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. 

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