patient;

          be conscious of their impact on patients;

          presumably…avoid suggestion. [author’s italics];

          act humanely;         

          [and]deal with ambiguity and paradox.

Allphin alludes to the necessity in training of offering a place for the neophyte analyst to discuss the most shameful of fears and feared transgressions, just as we offer to our patients.  Inviting in the shadowed side of our patients and ourselves allows for greater recognition.  Referring to Buber’s I-Thou  relationship and its concomitant absence of projections onto the other, Allphin writes  “The self cannot be whole if parts of it are unknown.” A good enough analyst is not free of flaws but rather is willing to own responsibility and make those flaws which affect the analytic relationship part of the negotiation as both participants strive toward mutual recognition.

As an aside, the issue of confidentiality and “duty to warn” will be discussed by Barry Cohen, Esquire on November 16, 2013 at the Tampa Law Center where we will discuss the none to rare clash between what is legally required and what is therapeutic.

Allphin,(2005). An ethical attitude in the analytic relationship. Journal of Analytical Psychology, 50:451-468

Poland, W.S. (2002). The Interpretive Attitude. J. Amer. Psychoanal. Assn., 50:807-826.

Fees, egads!

In the TBIPS course Practical Analytic Subjectivity I the class reads some interesting papers on money (fees). Myers  writes from a relational intersubjective point-of-view and states that

The fee expresses the analyst’s desire.

Negotiation of the fee serves then to bring to the forefront conflicting desires of two subjectivities, and the opportunity for mutual recognition. With mutual recognition comes the possibility of greater intimacy. Myers puts it like this

…the journey the patient takes to attain recognition and understanding of the therapist's separate needs is a desirable goal of therapy because it is the basis of real intimacy,

and so speaks to what Benjamin sees as “the underlying wish to interact with someone truly outside, with an equivalent center of desire.” Like Benjamin, Myesr, also relying on Winnicott’s ideas of survival, sees the joy in intersubjectivity:

the baby recognizes the mother anew and is cheered by her presence.

Furthermore:

By experiencing a patient's aggression and surviving it, we also help the patient to see that others in her life can survive hardy self-assertion.

Myers continues

By showing patients that we have a subjectivity, we offer them the chance to claim their own subjectivity.   [and]

            When we ask more of patients, they have permission to ask more of 
            us and of their environment.

Shields comes from a more traditional point of view and speaks to a panoply of possible meanings attributed to money and the fee, from its classical connection to feces and the anal character, to guilt about success, worth and autonomy.  Conflicts over fees may bring up issues with masochism, sadism, altruism; fears of punishment, or of abandonment by patients.

In a courageously self effacing clinical example, Shields reveals his countertransference dilemmas (perhaps including homophobia) when his  patient attacks the analyst’s benevolence and competence, making it impossible for the analyst to play with his own sexual desirability. I was reminded of Neil Altman’s excellent paper on race and withholding of payment.

Altman, N. (2000). Black and White Thinking: A Psychoanalyst Reconsiders Race. Psychoanal. Dial., 10:589-605.

Myers, K. (2008). Show Me the Money:(the “Problem” of) the Therapist's Desire, Subject… Contemp. Psa, 44:118-140.

Shields, J.D. (1996).  Hostage of the fee: Meanings of money, countertransference, and the beginning therapist.  Psa. Psychother., 10:233-250.

Discussing 'Relationship' in Psychoanalytic Training

According to Natterson, love, or the actualization of love, is the aim of the psychoanalytic treatment process where love is defined as “the desire to recognize” and “the caring interest in the patient’s subjectivity.” In an atmosphere and context of the mutual care giving of the therapeutic encounter, dependency and individuation are negotiated between patient and analyst. Lachmann and Beebe, though they do not call it love, offer a manifestation of mutual care giving in the therapeutic process where self- and mutual- regulation are enhanced. Lachmann rightly notes that it is the analyst’s responsibility to match posture, prosody, intensity, gaze, or attune to the patient’s self state, but Natterson, I think, would see this attempt at matching and attunement as  an act of love.  When, I wonder aloud for candidates, do we see evidence of care giving from the analysand to the analyst?

Candidate Dimitris Tsiakos writes this about Natterson’s paper: 

The question of how the therapeutic experience unleashes the potential for love and thus leads to actualization of self may be answered in the following way. The patient comes to therapy for help with a particular problem, but also the patient is bringing as subtext his or her unique version of a universal aim, namely, the achievement of love. Correspondingly, the therapist's desire to help improve the patient's life is an unstated but fundamental wish to give love. But what is the fate of the therapist? The therapist leads a complex life outside the therapeutic chamber, of course, and after a successful therapeutic experience has ended, the therapist, like the patient, brings his or her gains of love and self to the other areas of intersubjective relatedness, including the other therapeutic projects in which he or she participates. Love from others, love for others, and love for self all increase in essential simultaneity.

