Monday, October 28, 2013

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.

Tuesday, October 22, 2013

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. 

Tuesday, October 15, 2013

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.

Saturday, October 12, 2013

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.

Tuesday, October 8, 2013

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.


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.

Tuesday, October 1, 2013

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.