The two papers are a point of view about relationship in the analytic setting. At TBIPS we talk about the subjectivity of both participants and think about their relationship before we ever start talking about the contributions of the great, historical minds of Freud, Ferenczi, Klein, Winnicott, Sullivan, Kohut, Mitchell, Bromberg, and others, on formal theory and technique.

Lachmann, F.M., Beebe, B. (1996). Chapter 7 The Contribution of Self- and Mutual Regulation to Therapeutic Action: A Case Illustration. Progress in Self Psychology, 12:123-140.

Natterson, J.M. (2003). Love in Psychotherapy. Psa. Psychol., 20:509-521.

2013-2014 Film Series “Children and Trauma” kicks off on Sept 29 with The 400 Blows

    

     According to philosopher Janoff-Balman (1992) parents are charged with instilling 3 basic assumptions in their beloved children: 1) that the world is benevolent; 2) that the world is meaningful, and 3) that the self is worthwhile.  Psychoanalyst Eric Erikson noted that infancy, if the baby’s needs are attended to in a timely and good enough fashion, is the time a child learns a sense of basic trust, and that this early attunement is the most fundamental prerequisite of mental vitality. This sense of basic trust developed from the loving care children receive from their caregivers enables them to be content with themselves, with relationships, and with the world, and contributes to these three basic assumptions, that the world is benevolent, the world has meaning, and I am worthwhile; I have a right to be here. By providing for the child’s basic physical and emotional needs, parents contribute to the child’s sense of self and self worth.

    Traumatic life events impact our basic assumptions, our sense of trust, and our self esteem. Chronic neglect and disregard or mis-attunement and misrecognition are considered traumatic for they assault the child’s assumptions about the world and the self in the world. The self, necessary to sustain relationships with others, is undermined as is the belief that there is meaning to human experience. The child’s faith in the natural or divine order of things is violated, which can lead to a state of existential crisis. Children thus injured must then work hard to find divertissement from their existential anxiety, their sense of meaningless and sense of worthlessness. Their ability to participate in Society in a way that brings joy and allows them to share themselves with the world is vitiated. Without love, acceptance, being enjoyed, and engaging in mutual recognition—all which give meaning to life-- a child is at risk for cynicism and alienation; a child might feel unlovable, unacceptable, incapable of joy, and feel he does not deserve a place in the world.

Director Francois Truffaut like Doinel was an unwanted child. His mother gave him up to his grandparents for the first years of his life. He found solace and meaning in cinema. The famous final shot of the 400 blows is the face of Antione Doinel,  a restless boy who seems to beseech the audience with questions like’ where do I belong?’ and ‘what do I do now?’

Subjects, subjectivization, subjugation

Because Elise Snyder, founder of the China American Psychoanalytic Alliance, had been in Tampa last week discussing cross-cultural psychoanalysis (the pearl there being that every encounter is, to some extent, cross cultural) the paper Communicating across Boundaries, Building Crosscultural Bridges by Patrizio Campanile caught my eye. This led back to its main paper I Had Twenty-Five Piercings And Pink Hair When . . .”: Adolescence, Transitional Hysteria, And The Process Of Subjectivization. Neither paper was what I expected but both led to a very interesting discussion in the Friday afternoon TBIPS Study Group. 

Campanile got us to thinking about subjects in the psychoanalytic sense (as the center of experience with one’s own agency, will and desire) and subjects in the historical sense, under the will of the monarch. Subjectivization is the process of becoming a subject in the psychological sense, but to do so includes subjugating, if you will, multiple aspects of one’s self, a multiplicity of self states, under the rubric of a one self. Campanile notes this includes for the adolescent integrating, getting control over, subjugating one’s changing body, as well as, for the rest of us, other aspects of the self, such as our dreams when sleeping, over which we have little control. Symbolization, such as language, or giving words to experience, gives us the sense that we can organize things over which we have little, if any, control. 

I was reminded of people I have treated who have Tourette’s Syndrome and who tic and utter without the will to do so. They have told me that it is like there is an alien other who resides inside over which they have no control. It takes a huge amount of energy to postpone these involuntary movements and utterances until they are at home in private and then Tourette’s explodes, leaving them even more exhausted. Because Campanile’s papers use the traditional language of drive theory, the group mused about sexual urges being sometimes experienced as involuntary and alien. If psychoanalysis aims to allow richer, fuller human experience, then disavowal of ourselves as sexual beings is a denial in search of a cure.

Campanile, P. (2012). Communicating across Boundaries, Building Crosscultural Bridges. Psychoanal Q., 81:437-442.

Campanile, P (2012)  “I Had Twenty-Five Piercings And Pink Hair When . . .”: Adolescence, Transitional Hysteria, And The Process Of Subjectivization. Psychoanal Q, 81: 401-418.